Legislative Bill 439: Change Licensure And Regulation Provisions For Assisted-Living Facilities

Assisted-living facilities are an essential component to taking care of the nation’s aging geriatric population. This is especially important because “Americans aged 65 and older are increasingly using assisted living facilities (ALFs), particularly when experiencing physical and cognitive impairments”. These assisted living facilities are not skilled nursing facilities for patients who require around the clock care. Instead, they provide a place to live and resources that aid in the care for those who need assistance with their activities of daily life such as grooming, bathing, cooking, and medication administration. Due to the fact that assisted-living facilities are in high demand, it is essential that rules, regulations, and laws stay up-to-date regarding these facilities. Legislative Bill 439 was recently updated in order to ensure the health and safety of the geriatric population in assisted-living facilities.

Nebraska Senator, Wishart introduced Legislative Bill 439 on January 17th, 2017 in order to clarify and update laws and regulations of the Assisted Living Facility Act in order to make these facilities more regulated and functional. The bill was referred to the Health and Human Services Committee two days later to add appropriate amendments and changes. The enrollment and initial review was on February 21st, 2018 with the bill placed on final reading March 8, 2018. The final reading was presented to Governor Pete Ricketts on April 11, 2018 and later approved on April 18, 2018. The circumstances that precipitated the introduction of Legislative Bill 439 was in relation to the Assisted Living Facility Act to update and specify rules and regulations of such facilities. Updates were provided on complex and non-complex nursing interventions, defining a resident services agreement with the facility, and conditions determining whether an applicant is to be admitted or not. These changes for assisted-living facilities will improve the specifics of what the staff is and is not allowed to do, create a clearer understanding of the nurse-patient relationship, and add ease and clarity to the resident application process. The Legislative Bill 439 relates to the Health Care Facility Licensure Act through the maintenance of safety, health, decision-making, and gaining independence among every resident in the assisted-living facility. The purpose of such facility is to provide assistance of activities of daily living (ADLs) including things such as eating, promoting mobility, hygiene, toileting, dressing, and administration of medication all while promoting independence. Additional resources provided are specific complex and non-complex interventions carried out by nurses, which are regulated specifying what nurses can and cannot perform. Essentially, any complex nursing procedures that are not a part of the daily routine at the assisted-living facility are prohibited. They must only perform procedures and treatments that have a predictable outcome and do not require alteration of standard procedure. This is because “most often, licensed practical nurses, and certified nursing assistants staff these facilities on a daily basis. A registered nurse only makes periodic visits to consult and is not present full time”.

Therefore, the LPN’s and CNA’s are not medically trained to handle emergency situations, thus the residents must be in very stable condition and require minimal assistance. If needed, the certified staff may provide complex services when the registered nurse is present, however, these complex services are not to exceed ten hours per week per resident. If a resident requires more individualized care, they need to be in a facility with a higher acuity of care. Upon admission to assisted living facilities, the faculty administrators responsibility is to clearly state to each potential resident what the staff’s scope of practice as an assisted living facility is, and it is the responsibility of the resident to ensure that their medical needs are under the facility’s general scope of practice. Individuals seeking to be admitted and upon admission must annually present a list of medications or supplements taken to the facility. This list must include information regarding the dose, how that person uses it, and why the medication or supplement is taken. Any medications given to a person in a facility must be given by a registered nurse and such nurse is responsible for training their patient on the use of the specific medication. The Department of Health and Human Services is in charge of creating rules and regulations that licensed personnel must follow in order to provide care in a facility. These rules and regulations state that the minimum requirements for licensed personnel to care for patients include the need to maintain confidentiality, preserve infection control standards, accepting a patient’s refusal of medication, following the five rights when giving medications (right patient, right drug, right route, right dose, and the right time), documenting everything that occurred while with the patient, assuring safety of the patient, following specific rules and regulations set by the facility, being a mandatory reporter of all abuse situations, and allowing medication aids to provide medication to residents under their scope of practice.

A medication aide is required to take a forty-hour class, unless the aide has taken a twenty-hour course prior to January first of 2003, regarding the rules, regulations, standards, and competencies that are expected to be performed by such medication aide. An exam must then be passed by the medication aide and a registered nurse must personally train the aide in order for the medication aide to care for and provide medication to the residents

.According to a study discussing medication management in assisted-living facilities, “more than half of assisted living residencies (ALRs) (n = 547) administer medications to 80% to 100% of their residents. Almost half of ALRs use unlicensed assistive personnel (UAP)/medication aides to administer medications, as permitted by state regulations”. Therefore, it is extremely important that all medication aides go through extensive classes and training over the rules and regulations regarding the distribution of medication in order to ensure patient safety. However, it is important to consider the financial aspect of assisted-living facilities and how specific funds relate to the care and safety of the patients. According to Legislative Bill 439, the staff and costs needed to carry out the changes in this bill are not covered by fees or federal funds, and should be covered by the Nebraska Health Care Cash Fund for 2018-2019 and 2019-2020 constituting as the appropriation aspect of this bill. The Nebraska Health Care Cash Fund designates the State Treasurer to transfer sixty million three hundred thousand dollars on or before July 15th in 2014-2018, and the following years from the Nebraska Medicaid Intergovernmental Trust Fund and the Nebraska Tobacco Settlement Trust Fund to the Nebraska Health Care Cash Fund. The amount may reduce every year based on the amount unused by July 15th. The state investment officer advises the State Treasurer on the amount transferred first from the Nebraska Medicaid Intergovernmental Trust Fund, once that is depleted, the money is then transferred from the Nebraska Tobacco Settlement Trust Fund. After that the State Treasurer will transfer ten million dollars from the Nebraska Medicaid Intergovernmental Trust Fund to the General Fund on June 28 of 2018 and 2019.

No changes were made in regards to the financial aspect of Legislative Bill 439.In reference to the overall amendments of Bill 439, the main purpose is to update the assisted-living facilities by making distinctions between assisted-living facilities and nursing facilities. The definition of an assisted-living facility remains unchanged. The purpose of the facilities now includes the goal of promoting “individualized decision making and personal autonomy”. The definition of activities of daily living (ADL) was made more specific to spell out what ADL’s consist of in an assisted living facility. This Bill goes into depth about what an assisted living facility is defined as including a place of living that must include four or more residents who need assistance and can pay for the services provided. The meaning of assisted living facility was specified that these facilities do not include provide casual cares that are not scheduled. A place of residence does not qualify as an assisted-living facility if the person that has ownership of the place of residence hires a professional to tend to their needs. The definition of services provided was added to now promote the health and safety of the residents in the facility. According to the peer reviewed article, Licensed Nurse Staffing and Health Service Availability in Residential Care and Assisted Living, 18% of assisted-living facilities do not have complex interventions available.

The resident service agreement was added to identify the services provided and price of such services by the facility as well as identifies the needs of the specific resident. There are changes to the determinants of resident admission to no longer be based on whether a resident is eligible for admission or not, but if the facility can provide for the needs of the resident and if that resident is safe to be surrounded by other residents. Regulations over the admission process must include written information provided to the resident or the resident’s authorized representative who is specified as a guardian authorized by a court, or a person holding a power of attorney who is responsible for a resident. The information must now include a process to be used in order to address problems that may prevent a resident’s admission or the continuation of the living situation. These additions and changes provide the resident with confidence that their needs will be properly met throughout their extended stay. The significance of this bill relates to nursing, healthcare, and consumers being the residents of the assisted-living facility. Nursing is involved since at least 50% of staff must be licensed within the facility. This shows the residents will have more specialized care at a higher level provided through medication administration and implementation of complex interventions when needed. Nurses are able to modify standard procedures to meet residents individual needs through utilizing nursing judgment and the assessment process. Resources related to healthcare in these facilities correlate with medication administration and assistance if needed ensuring safety guidelines set by the Department of Health and Human Services are being followed.

Medication administration is important to prevent, manage, or treat any disease, illness, or condition. The residents are positively affected from the changes this bill made regarding rules and regulations of the facility as well as resources provided to include assistance with ADLs, access to staff 24/7, receiving three meals a day, and admission requirement changes allowing more flexibility with admission and continued stay. Residents are provided a “resident services agreement” to set out rules and responsibilities of both the facility and the resident benefiting both by being aware of regulations thus preventing future conflict. We are in full agreement with the passing of Legislative Bill 439 because it is essential that Nebraska is consistent and regulates the assisted living facilities so that the state can provide the best care possible for the geriatric population.

This bill changes previous definitions to further clarify what these facilities are, the requirements of the facility, and specifying regulations on providing care to the residents. As stated in the Nebraska Nurse Journal, these clarifications were necessary because “...it was determined that progress toward the goal was complicated by the provisions of the Assisted-Living Facility Act”. Due to the help of Legislative Bill 439, the nurse’s role in an assisted living facility is clear to the nurse as well as to the residents in assisted living facilities. This is important to keep all facilities running in uniform with standard procedures and policies