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New Jersey is unique in specifying that facilities and residents who are not Medicaid-eligible may contract with outside health care professionals for services that the facility does not provide. Of the 32 states that permit third-party hospice services to be provided, 19 refer to hospice care as an exception to the state's discharge criteria. An additional 13 states allow hospice services to be delivered but do not link this service to discharge criteria.

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The lack of regulatory provisions for hospice services does not mean that hospice or any other third-party providers are prohibited, so it is possible that the number of states in which hospice care is provided to residential care setting residents is higher than Regardless, it is clear that hospice services enable residents who need these services to avoid potentially disruptive transfers.

Four states have very detailed provisions regarding the furnishing of hospice services: Iowa , South Dakota , Texas , and Wyoming. The South Dakota rules are summarized here:.

A facility that admits or retains a resident who has elected hospice: must have the resident's physician order identifying the terminal illness; must have a written agreement with the hospice agency that delineates responsibilities; must provide the licensing agency with specified information about each hospice client; must be approved for medication administration; must be equipped with an automatic sprinkler system if a hospice patient becomes incapable of self-preservation; must have at least two staff on duty at all times if the hospice resident care needs require additional staffing or the resident is not capable of self-preservation, except when the hospice plan of care provides for adequate 24 hour bedside care, which can be provided by either family members or hospice staff during their intermittent visits.

The facility must include family members or hospice staff on a staffing schedule; each staff member must attend training within 30 days of employment and annually specific to the care for terminally ill residents; and training, including a competency evaluation by the facility nurse, nursing consultant, or hospice agency nurse, must include the following topics:.

Hospices provided care much longer and received much higher Medicare payments for beneficiaries in ALFs than for beneficiaries in other settings. Hospice beneficiaries in ALFs often had diagnoses that usually require less complex care. Also, for profit hospices received much higher Medicare payments per beneficiary than non-profit hospices. Thus, the role of hospice care in these settings might change in the next few years. Medication services are an important, and debated, component of residential care.

States often restrict the type of medications that unlicensed staff may administer to those prescribed for stable or predictable conditions. They also often prohibit the administration of as-needed pro re nata , or PRN medications because such medications require an assessment of symptoms to determine whether it should be taken--either by the individual for whom the drug is prescribed or by a licensed nurse. A California -based advocacy group recently argued that ALFs "pretend" that medication is always self-administered but that in fact unlicensed staff administer medications under the pretense that they are only assisting with medications.

Assistance typically includes reminders, assistance opening a container, offering liquids, and may or may not include centralized storage and record-keeping. Medication administration typically involves removing the correct dosage from a medication container and handing it to a resident or putting it in their mouth, or the direct application of a medication dose e. However, state regulations may specify what constitutes assistance with versus administration of medications in different ways.

As shown in Exhibit 3 , there is overlap between these two terms, with the result that residents may be receiving similar services under different names. That is, assistance in one state might be defined as administration in another--specifically, removing the correct dosage from a non-unit dose container is considered administration in most states but assistance in others. Assistance with medications provisions typically requires that the resident be capable of self-administration with limited assistance. A few states have especially detailed descriptions of certain medication services.

Compendium of Residential Care and Assisted Living Regulations and Policy: 2015 Edition

For example, Connecticut 's rules provide extensive provisions for the use of non-prescription topical medications and for medications administered by routes other than oral. Oklahoma has very detailed provisions regarding bulk medications, including the type of staff who may dispense from bulk medication containers and permitted types of bulk medications e. Colorado has a draft guideline for the use of medical marijuana in ALRs. Most likely reflecting differences in State Nurse Practice Acts, states vary regarding provisions about who is authorized to assist with or administer medications.

As shown in Exhibit 4 , 36 states permit unlicensed staff to administer medications and 18 permit unlicensed staff to assist with medications. Fifteen states require a licensed health care professional to administer all medications, and nine require licensed health care professionals to administer specific medications such as injections or Schedule II medications. If states do not require that licensed staff administer medications, they have two primary approaches to training requirements for unlicensed staff who will be assigned to administer medications:.

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Unlicensed staff who will administer medications must receive classroom-based training that some states use to certify individuals as certified medication aides or technicians. Unlicensed staff are taught how to assist with or administer medications by a licensed nurse and this nurse formally delegates the responsibility for medication administration to specific trained staff.

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Delegation means the transfer to a competent unlicensed individual the authority to perform a selected nursing task in a selected situation, as described in the state's Nurse Practice Act. Exhibit 5 lists state training requirements for unlicensed staff. All states require staff who assist with or administer medications to be trained, though training requirements vary. Twenty-four states require unlicensed staff to take a medication training course, and 21 states permit training through nurse delegation or training provided by a licensed health care professional such as a RN or physician.

Of the 24 states that require unlicensed staff to take a medication course, 13 require them to pass an examination. Administration of injectable medications is a frequently described medication task for which states have widely varying requirements. The administration of medications by injection is generally considered to be a skilled nursing task because incorrect technique can significantly harm the recipient. In settings that employ or contract with licensed practical nurses LPNs or RNs for some amount of time, more than 60 percent provide this service, compared with 36 percent of settings without LPNs or RNs.

Many states restrict the scope of medication services based on the route e. However, two states allow unlicensed staff to assist residents who self-administer injection medications Alabama and Montana , and eight states permit unlicensed staff to administer medications by injection. Massachusetts does not allow even licensed nurses to administer medications by injection though they may administer medications delivered through other routes: topical, inhalers, eye and ear drops, medicated patches, and suppositories.

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In recent years there has been an increasing focus on reducing overuse of psychotropic medications for residents in long-term care facilities. West Virginia has very detailed guidelines for psychotropic and behavior-modifying medications. If these medications are used, the facility must ensure the following: that the dosage is based on age recommendations; that the diagnosis justifies the medication use; that staff monitor daily for side effects or adverse effects; that adverse effects are reported to the resident's physician; and that measures to reduce the dose over time are taken.

In addition, monthly evaluation by a licensed health care professional is required and a physician must review the resident's record every 6 months and assess the need for continued use of the prescribed medication and the potential to decrease the dose. West Virginia permits approved Medication Assistive Personnel who have completed a competency-based training program to administer medications. Oregon 's and Idaho 's rules state that psychoactive medications are not to be used for the convenience of the staff.

Specifically, Idaho rules state that psychotropic medication must not be the first resort to address behaviors and that the facility must attempt non-drug interventions to assist and redirect residents' behavior.


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Older persons are at risk of negative health consequences due to inappropriate medication prescribing, medication administration errors, and adverse drug events. Medicare-certified nursing facilities are required to employ or obtain the services of a consultant pharmacist to assist with medication regimen review. Given that 68 percent of RCFs report that a physician or pharmacist reviews residents' medications for appropriateness, it seems likely that some facilities are exceeding regulatory requirements for medication review.

Each facility must contract with, or otherwise employ, a consultant pharmacist, who must prepare a written report to the facility at least quarterly each year describing:. Any areas in which the consultant pharmacist determines that the methods employed by the facility are deficient, or have the potential to adversely affect the health, safety, or welfare of residents.

Recommended alterations to the methods, or additions to the methods, to correct any methods determined to have the potential to adversely affect the health, safety, or welfare of residents. The consulting pharmacist must also review all orders for medication prescribed since the last review and prepare a report to the facility describing: 1 all instances in which medication has been improperly prescribed or administered; and 2 instances in which, in the opinion of the consultant pharmacist, the facility should seek physician review of the number or types of prescribed medications for residents.

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Kansas rules for pharmacist review are among the most prescriptive, requiring a review at least quarterly and following any significant change in the resident's condition. The review must include the following:. Based on the findings of this review, the pharmacist or licensed nurse must notify the resident's medical care provider of any issue that requires the medical provider's immediate action. South Dakota requires facilities to have a monthly pharmacist review that includes the resident's diagnosis, the drug regimen, and any pertinent laboratory findings and dietary considerations.

The pharmacist must report potential drug therapy irregularities and make recommendations for improving residents' drug therapy to the resident's prescriber and the facility administrator. Some states permit family members to assist resident relatives with medications. Such assistance offers the benefit of continuing established caregiver relationships and may save the resident money if medication services are not included in the basic rate. Montana permits families to set up medications, including insulin administered by injection.

Louisiana permits the resident's relatives or a personal representative to transfer medication from the original container to a pill organizer box the resident uses to self-administer medication. However, facilities differ regarding monitoring whether medications are being administered as prescribed. Utah permits family members or a designated responsible person to administer medications after signing a waiver indicating that they will agree to assume the responsibility to fill prescriptions, administer medications, and document their administration.

Residential care settings traditionally provide both lodging and meals i. State regulations vary regarding specific requirements for meals, snacks, and therapeutic diets. All states have requirements for food storage and safety, cooking equipment, and food service staffing, which are not included here. All but six states require providers to furnish three daily meals. The exceptions include Iowa 's assisted living programs, Maine 's assisted living programs, and New York 's enriched housing programs--each of which are required to provide only one daily meal.

Minnesota and Illinois require two daily meals Illinois requires the provision of a breakfast bar in this case if a facility does not provide breakfast. Ohio is unique in allowing RCFs to choose whether to serve no meals--or one, two, or three meals.

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Facilities that do not provide three meals must ensure that each resident unit is equipped with facility-maintained food storage and preparation appliances. All but 16 states require the provision of snacks, with some specifying one daily snack, and others "between meal snacks. Several states require providers to furnish therapeutic and modified diets, sometimes referred to as special diets when ordered by a physician.

For example, the District of Columbia requires facilities. Facilities must consult regularly with a dietitian, who must have access to the resident's record containing the physician's prescriptions for medications and special diet and must document in that record all observations, consultations, and instructions regarding the resident's acceptance and tolerance of prescribed diets.


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The dietitian and the residence director, or a qualified person designated by the residence director, must review residents' therapeutic diets at least every six months. States typically require that meals and snacks meet recommended dietary and nutrition standards, most frequently those of the Food and Nutrition Board of the National Academy of Science, National Research Council. However, some states refer more generally to federal guidelines or national standards. In addition, states may require that a dietitian review menus and recipes to assess whether meals meet nutritional standards.

Pennsylvania requires that between meal snacks and beverages be available "at all times, unless medically contraindicated. Colorado 's requirements for Alternative Care Facilities, the state's term for settings certified to receive Medicaid reimbursement, include a revision that requires facilities to provide clients "unscheduled access" to food and food preparation areas if the resident is determined capable of appropriately handling cooking activities.

Delaware 's rules do not specifically use the term "access at any time" but do require ALFs to provide access to a central kitchen if residents' units do not have kitchens. Thirty-five states specify that snacks should be available between meals but do not specify that they should be available at any time between the evening and morning meal. Presumably, residents in private apartments and rooms that have kitchens with food storage appliances will have access to food any time they want it.

States that do not require units with kitchens or access to a central kitchen may need to revise their regulations to comply with the new CMS requirement. Staffing is an important topic in all LTSS settings because studies indicate that staff have a significant impact on the health and well-being of residential care residents. All states require residential care settings to employ a manager, director, or an administrator who is responsible for daily operations, including staffing, oversight, and complying with regulatory requirements.

Generally, the administrator is expected to be employed full-time, but states may permit smaller settings with a licensed resident capacity under a specified number to employ a part-time administrator.

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