Section III. State Summaries

Residential Care and Assisted Living

This section includes brief State summaries that identify the agency responsible for issuing regulations, licensing, and providing oversight of licensed facilities. It is based on a review of State regulations and a conversation with staff from the licensing agency. The information presented may vary from State to State based on the discussion with State contacts. The summary describes the approach to regulation and survey practices and special initiatives. A section on communicating with consumers describes the information available to consumers and family members on the Web sites of licensing agencies and aging agencies.
    Alabama
    Alaska
    Arizona
    Arkansas
    California
    Colorado
    Connecticut
    District of Columbia
    Delaware
    Florida
    Georgia
    Hawaii
    Idaho
    Illinois
    Indiana
    Iowa
    Kansas
    Kentucky
    Louisiana
    Maine
    Maryland
    Massachusetts
    Michigan
    Minnesota
    Mississippi
    Missouri
    Montana
    Nebraska
    Nevada
    New Hampshire
    New Jersey
    New Mexico
    New York
    North Carolina
 
    North Dakota
    Ohio
    Oklahoma
    Oregon
    Pennsylvania
    Rhode Island
    South Carolina
    South Dakota
    Tennessee
    Texas
    Utah
    Vermont
    Virginia
    Washington
    West Virginia
    Wisconsin
    Wyoming

Alabama

Approach

The Department of Health licenses assisted living facilities. Facilities are monitored through licensing review and periodic inspections by the Board of Health (depending on funding for inspectors). Incidents are reported through a hotline. Written reports may be requested to determine the cause of an incident or whether the facility acted appropriately. Currently, facilities are inspected every 18 months.

The Department has developed a scoring system based on survey findings that rates facilities as green, yellow, or red. The ratings must be posted by the facility for 18 months or until the next survey. Administrators from facilities receiving a red rating must attend a meeting with the licensing director and develop a consent agreement that describes the corrective actions that will be made and the timetable for making them.

Facilities that receive a yellow or red rating often request earlier reviews to consider corrections they have made that would raise their rating. However, the Department does not have sufficient staff to make return inspections and maintain the survey cycle for other facilities. The rating system was implemented in the fall of 2004. Each facility's survey report and rating will be posted on the Department's Web site when more ratings have been completed. The Department spokesperson felt that listing facilities on the Web site as they were rated would give an unfair advantage to those at the beginning of the cycle.

The survey staff members follow a protocol that focuses on admission and retention related criteria. The areas include weight loss, falls, medication administration, wandering, exiting behaviors, and other behaviors. Interviews with residents and staff follow a protocol but do not emphasize satisfaction measures because of their perceived limited use.

Communicating with Consumers

The Department of Public Health Web site includes a list of facilities and regulations governing assisted living. The list includes the name of the facility, address, phone number, administrator, type of ownership (corporation, partnership, limited liability, non-profit), and license number.

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Alaska

Approach

A new section on certification and licensing in the Department of Health and Social Services is responsible for screening applicants, issuing licenses, and investigating complaints. The reorganization was implemented to consolidate all licensing activities and the responsibility for licensing assisted living homes that had been spread among State agencies.

Licenses for assisted living homes are issued for 2 years. Regulations require an annual monitoring visit or self-monitoring report filed by the facility. Surveyors follow a checklist based on the regulatory requirements. Surveyors observe residents during a tour of the facility to determine the level of activity and whether they are dressed, groomed, and appear well-nourished. Consumers may request information about complaints against a facility by telephone, and surveys findings may be requested in writing.

Staff members of the licensing agency describe its oversight and monitoring process as consultative. When a pattern of violations is identified, a more industry-wide—versus a one-on-one—training approach is implemented. The licensing agency holds orientation sessions quarterly for new assisted living homes.

Communicating with Consumers

The Department of Health and Social Services, Division of Public Health Web site includes a guide to licensing for providers, regulations, and a list of licensed assisted living homes containing the name of the administrator and the name of the facility, address, phone number, and capacity. Forms related to the licensing requirements and process will be added to the Web site.

The Division of Senior and Disabilities Services has an extensive array of materials, including radio and television public service announcements, which are directed to providers interested in developing assisted living homes.

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Arizona

Approach

The Department of Health Services, Division of Licensing Services is responsible for licensing and inspecting assisted living facilities. The Division inspects facilities annually and upon receipt of a complaint. Licenses may be renewed for 2 years for facilities that do not have deficiencies. Surveyors use a checklist based on the regulations to guide the on-site review. The review includes record reviews and interviews with residents, family members if available, and staff. The interviews are used to determine compliance with the regulations. Residents may be asked to comment on the food, activities, and who is at the facility at night. The surveyor may mention the name of the manager and ask if the resident knows the manager. Questions about making decisions and resident's rights are also asked.

Surveyors use the same format used for nursing homes to document deficiencies. Penalties for violations include civil money penalties, provisional licensing, and restricted admissions. Fines against unlicensed facilities have been increased. Once survey and complaint findings have been sent to the facility, they are available to the public.

Communicating with Consumers

The Division's Web site contains a database of facilities and enforcement actions for all licensed entities (assisted living, day care, behavioral health, and nursing facilities). The enforcement action information includes the date of the action, the amount of the fine (if any), and a number to call for more information about the action.

The Division is preparing to post survey and complaint findings. Findings for child care providers will be posted beginning in June 2005. Once completed, postings for nursing homes and assisted living homes will follow. Surveyors have been trained to write deficiencies without including confidential information so their reports can be posted without being redacted.

There is a one-page consumer's guide to choosing an assisted living facility. The guide includes brief responses to questions and sample questions. For example, "Who regulates assisted living facilities," "What is an assisted living facility," "How can I find information about facilities," "How do I file a complaint," "How can I choose a facility," and "Questions to ask."

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Arkansas

Approach

The Department of Human Services, Office of Long-Term Care, is responsible for licensing residential care facilities. Facilities are inspected twice a year and upon receipt of a complaint. Licenses are renewed annually. Surveyors follow protocols based on regulatory requirements. A separate protocol is used for facilities that advertise that they provide dementia care. Surveyors use a form similar to Form 2567 used to prepare citations for nursing homes. Surveyors interview residents to ask about the quality of the food, administration of medications, and other services provided by the facility. Survey findings are available to the public through the Freedom of Information Act (FOIA).

Facilities must maintain written policies, and procedures for monitoring quality of care are required.

The State believes that providing education to facilities has been successful. The State conducts mock surveys to educate the staff in newly licensed facilities about the process and expectations. The State offers staff in conjunction with the mock survey to teach facility staff about the regulations and how they are applied. In addition, the licensing agency provides educational seminars for all licensed facilities, usually in conjunction the with trade associations. Survey nurses do not provide consultation and training. The agency assigns different staff to carry out the training and surveying functions.

Communicating with Consumers

The licensing agency's Web site has links to the licensing regulations, a brief description of various settings, and a search function to find a facility. The database includes all licensed facilities by county, and it lists facilities by name rather than by licensing category. The search results include the name, address, and phone number; Web site and E-mail address (if any); the name of the administrator; the number of beds; payment sources accepted; and the type of facility (assisted living, nursing home). The provider section contains the application form, incident reporting form, and criminal background-check forms. The consumer section covers all licensed facilities, including assisted living, nursing homes, and intermediate care facilities for the mentally retarded (ICF-MRs).

The Division of Aging and Adult Services Web site provides information for developers interested in building affordable assisted living facilities. An "Assisted Living Choices" link contains the licensing regulations, a list of affordable facilities, and information about eligibility and how to apply for coverage.

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California

Approach

The Department of Social Services, Office of Regulatory Development, Community Care Licensing Division regulates residential care facilities for the elderly (RCFEs). The licensing agency replaced the system of annual inspections and now randomly selects and inspects 20 percent of the licensed facilities each year. The selection is structured to ensure that every facility is inspected at least every 5 years. Surveyors use a manual that guides the inspection process. The inspection includes interviews with residents and staff and record reviews. The surveyor determines the number of interviews he or she conducts at each facility. Standard protocols are not used.

Surveyors use laptop computers to complete the inspections. Results are uploaded to a central server. The Division expects to make inspection reports available to the public on its Web site in the near future.

Legislation passed in 2003 requires unannounced inspections of facilities that are on probation, have pending complaints, operate under a plan for compliance, or must have an annual inspection because the facilities receive payment from Medicaid. Inspectors also verify that residents who were required to move from the facility by the department are no longer at the facility.

Communicating with Consumers

The Division's Web site contains several documents to assist RCFE operators in complying with the licensing regulations. An online evaluation manual presents each regulation and related interpretive guidelines. A set of self-assessment guides is available; the guides are based on the regulations and serve as a checklist of the most common citations. Separate guides include a preadmission questionnaire, resident characteristics and admission criteria, administrative issues, operations issues (medications, units, and food service), resident records, and staff records.

The Web site has basic descriptions of the different types of facilities licensed by the State—residential care facilities for the elderly, residential care facilities for the chronically ill, adult day care, adult residential facilities, continuing care retirement communities, and social rehabilitation facilities—and a database to search for licensed facilities. The results include the name, contact person, address, phone number of the facility, and phone number of the regional office that has oversight responsibility. The Web site also has a section for posting information about new developments, regulatory changes, and other information of interest.

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Colorado

Approach

The Department of Public Health and Environment, Health Facilities Licensing and Certification is responsible for regulating and licensing assisted living facilities. Facilities are licensed annually. New facilities receive a health and life safety code inspection in each of the first 2 years. If are no serious problems identified, future surveys are done on alternate years. Facilities with deficiencies receive both surveys annually. Health survey staff members are RNs or social workers who have a health care background.

The survey process was changed in 2004. Surveyors found that using a checklist meant they focused more on process and paper documentation with less observation and followup. Surveyors start with a tour of the facility and observe as many residents as possible to identify triggers for further followup. Some residents may be monitored to see if the services identified in the clinical record are delivered or to assess their participation in activities. Surveyors interview a minimum of five residents, plus one interview for every ten residents. Surveyors use a standard list of questions covering the care and services provided to them.

In large facilities, surveyors organize a group meeting using open ended questions that address the quality of the meals, activities, treatment by the staff, access to help at night, how they spend their day, what kinds of care they receive, and issues or concerns that should be explored. Surveyors provide guidance during on-site reviews in a manner that cannot be construed as direction.

In July 2005, the Department implemented a Web-based deficiency reporting system. Facilities will receive a password to review the deficiencies, develop a plan of correction, and transmit the plan to the Department. Deficiencies and plans of correction will be posted on the Department's Web site by the end of 2005 and will be available to the public. The system was developed and pilot tested with facilities. Web postings for facilities that do not use the Web-based process will include the list of deficiencies but not the plans of correction.

Surveyors and other staff provide technical assistance to providers. Providers are encouraged to contact the Department with questions rather than waiting until a problem is discovered.

Communicating with Consumers

The Department's Web site has separate sections for consumers and providers. The consumer section contains links to licensing regulations, a list of licensed facilities, a profile of each facility, and the most frequently noted deficiencies. The facility profiles include information about reportable occurrences and complaints. Reportable occurrences include unexplained deaths, brain injuries, spinal cord injuries, life-threatening complications of anesthesia, life-threatening transfusion errors/reactions, severe burns, missing persons, physical abuse, verbal abuse, sexual abuse, neglect, misappropriation of property, diverted drugs, and malfunction/misuse of equipment.

The occurrence report describes the incident, the action taken by the facility, and the Department's findings. Complaint information is presented for the number and type of complaints, a description of the allegation, and the Department's findings.

The provider section contains licensing information, summaries of advisory committee meetings, the informal dispute resolution policy, a policy and procedures checklist, administration training, and interpretive guidelines on resident agreements, keeping bedridden residents after admission, and hot water temperatures.

In addition to the consumer and provider sections, there is a section on brochures on the Web site. The brochure section has a guide to choosing a facility and materials on how to resolve complaints and protect personal property.

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Connecticut

Approach

The Department of Health licenses assisted living service agencies (ALSAs) that serve residents in managed residential communities. Agencies are licensed and inspected biennially by RNs with experience in geriatrics. Surveys focus on resident reviews and interviews with a 10 percent sample of residents who receive ASLA services, staff records, and other regulatory requirements. Based on the clinical record reviews, surveyors talk with residents to determine whether they are receiving the care they need and whether the record correctly documents resident needs. Survey findings are available to residents and others upon request. They are not posted in each building.

ALSAs are required to establish a quality assurance committee that consists of a physician, a registered nurse, and a social worker. The committee meets every 4 months and reviews the ALSA policies on program evaluations, assessment and referral criteria, service records, evaluation of client satisfaction, standards of care, and professional issues relating to the delivery of services.

The quality assurance committee also conducts program evaluations. They examine the extent to which the managed residential community's policies and resources are adequate to meet the needs of residents. The committee is also responsible for reviewing a sample of resident records to determine whether agency policies are being followed, whether services are being provided only to residents whose level of care needs can be met by the ALSA, and whether care is being coordinated and appropriate referrals are being made when needed. The committee submits an annual report to the ALSA summarizing findings and recommendations. The report and actions taken to implement recommendations are made available to the State Department of Public Health.

Communicating with Consumers

The Department of Health's Web site posts online applications for ALSAs and managed residential communities.

The Division of Elderly Services' Web site presents a housing directory that includes listings of assisted living facilities with the name of the facility, a contact person and phone number. The current directory is dated May 2000.

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District of Columbia

Approach

The District of Columbia licenses community residence facilities. The Assisted Living Residence Regulatory Act was passed in June 2000. The law includes a philosophy of care that emphasizes personal dignity, autonomy, independence, privacy, and freedom of choice. The philosophy is that services and physical environment should enhance a person's ability to age in place in a home-like setting by increasing or decreasing services as needed. The rule-making process has not been completed.

Communicating with Consumers

The Department of Health Web site includes a list of community residence facilities with the name, address, phone number, and capacity. The site also contains a link to the licensing application and instruction packet.

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Delaware

Approach

The Department of Health and Social Services, Division of Long Term Care Residents Protection surveys facilities annually and upon receipt of a complaint. All surveyors are certified to conduct Federal surveys, and a few specialize in assisted living. Surveyors interview a sample of residents.

Facilities must develop and implement an ongoing quality assurance program that includes internal monitoring of performance and resident satisfaction. Satisfaction surveys of all residents must be conducted twice a year. Revisions to the regulations will require reporting of falls without injury and falls with injuries that do not require transfer to an acute care facility or do not require reassessment of the resident; errors or omissions in treatment or medication; injuries of unknown source; and lost items, in accordance with facility policy.

Communicating with Consumers

The Division of Long Term Care Residents Protection Web site includes a list of facilities (name, address, phone, and capacity), a list of frequently asked questions, and information about the adult abuse registry and the criminal background check law.

The Division of Services for Aging and Adults with Physical Disabilities has a link on the home page that describes assisted living, a link to a list of facilities, and a link to information on coverage of services in assisted living settings for Medicaid beneficiaries and other low-income residents. The forms and publications button has a link to a four-page brochure that describes assisted living, the services available, and sources of further information.

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Florida

Approach

The Florida Department of Elder Affairs is responsible for establishing regulations for assisted living facilities. The Agency for Health Care Administration (AHCA) is responsible for inspection, issuing licenses, and oversight. Licenses are issued for 2 years. Basic assisted living facilities are inspected twice each year by a registered nurse or appropriate designee. Facilities with an Extended Congregate Care or Limited Nursing Services license are visited twice a year. Survey guidelines are posted on the AHCA Web site. Abbreviated surveys may be conducted in facilities with a good compliance history.

Complaints are triaged into four levels. The most serious complaints are investigated within 24-hours. Survey findings are available at local libraries or by submitting a written request to AHCA.

Surveyors follow protocols that track regulatory requirements including facility records and staff and resident records. Surveyors talk with staff, residents and family members. They observe the residents, ask general questions (e.g., how do you like it here? Is the staff friendly? How is the food?) to assess whether the resident is receiving needed care and appropriate followup. For example, residents and/or their family members will be asked about their appetite if they seem to have lost weight. They also will be asked about when they began losing weight and how much weight they have lost. The surveyor will check with the staff to determine whether they are aware of the weight loss and how it is being addressed.

AHCA hired quality assurance nurses 5 years ago to provide consultation and assistance to nursing homes to improve compliance and quality of care. The program has been extended to assisted living facilities, and the nurses accompany surveyors on monitoring visits.

Rules adopted in 2001 allow facilities to voluntarily adopt an internal risk management and quality assurance program. Facilities are required to file preliminary and full adverse incident reports within 1 and 15 days, respectively. The reports are confidential as provided by law and cannot be used in civil or administrative actions, except in disciplinary proceedings by the Florida Agency for Health Care Administration or an appropriate regulatory board. Facilities must also report monthly liability claims filed. The quality assurance program is intended to assess care practices, incident reports, deficiencies, and resident grievances and develop plans of action in response to findings.

Since 2001, AHCA has prepared annual reports to the State legislature on adverse incidents in assisted living facilities and nursing facilities. Adverse incidents are those events over which facility staff or personnel could exercise control—rather than events that occur as a result of the resident's condition—which resulted in:

  • Death.
  • Brain or spinal damage.
  • Permanent disfigurement.
  • Fracture or dislocation of bones or joints.
  • Limitation of neurological, physical, or sensory function.
  • Need for medical attention to which the resident has not given his or her informed consent, including failure to honor advanced directives.
  • Transfer of the resident, within or outside the facility, to a unit providing a more acute level of care.

Or any event (regardless of facility control) that resulted in:

  • Abuse, neglect, or exploitation.
  • Resident elopement.
  • A report to law enforcement.

Assisted living facilities must notify the Agency within 1 business day of the occurrence of the incident. The agency is authorized to investigate any such incident as appropriate and may prescribe measures that must or may be taken in response to the incident. Assisted living facilities must submit a complete adverse incident report to the agency for each adverse incident within 15 days of the occurrence. The reporting facility also indicates if the incident was determined to be an adverse incident. The adverse incident report is confidential and is not discoverable or admissible in any civil or administrative action, except in disciplinary proceedings by the agency or the appropriate regulatory board.

AHCA reported receiving reports on 1,468 incidents between May 2001 and May 2002; 1,302 incidents between May 2002 and May 2003; and 1,996 incidents between 2003 and 2004. AHCA made on-site visits to investigate 48 incident reports.

The 2004 report noted that there has been a decrease in the number of serious deficiencies, but the reasons for the decline had not been identified. The reporting process allows licensing staff to observe the facility's risk management process without actually being on-site. The report noted that the content of reports from nursing homes has improved since 2001 and now clearly describe the incident and the action taken by the facility. On the other hand, reports from assisted living facilities do not clearly describe the incident and the actions taken to enhance resident safety and prevent recurrence of similar incidents.

Communicating with Consumers

The Department of Elder Affairs maintains a Web site on assisted living that includes several resources for developers interested in building affordable facilities.

The Agency for Health Care Administration's Web site contains links to the statute and regulations, an application package, survey guidelines, background screening information, incident reporting forms, and a monthly liability claim form. The agency is reviewing privacy and other legal issues related to the posting of survey and complaint findings.

Adverse incidents may be reported online. The Web site explains how to determine if an incident is adverse and presents guidelines for completing the report and FAQs. Both sites have links to statutes, regulations, application forms, specialty licenses, survey guidelines, and approved trainers.

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Georgia

Approach

The Office of Regulatory Services (ORS) conducts initial, annual, and followup inspections and complaint investigations. Inspections are generally conducted on an unannounced basis. ORS has the authority to take the following actions against a licensee: impose fines, revoke a license, limit or restrict a license, prohibit individuals in management or control, suspend any license for a definite period or for an indefinite period, or administer a public reprimand. Fines and revocations are the most common actions. ORS has the authority to take the following actions against applicants for a permit: refuse to grant a license, prohibit individuals in management or control, or limit or restrict a license.

Surveyors interview six residents and staff members or 10 percent of the residents, whichever is greater, using open-ended questions that elicit information about their well being, length of stay, how they are treated, if they have had any problems and how they were resolved, and whether they know of problems that other residents have had

Communicating with Consumers

The ORS Web site includes links to the applicable rules and regulations, application for a permit, and a list of frequently asked questions about personal care homes and criminal background checks for employees. The Web site has a searchable database that also includes inspection reports. Each report includes a citation and description of the regulation and the evidence supporting the deficiency.

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Hawaii

Approach

The Department of Health licenses assisted living facilities. Facilities in good standing receive a 2-year license. A provisional license for a shorter period of time may be issued for facilities that have substantiated complaints. Facilities that receive a deficiency and submit an acceptable plan of correction are determined to be in "good standing."

Surveyors use a protocol that follows the regulatory requirements. Surveyors ask a standard set of questions during interviews with residents and staff. Resident questions probe for information about the person's needs, the service provided, food service, and other areas. Staff members are asked about their awareness of the resident's needs, the tasks they perform for specific residents, and the overall care plan. Responses are compared to the resident's record.

The licensing agency holds quarterly meetings with providers to discuss general survey findings and other regulatory issues.

Communicating with Consumers

The Department of Health Web site includes a list of residential care facilities and the number of reported vacancies. Data for assisted living facilities will be posted in the near future. Agency staff are examining options for developing a methodology to profile or rate facilities. The agency is also considering the posting of survey findings on their Web site, but they need additional staff support to do so. A comprehensive handbook is available to consumers. It describes different residential options and provides checklists to compare facilities. The handbook is not available on the Web site.

The Executive Office on Aging Web site has a series of links (information, useful links, and locating services) that lead to a search function: AssistGuide. This function allows consumers to search for available services, including assisted living facilities.

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Idaho

Approach

The Department of Health and Welfare licenses residential and assisted living facilities. With the exception of the initial surveys for licensure, all inspections and investigations are unannounced. Inspections are conducted at least annually. Historically, the State used a consultative process that improved overall quality of care and compliance. Surveyors provided input and suggestions to address problems that were identified.

Because of staff shortages, there is less time to provide consultation during the survey process. In October 2004, the department began surveying facilities every 3 years if there had been no deficiencies during two consecutive surveys and no complaints. To qualify, facilities must not have citations in the core survey areas—abuse, neglect, exploitation, providing adequate care to meet the needs of the resident, fire suppression/smoke detection system operable, allowing surveyors access to facility/staff/residents—and have a licensed administrator responsible for the day-to-day operation of the facility.

About 25 percent of the facilities qualify for an abbreviated survey. The abbreviated surveys include an off-site review; entrance conference; tour of the facility; observations; interviews with residents, family members/representatives, and staff; record review, technical assistance; and an exit conference.

Surveyors interview residents about the care received, resident rights, the resident's perception of care, how they are treated by staff, what service needs they have and whether these needs are being met, whether they have a complaint, how the facility responds to complaints, and whether they are involved in care planning and other areas. The guidelines determine how many residents are interviewed based on the size of the facility; 3-10, three residents; 11-20, four residents; 21-50, seven residents; and 51 or more, ten residents.

Inspections include reviews of the quality of care and service delivery, resident records, and other items relating to the operation of the facility. If deficiencies are found, the administrator submits a plan of correction, and followup surveys are conducted to determine if corrections have been made. Complaints against the facility are investigated by the licensing agency.

Communicating with Consumers

The Bureau of Facility Standards' Web site will be expanded to include the 10 more frequently cited deficiencies, training programs, technical guidance, and links to best practices. Best practice information will include links to two State associations, the Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality, and national Web sites with links to best practices.

The Web site also includes a survey and technical assistance guide, policies and procedures, and survey checklists for residents' rights, the administrator, training, records, resident care, activity, nursing services and medications, food services, environment and fire/life safety, and behavior management.

The Commission on Aging is collaborating with the Idaho Legal Aid Services to prepare a consumer guide that will be posted on the Commission's Web site.

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Illinois

Approach

The Department of Public Health licenses assisted living and shared housing establishments. Facilities are inspected annually. Visits are not announced and focus on compliance with the rules, solving resident issues and concerns, and the facility's quality improvement (QI) process.

The monitoring process is collaborative in nature, with an emphasis on meeting the needs of the residents. During this process, surveyors provide information on best practices and share concerns about the quality of care. They provide suggestions for how to improve services and/or offer the names of individuals the facility may contact for assistance. Oversight is not enforcement-driven but is based more on a social model promoting quality of care. Contract employees are being replaced with State employees for monitoring activities, particularly individuals who understand the social model and philosophy of assisted living.

Each facility must have a QI program that covers oversight and monitoring and resident satisfaction. A system is needed to detect and resolve problems. The existence, results, and process of the QI system cannot be used as evidence in any civil or criminal proceeding.

Facilities participating in the supportive living facilities (SLF) program are certified by Medicaid and are monitored at least annually by the Department of Public Aid. Monitoring includes contract requirements, resident autonomy, resident rights, adequacy of service provision, quality assurance process, safety of the environment, program policies and procedures, information provided to low-income residents, review of resident assessment and service plans, resident satisfaction surveys, check-in system, and food service.

Facilities must have a grievance process and a quality assurance process. Complaints may be heard informally. If not resolved or if the resident prefers, grievances may be submitted through the facility's formal process. Residents may use the Medicaid appeals process for denial or delay of service.

The rules require that facilities establish an internal quality assurance plan that covers resident satisfaction; an evaluation of the care and services provided; tracking improvements based on care outcomes; a system of quality indicators; procedures for preventing, detecting and reporting resident neglect and abuse; and ongoing quality improvement. A system with outcome indicators must be developed that measures: quality of services; residents' rating of services; cleanliness and furnishings in common areas; service availability and adequacy of service provision and coordination; provision of a safe environment; socialization activities; and resident autonomy.

Communicating with Consumers

The Department of Public Health's Web site contains the assisted living regulations, a list of facilities, and the application to obtain a license.

The Department of Public Aid Web site has a list of facilities and fact sheets for providers and residents that explain the program and certification requirements.

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Indiana

Approach

The Department of Health regulates residential care facilities. The Department conducts annual surveys, followup surveys, and complaint investigations. Survey findings are posted at each facility and may be obtained from the Department of Health upon request. Most surveyors are registered nurses, and they use a protocol that tracks the regulations to guide their survey activities. During the on-site review, surveyors interview at least three residents, including the resident council president, if applicable. A standard set of questions based on the resident rights provisions of the regulations are asked, such as:

  • Are you able to have privacy when you want it?
  • Do staff and other residents respect your privacy?
  • Do you have a private place to meet with visitors?
  • Do you have privacy when you are on the telephone?
  • Do you receive your mail unopened?
  • Are you aware of the rights you have as a resident?
  • Does staff treat you with respect?
  • Does staff make an effort to resolve your problems?
  • Has any resident or staff member ever physically harmed you?
  • Has anyone ever taken anything belonging to you without permission?
  • Has anyone ever yelled or swore at you? If so, did you report this to someone? How did they respond?

Responses to the interviews are recorded on a form. Surveyors respond to questions from facility staff but do not provide consultation. Complaints are investigated based on their assigned priority level. Complaints alleging harm are investigated within 10 business days.

Communicating with Consumers

The Department of Health's Web site includes a list of facilities (name, address, and telephone and fax numbers), a link to the regulations governing residential care facilities, and links to a training manual for special care facilities. The Family and Social Services Administration Web site includes a disclosure form that must be completed by special care facilities.

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Iowa

Approach

The Department of Elder Affairs is responsible for developing regulations for assisted living programs. Monitoring, inspections, and enforcement are the responsibility of the Department of Inspections and Appeals (DIA). Certificates are issued for 2 years. Monitoring visits are also done every 2 years by a registered nurse and masters level sociologist.

A protocol based on the certification requirements is used to guide the review. Monitors interview a sample (10-20 percent) of tenants, program staff, and family members using a protocol. Tenants are asked a series of questions about privacy, whether service schedules meet their preferences, whether their life is meaningful, and whether they recommend the facility to others. The regulations require that DIA make on-site visits to investigate complaints within 48 hours if there is immediate danger; however, the Department usually investigates within 24 hours.

During the monitoring process, staff members hold community meetings with tenants during their site reviews. The meetings often identify concerns about quality and practice for the monitors. A summary of the community meeting is included in the monitoring report, which is posted on the DIA Web site. During the review, rules may be clarified and explained to site managers and staff. Monitoring staff members often participate in training meetings organized by three associations representing assisted living programs.

Communicating with Consumers

The DIA Adult Services Bureau Web site includes frequently asked questions, a list of standard facilities and dementia care facilities (name, address, phone, contact, number of units and beds, and the initial certification date), an application form and packet, and a form to request a waiver of a rule.

Inspection reports and complaint investigations were available for reviews that have been done since the regulations were changed in May 2004. After July 2005, reports were no longer posted due to staff reductions. Users must enter the name of the facility to access survey and complaint information. The information includes the date and type of the visit, number of deficiencies, percent quality, certification action, number of violations, class and description, fine amount, whether the violation is one time or daily, and the status of the violation.

The monitoring report includes the number of residents, tenant satisfaction, complaint history and observations from resident records, policy, and practice. The monitoring process includes interviews with residents and family members and a community meeting. The report includes a narrative summary of the interviews and meeting. The complaint report includes the date of the investigation, relevant definitions of terms, accreditation status, complaint history, a description of the complaint, and the findings.

Complaints may be submitted online through the Web site. The site also includes a registry for certified nurse aides.

The Department of Elder Affairs' Web site has links to the regulations governing certification of facilities, a brief description about assisted living, and a number to call to register complaints.

Current as of September 2006
Internet Citation: Section III. State Summaries: Residential Care and Assisted Living. September 2006. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/final-reports/residentcare/rescare6.html