Frequently Asked Questions - G-H-I-J
If the Licensee will be taking your resident to appointments (doctor, dentist, church) in the Licensee's personal or business automobile, a prudent consumer will ask for evidence of current automobile coverage.
Property owners having mortgages on their property are generally required by their lender to carry Risk of Loss coverage for Fire, earthquake, flood and other acts of God. The consumer is encouraged to ask to see proof of current policy coverage if you concerns about the risks the facility owner is insured against.
Whether to carry liability insurance is no longer left to the discretion of the licensee. Effective 7/1/2015 there is a law requiring every RCFE in the state to carry liability insurance compliant with the statute, Health and Safety Code 1569.605.
Because this is a new requirement, CARR recommends that consumers ask the licensee to produce proof of insurance to be assured the facility has the coverage required under the new law: $1,000,000 per occurrence, and $3,000,000 in aggregate.
This law was sponsored and drafted by CARR, introduced and carried by Speaker of the Assembly (Emeritus) Toni Atkins.
Community Care Licensing (CCLD) is required to inspect each Residential Care Facility for the Elderly (RCFE) at least once every 5 years (Title 22, §87756 (d)). CCLD is also obligated to visit (unannounced) approximately 20% of the facilities within its jurisdiction, annually (Title 22, §87756(c). Other reasons for unannounced visits may include, but are not limited to, the following:
- The Licensee is on probation,
- An accusation against a Licensee is pending (i.e. a complaint has been reported)*,
- When the terms of a compliance plan require an annual evaluation (i.e a visit is necessary to verify compliance on a deficiency issue),
- When the facility requires an annual visit as a condition of receiving federal financial participation, and
- To ensure a person who has been ordered out of an RCFE, is no longer at the facility.
The Inspection report is called Facility Evaluation Report (Form LIC 809). The LIC 809 is the "primary paperwork used to document the level of facility compliance" (§3-3010 - Evaluator's Manual 10RM-12, August 2010). The Facility Evaluation Report is a Public Document available in the public file.
Facility searches on this site display LIC 809s available in the public file for individual RCFEs, at the time of CARR's review. Previewing these evaluations will offer insight into the challenges faced by particular facilities. When reviewing a facility's public file, note how frequently (or infrequently) the facility has been evaluated. Fewer visits by the state is not a direct indication of fewer deficiencies, or a higher level of compliance.
*Complaints are recorded on LIC 9099s.
Title 22, §87101(h)(1), defines "healing wounds include cuts, stage one and two dermal ulcers [bedsores] as diagnosed by a physician, and incisions that are being treated by an appropriate skilled professional with the affected area returning to its normal state."
Healing wounds are sometimes referred to as 'decubitus ulcers," "pressure sores," or "bed sores."
Use: Third party caregivers or skilled medical professionals hired through Home Healthcare (HHC) agencies can be used in an RCFE. These individuals can be hired either a) by the RCFE to provide the skilled medical professional services necessary to meet the resident’s incidental medical needs, or b) by the resident’s family or responsible party to augment care and services being provided by the facility.
Medicare Certification: Home health care (HHC) agencies offer a variety of skilled medical services, and most are not required by the state to be licensed. However if use of HHC individuals is expected to be paid by Medicare, it is important to select a Medicare-certified HHC agency, as services rendered by a non-Medicare certified agency will not be reimbursed.
Facility-Provided Home Health Services: Typically, the resident’s care plan prepared by the Licensee will stipulate the requirement for use of a home health aide to provide injections, wound care, or other specialized care that the Licensee is unable by regulation to provide.
Resident-Provided Home Health Services: There are times when family members (or responsible parties) of the resident elect to have additional care, assistance and supervision provided for their residents. The resident may receive Home Healthcare services directly, and apart from any care and supervision provided by the facility.
In these instances, the family or other responsible party would independently arrange for the service, interview the caregiver, arrange for payment, and would be responsible for coordinating with the Licensee, this 3rd party’s presence in the facility, including Criminal Background Checks (see below).
Criminal Background Checks: Title 22, Section 87411 exempts “licensed or certified medical professionals from criminal background check requirements. Thus a privately paid personal assistant who is also a licensed medical professional is exempt. In addition, a privately paid personal assistant who has a current certification as a Certified Nursing Assistant and/or a Certified Home Health Aide is exempt.” The operative word here is “certified.”
What You Should Know:
Consumers should ask to see evidence of a home health aide’s certification if the agency or the individual represents they are “certified.” The licensee must keep a copy of the person’s current license or certification on file in the facility.
Some RCFEs may have Home Health Agencies that they regularly use. The Licensee or Administrator may tell you that you have to use ‘their’ home health agency. That is not true. You and your resident have the choice of which home health agency you use.
Notes in italics represent the views and/or experience of CARR regarding this topic and/or regulation..
Pursuant to Title 22, §87101(f)(1), a "facility hospice care waiver" means ". . . a waiver from the limitation on retention of residents who require more care and supervision than other residents and residents who are bedridden other than for temporary illness." This ". . . waiver granted by [CCLD] will permit the retention in a facility of a designated maximum number of terminally ill residents who are receiving hospice services from a hospice agency." The ". . . waiver will apply only to those residents who are receiving hospice care in compliance with a hospice care plan meeting the requirements. . ." of Title 22, §87633.
Hospice waivers are frequently posted near the facility license. A facility's license should also accurately reflect the number of state-approved hospice waivers.
Title 22 §87625
Facilities are permitted to accept or retain residents who have a manageable bowel and/or bladder incontinence condition provided the condition can be managed with any of the following:
(1) Self care by the resident
(2) A structured bowel/bladder retraining program designed by an appropriately skilled professional that assists the resident in restoring a normal pattern of continence
(3) A program of scheduled toileting at regular intervals
(4) The use of incontinent care products
If a facility chooses to provide care for a resident with an incontinence issue, they are responsible for ensuring all of the following:
(1) Residents that would benefit from scheduled toileting are assisted an/or reminded to go to the bathroom at regular intervals rather than being diapered.
Diapering should be used as a convenience and comfort for the residents, NOT for the convenience and comfort of the facility staff.
(2) Residents that are incontinent are checked during those periods of time when they are known to be incontinent, including during the night.
(3) Residents that are incontinent must be kept clean and dry and the facility must remain free of odors from incontinence.
(4) Bowel and/or bladder programs are designed by an appropriately skilled professional with training and experience in care of elderly persons with bowel and/or bladder dysfunction and with experience in the development of retraining programs for restoration of normal patterns of continence.
(5) The appropriate skilled professional who developed the incontinence program for the facility provides training to facility staff responsible for implementing the program and must re-assess residents' conditions and evaluate the effectiveness of the current program.
(6) Privacy is always afforded when care is provided.
(7) Facilities and their staff are never allowed to withhold fluids to control a resident's incontinence nor are they allowed to catheterize an incontinent resident for the convenience of staff.
While not mentioned in Title 22, another important issue here is the facility's policy on charging for incontinence care and supplies. These are policies seen by CARR within local RCFEs:
Some facilities include incontinence care and supplies in the monthly rate.
Some consider incontinence care as part of standard care provided, and include it in the monthly rate but charge for supplies; some give residents/their families the option provide their own disposable briefs.
Still other facilities consider incontinence care an additional service, and charge residents for care based on the level of assistance needed, as well as charging for the supplies.
Ask facilities about their individual policies, and also read the admissions agreement carefully to be prepared if incontinence issues arise, or if they become more severe. Familiarize yourself with the experience and oversight of the staff by an appropriately skilled professional regarding incontinence care. During CARR's review of the public files, and based on our field experience, many accidents, injuries and conflicts have occurred during times when the resident was being assisted with toileting, and/or from lack of attention to incontinence needs. Proper technique, critical thinking skills, and compassion are necessary to ensure safe and dignified incontinence care for the resident. Also explore the willingness, experience of the staff, and the staffing levels of a facility to see if your resident will receive the attention s/he requires.
To retain a terminally ill resident, and permit her to receive care from a hospice agency, an RCFE must obtain a hospice waiver from Community Care Licensing (CCLD).
A hospice waiver, according to Title 22 (§87632), allows for variance with regard to a specific regulation based on a facility-wide need or circumstance which is not typically tied to a specific resident and which would otherwise not be allowed in an RCFE setting.
When a facility requests a hospice waiver it is requesting permission to accept any resident at any time in the future who may require hospice services. And since many services provided under hospice care go beyond the scope of practice for unlicensed professionals, the facility will require the assistance of a state and Medicare-certified hospice agency to provide this higher level of care.
Requests for hospice waivers are made to CCLD, in advance, by the facility. The facility must submit a written request that includes, but is not limited to, the following:
(1) Specification of the maximum number of terminally ill residents the facility wants to have at any one time.
(2) A statement by the Licensee that he has read the section in Title 22 pertaining to hospice care.
(3) A statement by the facility that the terms and conditions of all hospice care plans which are designated as the responsibility of the facility, or under the control of the facility, shall be adhered to by the facility. This is basically a promise by the facility to follow all the rules. For a narrative on "all the rules" : Providing Hospice Care.
Per Title 22, CCLD can deny a waiver request if the facility is not in substantial compliance. Waiver requests will not be approved unless the facility demonstrates the ability to meet the care and supervision needs of terminally ill residents and states a willingness to provide additional staff if required by the hospice plan.
CCLD is required to respond to a hospice waiver request within 30 days of receipt, either to notify the facility the request has been received, that the request is deficient, and/or that the request has been approved or denied.
When hospice services are required by a resident, C onsumers should be aware that:
(1) A Licensee is only required to read the Title 22, § 87633, pertaining to hospice care. They are not required to have any other mastery of the requirements. When granting a hospice waiver, CCLD does take into consideration the facility's history of compliance. It is imperative that consumers review a facility's evaluations and complaints (LIC 809s & LIC 9099s) to evaluate for themselves the ability of a facility to continue to provide quality care when a resident is receiving hospice care.
(2) Title 22 (for RCFEs) contains no staffing requirements or resident-to-staff ratios for RCFEs. The regulations require only "sufficient staff" as determined by the facility and, at times, CCLD.
(3) When interviewing potential facilities, inquire about the facility's ability to care for hospice residents (experience, staffing levels, etc). While the resident may not require such services upon admission, he may need them in the future: moving at a later date, to a better-equipped facility, may not be a viable option.
Title 22 §87633
If a hospice waiver has been granted by CCLD to the facility, the hospice waiver document (usually a letter on CCLD letterhead) should be posted prominently in the facility near the facility's license. The number of hospice residents permitted in the facility at any one time will be included on the waiver. The facility's responsibilities to hospice residents are individually discussed.
Selecting a Hospice Agency
The right to select a hospice agency is reserved to the resident and his/her responsible party. A facility may suggest a particular hospice agency, and may even hold a hospice agency license itself, but under no circumstances is the resident required to contract with the agency suggested by the RCFE. CONSUMERS ARE ALLOWED TO USE ANY HOSPICE AGENCY THEY CHOOSE. Further, and per Title 22, the contract for hospice services is between the resident and the hospice agency, not between the facility and the hospice agency. However, the facility is responsible for ensuring that the hospice care plan developed for the resident complies with the requirements of Title 22, and that all the resident's care needs are being met at all times (regardless of the specific responsibility of the facility or the hospice agency).
All contracted hospice agencies must be both licensed by the state and certified by the Medicare program.
Hospice Care Plans
A written hospice care plan must be developed for each terminally ill resident by that resident's hospice agency, and agreed to by the Licensee and the resident (or the resident's responsible party), prior to the initiation of hospice services in the facility for that resident. All hospice care plans must be fully implemented by the facility and by the hospice agency. It is the facility's responsibility to ensure that the plan is current, accurately matches the services being provided and that the resident's needs are being met AT ALL TIMES.
The plan, which shall be maintained in the facility for each hospice resident, must include the following:
(1) The name and contact information (including 24-hour emergency phone number) of the hospice agency and the resident's physician;
(2) Designation of the resident's primary contact person at the hospice agency, and primary and alternate caregivers at the facility
(3) A full description of services to be provided by hospice agency (including type and frequency of services)
(4) A full description of services that are the responsibility of the facility (including storage and handling of medication, the maintenance and use of medical supplies and equipment, etc.). "The plan shall neither require nor recommend that facility personnel other than a skilled professionals preform any procedures that must legally be provided by an appropriately skilled professional" (Title 22 § 87633). This includes the administration of medications. For procedures related to the appropriate assistance with medications as performed by facility staff see Medication Management.
(5) Identification of the training needed, which staff members need this training, and who will provide the training regarding the facility's responsibilities to the hospice resident.
General training topics include turning and repositioning the resident, incontinence care, skin breakdown, hydration, etc. Additionally, it is the facility's responsibility to ensure that all staff are knowledgeable about each individual resident's anticipated dying process so as to adequately meet the care plan requirements.
The hospice agency is required to provide training to facility staff regarding the specific needs (current and on-going) of the individual resident under their care.
(6) A description of all hospice services to be provided or arranged in the facility, by persons other than the facility or hospice agency (i.e. clergy, resident's family and friends).
CCLD may require, at any time, a revision of the hospice care plan if the plan is not fully implemented or if it determines that a revision is necessary to protect the health and safety of the resident.
As a resident's dependency and frailty increases, his ability to self-administer medications will likely diminish. By regulation, facility staff are only allowed to assist in self-administration of medications. If a resident requires someone else to administer medications, that someone must be a skilled medical professional.
Once self-administration is no longer possible, two options remain:
(1) A skilled medical professional can administer medications to the resident. As hospice agency nurses do not remain at the facility 24/7, but rather make rounds to a number of facilities on a given day, it is important to establish in the care plan who else will be available to administer medications. If the facility has a skilled medical professional on-staff, then that authorized person may administer.
(2) Another option is that the hospice agency train a resident’s family member(s) or friend(s) how to properly administer medications. Such designations must be documented in the hospice care plan. If a skilled medical professional is not available, nor an authorized family or friend, medications may not be administered by facility staff, or any other paid aide or personal attendant, and the resident will need to be placed into a higher level of care. Please note also that Title 22 specifies that fellow residents may not be considered a “friend” or “relative” who is able to administer medications.
Additional notes: (1) Morphine pumps are allowed in RCFEs but must be administered by the resident or appropriately skilled professional, and its use must be documented in the hospice care plan. (2) Nasogastric tubes (aka feeding tubes) and serious infections are not allowed in RCFEs.
Restricted Health Conditions (§ 87612)
Title 22 states that a facility does not need the approval of CCLD to care for a hospice resident with a restricted health condition provided the resident is currently receiving hospice care and the restricted health condition is addressed in the hospice care plan. Also see Restricted Health Conditions.
Hospital Beds and Bed Rails
Hospital beds and full bed rails are permissible if the hospice care nurse indicates they are necessary in the hospice care plan. Otherwise, half bed rails that are used only to assist a resident with mobility are allowed within the RCFE setting. Written authorization from a physician is required to be maintained in the residents file if half bed rails are to be used for any reason for any resident. (§ 87608)
If a hospice resident becomes bedridden, the facility may accept and/or retain the resident provided they notify the local fire authority within 48 hours of the estimated length of time the resident will be bedridden.
Facilities are required to maintain the following hospice care records:
- An accurate hospice care plan
- A record of all hospice-related staff training provided
- A record of dosages of medications that are centrally stored for each resident receiving hospice services in the facility
Other documentation includes:
- The resident’s (or resident’s Health Care Surrogate Decision Maker’s) written request for retention and hospice services in the facility, as well as any Advance Health Care Directive, Request to Forego Resuscitative measures, and/or Do-Not-Resuscitate Form.
- Contact info of hospice agency and emergency contacts
- A copy of the written certification statement of the resident’s terminal illness from the director or physician of the hospice agency, and the resident’s individual physician (if they have one)
- If the hospice resident shares a room with another, a statement signed by the resident’s roommate that she is aware of the resident’s condition, and voluntarily agrees to grant access to shared living spaces to the hospice agency, caregivers, friends, family and others. (The roommate may verbally, or in writing withdraw the agreement at any time and alternative arrangements must be made to accommodate the needs of the hospice resident.)
The home page of the Hospice Foundation of America describes Hospice as a ". . . special concept of care designed to provide comfort, pain relief and support to residents and their families when a life-limiting illness no longer responds to cure-oriented treatments. This type of care neither prolongs life nor hastens death, but rather has the goal to improve the quality of a resident's last days (or months) by offering comfort and dignity." Source: http://www.hospicefoundation.org
RCFEs caring for residents receiving hospice services must meet specific qualifications as stipulated in Title 22, §87633. Providing Hospice Care.