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If you’ve been around assisted living more than a decade, you have likely seen the increasing acuity and changing dynamics of the typical assisted living resident. Each assisted living’s services, and therefore the residents’ characteristics, are largely driven by facility-specific details in the disclosure form. This completed form allows for two assisted living communities, perhaps situated side-by-side, or even owned by the same company, to serve residents who have very different needs.
Regardless of the facility's disclosure form, though, there are some basic tenets to all assisted living settings regarding the level of care offered. WAC 388-78A-2050 states that the assisted living facility may only admit and retain residents following specific criteria. This article aims to outline what these specific resident characteristics criteria are, and considerations to take to ensure the residents living and receiving care in an assisted living setting are safe to do so.
First, assisted living management must determine that the facility can appropriately serve the resident with available staff based on the scope of care outlined in the disclosure form. This includes the provision of reasonable accommodations such as specialty training for staff when a resident has a special need. Other reasonable accommodation expectations can be found in WAC 388-78A-2020 and are highlighted below:
"Reasonable accommodation" or "reasonably accommodate" have the meaning given in federal and state antidiscrimination laws and regulations which include, but are not limited to, the following:
Reasonable accommodation means that the assisted living facility must:
- Not impose admission criteria that excludes individuals unless the criteria is necessary for the provision of assisted living facility services;
- Make reasonable modification to its policies, practices, or procedures if the modifications are necessary to accommodate the needs of the resident;
- Provide additional aids and services to the resident.
Reasonable accommodations are not required if:
- The resident or individual applying for admission presents a significant risk to the health or safety of others that cannot be eliminated by the reasonable accommodation;
- The reasonable accommodations would fundamentally alter the nature of the services provided by the assisted living facility; or
- The reasonable accommodations would cause an undue burden, meaning a significant financial or administrative burden.
Perhaps one of the least understood resident characteristics requirements encompasses the somewhat nebulous term “stable and predictable.” WAC 388-78A-2050 states that a resident must not require the frequent presence and frequent evaluation of a registered nurse. While not expressly defined as stable and predictable, this expectation is better defined in the nurse practice act and is found there, in WAC 246-840-920, when describing the parameters of RN delegation:
"Stable and predictable condition" means the registered nurse delegator determines the patient's clinical and behavioral status is nonfluctuating and consistent. Stable and predictable may include a terminally ill patient whose deteriorating condition is expected. Stable and predictable may include a patient with sliding scale insulin orders. The registered nurse delegator determines the patient does not require frequent nursing presence and evaluation.
This entire idea of a resident needing to be stable and predictable can be confusing, particularly since there is no requirement that an assisted living facility employ or contract with a registered nurse if the facility does not offer nursing services; who, then, determines whether a resident requires the frequent presence and frequent evaluation of a registered nurse?
This determination is best highlighted through individual facility policies and procedures. This determination can be included in training for whomever conducts preadmission and ongoing resident assessments. Determination of a resident’s "stable and predictable" status is best done as a team, where options and considerations can be voiced and plans brainstormed.
Both the assisted living regulation and the nurse practice act highlight instances when certain conditions can be considered stable and predictable. Combining the nurse practice act (WAC 246-840-920) and resident characteristics regulation (WAC 388-78A-2050) carves out some resident conditions that would allow the resident’s continued stay in the facility, even when the idea of stable and predictable status is in question.
The Dying Resident
The assisted living regulation outlines that a resident on hospice (who is predictably declining towards death) can fall into reasonable resident characteristics. The nurse practice act piggybacks that statement by including terminally ill patients (wording in this regulation does not mention hospice) whose deteriorating condition is expected. In effect, anyone who is predictably dying may be considered stable and predictable, regardless of hospice status. Of course, additional consultation with the dying resident’s primary care provider and family would need to take place to ensure proper care and service delivery through the dying process.
The Resident on Sliding Scale Insulin
The nurse practice act calls out that a resident receiving sliding-scale insulin can be deemed stable and predictable for the purposes of nurse delegation of insulin injections. That would imply that the assisted living facility that offers insulin injections may deem a resident stable and predictable for the purposes of moving in and continuing residency at the facility as well. Again, the expectation that each individual resident’s condition is considered and determined to be stable and predictable would demonstrate the facility’s due diligence in this area. Likewise, the facility’s staffing and provision of intermittent nursing services would play a part in determining the resident’s ability to move in or continue residency.
Resident with a Short-Term Illness
The assisted living regulations allow for residents who are experiencing a short-term illness (less than 14 days in duration) to remain in the facility, provided the facility has the capacity to meet the resident’s identified needs. The facility’s capacity to fulfill the resident’s needs can be accomplished in several different and often creative ways, including but not limited to, current staffing, contracted staffing, home health services, or even out-patient services. For example, if a resident experiences an infection that only an intravenous antibiotic can treat, the assisted living may be able to accommodate that resident’s condition by the facility nurse administering the IV antibiotics in the resident’s apartment for the duration of the medication order. This is perfectly within the realm of licensure. Some assisted living centers cannot accommodate this type of illness due to limited nursing staff hours or perhaps the nurse on staff is not competent to administer IV medications. In these situations, the resident could potentially receive the IV infusion at a local medical clinic each day (with coordinated travel arrangements) or spend a short time in a rehabilitation setting to receive the IV care. Again, each situation must be addressed on an individual basis depending on the resident’s unique care needs and the facility’s staffing capabilities.
AL Questions? Email Vicki McNealley or call 1-800-562-6170, ext. 107.
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