Assisted Living in Pennsylvania

Agency: Department of Public Welfare, Bureau of Adult Residential Licensure (Personal Care Homes)
Phone: (717) 783-3670
Website: www.dpw.state.pa.us

A personal care home (PCH) is a residence in which food, shelter, and personal assistance or supervision are provided for a period exceeding 24 hours, for four or more adults who are not relatives of the operator, who do not require the services of or in a licensed long-term care facility, but who do require assistance or supervision in ADLs or instrumental activities of daily living (IADLs). The term includes a residence that has held or presently holds itself out as a personal care home and provides food and shelter to four or more adults who need personal care services, but who are not receiving the services. An assisted living residence (ALR) is any premises in which food, shelter, assisted living services, assistance or supervision, and supplemental health care services are provided for a period exceeding 24-hours for four or more adults who are not relatives of the operator, who require assistance or supervision in matters such as dressing, bathing, diet, financial management, evacuation from the residence in the event of an emergency, or medication prescribed for self-administration.

Facility Scope of Care:
PCHs may provide assistance with ADLs, IADLs, and medications. ADLs include eating, drinking, ambulating, transferring in and out of a bed or chair, toileting, bladder and bowel management, personal hygiene, securing health care, managing health care, self-administering medication, and proper turning and positioning in a bed or chair. IADLs include activities done on a behalf of a resident such as doing laundry, shopping, securing and using transportation, managing finances, using a telephone, making and keeping appointments, caring for personal possessions, writing correspondence, engaging in social and leisure activities, using a prosthetic device, and obtaining and keeping clean, seasonal clothing. ALRs must provide assisted living services which, at a minimum, include: nutritious meals and snacks; laundry services; a daily program of social and recreational activities; assistance with performing ADLs and IADLs; assistance with self-administration of medication or medication administration; housekeeping services essential for the health, safety, and comfort of the resident based upon the resident's needs and preferences; transportation; financial management; 24-hour supervision; monitoring and emergency response; activities and socialization; and basic cognitive support services. ADLs include eating, drinking, ambulating, transferring in and out of a bed or chair, toileting, bladder and bowel management, personal hygiene, securing health care, managing health care, self-administering medication and proper turning and positioning in a bed or chair. IADLs include activities done on behalf of a resident such as: doing laundry; shopping: securing and using transportation; financial management; using a telephone; making and keeping appointments; caring for personal possessions; writing correspondence; engaging in social and leisure activities; using a prosthetic device, and obtaining and keeping clean, seasonal clothing. The ALR must provide or arrange for the provision of supplemental health care services, including, but not limited to, the following: hospice services, occupational therapy, skilled nursing services, physical therapy, behavioral health services, home health services, escort service if indicated in the resident's support plan or requested by the resident to and from medical appointments, and specialized cognitive support services. An ALR must provide, at a minimum, two core service packages: an Independent Core Package and an Enhanced Core Package. The core package is provided to residents who do not require assistance with ADLs and must include the following services: 24- hour supervision, monitoring and emergency response; nutritious meals and snacks; housekeeping services; laundry services; assistance with unanticipated ADLs for a defined recovery period; a daily program of social and recreational activities; and basic cognitive support services. The Enhanced Core Package is available to residents who require assistance with ADLs and must include services provided in the basic core package as well as assistance with ADLs and unanticipated ADLs for an undefined period of time; transportation; and assistance with selfadministration of medication or medication administration. If a resident wishes not to have the residence provide a particular service, the resident-residence contract must indicate the service not being provided and the corresponding fee schedule adjustment.

Move-In/Move-Out Requirements:
For PCHs, residents eligible for nursing home care may not be admitted into a home. Admission of residents with special needs is allowed only if the home complies with certain additional staffing, physical site, and fire safety requirements. A home must have a written program description including the services the home intends to provide and the needs of the residents that can be safely served. For ALRs, a medical evaluation, a resident initial assessment, and a preliminary support plan must be completed for each potential resident prior to admission. These documents may be completed within 15 days after admission if the following conditions apply: the resident is being admitted directly to the residence from an acute care hospital; the resident is being admitted to escape from an abusive situation; or the resident has no alternative living arrangement. The ALR must certify, prior to admission, that the needs of the potential resident can be met by the services provided by the residence. The certification must be made by the administrator acting in consultation with the supplemental health care providers, the individual's physician or certified registered nurse practitioner, or the medical director of the residence. If the ALR cannot meet the needs of the potential resident, the residence must provide a written decision denying admission and a basis for the denial. A potential resident who requires assisted living services but does not currently require assistance in obtaining supplemental health care services may be admitted to the residence, provided the resident is only provided supplemental health care services required or requested by the resident. Individuals requiring the services of a licensed long-term care nursing facility, including those with mobility needs, may reside in a residence, provided that appropriate supplemental health care services are provided those residents and the design, construction, staffing, and operation of the residence allows for their safe emergency evacuation. An ALR may not admit, retain, or serve an individual with any of the following conditions or health care needs unless the residence seeks approval from the licensing agency: ventilator dependency; stage III and IV decubiti and vascular ulcers that are not in a healing stage; continuous intravenous fluids; reportable infectious diseases in a communicable state that requires isolation of the individual or requires special precautions by a caretaker to prevent transmission of the disease unless the Department of Health directs that isolation be established within the residence; nasogastric tubes; physical restraints; or continuous skilled nursing care 24 hours a day. The licensing agency may approve an exception related to any of the conditions or health care needs listed above under specified conditions and procedures. With regard to moving out, an ALR must ensure a safe and orderly transfer or discharge that is appropriate to meet the resident's needs and allows the resident to participate in the decision relating to relocation. If the residence initiates a transfer or discharge, or if the legal entity chooses to close the residence, the residence must provide a 30-day advance written notice to the resident, the resident's family, or designated person and the referral agent citing the reasons for the transfer or discharge, the effective date of the transfer or discharge, the location to which the resident will be transferred or discharged, an explanation of the measures the resident or the resident's designated person can take if they disagree with the residence decision to transfer or discharge, and the resident's transfer or discharge rights. An ALR resident may only be transferred or discharged under the following conditions: -- The resident is a danger to himself or others and the behavior cannot be managed through interventions, services planning, or informed consent agreements. -- The legal entity chooses to voluntarily close the residence, or a portion of the residence. -- The residence determines that a resident's functional level has advanced or declined so that the resident's needs cannot be met in the residence or within the scope of licensure for a residence. -- Meeting the resident's needs would require a fundamental alteration in the residence's program or building site, or would create an undue financial or programmatic burden on the residence. -- The resident has failed to pay after reasonable documented efforts by the residence to obtain payment. -- The closure of the residence is initiated by the licensing agency. -- The residence has documented repeated violation of the residence rules. -- A court has ordered the transfer or discharge

Resident Assessment:
For PCHs, a preadmission screening must be completed prior to move in to assess the needs of the resident and whether the home can meet these needs. A medical evaluation must be completed 60 days prior to or 30 days after moving into the home. A PCH assessment, including an assessment of mobility needs, medication administration needs, communication abilities, cognitive functioning, ADLs, IADLs, referral sources, and personal interests and preferences, must be completed within 15 days of admission. A support plan must be developed to meet the needs identified in the assessment and implemented within 30 days after admission. The Department requires specified forms to be used in each instance. For ALRs, a medical evaluation must be completed within 60 days prior to admission or within 15 days after admission if certain conditions apply. An initial assisted living resident assessment must be completed within 30 days prior to admission or within 15 days after admission if certain conditions apply. The initial assessment must include, at a minimum, the individual's need for assistance with ADLs and IADLs; mobility needs; the individual's ability to self-administer medication; medical history, medical conditions, and current medical status and how they impact or interact with the individual's service needs; the need for supplemental health care services; special diet or meal requirements; the ability to safely operate key-locking devices; and the ability to evacuate from the residence. Additional assessments shall be completed annually, or if the condition of the resident significantly changes prior to the annual assessment or at the request of the licensing agency upon cause to believe that an update is required. A preliminary support plan must be developed within 30 days prior to admission or 15 days after admission if certain conditions apply. A final support plan is developed and implemented within 30 days after admission. The support plan must document the dietary, medical, dental, vision, hearing, mental health, or other behavioral care services that will be made available to the individual, or referrals for the individual to outside services if the individual's physician, physician's assistant, or certified registered nurse practitioner, determine the necessity of these services. The support plan must document the assisted living services and supplemental health care services, if applicable, that will be provided to the individual; the ability of the individual to self-administer medications or the need for medication reminders or medication administration; and the ability of the resident to safely operate key-locking devices. The final support plan must also identify strategies that promote interactive communication on the part of and between direct care staff and individual residents. The residence must review each resident's final support plan on a quarterly basis and modify it as necessary to meet the resident's needs. The ALR may use it own assessment and support plan forms if they include the same information as the licensing agency's forms.

Medication Management:
A PCH must provide residents with assistance, as needed, with medication prescribed for the resident's self-administration. A home may provide medication administration services for a resident who is assessed to need medication administration services. Medications must be administered by licensed medical personnel or by a staff person who has completed a Departmentapproved medication administration course that includes passing the Department's performance-based competency test. An ALR must provide residents with assistance, as needed, with medication prescribed for the resident's self-administration. This assistance includes helping the resident to remember the schedule for taking the medication, storing the medication in a secure place, and offering the resident the medication at the prescribed times. A residence shall provide medication administration services for a resident who is assessed to need medication administration services and for a resident who chooses not to self-administer medications. Prescription medication that is not self-administered by a resident shall be administered by a licensed professional or a staff person who has completed the licensing agency's medication administration training and has passed the performance-based competency test.

Physical Plant Requirements:
In PCHs, resident bedrooms must be a minimum of 80 square feet and multiple-occupancy bedrooms must provide a minimum of 60 square feet per resident. A bedroom for one or more residents with a mobility need must have at least 100 square feet per resident and allow for passage of beds and for the comfortable use of assistive devices, wheelchairs, walkers, special furniture, or oxygen equipment. Other physical requirements address environmental safety, sanitation, general safety, and fire safety. For ALRs, for new construction after Jan. 18, 2011, each living unit for a single resident must have at least 225 square feet of floor space measured wall-to-wall, excluding bathrooms and closet space. If two residents share a living unit, there must be a total of 300 square feet. The kitchen capacity, at a minimum, must contain a cabinet for food storage, a small bar-type sink with hot and cold running water, and space with electrical outlets suitable for small appliances such as a microwave oven and a small refrigerator. The cooking appliance or small refrigerator, or both, must be provided by the residence if desired by the resident or his/her designated person. If the resident or designated person wishes to provide his own cooking appliance or small refrigerator, or both, it must meet the residence's safety standards. For ALR facilities in existence prior to Jan. 18, 2011, each living unit must have at least 160 square feet measured wall-to-wall, excluding bathrooms and closet space. If two residents share a living unit, there must be a total of 210 square feet. The kitchen capacity, at a minimum, must provide space with electrical outlets suitable for small appliances, such as a microwave oven and a small refrigerator. The cooking appliance or small refrigerator, or both, must be provided by the residence if desired by the resident or designated person. If the resident or designated person wishes to provide his own cooking appliance or small refrigerator, or both, it shall meet the residence's safety standards. The residence shall provide access to a sink for dishes, a stovetop for hot food preparation, and a food preparation area in a common area. A common resident kitchen may not include the kitchen used by the residence staff for the preparation of resident or employee meals, or the storage of goods. Each living unit must have a door with a lock, except where a lock would pose a risk or be unsafe, and must be equipped with an emergency notification system to notify staff in the event of an emergency.

Residents Allowed Per Room:
In a PCH, a maximum of four residents is allowed per bedroom. No more than two residents are permitted in each secure dementia care unit bedroom. ALRs may not require residents to share a living unit. However, two residents may voluntarily agree to share one living unit provided that the agreement is in writing and contained in each resident-residence contract. No more than two residents may reside in any living unit.

Life Safety:
For PCHs, there must be two exits on each floor of the home. Operable automatic smoke detectors must be located in the hallways within 15 feet of each bedroom door. If the home serves nine or more residents, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is interconnected and audible throughout the home. If one or more residents or staff persons are not able to hear the smoke detector or fire alarm system, a signaling device approved by a fire safety expert shall be used. There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. There shall be one unannounced fire drill once a month held at various times of the day and night, under normal staffing conditions. A nighttime drill must be held every six months. During fire drills, all residents must exit the building within the time specified by a fire department or within 2.5 minutes. For ALRs, stairways, hallways, doorways, passageways, and egress routes from living units and from the building must be unlocked and unobstructed. All buildings must have at least two independent and accessible exits from every floor, arranged to reduce the possibility that both will be blocked in an emergency situation. For a residence serving nine or more residents, an emergency evacuation diagram of each floor showing corridors, line of travel to exit doors, and location of the fire extinguishers and pull signals must be posted in a conspicuous and public place on each floor. If the ALR serves one or more residents with mobility needs above or below residence grade level, there must be a fire-safe area, as specified by a fire safety expert, on the same floor as each resident with mobility needs. There must be an operable automatic smoke detector in each living unit. If the residence serves nine or more residents, there must be at least one smoke detector on each floor interconnected and audible throughout the residence or an automatic fire alarm system that is interconnected and audible throughout the residence. If one or more residents or staff persons are not able to hear the smoke detector or fire alarm system, a signaling device approved by a fire safety expert must be used and tested so that each resident and staff person with a hearing impairment will be alerted in the event of a fire. Smoke detectors and fire alarms must be tested for operability at least once per month. In residences housing five or more residents with mobility needs, the fire alarm system must be directly connected to the local fire department or 24-hour monitoring service approved by the local fire department, if this service is available in the community. There must be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including public walkways and common living areas every 3,000 square feet, the basement, and attic. If the indoor floor area on a floor including the basement or attic is more than 3,000 square feet, there shall be an additional fire extinguisher with a minimum 2-A rating for each additional 3,000 square feet of indoor floor space. A fire extinguisher with a minimum 2A-10BC rating must be located in each kitchen of the residence. There must be one unannounced fire drill once a month held on different days of the week and at various times of the day and night, under normal staffing conditions. A fire drill must be held during sleeping hours once every six months. Residents must evacuate to a designated meeting place away from the building or within the fire-safe area during each fire drill.

Alzheimer's Unit Requirements:
For PCHs, in addition to the assessments and support plans required in a standard PCH, a resident of a dementia care unit must have a written cognitive preadmission screening in collaboration with a physician or a geriatric assessment team within 72 hours prior to admission to a secure dementia care unit. The resident must be assessed annually for the continuing need for the secured dementia care unit. The resident-home contract must include the services provided in the dementia care unit, admission and discharge criteria, change in condition policies, special programming, and costs and fees. Facilities must offer the following types of activities at least weekly: gross motor activities, such as dancing, stretching, and other exercise; self-care activities, such as personal hygiene; social activities, such as games, music, and holiday and seasonal celebrations; crafts, such as sewing, decorations, and pictures; sensory and memory enhancement activities, such as review of current events, movies, story telling, picture albums, cooking, pet therapy, and reminiscing; and outdoor activities, as weather permits, such as walking, gardening, and field trips. At least two hours per day of personal care services must be provided to each resident. Additional staffing is required to provide the services specified in each resident's support plan. In PCHs, no more than two residents are permitted in each secure dementia care unit bedroom. In a dementia care unit, keyoperated locks are not permitted. All doors must be equipped with magnetic locks that automatically open when the fire alarm system is activated. The ALR statute establishes standards for special care units, which are a residence or portion of a residence providing in the least restrictive manner 1) specialized care and services for residents with Alzheimer's disease or dementia, and/or 2) intense neurobehavioral rehabilitation for residents with severely disruptive and potentially dangerous behaviors as a result of brain injury. Admission to a special care unit must be in consultation with the resident's family or designated person. Prior to admission other service options that may be available to a resident must be considered. Each resident record must have documentation that the resident or potential resident and, when appropriate, the resident's designated person or the resident's family have agreed to the resident's admission or transfer to the special care unit. No more than two residents may occupy a living unit regardless of its size. Special care units are permitted to have doors equipped with keylocking devices, electronic card operated systems, or other devices that prevent immediate egress if they have written approval from the Pennsylvania's Department of Labor and Industry, Department of Health, or appropriate local building authority permitting the use of the specific locking system. A residence must have a statement from the manufacturer, specific to that residence, verifying that the electronic or magnetic locking system will shut down, and that all doors will open easily and immediately upon a signal from an activated fire alarm system, heat or smoke detector; a power failure to the residence; or overriding the electronic or magnetic locking system by use of a key pad or other lock-releasing device. The residence must provide space for dining, group and individual activities, and visits. Each resident in a special care unit shall be considered to be a resident with mobility needs and therefore must receive two hours per day of assisted living services. In ALR special care units for Alzheimer's disease or dementia, in addition to the medical evaluation required of all residents, a written cognitive preadmission screening completed in collaboration with a physician or a geriatric assessment team and documented on the licensing agency's cognitive preadmission screening form must be completed for each resident within 72 hours prior to admission. A support plan that identifies the resident's physical, medical, social, cognitive, and safety needs must be developed within 72 hours of admission or within 72 hours prior to the resident's admission to the special care unit. The support plan must be reviewed, and if necessary, revised at least quarterly and as the resident's condition changes. Residents of a special care unit for Alzheimer's disease or dementia must also be assessed quarterly for the continuing need for the unit. The following types of activities must be offered at least weekly to residents of a special care unit for residents with Alzheimer's disease or dementia: Gross motor activities, such as dancing, stretching, and other exercise; self-care activities, such as personal hygiene; social activities, such as games, music, and holiday and seasonal celebrations; crafts, such as sewing, decorations, and pictures; sensory and memory enhancement activities, such as review of current events, movies, storytelling, picture albums, cooking, pet therapy, and reminiscing; and outdoor activities, as weather permits, such as walking, gardening, and field trips.

Staff Training for Alzheimer's Care:
For PCHs, each staff person must have six hours of annual training related to dementia care and services in addition to the 12 hours of annual training required of direct care staff in a standard PCH. For ALRs, each direct care staff person working in a special care unit for residents with Alzheimer's disease or dementia must have eight hours of initial training within the first 30 days of the date of hire and a minimum of eight hours of annual training related to dementia care and services, in addition to the 16 hours of annual training required in the standard ALR. The training for each direct care staff person working in a special care unit for residents with Alzheimer's disease or dementia at a minimum must include the following topics: an overview of Alzheimer's disease and related dementias; managing challenging behaviors; effective communications; assistance with ADLs; and creating a safe environment.

Staffing Requirements:
For PCHs, an administrator must be in the home an average of 20 hours or more per week in each calendar month. At least one direct care staff person shall be awake at all times residents are present in the home. Direct care staff must be present to provide one hour of personal care per day for mobile residents and two hours per day for residents with mobility needs, 75 percent of which shall be given during waking hours. Additionally, there must be staff available to meet the needs of each individual resident as specified in the resident's support plan. At least one staff person for every 50 residents who is trained in first aid and CPR must be present in the home at all times. Direct-care staff must be at least 18 years of age and have a high school diploma or GED. For ALRs, the administrator must be present in the residence an average of 36 hours or more per week, in each calendar month. At least 30 hours per week must be during normal business hours. If the administrator is unavailable to meet the hourly requirements due to a temporary absence, the administrator must assign an administrator designee to supervise the residence during his/her absence. A direct care staff person 21 years of age or older must be present in the residence whenever at least one resident is present. The direct care staff person may be the administrator if the administrator provides direct care services. Direct care staff persons must be available to provide at least one hour per day of assisted living services to each mobile resident and at least two hours per day to each resident with mobility needs. At least 75% of the ALR service hours must be available during waking hours. Direct care staff persons on duty in the residence shall be awake at all times. Staffing must be provided to meet the needs of the residents as specified in the resident's assessment and support plan. Residence staff or service providers who provide services to the residents in the residence shall meet the applicable professional licensure requirements. An ALR must have a licensed nurse available in the building or on call at all times. The licensed nurse shall be either an employee of the residence or under contract with the residence. The residence must have a dietician on staff or under contract to provide for any special dietary needs of a resident as indicated in his/her support plan. For every 35 residents, there shall be at least one staff person trained in first aid and certified in obstructed airway techniques and CPR present in the residence at all times.

Staff Education Training:
For PCHs, prior to or during the first work day, all direct care staff persons must have an orientation in general fire and smoking safety, evacuation procedures, staff duties, and emergency preparedness. Within 40 scheduled working hours, direct care staff persons must have an orientation that includes: (1) Resident rights; (2) Emergency medical plan; (3) Mandatory reporting of abuse and neglect under the state's Older Adult Protective Services Act; and (4) Reporting of reportable incidents and conditions. Prior to providing unsupervised ADL services, direct care staff persons must successfully complete and pass the Department-approved direct care training course and competency test. For ALRs, direct care staff must be 18 years of age or older and have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. Prior to or during the first work day, direct care and other staff including ancillary staff, substitute personnel, and volunteers, must have an orientation in general fire safety and emergency preparedness including the following: evacuation procedures; staff duties and responsibilities during fire drills, as well as during emergency evacuation, transportation and at an emergency location, if applicable; the designated meeting place outside the building or within the firesafe area in the event of an actual fire; smoking safety procedures, the residence's smoking policy and location of smoking areas, if applicable; the location and use of fire extinguishers; smoke detectors and fire alarms; and telephone use and notification of emergency services. Direct care staff must complete an initial orientation approved by the licensing agency and must be certified in first aid and CPR before providing direct care to residents. Within 40 scheduled working hours, ALR direct care staff, ancillary staff, substitute personnel, and volunteers must have an orientation training that includes the following: resident rights; emergency medical plan; mandatory reporting of abuse and neglect under the Older Adult Protective Services Act; reporting of reportable incidents and conditions, safe management techniques; and core competency training that includes person-centered care, communication, problem solving and relationship skills, and nutritional support according to resident preference. ALR direct care staff may not provide unsupervised assisted living services until completion of 18 hours of training including a demonstration of job duties, followed by supervised practice, and successful completion and passing the licensing agency-approved direct care training course and passing of the competency test. Initial direct care staff training includes safe management techniques; assisting with ADLs and IADLs; personal hygiene; care of residents with mental illness, neurological impairments, mental retardation, and other mental disabilities; the normal aging-cognitive, psychological and functional abilities of individuals who are older; implementation of the initial assessment, annual assessment, and support plan; nutrition, food handling, and sanitation; recreation, socialization, community resources, social services, and activities in the community; gerontology; staff person supervision, and other specified elements. ALR administrative staff, direct care staff, ancillary staff, substitute personnel, and volunteers shall receive at least four hours of dementia-specific training within 30 days of hire.

Medicaid Policy and Reimbursements:
While Medicaid funding is not available for PCHs, the Commonwealth does provide a state supplement to Supplemental Security Income for residents in PCHs. Currently there is no Medicaid funding available for services provided in ALRs. However, the licensing agency is exploring the possibility of a home and community-based waiver for assisted living services in the future.