Total Care Waiver

Understanding California's Oversight & Regulation

Facilities are required to obtain a Hospice Care Waiver from the Department if they wish to retain clients receiving hospice care services (§ 87632).  Once granted, the waiver slot(s) can be applied to any future resident or residents needing hospice services without additional approval from the Department. 

Residents receiving hospice care services may eventually require “total care”.   Total care is defined as a condition where residents depend on others to perform all of their activities of daily living.  Under Title 22, total care is considered a prohibited health condition in assisted living facilities (LINK). 

Previously, to care for residents requiring total care, a facility would request a total care exception to allow a particular resident to be retained in the facility.  However, in response to facilities requests, the Department has streamlined the process and expanded its application by creating a Total Care Waiver.  Now, facilities may request a Total Care Waiver within their request for a Hospice Waiver.  And like the Hospice Waiver, once granted, the Total Care Waiver slot(s) can be applied to any future resident or residents needing total care without additional approval from the Department. [Consumers should note that while exceptions apply to specific individuals, waivers are applied facility-wide.]

The requirements for requesting a total care waiver are as follows (§ 87616):

1.  A facility must submit a plan for ensuring that the total care residents’ needs can be met.

2. The plan must also address how the facility will minimize this impact on the other residents.

3. The facility must provide documentation of the resident’s current health condition, including medical reports, etc. or retain the hospice care plan at the facility for Department review

To view the actual policy: (LINK

Consumers should note all of the following: 

Once granted, Total Care Waivers expand the scope of care provided by an assisted living facility.  Without a waiver, total care residents would be required to move into a skilled nursing facility (aka nursing home) to be under the supervision of a medical team.  And while hospice nurses are to be involved in the care provided to total care residents, facilities remain the primary provider of care and supervision.

CARR reminds consumers that assisted living facilities are licensed as non-medical facilities.  Facilities are not mandated to maintain any patient-to-staff ratios nor are they required to employee nursing staff (even if granted a Total Care Waiver).  Additionally, the State inspects facilities only once every five years. Should a resident require total care, safety and quality of care can only be achieved through ongoing communications between all parties involved (facility staff, hospice, family members and resident) and extreme vigilance. 

Should you believe that a facility is failing to provide the care promised or is in need of additional staff, CARR recommends consumers document all events that will support such claims and to file a complaint with the Department.  CARR remains concerned about this expansion of resident care, as we have noted facilities with intolerable compliance histories who are not stripped of their hospice waivers. 

CARR questions the policy and procedures surrounding Total Care Waivers and has sought comment from the Department as of May 22, 2012.

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

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