Are Assisted Living Facilities required by law to have a nurse on staff?

Home Health Columnist / Guide · Mar 31, 2013

Regulations vary by state:

State Regulations - Assisted Living Federation of America

In PA, most facilities are licensed as Personal Care Homes.

2600.53 Qualifications and responsibilities of administrators.
(a) The administrator shall have one of the following qualifications:
(1) A license as a registered nurse from the Department of State.
(2) An associate's degree or 60 credit hours from an accredited college or
university.
(3) A license as a licensed practical nurse from the Department of State
and 1 year of work experience in a related field.
(4) A license as a nursing home administrator from the Department of
State.
(5) For a home serving 8 or fewer residents, a general education develop-
ment diploma or high school diploma and 2 years direct care or administrative
experience in the human services field.
(b) The administrator shall be 21 years of age or older.
© The administrator shall be responsible for the administration and manage-
ment of the home, including the health, safety and well-being of the residents,
implementation of policies and procedures and compliance with this chapter.
(d) The administrator shall have the ability to provide personal care services
or to supervise or direct the work to provide personal care services.
(e) The administrator shall have knowledge of this chapter.
(f) The administrator shall have the ability to comply with applicable laws,
rules and regulations, including this chapter.
(g) The administrator shall have the ability to maintain or supervise the main-
tenance of financial and other records.
(h) The administrator shall be free from a medical condition, including drug
or alcohol addiction, that would limit the administrator from performing duties
with reasonable skill and safety

More stringent Assisted Living Facility regulations established Jan 2011

2800.53. Qualifications and responsibilities of administrators.
(a) The administrator shall have one of the following qualifications:
(1) A license as an RN from the Department of State and 1 year, in the prior 10 years, of direct care or administrative experience in a health care or human services field.
(2) An associate's degree or 60 credit hours from an accredited college or university in a human services field and 1 year, in the prior 10 years, of direct care or administrative experience in a health care or human services field.
(3) An associate's degree or 60 credit hours from an accredited college or university in a field that is not related to human services and 2 years, in the prior 10 years, of direct care or administrative experience in a health care or human services field.
(4) A license as an LPN from the Department of State and 1 year, in the prior 10 years, of direct care or administrative experience in a health care or human services field.
(5) A license as a nursing home administrator from the Department of State and 1 year, in the prior 10 years, of direct care or administrative experience in a health care or human services field.
(6) With the exception of administrators qualified under 2600.53(a)(5) (relating to qualifications and responsibilities of administrators), experience as a personal care home administrator, if the following requirements are met:
(i) Employed as a personal care home administrator for 2 years prior to January 18, 2011.
(ii) Completed the administrator training requirements and pass the Department-approved competency-based training test in 2800.64 (relating to administrator training and orientation) by January 18, 2012.
(b) The administrator shall be 21 years of age or older.
© The administrator shall be responsible for the administration and management of the residence, including the health, safety and well-being of the residents, implementation of policies and procedures and compliance with this chapter.
(d) The administrator shall have the ability to provide assisted living services or to supervise or direct the work to provide assisted living services.
(e) The administrator shall have knowledge of this chapter.
(f) The administrator shall have the ability to comply with applicable laws, rules and regulations, including this chapter.
(g) The administrator shall have the ability to maintain or supervise the maintenance of financial and other records.
(h) At all times the administrator shall be free from a medical condition, including drug or alcohol addiction that would limit the administrator from performing duties with reasonable skill and safety.

Long Term Care Columnist / Guide · Mar 31, 2013

As NRSKaren said, the regulations vary by state, but I believe that ALFs do have to have at least a nurse consultant available, even on a limited basis, if the residents have any nursing needs. And if they don't have nursing needs, they are usually in independent living (IL) rather than AL.

In fact, the acuity of ALF residents is rising---we are taking people now who are much sicker and more frail than we did 10 years ago, including insulin-dependent diabetics, those with wound vacs and ostomies, even those who need 2-person transfers and full ADL care. I call it 'nursing home lite'. Trouble is, there aren't enough actual nurses to manage residents with this many needs; typically, a nurse is in the building 20-30 hours/week for consultation and training. I work a 40-hour week, but I have 85 residents, and trust me, it is TOO MUCH work for a single RN. I can't even imagine how any AL can function without at least one full-time nurse!

Home Health Columnist / Guide · Mar 31, 2013

Assisted living = residents new HOME. Therefore, if they have a SKILLED NEED, home health care agencies are able to provide care for SN, PT, OT, ST as these are not being paid for under most facility agreements while personal care assistance is paid.

I am seeing an increase in Philadelphia area of " assisted Senior Living" communities having relationships with 1-2 agencies that have excellent track record in providing care, healing wounds, having tele health programs etc allowed in their buildings to provide skilled care with dedicated staff assigned to facility with patient choice of agency honored.

stardust80916 · Apr 1, 2013

In Colorado no. The regulations are very vague. However, most facilities on the front range will only employ CNAs and LPNs. They use CNAs with their QMAP to pass the meds under the supervision of an LPN. The western slope has not caught up to speed with this practice yet. Most tend to not require CNAs, unfortunately in most cases, you are doing the work of a CNA without adequate training or pay. With that said, some residents at one point or another require basic skilled care. This is when HH or hospice is brought in for further assistance as long as the resident still meets the criteria of AL. Then skilled care can be completed under the supervision of an LPN or RN, while the resident continues to live at the ALF.

On another note, QMAPs are NOT allowed to administer anything considered invasive. We aren't even allowed to do finger sticks. So, if a resident is diabetic, then they must be able to perform their own finger sticks and their own injections. If not then one of two things happens, either they are sent to a nursing home or they bring in HH or hospice(which ever is appropriate) to do the invasive procedures. Insulin is tricky though, QMAPs are not allowed to fill syringes. So, generally HH is called in to fill them, although there is a growing trend towards the insulin pens as long as the resident can use it with minimal assistance. The regs are vague there too. The same goes for ostomy care and incontinence. They MUST be able to manage it on their own. However, if an incontinent resident has an accident every once in a while that is considered acceptable. We're all human, it happens whether you're young or old. If the incontinence accidents become more frequent though, then they are sent to skilled care.

What if a resident has a medical need and HH or hospice is not appropriate you may ask. Then we contact the resident's doctor or nurse via phone or fax and get their advice. However, QMAPs are not trained to assess, so wording is key! We can only make observations and report that as such. We can also contact the nurse or doctor on resident request, however per resident request MUST be stated in the inquiry.

A growing trend among QMAPs is they are going out of their scope of practice, which is very easy to do. Trust me! I've heard of plans to eliminate QMAPs all together. However, I feel if better training were provided(instead of a 2 day course that only teaches you how to fill out a MAR, administer medications according to state regulations, and fill MRBs)this problem could be alleviated. I can't tell you how many times a resident has asked me what a medication is and what it's for. The only thing they teach you in QMAP class is to refer to your drug handbook. I for one feel that this kind of information needs to be included in the curriculum, such as commonly given geriatric medications. (Lasix, Metoprolol, Warfarin, etc...) I believe that if I am the one administering the meds, then I should be aware of the uses, common side effects, and affects. Any one else in CO that is a QMAP feel this way? Also, QMAPs are NOT allowed to administer anything, prescription medications, OTCs, even titrate O2 without doctor's orders.

Doctor's orders can be even more of a headache. They MUST be complete and detailed! We cannot assume anything, as we are not trained to do so. A lot of doctors and nurses do not understand this practice and send incomplete orders. Then we have to contact the office once again to get them complete.

So, Colorado seems to be somewhat different than the aforementioned states. The state regulations are difficult to decipher because of so much gray matter. I for one am fairly knowledgeable after 5 years experience. It does take time to fully understand all the regulations, some of which I am sure I do not know. As mentioned before it does vary by state. I just gave what knowledge I had. Hope it helps!

Lundazi · Apr 1, 2013

Thank for the reply.it dose help

DSkelton711 · Apr 6, 2013

In Alabama Assisted Living Facility does not require nurse oversight, but Specialty Care Assisted Living requires an RN for admissions, careplans, monthly assessments and other items, but they do not need to work 40 hour weeks or anything like that. Many just work parttime. Where I was, though, we operated at a higher standard: RN 8 hours per day minimum, LPN to administer meds and monitor unit. CNAs had to be actually certified and be on the state registry.