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TITLE 26HEALTH AND HUMAN SERVICES
PART 1HEALTH AND HUMAN SERVICES COMMISSION
CHAPTER 553LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES
SUBCHAPTER CSTANDARDS FOR LICENSURE
RULE §553.41Standards for Type A and Type B Assisted Living Facilities

(a) Employees.

  (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 have:

      (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 management.

      (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.

  (3) Staffing.

    (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 facility manager;

      (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; and

      (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; and

      (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; and

      (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 items:

    (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 bath);

    (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, communication devices);

    (K) physical functioning (transfer status; ambulation status; toilet use; personal hygiene; ability to dress, feed and groom self);

    (L) continence status;

    (M) nutritional status (weight changes, nutritional problems or approaches);

    (N) oral/dental status;

    (O) diagnoses;

    (P) medications (administered, supervised, self-administers);

    (Q) health conditions and possible medication side effects;

    (R) special treatments and procedures;

    (S) hospital admissions within the past six months or since last assessment; and

Cont'd...

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