(1) Manager. Each facility must designate, in writing,
a manager to have authority over the operation.
(A) Qualifications. In small facilities, the manager
must have proof of graduation from an accredited high school or certification
of equivalency of graduation. In large facilities, a manager must
(i) an associate's degree in nursing, health care management,
or a related field;
(ii) a bachelor's degree; or
(iii) proof of graduation from an accredited high school
or certification of equivalency of graduation and at least one year
of experience working in management or in health care industry management.
(B) Training in management of assisted living facilities.
After August 1, 2000, a manager must have completed at least one educational
course on the management of assisted living facilities, which must
include information on the assisted living standards; resident characteristics
(including dementia), resident assessment and skills working with
residents; basic principles of management; food and nutrition services;
federal laws, with an emphasis on the Americans with Disability Act's
accessibility requirements; community resources; ethics, and financial
(i) The course must be at least 24 hours in length.
(I) Eight hours of training on the assisted living
standards must be completed within the first three months of employment.
(II) The 24-hour training requirement may not be met
through in-services at the facility, but may be met through structured,
formalized classes, correspondence courses, training videos, distance
learning programs, or off-site training courses. All training must
be provided or produced by academic institutions, assisted living
corporations, or recognized state or national organizations or associations.
Subject matter that deals with the internal affairs of an organization
will not qualify for credit.
(III) Evidence of training must be on file at the facility
and must contain documentation of content, hours, dates, and provider.
(ii) Managers hired after August 1, 2000, who can show
documentation of a previously completed comparable course of study
are exempt from the training requirements.
(iii) Managers hired after August 1, 2000, must complete
the course by the first anniversary of employment as manager.
(iv) An assisted living manager who was employed by
a licensed assisted living facility on August 1, 2000, is exempt from
the training requirement. An assisted living manager who was employed
by a licensed assisted living facility as the manager before August
1, 2000, and changes employment to another licensed assisted living
facility as the manager, with a break in employment of no longer than
30 days, is also exempt from the training requirement.
(C) Continuing education. All managers must show evidence
of 12 hours of annual continuing education. This requirement will
be met during the first year of employment by the 24-hour assisted
living management course. The annual continuing education requirement
must include at least two of the following areas:
(i) resident and provider rights and responsibilities,
abuse/neglect, and confidentiality;
(ii) basic principles of management;
(iii) skills for working with residents, families,
and other professional service providers;
(iv) resident characteristics and needs;
(v) community resources;
(vi) accounting and budgeting;
(vii) basic emergency first aid; or
(viii) federal laws, such as Americans with Disabilities
Act, Civil Rights Act of 1991, the Rehabilitation Act of 1993, Family
and Medical Leave Act of 1993, and the Fair Housing Act.
(D) Manager's responsibilities. The manager must be
on duty 40 hours per week and may manage only one facility, except
for managers of small Type A facilities, who may have responsibility
for no more than 16 residents in no more than four facilities. The
managers of small Type A facilities must be available by telephone
or pager when conducting facility business off-site.
(E) Manager's absence. An employee competent and authorized
to act in the absence of the manager must be designated in writing.
(2) Attendants. Full-time facility attendants must
be at least 18 years old or a high-school graduate.
(A) An attendant must be in the facility at all times
when residents are in the facility.
(B) Attendants are not precluded from performing other
functions as required by the assisted living facility.
(A) A facility must develop and implement staffing
policies, which require staffing ratios based upon the needs of the
residents, as identified in their service plans.
(B) Prior to admission, a facility must disclose, to
prospective residents and their families, the facility's normal 24-hour
staffing pattern and post it monthly in accordance with §92.127
of this title (relating to Required Postings).
(C) A facility must have sufficient staff to:
(i) maintain order, safety, and cleanliness;
(ii) assist with medication regimens;
(iii) prepare and service meals that meet the daily
nutritional and special dietary needs of each resident, in accordance
with each resident's service plan;
(iv) assist with laundry;
(v) assure that each resident receives the kind and
amount of supervision and care required to meet his basic needs; and
(vi) ensure safe evacuation of the facility in the
event of an emergency.
(D) A facility must meet the staffing requirements
described in this subparagraph.
(i) Type A facility: Night shift staff in a small facility
must be immediately available. In a large facility, the staff must
be immediately available and awake.
(ii) Type B facility: Night shift staff must be immediately
available and awake, regardless of the number of licensed beds.
(4) Staff training. The facility must document that
staff members are competent to provide personal care before assuming
responsibilities and have received the following training.
(A) All staff members must complete four hours of orientation
before assuming any job responsibilities. Training must cover, at
a minimum, the following topics:
(i) reporting of abuse and neglect;
(ii) confidentiality of resident information;
(iii) universal precautions;
(iv) conditions about which they should notify the
(v) residents' rights; and
(vi) emergency and evacuation procedures.
(B) Attendants must complete 16 hours of on-the-job
supervision and training within the first 16 hours of employment following
orientation. Training must include:
(i) in Type A and B facilities, providing assistance
with the activities of daily living;
(ii) resident's health conditions and how they may
affect provision of tasks;
(iii) safety measures to prevent accidents and injuries;
(iv) emergency first aid procedures, such as the Heimlich
maneuver and actions to take when a resident falls, suffers a laceration,
or experiences a sudden change in physical and/or mental status;
(v) managing disruptive behavior;
(vi) behavior management, for example, prevention of
aggressive behavior and de-escalation techniques, practices to decrease
the frequency of the use of restraint, and alternatives to restraints;
(vii) fall prevention.
(C) Direct care staff must complete six documented
hours of education annually, based on each employee's hire date. Staff
must complete one hour of annual training in fall prevention and one
hour of training in behavior management, for example, prevention of
aggressive behavior and de-escalation techniques, practices to decrease
the frequency of the use of restraint, and alternatives to restraints.
Training for these subjects must be competency-based. Subject matter
must address the unique needs of the facility. Suggested topics include:
(i) promoting resident dignity, independence, individuality,
privacy, and choice;
(ii) resident rights and principles of self-determination;
(iii) communication techniques for working with residents
with hearing, visual, or cognitive impairment;
(iv) communicating with families and other persons
interested in the resident;
(v) common physical, psychological, social, and emotional
conditions and how these conditions affect residents' care;
(vi) essential facts about common physical and mental
disorders, for example, arthritis, cancer, dementia, depression, heart
and lung diseases, sensory problems, or stroke;
(vii) cardiopulmonary resuscitation;
(viii) common medications and side effects, including
psychotropic medications, when appropriate;
(ix) understanding mental illness;
(x) conflict resolution and de-escalation techniques;
(xi) information regarding community resources.
(D) Facilities that employ licensed nurses, certified
nurse aides, or certified medication aides must provide annual in-service
training, appropriate to their job responsibilities, from one or more
of the following areas:
(i) communication techniques and skills useful when
providing geriatric care (skills for communicating with the hearing
impaired, visually impaired and cognitively impaired; therapeutic
touch; recognizing communication that indicates psychological abuse);
(ii) assessment and interventions related to the common
physical and psychological changes of aging for each body system;
(iii) geriatric pharmacology, including treatment for
pain management, food and drug interactions, and sleep disorders;
(iv) common emergencies of geriatric residents and
how to prevent them, for example falls, choking on food or medicines,
injuries from restraint use; recognizing sudden changes in physical
condition, such as stroke, heart attack, acute abdomen, acute glaucoma;
and obtaining emergency treatment;
(v) common mental disorders with related nursing implications;
(vi) ethical and legal issues regarding advance directives,
abuse and neglect, guardianship, and confidentiality.
(b) Social services. The facility must provide an activity
and/or social program at least weekly for the residents.
(c) Resident assessment. Within 14 days of admission,
a resident comprehensive assessment and an individual service plan
for providing care, which is based on the comprehensive assessment,
must be completed. The comprehensive assessment must be completed
by the appropriate staff and documented on a form developed by the
facility. When a facility is unable to obtain information required
for the comprehensive assessment, the facility should document its
attempts to obtain the information.
(1) The comprehensive assessment must include the following
(A) the location from which the resident was admitted;
(B) primary language;
(C) sleep-cycle issues;
(D) behavioral symptoms;
(E) psychosocial issues (i.e., a psychosocial functioning
assessment that includes an assessment of mental or psychosocial adjustment
difficulty; a screening for signs of depression, such as withdrawal,
anger or sad mood; assessment of the resident's level of anxiety;
and determining if the resident has a history of psychiatric diagnosis
that required in-patient treatment);
(F) Alzheimer's/dementia history;
(G) activities of daily living patterns (i.e., wakened
to toilet all or most nights, bathed in morning/night, shower or
(H) involvement patterns and preferred activity pursuits
(i.e., daily contact with relatives, friends, usually attended religious
services, involved in group activities, preferred activity settings,
general activity preferences);
(I) cognitive skills for daily decision-making (independent,
modified independence, moderately impaired, severely impaired);
(J) communication (ability to communicate with others,
(K) physical functioning (transfer status; ambulation
status; toilet use; personal hygiene; ability to dress, feed and groom
(L) continence status;
(M) nutritional status (weight changes, nutritional
problems or approaches);
(N) oral/dental status;
(P) medications (administered, supervised, self-administers);
(Q) health conditions and possible medication side
(R) special treatments and procedures;
(S) hospital admissions within the past six months
or since last assessment; and