Frequently Asked Questions - Understanding RCFE Care & Services

Title 22 § 87611 & § 87612

Here are the general requirements facilities must abide by when they accept and/or retain a resident with any of the following allowable health conditions: Oxygen administration, colostomy/ileostomy, IPPB, Contractures, Healing Wounds (bedsores - Stage I & II).

The facility must complete and maintain a current, written record of care for each resident that has one or more of these conditions.  This record must include, at a minimum, the following:

(1) Documentation from the physician that includes type of condition, stability of condition,  method of intervention, resident's ability to perform procedure and the appropriately skilled professional who will assist should resident require assistance with procedure.

(2) The names, address and telephone number of vendors (if any) and all appropriately skilled professionals providing services.

(3) Emergency contacts.

You, as the resident, or responsible party may wish to request a copy of this updated information.

In addition to this written record, the facility is also required per Title 22 § 87611 & 87613 to ensure:

(1) That facility staff have the knowledge and ability to recognize and respond to problems related to health conditions and must contact the physician, appropriately skilled professional, and/or vendor as necessary.

(2) The facility must monitor the ability of the resident to provide self care for these health conditions and document any change in that ability. 

Though not in the regulations, communicating changes in status to other relevant parties (physicians, responsible parties, CCLD if necessary, etc.) would be ideal.

(3) The facility must ensure that the resident is cared for in accordance with the physician's orders and that the resident's medical needs are met.

Remember, these are non-medical facilities.  Be aware of the facilities' policies, procedures, outsourcing and histories as they pertain to residents' medical needs to solicit the most appropriate care for your resident.

The regulations go on to say that the duty established by this section does not infringe on the right of a resident to receive or reject medical care or services. 

Should this circumstance arise, be sure it is the resident's intent to refuse services, and not any idleness of the facility, that resulted in foregone medical attention or care.

Additionally, if a facility has had any of the following within the last two years, the Department must approve the facility's acceptance or retention of a resident with the above mentioned health conditions - A probationary license, administrative action, non-compliance conference,or notice of deficiency involving direct care that required correction within 24 hours.

Title 22 (§87464)

RCFEs are required to provide §87464(f): safe and healthful living accommodations and services, regular observation of the resident's physical and mental condition, three meals per day plus snacks, personal assistance with ADLs, medication management, social and recreational activities, transportation, housekeeping and maintenance.

"The services provided by the facility shall be conducted so as to continued and promote, to the extent possible, independence and self-direction for all persons accepted for care.  Such persons shall be encouraged to participate as fully as their conditions permit in daily living activities both in the facility an in the community."

Basic services must be provided to obtain and retain an RCFE license.

Title 22 (§87608)

Bed rails ". . . that extend from the head, half the length of the bed, and used only for assistance with mobility shall be allowed." (§87608(5)(A).

"A written order from a physician indicating the need for the postural support (in this case, bed rails) shall be maintained in the resident's record.  The licensing agency shall be authorized to require other additional documentation if needed to verify the order." (§87608, (3). 

"Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care, and have a hospice care plan that specifies the need for full bed rails."  §87608(5)(B)

Bed rails may not be used as a restraint, for the convenience of staff, or to substitute for staff. 

Title 22, §87606 

(e) & (H&S Code 1569.72(e):   ". . . a bedridden resident may be retained in an RCFE in excess of 14 days if all of the following requirements are satisfied:

"(1) The facility notifies [CCLD] in writing regarding the temporary illness or recovery from surgery.

"(2) The facility submits to [CCLD], with notification, a physician and surgeon's written statement  that the resident's illness or recovery is of a temporary nature.  The statement shall contain an estimated date upon which the illness or recovery will end or upon which the resident will no longer be confined to a bed.

"(3) [CCLD] determines that the health and safety of the resident is adequately protected in that facility and that transfer to a higher level of care is not necessary.

Title 22,§87606(b) & H&S Code 1569.72(f):  "Notwithstanding the length of stay of a bedridden resident, every facility admitting or retaining a bedridden resident shall, within 48 hours of the resident's admission or retention in the facility, notify the local fire authority with jurisdiction in the bedridden resident's location of the length of time the resident will retain his/her bedridden status in the facility."

Title 22 §87623

The facility shall be permitted to accept or retain a resident who requires the use of an indwelling catheter under the following circumstances:

(1) If the resident is physically and mentally capable of caring for all aspects of the condition except insertion and irrigation.  Insertion and irrigation shall only be performed by an appropriately skilled professional in accordance with the physician's orders.  This includes changing the bag and tubing.

(2) Privacy is maintained when care is provided.

(3) Facility ensures that waste materials are disposed of properly (See §87303).

Additionally, the bag may be emptied by facility staff who receive instruction from an appropriately skilled professional.  If this is the case, the facility is required to maintain written documentation from the appropriately skilled professional outlining the instruction of the procedures delegated and the names of the facility staff who have been instructed.  The staff's performance must be evaluated by the professional at least annually but as often as necessary.

Title 22 §87621

The facility shall be permitted to accept or retain a resident who has a colostomy or ileostomy under the following circumstances:

(1) The resident is mentally and physically capable of providing all routine care for his/her ostomy; and the physician has documented that the ostomy is completely healed; OR

(2) If assistance in the care of the ostomy is provided by an appropriately skilled professional.

(3) Privacy is afforded when care is provided.

(4) The used bags are discarded appropriately.

Additionally, the bag and adhesive may be changed by facility staff who have been instructed by the appropriately skilled professional.  The facility must maintain written documentation provided by the appropriately skilled professional,  outlining the instruction of the procedures delegated, and the names of the facility staff who have been instructed.  The appropriately skilled professional shall review the procedures and techniques no less than twice a month.

Title 22 §87626

Contractures are the shortening of the muscle or joint resulting from and/or exacerbated by (among other things) inactivity.

Title 22 §87626(a)(1) ". . . the Licensee shall be permitted to accept or retain a resident who has contractures under the following circumstances:

(1) If the contractures do not severely affect functional ability and the resident is able to care for the contractures by him/herself (i.e. perform physical therapy exercises independently) ; or

(2) If the contractures do not severely affect functional ability and care and/or supervision is provided by an appropriately skilled professional (i.e, a skilled professional is responsible for assisting in the performance of exercises).

If a resident is experiencing contractures at the time of placement, it is important you discuss with the facility the resident's expectations regarding exercises and physical activity, and assess the facility's ability to meet the requirements, and your expectations. Facilities maintaining a limited activity program, or having inexperienced staff may cause contractures to worsen,  leading to decreased mobility, decreased quality-of-life, possible bedridden status, and perhaps make care in a skilled nursing home more immediate.  Here again, vigilance and communication are key. 

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.

Medications

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)

Fire Clearance

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.

Records

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.)

 

 

 

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.

Title 22, §87415

The Licensee must designate the following number of people to assist in caring for residents in the event of an emergency between the hours of 10 pm and 6 am:

  • For facilities with 16 or fewer residents, one employee must be on the premise but need not be awake.
  • For facilities with 16 to 100 residents, a total of two employees must be available.  At least one person shall be on the premises and awakeAnother employee shall be on call, and be capable of responding within 10 minutes.
  • For facilities with 101 to 200, a total of three employees must be available.  One employee must be on the premise and awakeAnother employee on the premise but on call.  And still another, on call and capable of responding within 10 minutes.
  • For every additional 100 residents (or fraction thereof), an additional employee must be on the premise and awake.
  • In facilities that require a signal system (Title 22, §87303), at least one employee must be located to enable an immediate response to the signal.  If the signal system is visual only, this employee must be awake.

Anyone can submit an application to CCLD to open an RCFE.

Title 22 stipulates that CCLD needs "evidence satisfactory to the department that the applicant is of reputable and responsible character" (§87155) and that the applicant must meet  and comply with all application requirements (i.e. completed application, attendance at Orientation and other Component reviews,  payment of Licensing fees, etc).

Title 22 §87618

A facility may accept or retain a resident who requires the use of oxygen GAS if:

(1) the resident is mentally and physically capable of operating the equipment, is able to determine his/her need for oxygen, and is able to administer it him/herself *; OR

(2) intermittent oxygen administration is performed by an appropriately skilled professional.

*The facility is responsible for continuously monitoring the resident's ongoing ability to operate the equipment in accordance with the physician's orders.

Since a licensed professional is not required per regulation to be onsite 24/7 in an RCFE, in some cases the ability of a facility to guarantee intermittent administration and assistance by a skilled professional may be difficult. 

The regulations do, however, require that the facility staff have knowledge of, and the ability to operate the oxygen equipment.  But they are not allowed to assist the resident, per the regulations; only an appropriate skilled professional is allowed to provide this assistance. 

In addition to the administration of oxygen, Title 22 includes the following requirements as they pertain to the oxygen equipment:

(1) The facility shall submit a written report to the local fire jurisdiction notifying them oxygen is in use at the facility.

(2) "No Smoking-Oxygen in Use" signs shall be posted in appropriate areas.

(3) Smoking shall be prohibited where oxygen is in use.

(4) Oxygen tanks that are not portable must be secured in a stand or to a wall.

(5) Plastic tubing from the nasal canula or mask to the oxygen shall be long enough to allow movement by the resident but not constitute a hazard to the resident or others.

(There are special conditions if oxygen tubing exceeds 7 feet in length. Refer to Title 22 or contact CARR if you require detailed information.)

(6) Oxygen from a portable source shall be used by residents when they are outside their rooms.

(7) Equipment shall be operable.

(8) Equipment shall be removed when no longer in use.

(9) Room size should be appropriate to accommodate all equipment.

A facility may accept or retain a resident who requires the use of LIQUID oxygen if:

(1) The licensee obtains prior approval from the licensing agency; AND

(2) If the resident is mentally and physically capable of operating the equipment, is able to determine his/her need for oxygen, and is able to administer it him/herself.

 The regulations do not speak to a resident remaining in an RCFE if he requires assistance with liquid oxygen.  Even if a licensed skilled professional is available to assist,  it is not clear that the regulations allow this type of assistance.  If this could be an issue for your resident, contact CCLD for regulatory clarification. 

Title 22 §87631

Stage I and Stage II pressures sores (aka bedsores) are medical conditions allowed to be treated within a Residential Care Facility for the Elderly (RCFE).  They are listed under Healing Wounds in Title 22.  The regulations are summarized below.   RCFEs are allowed to accept and/or retain residents with a healing wound under the following circumstances:

(1) Care for healing wounds is performed by or under the supervision of an appropriately skilled professional.

(2) Stage I or II pressure sores must be diagnosed by an appropriately skilled professional. 

(a) The resident must receive care for the pressure sore from an appropriately skilled professional.

(b) All aspects of care performed by the medical professional and facility staff shall be documented in the resident's file.

Since RCFEs are non-medical facilities, and therefore not required to have an appropriately skilled professional on-staff, bedsores pose a serious challenge for facilities and their residents.  Bedsores can escalate to life-threatening condition if not given proper attention.  

Mini-Primer on Bedsores (aka Decubitus Ulcers):

(A) Bedsores are skin ulcers that develop from pressure when people lie in bed or sit in a chair for long periods of time.  Infrequent rotation and repositioning of elderly persons who have difficulty moving independently is a primary cause.  Those individuals with diabetes are at a greater risk of developing bedsores due to poor circulation.  And anything but meticulous incontinence care can threaten skin integrity which can lead to skin deterioration and/or pressure sores.

(B) A Stage I bedsore is when the affected skin looks red and may feel warm to the touch.  The area may also burn, hurt or itch.  A Stage II bedsore is when the affected skin is more damaged, which can result in an open sore that looks like an abrasion or a blister.  The skin around the wound may be discolored and very painful.

(C) Prompt identification and treatment of these wounds is imperative to increase the likelihood of recovery. 

(D) Prior to placement, knowing the following may be helpful:

  • The facility's access to an appropriately skilled professional

  • The facility's policy and history as it pertains to bedsores and incontinence care. See LIC 809s & LIC 9099s.

  • The facility's staffing ratio and the competency of the staff (could they identify the warning signs)

  • Does the facility excel at keeping residents active, mobile, and comfortable?

ADDITIONAL RESOURCES: 

www.webmd.com

http://www.npuap.org/resources.htm (illustrations of bedsore stages)

Title 22 §87608.

The following regulations pertain to postural supports:

(1) Supports shall be limited to devices used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of a bed, a chair, etc.  Included here are physician-prescribed orthopedic devices (braces or casts) used for support of a weakened body part or correction of body parts.

(2) Supports shall be fastened or tied in a manner that permits quick release by the resident.

(3) A written order from a physician indicating the need for the support shall be maintained in the resident's record, and if necessary CCLD may require additional documentation to verify the order.

(4) If the use of the support changes the ambulatory status of a resident to non-ambulatory, the licensee shall ensure that the appropriate fire clearance has been secured prior to the use of the support.

(5) Under no circumstances shall postural supports include tying, depriving or limiting the used of a resident's hands or feet.

(6) Bed rails that extend from the head half the length of the bed and are used only for assistance with mobility shall be allowed.

(7) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and who have a hospice care plan that specifies the need for full bed rails.

Definition:  Merriam-Webster’s online dictionary defines “restraints” to mean the “action of keeping someone or something under control,” or “a measure or condition that keeps someone or something under control or within limits.

Personal Rights:  Restraint of a resident violates a resident’s Personal Rights, Title 22, Section 87572: 

a)    a resident is to be free from corporal or unusual punishment, humiliation, intimidation, mental abuse, or other actions of a punitive nature. . .” ,

b)   a resident is to be able to leave or depart the facility at any time and not to be locked into any room, building, or on facility premises by day or night.  This does not prohibit the establishment of house rules, such as the locking of doors at night, for the protection or residents; not does it prohibit, with permission of the licensing agency, the barring of windows against intruders.

Many things in an assisted living facility can be used to restrict the movement, motion and activity of residents:  postural supports (braces, soft ties intended to keep a resident upright, casts), bed-rails, geri-chairs, sliding trays, locks on doors, wooden bars in sliding doors, and drugs.

Postural Supports allowed by Title 22 ( Section 87608(a)(1) include “ . . . appliances or devices such as braces, spring release trays, or soft ties . . .used to achieve proper body position and balance, to improve a resident’s mobility and independent functioning, or to position, rather than restrict” a resident’s movement.

Postural supports require a) “quick release” by the resident and b) a written order from a doctor prior to use. 

Postural supports may not be used to tie, limit or deprive a resident of the use of her hands or feet.

Bed-Rails are allowed by Title 22, a postural support under Section 87608(5)(a); they may be used for mobility aids only.  Bed-rails that extend from the “. . .head half the length of the bed, and used only for assistance with mobility shall be allowed.”   Full bed-rails are prohibited except for residents receiving hospice care, with a care plan that specifies the need for full bed-rails.  Bed-rails are not to be used as a restraint to keep a resident in bed during the night, or to facilitate an understaffed facility. 

Geri-chairs with sliding trays:    Geri-chairs are standard in many facilities;  they allow the resident to be positioned in an upright position with the tray pushed close to the body thereby facilitating independent feeding and ease of swallowing.   However, CARR has seen these chairs be misused by laying the person back in the chair to a quasi-supine position incapacitating an individual from getting out of the chair – they are essentially ‘pinned’ into the chair. 

Locked Doors:    At no time may a resident be locked in or locked out of his room.   If a door has a lock on the inside, the lock must be a single-action so the resident can quickly get out. 

Blocked Sliding Doors:   Another form of restraint or restriction of a resident’s movements occurs when the Licensee has blocked the exit door to the outside.   Rooms are approved for non-ambulatory when the room has an exit to the outside, for example: a French door, a sliding door on a track, or a regular door.  CARR has seen documentation where furniture, storage boxes has blocked the exit, or where a stick has been placed in a sliding door track preventing the door from being used as an exit.  Blocked exits are considered a form of restraint.  Blocked exits are also a violation of Title 22, Section 87307(d)(6). 

Psychoactive Drugs:     California Advocates for Nursing Home Reform (CANHR) is a leading advocate of minimizing or eliminating the use of psychoactive drugs on residents of skilled nursing facilities and in residential care facilities for the elderly.  According to CANHR there are four types of psychoactive drugs:  antipsychotics (Zypreza, Haldol); anti-anxiety drugs (Ativan, Valium);  anti-depressants (Prozac and Zoloft);  sedatives and hypnotics (Halcion/Restoril).   The subject of misuse and overuse of these drugs is huge; suffice it to say here that if your resident is taking these drugs,  your resident is susceptible to the drugs being used as a chemical restraint. 

Risks of Restraints:  The risks of a resident being restrained include physical and emotional distress.  Physical manifestation can include decubitus ulcers (bedsores), bruising, incontinence, constipation; emotional manifestations include emotional distress, intimidation, anger, isolation, and loss of personal dignity.  The long-term effects of being on psychoactive drugs are myriad, and in many cases, exacerbate existing medical conditions, hastening death.

Why would a facility use restraints on a resident?    Facilities are frequently understaffed; Title 22, Section 87411 requires that ‘facility personnel shall at all times be sufficient in numbers, . . . and competent to provide services necessary to meet resident needs.”  That said, facilities generally staff lean, therefore it may be to the benefit of the facility to periodically restrain residents, particularly those tending to be wanderers, those who may be disruptive,  or those who may be aggressive. 

Consumers are asked to be ever watchful and vigilant and be on guard for a resident in, or under restraint.  Be watchful not only for your resident, but for others in the facility as well.

Resource:  The Ombudsman Services of Northern California publishes a helpful on-line guide “RCFE Regulation Reference Guide”  http://rcfe.lsnc.net/restraints/ that provides general guidance what is allowed and what isn’t allowed regarding restraint of residents.

Notes in italics represent the views and/or experience of CARR regarding this topic and/or regulation. 

Title 22 (§87612)(a)

"The Licensee may provide care for residents who have any of the below-listed restricted health conditions, or who require any of the below-listed health services."  [Each below-listed condition has additional requirements associated with it, in order for facilities to be able to provide that specific type of care.]

1) Administration of Oxygen (§87618)

2) Catheter Care (§87623)

3) Colostomy/ileostomy Care (§87621)

4) Contractures (§87626)

5) Diabetes (§87628)

6) Enemas, suppositories, and /or fecal impaction removal (§87622)

7) Incontinence of bowel and/or bladder (§87625)

8) Injections (§87629)

9) Intermittent Positive Pressure Breathing Machine (§87619)

10) Stage 1 & 2 pressure sores (dermal ulcers) (§87631(a)(3))

11) Wound care (§87631)

Supplemental Security Income, also known as SSI, is a benefit paid to qualifying blind, disabled, or 65+ year old individuals having fewer than $2,000 in assets.  SSI monies (about $650 provided by the federal government; the remainder comes from state funds) can be used to pay for 24/7 care and supervision in an RCFE, however by law, the RCFE cannot charge more than the rate set by California for assisted living services.  As of 2011, the monthly rate for RCFEs from SSI funds is $982/month.  Since the maximum SSI a qualifying elder can receive is $1,100, the individual is left with #128 for personal items and discretionary spending.

Families note:  the RCFE cannot require that family members supplement the resident's monthly SSI payment to, nor can the Admissions Agreement be modified to include additional assistance by family members; RCFE owners can not receive a family supplement over and above the stipulated SSI amount for the resident's room, board and care. 

The fact is that few facilities accept residents who only receive SSI benefits because the rate is well below the normal monthly rate of $2,500 to $3,000 charged by RCFEs. To find out whether the assisted living facility takes SSI, the consumer has to call the candidate RCFE, asking whether they accept SSI clients.  There is no single place where a consumer can refer to that would advise which RCFEs accept  SSI clients.  

One source a consumer can look is the LIC 401, Monthly Operating Statement, completed by the RCFE application and submitted to the state as part of the license application package.  CARR regularly scans and posts the LIC 401 for individual facilities - so if it is available in the public record, it will likely be posted on this site.  The first part of the LIC 401 requires the licensee to account for his monthly revenue.  The first line in this section provides for SSI residents.  CARR has seen some licensees indicate that of a 6-bed intended occupancy, the licensee will calculate his total revenues based on having 1 or 2 SSI residents.  CARR is the first to acknowledge this source as unreliable, but if the licensee indicated a revenue stream coming from SSI clients, it may indicate the potential for the licensee to accept an SSI client.    

Information contained in this FAQ is based in part on research done by BA, CARR's spring SDSU intern.  Thanks BA.  

 

According to Title 22 a skilled professional (aka a licensed professional (Title 22 §87101(l)(2), or medical professional (Title 22, §87101(m)(1)) refers to a person licensed in California to provide medical care or therapy or to perform necessary medical procedures.  This includes:

  • Physicians/surgeons/physician's assistants;
  • RNs/LVNs/Nurse practitioners;
  • Physical/occupational/respiratory therapists;
  • Psychiatric technicians, etc. 

Each must operate within his/her scope of practice.

This term does not include an uncertified caregiver, medication technician, administrator and/or Licensee, unless that individual also maintains a valid skilled professional license mentioned above.

Title 22, §87411

Title 22 does not mandate staffing requirements for residential care facilities; Title 22 states that "facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. 

The 'sufficient number' required is determined by the Licensee.  Aside from the Personnel Record (LIC 501) submitted during the application process, the public files at CCLD offer little information about a facility's staffing levels.

As residents' status changes, the balance of staffing levels may be impacted.   If you believe a resident's needs are being unfulfilled due to inappropriate staffing levels, contact the LPA assigned to your facility, or file a complaint with CCLD. 

According to Title 22 (§ 87412) personnel records, in all cases, shall demonstrate adequate staff coverage necessary for facility operation by documenting the hours actually worked.  If sharing this documentation with you is against the facility's policy or if they are reluctant to provide that information to you,  be aware that all personnel records must be made available to LPAs during normal business hours (§87412). Contacting the LPA assigned to the facility for assistance in this matter is appropriate.

Any staff may take the vital signs of a resident.  However, if the reading is to be used to determine the need for medication, the reading must be taken by an appropriately skilled professional.  

Title 22, §87411

Volunteers may be used in RCFEs, but may not be included in the facility staffing plan.  They must be supervised and are not authorized to assist residents with activities of daily living.