Frequently Asked Questions

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.

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.  

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.  

 

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” 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, §87411

According to Title 22, facility personnel at all times must be sufficient in number and competency to provide services necessary to meet residents needs.  Additional staff should be employed as necessary to perform office work, cooking, housekeeping and facility maintenance.  For additional information, see FAQ Staffing in an RCFE.

All personnel who supervise and/or provide care to residents must be at least 18 years old, in good health as verified by a physician, must possess a current First Aid certificate, and must obtain a criminal record clearance from the Department of Justice. 

All staff who provide direct care to residents are required to receive at least 10 hours of initial training within the first 4 weeks of employment and must receive at least 4 hours of additional training annually.  The most popular training tools used in RCFEs are video instruction tapes/CDs and, at times, on-site trainings from persons knowledgeable on the specific subject(s).   

While proof of receiving the appropriate training is available on all employees in their personnel file, how much knowledge employees actually retain from videos/training is unknown.  Therefore, consumers may want to look for the following characteristics to assess the competency of the care staff:      (The following are mentioned in Title 22 as evidence of safe and effective job performance.)

(1) Familiarity with the aging process;

(2) The importance and techniques of personal care services and supervision;

(3) Respectful of Residents Rights;

(4) Knowledge of the psychosocial needs of the elderly (i.e. recreation, companionship);

(5) Knowledge necessary in order to recognize early signs of illness and the need for professional help (includes dementia);

(6) Knowledge of community resources;

(7) Ability to communicate with residents;

(8) Principles of good nutrition and sanitation;

(9) Knowledge of safely assisting with prescribed medications which are self-administered (Medication Management)

If you are concerned with the staffing level, or competency of staff in a particular RCFE, documenting your concerns and sharing the documentation with the LPA assigned to your facility may be helpful.

CCLD "may require a facility to provide additional staff whenever it determines through documentation that additional staff is required to provide adequate services" (Title 22, § 87411). 

Title 22, §87217(a) et.al.

Licensees are not ". . .required to handle residents' cash resources.  [However, if it is deemed and documented through an appraisal, that] a resident is incapable of handling his own cash resources, his cash resource must be safeguarded in accordance with the regulations. . .".    If the Licensee elects to safeguard a resident's cash resources, the Licensee does so pursuant to the stipulations of Title 22, §87217, paraphrased and summarized below:

  • Accurate records shall be kept and adequate safeguards maintained  (§87217(c)
  • Receipts for articles or cash must be given.  (§87217(b)
  • There is to be no commingling with facility funds. [This does not prohibit the Licensee from providing advances or loans to residents from facility money.]  (§87217(e)
  • No facility shall make expenditures from these resources for basic services. [There is an exception with regard to Social Security monies if Licensee is representative payee].  (§87217(f)
  • "No Licensee or employee shall (a) accept appointment as a guardian or conservator of the person and/or estate of any resident, (b) accept any general or special power of attorney for any resident, (c) become substitute payee for any payments made to any resident [unless involving Social Security monies & licensee is representative payee], or (d) become the joint tenant on any account with a resident.*" (§87217(d). 
  • Cash resources entrusted to the Licensee and  kept on the facility premises shall be locked and secured. (§87217(h)
  • Cash resources not kept at the facility must be immediately upon admission be deposited into a bank account separate from the personal and business accounts of the licensee provided that the account title clearly notes that it is residents' money and the resident has access to the money upon demand to the licensee.  (§87217(h)
  • All monetary gifts and any gift exceeding an estimated value of $100, which are given to the licensee by or on behalf of a resident shall be recorded (this does not include friends or relatives of deceased residents).  (§87217(k)
  • Any Licensee who is entrusted to safeguard resident cash resources shall file or have on file with the licensing agency a copy of a surety bond issued by a company to the State of California as principal. (§87216(a)

If a resident needs assistance from a facility with her finances, verify that the RCFE under consideration is bonded and that the amount is sufficient to adequately safeguard the money of the resident.  CCLD verifies that the bond held is sufficient , however there is no substitute for performing your own due diligence. 

*Except as provided in approved agreements with continuing care facilities.

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)

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. 

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.

Title 22 (§ 87507) only mandates refunds in two (2) situations:

1)      The Department orders the relocation of a resident.  In this case, the resident is relieved of any advance notice requirements contained in the admissions agreement.

2)      Upon the death of a resident, the agreement between the facility and the resident is terminated and relatives are not liable for any payment beyond that due at the date of death, unless agreed to in writing or ordered by a court.

Title 22 includes no other provisions for refunds or advanced notice requirements for residents or families.  Refund policies (outside of the above) are at the discretion of the facility and will be stated in the admissions agreement.  Therefore, it is imperative you familiarize yourself with a facility's policy regarding events that may prompt a resident's departure from the facility:

  •  Personal decision to move
  •  Sickness/Injury/Higher level of care
  •  Depleted Resources

If the terms set forth in the admissions agreement are not agreeable to you, search for a facility that has more reasonable policies or see if there is room for negotiation (and get all agreements in writing, no verbal assurances).  For example, is the required notification for moving 30 days or 60 days?  Is there the option for a reduced payment or per diem rate should the resident need to relocate temporarily?  How soon must you remove the resident's personal effects after death to avoid being charged?

While consumers always have the right to ask for a refund and to file a complaint against a facility they believe is taking advantage, the policy that is contained in the signed admissions agreement is binding.

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)

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.

The admissions process is the point at which you, the consumer, can identify if the facility you have chosen will be able to meet all of the resident's needs and expectations.  Before accepting a resident, the regulations state that a facility must evaluate the appropriateness of the resident for the facility.  This evaluation typically consists of an interview, a pre-admissions appraisal, a medical assessment, and presentation of the Admissions Agreement (Title 22 §87456).  Presented here is what you can expect from each of these events.

[If at any point a facility conveys a sense of urgency, for example "Act now or your spot may be taken", it is important for consumers to know that approach may be a marketing strategy, not a fact.]

You can expect the following from the facility:

(1) An interview with the Licensee/Administrator (§87457)

According to Title 22, during this interview, sufficient information must be given about the facility and its services so that all persons involved in the placement can make an informed decision regarding admission.  Topics for discussion include the prospective resident's desires, expectations, their personal and medical background, and any specific resident needs.  Topics should be discussed in detail, with the facility describing how it will provide the care required by this resident.

(2) A pre-admission appraisal (§87457)

The form LIC 603 is used by facilities to document the appraisal.  This form can be used as a tool to assist you in your interview of the facility.  By reviewing these questions ahead of time, you will be prepared to ask the facility, specifically, how it plans to provide for the resident's needs. 

Title 22 also requires that if the initial appraisal (or any reappraisal) identifies a service need which is not being met by the general program of the facility, the facility must then obtain advice from a physician, social worker or other appropriate consultant to determine if the needs can be met by the facility.  Then they must create a plan outlining how those needs will be accommodated if the individual becomes or remains a resident.  The plan is required to include time frames, objectives, responsible parties, and methods for evaluating progress.  It is imperative that this plan be documented and signed by both parties and a copy maintained in and outside the resident's file to avoid confusion when concerns arise. 

Facilities are not required to accept every resident.  It is their responsibility to accept and retain only those residents whose needs can be met.

(3) The request for a recent medical assessment (Title 22 §87458)

The form LIC 602A, is the Physician's Report.  This assessment must be completed and signed by a physician.  It is important to remember  that RCFEs are non-medical facilities.  The staff employed by RCFEs are not required to have any medical experience aside from general training requirements (Title 22 §87411).  If you feel the resident may need medical support, even intermittently, you will want to investigate the following:

  • the medical experience of the caregivers employed by the facility
  • the medical experience and critical thinking skills of the Administrator/Licensee
  • the availability of an RN or LVN (one employed by the facility or available for consult)
  • and/or you might want to verify whether a higher level of care may better serve the needs of the resident.

(4) Presentation of the Admissions Agreement

Community Care Licensing offers LIC 604A for facilities to use as their Admissions Agreement.  [Based on CARR's review of the files, many smaller facilities use this standard form.  Larger, corporate-owned facilities tend to use their own Admissions Agreement crafted by an attorney.]

Admission Agreement Summary (Title 22 §87507)

1) Facility and Licensee Contact Information

2) Resident Information

  • Providing your Social Security Number is voluntary
  • Providing information pertaining to financial status, property ownership and (life) insurance information are not required per regulation

3) Basic Services

  • A detailed list and description of what constitutes the basic services provided by the facility must be in the admissions agreement (To see what is required at a minimum see Title 22 §87464)
  • The monthly private pay rate for basic services must be stated in the admissions agreement
  • The monthly SSI/SSP rate for basic services must be stated in the admissions agreement and cannot be in excess of the SSI/SSP rate.  CCLD's Evaluator Manual (§87464) states that It is a violation of law for a licensee to purposely obtain an SSI/SSP beneficiary's personal and incidental needs allowance to pay for basic services.   [Title 22 § 87464 states that voluntary payments from family are allowed;  CARR recommends contacting Community Care Licensing for guidance if this issue arises]

4) Optional Items and Services

  • Those services not included under basic services, but are available to residents if  they choose to receive them, must be listed in the admissions agreement alongside the costs associated with each optional item or service.  The resident must agree to purchase these services at an extra charge, in the admission agreement.
  • Typical optional items/services include incontinence products, cosmetology services, special food services or products (such as kosher food), etc.
  • Verify the facility's policy on notifying resident's and/or their responsible party should these services become necessary, and the policy on arranging payment.
  • Verify the facility's policy on implementing these services should they be desired, and the policy on arranging payment.
  • Facility's are allowed to post a list of these services in an accessible location if they are not included in the admissions agreement; therefore verifying policies regarding implementation of services and fees is helpful.

5) Policies on Rate Changes

  • Facilities must provide 60 days written notice to resident of any basic rate change.
  • For SSI/SSP rate changes, residents must be notified as soon as facility is notified.

6) Refund Conditions

7) Eviction Procedures (Title 22 § 87224)

As with any contract, read it entirely and be watch for

  • Hidden fees (levels of care or itemized services when additional assistance becomes necessary)
  • Pre-admission fees (non-refundable)
  • Terms of agreement tucked inside residential Handbooks that must be signed and dated.

If you have questions concerning the admission agreement provisions, contact Community Care Licensing or have your attorney review the document for you before you sign. 

Title 22 § 87611 and § 87612 

These 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, Intermittent Positive Pressure Breathing (IPPB) machines, 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 under Title 22 § 87611 and 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, RCFEs are non-medical facilities.  Be aware of the facilities' policies, procedures, outsourcing and compliance track record 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. 

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

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

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 §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 §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.