Transcription

CHAPTER 7ASSISTED LIVING FACILITIES (ALF’S)7.1

ASSISTED LIVING FACILITIESI. TYPES OF ALF FACILITIES(Regulations are under ACHA Regulations 58A-5 and can be found at:http://ahca.myflorida.com/mchq/long term care/Assisted living)1.2.3.4.5.Standard ALF licenseECC (Extended Congregate Care)LNS (Limited Nursing Services)LMH (Limited Mental Health) - the facility will care for 3 or more residents with mental illnessWhile assisted living is the most common licensure term, some states still use other terms to describeassisted living, such as residential care, personal care, basic care, domiciliary care, housing with services,and board and care.ECC, LNS and LMH – this type of license is required if the facility will offer 1 or more of the followingPersonal Services:1) Administration of Medications2) Assistance with 1 or more of the ADL’s (ambulation, bathing, dressing, eating, grooming and toileting)II. ADULT FAMILY CARE HOMES(Regulations are under ACHA Regulations 58A-14 and can be found at:http://ahca.myflorida.com/MCHQ/Long Term Care/Assisted living/afc/58%20A-14.pdfThis facility is similar to an ALF but limited to 5 residentsIII. GENERAL REQUIREMENTS OF THE ALF1.2.3.4.5.6.Must post Resident Bill of RightsMust provide all residents with access to a phone (in a private area)Last ACHA inspection is posted in a prominent location for reviewOmbudsman information is posted with complaints against the facilityMust maintain copies of all inspections for 5 yearsThe facility must have an administrator (can be the owner) that ensures the facility is safe, clean,provides adequate nutrition and appropriate temperature ranges7. Must maintain a “Resident File” for each resident in the building8. If the facility is licensed for more than 17 residents(1) must have written Policy & Procedure manual on how residents will be assisted(2) must have written schedule for cleaning equipment, storage and work areas(3) must have written policies for nutritional services9. All residents must have been seen by a healthcare professional within 60 days of admission or within 30days after admission.10. A contract between each resident and facility which is signed before admission. Facility keeps a copy,the resident gets a copy. Facility must keep their copy of every contract for 5 years after it’s expirationdate.11. The facility must maintain an accurate Medication Administration Record (MAR) orMedication Observation Record (MOR) for all residents on supervised medication7.2

III. STAFF REQUIREMENTS1.The Administrator(1) 21 years of age or older(2) high school diploma or GED(3) must have completed 26 contact hours of “ALF Core Training”(4) 12 hours of Continuing education2.For Manager (in absence of Administrator)(1) must always have at least 1 person in charge(2) at least 18 year of age(3) must have training in First Aid(4) must have 2 hours of CE on HIV within 6 months of starting(5) every 2 years must complete 1 hour of HIV C.E.3.Staff providing Personal Care(1) must have 1 hour CE in Infection Control (including Universal Precautions)(2) must have 3 hours of training within 30 days of employment on resident behaviors, assistance withADL’s etc.(3) must have 2 hours CE on HIV within 6 months of hire(4) 1 hour of additional CE every 2 years4.For Facilities providing Special Services (i.e. Alzheimers Disease)(1) must have 4 hours of additional training in Alzheimer’s Disease within 3 months of hiring(2) if employee is involved in direct care – must have 4 more hours of training within 9 months of hirein Alzheimer’s diseaseIV. THE RESIDENT’S RECORD (The Chart)1.2.3.4.5.A Resident Record must be maintained for every current ResidentThis Resident Record must be retained for 1 year after the discharge dateA copy of any P.O.A. (power of attorney) must be in the fileMust include statements about:(1) Physical and Mental status(2) Resident’s capability of administering own meds or their need for supervision or assistance(3) ADL’s – independent, requires supervision or requires individual assistance with ADL’sSigned orders for all medications, diet and therapiesV. MEDICATIONS1.O.T.C. Drugs(1) No Floor Stock allowed(2) When an OTC is prescribed by doctor it is treated as if it is a Prescription Medication(3) A resident can pick up or order an OTC without a doctor’s order2.PRN Drug Orders(1) If a nurse is present that may evaluate the resident and then give a PRN medication as a result oftheir assessment(2) If a Med Tech is present they may only assist in the administration of a PRN order is the Residenthas requested the medication. The Med Tech can not make a judgement that the resident needs aPRN drug(3) PRN orders must have a frequency and a reason for use as part of the order3.Changes in Medication Instructions(1) Facility must document the Date of Revision7.3

(2) Signature of staff who received the change in order AND(3) Use an ancillary label which says “Order Change – See MAR”(4) As an alternative, the pharmacy may relabel the product. NOTE: Facility staff are not allowed toalter a prescription label4.Resident leaves the facility(1) On discharge, the meds should be turned over to the resident, their legal guardian or familymember(2) If meds are not taken at discharge they must be stored for at least 15 days. After 15 days the medsare considered abandoned and can be destroyed5.Destruction of Medications(1) Meds may be destroyed by the administrator or there designee plus one witness OR(2) Meds may be destroyed by a Pharmacist6.Drugs that can be considered “Chemical Restraints”(1) this includes: Antipsychotics, Sedative Hypnotics, Tranquilizers, Antidepressants(2) These residents MUST be reviewed by the prescriber AT LEAST annually7.Self Medication(1) if a resident keeps meds in their apartment they must be stored so that other residents don’t haveready access to them(2) residents may have their prescription meds supervised and stored centrally by thefacility but may still keep OTC medications in their apartment. The OTC’s stored in theresidents room do not have to be charted on the MAR(3) a doctor may write an order that “all meds (OTC’s included) must be supervised and storedcentrally if a resident is a high risk for abuse or inappropriate use8.Drug Samples in the facility(1) A doctor may give his patient samples in an ALF as long as the sample drug is labeled with theresident’s name, the practitioner’s name, the date dispensed, name and strength of the drug anddirections for it’s use (unless these are on the sample package)VI.REQUIREMENTS FOR A CONSULTANT1.If the facility has a special ALF Pharmacy license it must employee a Consultant Pharmacist.(1) must do monthly inspections(2) must provide written report to administrator2.In the case of a Class I, Class II or an unresolved Class III deficiency(1) ACHA may require the facility hire a licensed RN or a Consultant Pharmacist to help resolve thedeficiencies(2) Administrator must obtain a copy of the Consultant License(3) The consultant’s visit must take place within 7 days for a Class I or Class II deficiency(4) The consultant’s visit must take place within 14 days for a Class III violation(5) The consultant must provide the administrator with a corrective action plan within 10 days of theirvisit(6) Consultant must continue at the facility until the Administrator and the Consultant sendLetters to ACHA requesting that the Consulting arrangement be terminated. ACHA must agree inwriting before termination of consultant services7.4

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A COMPARISON OF ALF'S TO NURSING HOMESSUBJECTNURSING HOMESALF'SNew verbal RX's should be verified withprescriber and must contain quantity and refillinfo (same as a community rx)Pharmacy receives and fills newtelephone RX from facility staffThis is an acceptable practice in a nursinghomePharmacy receives a directionschange on an existing orderThe drug may be picked up and relabeled,The drug may be picked up and relabeled,replaced with a new container (if special ALFreplaced with a new container or an ancillaryPharmacy license in place) or an ancillarylabel can be used to indicate "order change label can be used to indicate "order change refer to MAR)"refer to MAR)"A medication is discontinuedThe drug may be returned for credit as longas the product is unit dosed, non-controlled,and in the possession of nursing staff.Controlled substances cannot be returned toPharmacyThe drug may be returned for credit as longas the product is unit dosed, non-controlled,and in the possession of nursing staff (only inthose ALF's with a Special ALF Pharmacylicense). Controlled substances cannot bereturned to PharmacyFlorida law requires the vendor Pharmacy toA residents has a RX retirementFlorida law does not allow the vendorrepackage meds from retirement plan andPharmacy servicing an ALF to repackagebenefit and the facility asks thecan charge for this service. DEA does notmedications from another Pharmacy. Thisvendor Pharmacy to repackage medsallow a registrant (i.e. Pharmacy) to handlelaw is specific to nursing homes onlydispensed by retirement plancontrols dispensed by another DEA registrantThe facility requests a refill on anexisting order which has run out ofrefillsThe Physician signature on the monthly POSA prescription in the ALF is treated as an RXgives authorization to refill the medication.in retail practice. The prescriber must beExclusions would include CII meds and drugscontacted for refill authorizationwith a specific stop dateDEA does not address this practice in theDEA allows the Pharmacy to treat faxed CII ALF therefore the Pharmacy is required toThe Pharmacy receives a faxed orderorders from a nursing home (and Hospice) as handle the order as an "Emergencyfor a new Schedule II drugthe original hard copy scriptTelephone Order" and must obtain a writtenRX per DEA regsThe facility(or Physician) asks that aresident's medication to be stored intheir roomFederal regulations only allow life savingmedication to be stored in the residentsroom. This is limited to NTG products andfast acting inhalersThe resident is allowed to store meds in theirroom as long as their Physician has notwritten an order for supervision of medicationadministrationA residents leaves the facility andIn the nursing home the physician must write In the ALF a resident can be released withwishes to take his/her medication with an order that would allow the resident to be their medication without any specialthemrequirementsreleased with their medicationFloor Stock (OTC drugs)The nursing home is allowed to have OTCThe ALF CANNOT have floor stock products.floor stock. If they service Medicaid residentsAll medication must be labeled "patientthey must provide certain OTC categories forspecific"these residentsEmergency KitsThe nursing home is required to have anemergency kit in the facility at all times7.13The ALF CANNOT have an Emergency kiteven if they have a Special ALF Pharmacylicense

Assisted Living Facility and Adult Family Care HomeResidents' Bill of RightsFLORIDA STATUTES 400.428 and 400.628 (respectively)No resident of a facility shall be deprived of any civil or legal rights, benefits, or privileges guaranteed by law, the Constitutionof the State of Florida, or the Constitution of the United States as a resident of a facility. Every resident shall have the right to:Live in a safe and decent living environment, free from abuse and neglect.Be treated with consideration and respect and with due recognition of personal dignity, individuality, and the needfor privacy.Retain clothes and other personal property.Unrestricted private communication including receiving and sending unopened correspondence, access to atelephone, and visiting with any person of his/her choice during visiting hours.Participate in and benefit from community services and activities to achieve the highest possible level ofindependence, autonomy, and interaction with the community.Manage his/her own financial affairs.Share a room with spouse if both are residents of the facility.Reasonable opportunity to exercise.Exercise civil and religious liberties, including personal decisions.Adequate and appropriate health care.Thirty (30) days notice of relocation or termination of residency.Present grievances and recommend changes in policies, procedures, and services to the facility without restraint,interference, coercion, discrimination, or reprisal.(ALF) Be free from physical and chemical restraints other than those prescribed by the resident’s physician andconsented to, by the resident or resident’s legal guardian, F.S. 400.441 (1)(i) or (AFCH) Be free from chemicaland physical restraints except as ordered by a physician, F.S. 400.628.7.14

58A-5.0185 Medication Practices.Pursuant to Sections 429.255 and 429.256, F.S., and this rule, licensed facilities may assist with the self-administration oradministration of medications to residents in a facility. A resident may not be compelled to take medications but may becounseled in accordance with this rule.(1) SELF ADMINISTERED MEDICATIONS.(a) Residents who are capable of self-administering their medications without assistance shall be encouraged and allowed to doso.(b) If facility staff note deviations which could reasonably be attributed to the improper self-administration of medication, staffshall consult with the resident concerning any problems the resident may be experiencing with the medications; the need topermit the facility to aid the resident through the use of a pill organizer, provide assistance with self-administration ofmedications, or administer medications if such services are offered by the facility. The facility shall contact the resident’shealth care provider when observable health care changes occur that may be attributed to the resident’s medications. Thefacility shall document such contacts in the resident’s records.(2) PILL ORGANIZERS.(a) A “pill organizer” means a container which is designed to hold solid doses of medication and is divided according to dayand time increments.(b) A resident who self-administers medications may use a pill organizer.(c) A nurse may manage a pill organizer to be used only by residents who self-administer medications. The nurse is responsiblefor instructing the resident in the proper use of the pill organizer. The nurse shall manage the pill organizer in the followingmanner:1. Obtain the labeled medication container from the storage area or the resident;2. Transfer the medication from the original container into a pill organizer, labeled with the resident’s name, according to theday and time increments as prescribed;3. Return the medication container to the storage area or resident; and4. Document the date and time the pill organizer was filled in the resident’s record.(d) If there is a determination that the resident is not taking medications as prescribed after the medicinal benefits areexplained, it shall be noted in the resident’s record and the facility shall consult with the resident concerning providingassistance with self-administration or the administration of medications if such services are offered by the facility. The facilityshall contact the resident’s health care provider regarding questions, concerns, or observations relating to the resident’smedications. Such communication shall be documented in the resident’s record.(3) ASSISTANCE WITH SELF-ADMINISTRATION.(a) For facilities which provide assistance with self-administered medication, either: a nurse; or an unlicensed staff member,who is at least 18 years old, trained to assist with self-administered medication in accordance with Rule 58A-5.0191, F.A.C.,and able to demonstrate to the administrator the ability to accurately read and interpret a prescription label, must be available toassist residents with self-administered medications in accordance with procedures described in Section 429.256, F.S.(b) Assistance with self-administration of medication includes verbally prompting a resident to take medications as prescribed,retrieving and opening a properly labeled medication container, and providing assistance as specified in Section 429.256(3),F.S. In order to facilitate assistance with self-administration, staff may prepare and make available such items as water, juice,cups, and spoons. Staff may also return unused doses to the medication container. Medication, which appears to have beencontaminated, shall not be returned to the container.(c) Staff shall observe the resident take the medication. Any concerns about the resident’s reaction to the medication shall bereported to the resident’s health care provider and documented in the resident’s record.(d) When a resident who receives assistance with medication is away from the facility and from facility staff, the followingoptions are available to enable the resident to take medication as prescribed:1. The health care provider may prescribe a medication schedule which coincides with the resident’s presence in the facility;2. The medication container may be given to the resident or a friend or family member upon leaving the facility, with this factnoted in the resident’s medication record; 58A-5 ASSISTED LIVING FACILITIES OCTOBER 2010 Page 167.15

3. The medication may be transferred to a pill organizer pursuant to the requirements of subsection (2), and given to theresident, a friend, or family member upon leaving the facility, with this fact noted in the resident’s medication record; or4. Medications may be separately prescribed and dispensed in an easier to use form, such as unit dose packaging;(e) Pursuant to Section 429.256(4)(h), F.S., the term “competent resident” means that the resident is cognizant of when amedication is required and understands the purpose for taking the medication.(f) Pursuant to Section 429.256(4)(i), F.S., the terms “judgment” and “discretion” mean interpreting vital signs and evaluatingor assessing a resident’s condition.(4) MEDICATION ADMINISTRATION.(a) For facilities which provide medication administration a staff member, who is licensed to administer medications, must beavailable to administer medications in accordance with a health care provider’s order or prescription label.(b) Unusual reactions or a significant change in the resident’s health or behavior shall be documented in the resident’s recordand reported immediately to the resident’s health care provider. The contact with the health care provider shall also bedocumented in the resident’s record.(c) Medication administration includes the conducting of any examination or testing such as blood glucose testing or otherprocedure necessary for the proper administration of medication that the resident cannot conduct himself and that can beperformed by licensed staff.(d) A facility which performs clinical laboratory tests for residents, including blood glucose testing, must be in compliancewith the federal Clinical Laboratory Improvement Amendments of 1988 (CLIA) and Part I of Chapter 483, F.S. A valid copyof the State Clinical Laboratory License and the CLIA Certificate must be maintained in the facility. A state license or CLIAcertificate is not required if residents perform the test themselves or if a third party assists residents in performing the test. Thefacility is not required to maintain a State Clinical Laboratory License or a CLIA Certificate if facility staff assist residents inperforming clinical laboratory testing with the residents’ own equipment. Information about the State Clinical LaboratoryLicense and CLIA Certificate is available from the Clinical Laboratory Licensure Unit, Agency for Health CareAdministration, 2727 Mahan Drive, Mail Stop 32, Tallahassee, FL 32308; telephone (850)487-3109.(5) MEDICATION RECORDS.(a) For residents who use a pill organizer managed under subsection (2), the facility shall keep either the original labeledmedication container; or a medication listing with the prescription number, the name and address of the issuing pharmacy, thehealth care provider’s name, the resident’s name, the date dispensed, the name and strength of the drug, and the directions foruse.(b) The facility shall maintain a daily medication observation record (MOR) for each resident who receives assistance withself-administration of medications or medication administration. A MOR must include the name of the resident and any knownallergies the resident may have; the name of the resident’s health care provider, the health care provider’s telephone number;the name, strength, and directions for use of each medication; and a chart for recording each time the medication is taken, anymissed dosages, refusals to take medication as prescribed, or medication errors. The MOR must be immediately updated eachtime the medication is offered or administered.(c) For medications which serve as chemical restraints, the facility shall, pursuant to Section 429.41, F.S., maintain a record ofthe prescribing physician’s annual evaluation of the use of the medication.(6) MEDICATION STORAGE AND DISPOSAL.(a) In order to accommodate the needs and preferences of residents and to encourage residents to remain as independent aspossible, residents may keep their medications, both prescription and over-the-counter, in their possession both on or off thefacility premises; or in their rooms or apartments, which must be kept locked when residents are absent, unless the medicationis in a secure place within the rooms or apartments or in some other secure place which is out of sight of other residents.However, both prescription and over-the-counter medications for residents shall be centrally stored if:1. The facility administers the medication;2. The resident requests central storage. The facility shall maintain a list of all medications being stored pursuant to such arequest;3. The medication is determined and documented by the health care provider to be hazardous if kept in the personal possessionof the person for whom it is prescribed; 58A-5 ASSISTED LIVING FACILITIES OCTOBER 2010 Page 177.16

4. The resident fails to maintain the medication in a safe manner as described in this paragraph;5. The facility determines that because of physical arrangements and the conditions or habits of residents, the personalpossession of medication by a resident poses a safety hazard to other residents; or6. The facility’s rules and regulations require central storage of medication and that policy has been provided to the residentprior to admission as required under Rule 58A-5.0181, F.A.C.(b) Centrally stored medications must be:1. Kept in a locked cabinet, locked cart, or other locked storage receptacle, room, or area at all times;2. Located in an area free of dampness and abnormal temperature, except that a medication requiring refrigeration shall berefrigerated. Refrigerated medications shall be secured by being kept in a locked container within the refrigerator, by keepingthe refrigerator locked, or by keeping the area in which refrigerator is located locked;3. Accessible to staff responsible for filling pill-organizers, assisting with self-administration, or administering medication.Such staff must have ready access to keys to the medication storage areas at all times; and4. Kept separately from the medications of other residents and properly closed or sealed.(c) Medication which has been discontinued but which has not expired shall be returned to the resident or the resident’srepresentative, as appropriate, or may be centrally stored by the facility for future resident use by the resident at the resident’srequest. If centrally stored by the facility, it shall be stored separately from medication in current use, and the area in which it isstored shall be marked “discontinued medication.” Such medication may be reused if re-prescribed by the resident’s health careprovider.(d) When a resident’s stay in the facility has ended, the administrator shall return all medications to the resident, the resident’sfamily, or the resident’s guardian unless otherwise prohibited by law. If, after notification and waiting at least 15 days, theresident’s medications are still at the facility, the medications shall be considered abandoned and may disposed of inaccordance with paragraph (e).(e) Medications which have been abandoned or which have expired must be disposed of within 30 days of being determinedabandoned or expired and disposition shall be documented in the resident’s record. The medication may be taken to apharmacist for disposal or may be destroyed by the administrator or designee with one witness.(f) Facilities that hold a Special-ALF permit issued by the Board of Pharmacy may return dispensed medicinal drugs to thedispensing pharmacy pursuant to Rule 64B16-28.870, F.A.C.(7) MEDICATION LABELING AND ORDERS.(a) No prescription drug shall be kept or administered by the facility, including assistance with self-administration ofmedication, unless it is properly labeled and dispensed in accordance with Chapters 465 and 499, F.S., and Rule 64B16-28.108,F.A.C. If a customized patient medication package is prepared for a resident, and separated into individual medicinal drugcontainers, then the following information must be recorded on each individual container:1. The resident’s name; and2. Identification of each medicinal drug product in the container.(b) Except with respect to the use of pill organizers as described in subsection (2), no person other than a pharmacist maytransfer medications from one storage container to another.(c) If the directions for use are “as needed” or “as directed,” the health care provider shall be contacted and requested toprovide revised instructions. For an “as needed” prescription, the circumstances under which it would be appropriate for theresident to request the medication and any limitations shall be specified; for example, “as needed for pain, not to exceed 4tablets per day.” The revised instructions, including the date they were obtained from the health care provider and the signatureof the staff who obtained them, shall be noted in the medication record, or a revised label shall be obtained from thepharmacist.(d) Any change in directions for use of a medication for which the facility is providing assistance with self-administration oradministering medication must be accompanied by a written medication order issued and signed by the resident’s health careprovider, or a faxed copy of such order. The new directions shall promptly be recorded in the resident’s medication observationrecord. The facility may then place an “alert” label on the medication container which directs staff to examine the reviseddirections for use in the MOR, or obtain a revised label from the pharmacist.(e) A nurse may take a medication order by telephone. Such order must be promptly documented in the resident’s medicationobservation record. The facility must obtain a written medication order from the health care provider within 10 58A-5 ASSISTEDLIVING FACILITIES OCTOBER 2010 Page 187.17

working days. A faxed copy of a signed order is acceptable.(f) The facility shall make every reasonable effort to ensure that prescriptions for residents who receive assistance with selfadministration of medication or medication administration are filled or refilled in a timely manner.(g) Pursuant to Section 465.0276(5), F.S., and Rule 64F-12.006, F.A.C., sample or complimentary prescription drugs that aredispensed by a health care provider, must be kept in their original manufacturer’s packaging, which shall also include thepractitioner’s name, the resident’s name for whom they were dispensed, and the date they were dispensed. If the sample orcomplimentary prescription drugs are not dispensed in the manufacturer’s labeled package, they shall be kept in a containerthat bears a label containing the following:1. Practitioner’s name;2. Resident’s name;3. Date dispensed;4. Name and strength of the drug;5. Directions for use; and6. Expiration date.(h) Pursuant to Section 465.0276(2)(c), F.S., before dispensing any sample or complimentary prescription drug, the resident’shealth care provider shall provide the resident with a written prescription, or a fax copy of such order.(8) OVER THE COUNTER (OTC) PRODUCTS. For purposes of this subsection, the term OTC includes, but is not limited to,OTC medications, vitamins, nutritional supplements and nutraceuticals, hereafter referred to as OTC products, which can besold without a prescription.(a) A stock supply of OTC products for multiple resident use is not permitted in any facility.(b) OTC products, including those prescribed by a licensed health care provider, must be labeled with the resident’s name andthe manufacturer’s label with directions for use, or the licensed health care provider’s directions for use. No other labelingrequirements are necessary nor should be required.(c) Residents or their representatives may purchase OTC products from an establishment of their choice.(d) A facility cannot require a licensed health care provider’s order for all OTC products when a resident self-administers his orher own medications, or when staff provides assistance with self-administration of medications pursuant to Section 429.256,F.S. A licensed health care provider’s order is required when a licensed nurse provides assistance with self-administration oradministration of medications, which includes OTC products. When such an order for an OTC product exists, only therequirements of paragraphs (b) and (c) of this subsection are required.Rulemaking Authority 429.256, 429.41 FS. Law Implemented 429.255, 429.256, 429.41 FS. History–New 10-17-99, Amended 7-30-06, 4-1510, 10-14-10.7.18

Standard ALF license 2. ECC (Extended Congregate Care) 3. LNS (Limited Nursing Services) 4. LMH (Limited Mental Health) - the facility will care for 3 or more residents with mental illness 5. While assisted living is the most common licensure term, some states stil