Assisted Living Licensure – Impact on the Consumer

Lindsey Krueger, Health Regulation Division Program Manager

PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOTANS Assisted Living Licensure –Impact on the Consumer

Minnesota Statutes Chapter 144G Agenda

. Assisted Living History -Lindsey Krueger (MDH) . Assisted Living “Today” . Assisted Living “Tomorrow” . Assisted Living Bill of Rights . Assisted Living Staff Training . Resources • Minnesota Senior Linkage Line (SLL) -Elissa Schley (DHS) • Office of Ombudsman for Long-Term Care (OOLTC) -Maisie Blaine (OOLTC) • Office of Ombudsman for Mental Health and -Andrea Strobel-Ayres (OMHDD) Developmental Disabilities (OMHDD)

3 Housekeeping

▪ Presenters are unmuted – please announce yourself and your role prior to speaking ▪ Public attendees are muted – please submit any comments or questions in the chat feature (bottom right)

4 Background

Assisted Living Establishments

1980’s

• 0 Assisted Living Establishments

2014

• 58% of residents in assisted living were over age 85 and 39% had dementia

Today

• 2,480 Housing With Services

• 1,663 Home Care Providers

• Approx. 60,000 clients

5 Currently In Place

144D and 144G 144A . . Annual registration Annual license . . No inspection Temporary license inspection + every 3 years . . No mandatory incident reporting Required incident reports . . No complaint investigation Complaint investigation authority . . No physical environment requirements Client care and business-related requirements . . Protected by landlord tenant law Protected by 144A, VAA and child maltreatment

6 May 2019

 Passage of Assisted Living Licensure (ALL) Law • Establishing Assisted Living Licensure and removing Housing with Services Registration • Effective date August 1, 2021  144G.09 subd. 3 authorized MDH rulemaking authority

7 ALL Rulemaking Process

 MDH drafts rules as directed in 144G.09 . Rules Advisory Committee included stakeholders who participated in drafting 144G • Meetings were held from Nov. 2019 – Nov. 2020 • Included Public attendance and input  Report of the Administrative Law Judge and the Report of the Chief Administrative Law Judge (PDF) (www.health.state.mn.us/facilities/regulation/assistedliving/docs/ hearing/rulereport.pdf)

8 Assisted Living Licensure

May 2019 Passage of Assisted Living Licensure Law (144G) ▪ Established Assisted Living Licensure and removed Housing with Services Registration ▪ Effective August 1, 2021

Assisted HWS Comprehensive Living Homecare License Licensure (144D) (144A) (144G)

9 Notice of and Planning for Discharge/Closures

Current comprehensive home care or HWS providers with NO intent to convert (to ALL) or continue to provide homecare services under chapter 144A: Must notify clients at least 60 days before expiration of their license, or by May 31, 2021, whichever is earliest.

10 60 Day Notice Requirements

144G.191 Subd.3. (c) (1-5) and Subd. 4 (b) (1-5) 60 Day notice requirements:

(1) state that the provider will no longer be providing home care services under chapter 144A or that the housing with services establishment does not intend to convert to an assisted living facility (whichever is applicable to your setting);

(2) include the date when the provider/HWS establishment will no longer be providing these services;

(3) include the name, e-mail address, and phone number of the individual associated with the comprehensive home care/HWS provider that the recipient of home care services may contact to discuss the notice;

(4) include the contact information consisting of the phone number, e-mail address, mailing address, and website for the Office of Ombudsman for Long-Term Care and the Office of Ombudsman for Mental Health and Developmental Disabilities; and

(5) for recipients of home care services who receive home and community-based waiver services under section 256B.49 and chapter 256S, also be provided to the resident's case manager at the same time that it is provided to the resident.

This notice MUST be provided to the residents at least 60 days before the expiration of the license/registration, or no later than May 31, 2021.

11 Key Highlights of Assisted Living Licensure

 Single license and assisted living contract  Physical environment requirements & fire safety  Enhanced Bill of Rights and consumer protections  Licensing of Assisted Living Directors  Facility responsibilities and requirements  Surveys, investigations, and enforcement

12 Two Categories of Licensure

Assisted Living License Assisted Living License w/Dementia Care

• Provides housing and AL services to residents • Can advertise, market, or promote as providing specialized care for residents with dementia • May provide AL services to residents with dementia • Must meet requirements of AL Facility license and additional requirements: • Must meet resident’s assessed needs o License

• Diagnosis does not dictate setting o Training • Prohibited from having a secured dementia o Programming care unit • May have a secure dementia care unit

13 Definitions

RESIDENT ASSISTED LIVING (144G.08 Subd. 59) CONTRACT (144G.08 Subd. 5) A person living in an assisted living The legal agreement facility who has between a resident and an executed an assisted living facility for assisted living housing and, if applicable, contract. assisted living services.

14 Minimum Requirements - Staffing

Staffing (144G.41 Subd. 1 (11)(12)) . Biannual evaluation of staffing levels . Must always meet the scheduled and reasonably foreseeable unscheduled needs of each resident . One or more persons are awake and available 24/7

(144G.81 Subd. 4) An assisted living facility with dementia care providing services in a secured dementia care unit must have an awake person who is physically present in the secured dementia care unit 24 hours per day, seven days per week, who is responsible for responding to the requests of residents for assistance with health and safety needs and: . capable of communicating with residents . capable of providing or summoning the appropriate assistance . capable of following directions

15 Physical Environment - Highlights

Starting August 1, 2021: ▪ A physical environment survey every two years ▪ Plan reviews and final construction inspections for a new license or new construction, by MDH ▪ Smoke detectors in each occupied room or automatic sprinkler system ▪ Portable fire extinguishers and fire drills ▪ Physical environment in good repair ▪ Existing buildings must always be maintained in a manner that does not “constitute a distinct hazard to life”

16 Meal Requirements – 144G.41 Subd. 1 (13)

Offer to provide or make at least three nutritious meals daily with snacks available. This includes: o seasonal fresh fruit and fresh vegetables o menus must be prepared at least one week in advance o meal substitutions must be of similar nutritional o residents must be informed in advance of menu changes o food must be prepared and served according to the Minnesota Food Code o cannot require a resident to include and pay for meals in their contract

17 Assisted Living Director - Highlights

Licensed Assisted Living Director (LALD) ▪ Board of Executives of Long-Term Services and Supports (BELTSS) • Approves director’s qualifications and training • MDH will check licenses upon ALL application review ▪ LALD = Person who administers, manages, supervises, or is in general administrative charge of an assisted living facility

18 Surveys and Enforcement - Highlights

Surveys ▪ Assisted Living Facilities surveyed every two years ▪ Provisional (new) licenses surveyed within one year Enforcement ▪ Increased fines for violations ▪ Fine for substantiated maltreatment finding ▪ Follow-up surveys required for Level 3/Level 4 violations

19 144G.90 REQUIRED NOTICES. Subdivision 1.Assisted living bill of rights; notification to resident. (a) An assisted living facility must provide the resident a written notice of the rights under section 144G.91 before the initiation of services to that resident. The facility shall make all reasonable efforts to provide notice of the rights to the resident in a language the resident can understand.

RESIDENT RIGHTS AND PROTECTIONS 144G.91 ASSISTED LIVING BILL OF RIGHTS

Subdivision 1.Applicability. Subd. 7.Courteous treatment.

Subd. 2.Legislative intent. Subd. 8.Freedom from maltreatment.

Subd. 3.Information about rights. Subd. 9.Right to come and go freely.

Subd. 4.Appropriate care and services. Subd. 10.Individual autonomy.

Subd. 5.Refusal of care or services. Subd. 11.Right to control resources.

Subd. 6.Participation in care and service Subd. 12.Visitors and social participation. planning.

21 Bill of Rights continued

Subd. 20.Grievances and inquiries. Subd. 13.Personal and treatment privacy. Subd. 21.Access to counsel and advocacy Subd. 14.Communication privacy. services.

Subd. 15.Confidentiality of records. Subd. 22.Information about charges.

Subd. 16..Right to furnish and decorate. Subd. 23.Information about individuals providing services. Subd. 17..Right to choose roommate. Subd. 24.Information about other providers and services. Subd. 18.Right to access food. Subd. 25.Resident councils. Subd. 19.Access to technology. Subd. 26.Family councils.

22 Assisted Living Facility Staff Training

Required Orientation

• Who: All staff providing and supervising direct services to residents

• When: Before providing assisted living services to residents

• What: Assisted living facility licensing requirements/regulations

23 Required Annual Training

Who: All staff providing direct services to residents

When: Eight hours completed for every 12 months of employment

What: Topics relevant to providing assisted living services and must include: • Reporting of maltreatment of vulnerable adults under section 626.557 • Review of assisted living Bill of Rights and how to operate within them • Review of infection control techniques • Effective problem-solving approaches when working with challenging resident behaviors • Facility’s policies and procedures related to assisted living services provision • Principles of person-centered planning

24 Required Dementia Training

Who: Supervisors of direct-care staff When: Eight hours within 120 working hours of start date

Who: Direct-Care staff When: Eight hours within 160 working hours of start date

Who: Non-direct-care staff (maintenance, housekeeping, food service, etc.) When: Four hours within 160 working hours of start date

25 Dementia Training Content

Content must include:  An explanation of Alzheimer’s disease and other dementias  Assistance with activities of daily living  Problem solving with challenging behaviors  Communication skills  Person-centered planning and service delivery

26 Delegated Nursing Tasks

Prior to providing delegated nursing services to assisted living residents, unlicensed personnel (individuals not otherwise licensed or certified by a governmental health board or agency who provide services to a resident), including temporary staff, must complete a written or oral test to demonstrate competency on the following: . documentation requirements . reports of changes in the resident's condition . basic infection control . maintenance of a clean and safe environment . training on the prevention of falls . medication, exercise, and treatment reminders

27 Delegated Nursing Tasks Cont.

. basic nutrition . preparation of specialized diets . communication skills . awareness of confidentiality and privacy . understanding appropriate boundaries . procedures to use in handling various emergency situations . awareness of commonly used health technology equipment . observing, reporting, and documenting resident status . basic knowledge of body functioning and changes in body functioning, injuries . recognizing physical, emotional, cognitive, and developmental needs of the resident

28 Practical Skills Test

A practical skills test on the following items is required:

. A ppropriate and safe techniques in personal . Safe transfer techniques and hygiene and grooming, including: ambulation • hair care and bathing . R ange of motioning and • care of teeth, gums, and oral prosthetic devices positioning • care and use of hearing aids . A dministering medications or • dressing and assisting with toileting • standby assistance techniques and how to perform treatments as required them . A ny other delegated tasks not • reading and recording temperature, pulse, and included in this list respirations of the resident

29 Delegation of Medication Administration

When administration of medications is delegated to unlicensed personnel, the assisted living facility must ensure that the registered nurse has:  Taught proper methods  ULP demonstrates competent ability to the RN  RN provides specific instructions in the resident record  Communicate the individual needs of the resident to ULP

30 Assisted Living facility with Dementia Care Staff Training

Required Dementia Care Training:

Who: Direct-Care employees When: Eight hours within 80 working hours of start date

Who: Non-direct-care staff (maintenance, housekeeping, food service, etc.) When: Four hours within 160 working hours of start date

31 Content Included

 An explanation of Alzheimer’s disease and other dementias  Assistance with activities of daily living  Problem solving with challenging behaviors  Communication skills  Person-centered planning and service delivery

32 Supervising Staff Training

Persons providing or overseeing staff training must have experience and knowledge in the care of individuals with dementia, including:

 Two years of work experience related to Alzheimer's disease or other dementias, or in health care, gerontology, or another related field.

 Completion of training per above content and successfully passing a skills competency or knowledge test required by the commissioner.

33 Assisted Living Director Required Training

The assisted living director of an assisted living facility with dementia care must complete and document that at least ten hours of the required annual continuing educational requirements related to the care of individuals with dementia.

34 Uniform Disclosure of Assisted Living Services and Amenities

35 Introduction to UDALSA

Proposed Rule: Statute: 4659.0090 Subp. 3 144G.40 subd. 2 (www.health.state.mn.us/facilities/regulation/assi (www.revisor.mn.gov/statutes/cite/144G.40) stedliving/docs/proposedrules.pdf) All facilities must provide to prospective residents. Submission of checklist to commissioner. A) An applicant or licensee shall submit a completed checklist with the license application or Purpose: renewal. B) Whenever a facility changes the services that Describe the services, supports, and amenities the facility offers under the assisted living facility available at the assisted living facility. contract, the facility must submit an updated checklist to the commissioner within 30 calendar days of the change in services.

36 How the Senior LinkAge Line Can Help You

Elissa Schley Options Counseling Policy Analyst

We Are Aging | mn.gov/senior-linkage-line 37 Senior LinkAge Line Contact Centers

• Dancing Sky Area Agency on Aging • Arrowhead Area Agency on Aging • Central Minnesota Council on Aging • Trellis • Minnesota River Area Agency on Aging • Southeastern Area Agency on Aging What the Senior LinkAge Line offers

Free Neutral Objective

We Are Aging | mn.gov/senior-linkage-line 39 How you can connect

There are many ways to connect with the Senior LinkAge Line. • Call • In-person • Online • Via chat Call the Senior LinkAge Line

800-333-2433

We Are Aging | mn.gov/senior-linkage-line 41 Connect online: mn.gov/senior-linkage-line Connect online: Minnesotahelp.info

Minnesotahelp.info Housing Support

• Support and counsel people deciding to move or remain in their home • People press Option 1 for dedicated support • Provide options to help meet their needs • Goal is to help people before a crisis • Housing with Services Managers can make a referral online

4/21 We Are Aging | mn.gov/senior-linkage-line 44 Verification Codes

Verification code is: • “Verification of the counseling” • Required for assisted living • Generated by SLL staff or Lead Agency Staff • Shared with housing manager • Good for life

4/21 We Are Aging | mn.gov/senior-linkage-line 45 Submit Referrals Online 24/7

• mn.gov/senior-linkage-line • mn.gov/board-on-aging/

Direct link: https://mnhelpreferral.revation.com/

4/21 We Are Aging | mn.gov/senior-linkage-line 46 800-333-2433

We Are Aging

We Are Aging | mn.gov/senior-linkage-line 47 OFFICE OF OMBUDSMAN FOR LONG-TERM CARE

Maisie Blaine, Ombudsman Specialist Office of Ombudsman for Long-Term Care March 15th, 2021

Ombudsman Funding, Structure, and Mandate

. “Ombudsman” is a Swedish . A program of the Older Americans word for “advocate” Act (OAA) in each state to: . Every state is required to have • Investigate and resolve a full time Ombudsman: Cheryl complaints Hennen, SLTCO • Provide information to residents, . Administered through the families, staff (e.g., residents’ Minnesota Board on Aging rights) since 1980 • Advocate for systemic changes to improve residents’ care and quality of life. OOLTC Central Person-Centered Client Advocacy Intake Line in . The OOLTC serves adults seeking or receiving St. Paul: licensed long-term care services and supports 651-431-2555 or in Minnesota 1-800-675-3591 • No income screening Answered 8-4:30 • No citizenship requirement Mon - Fri • No referral requirement . Welcome calls from residents, family, friends, Email: MBA.OOLTC@ and facility staff state.mn.us . Free and confidential service of the Minnesota Board on Aging Statewide Region-Based Advocacy • Growing to 25 Regional Ombudsman staff • 35 trained Certified Ombudsman Volunteers • Call the Central Intake Line to find your Regional Ombudsman: 651-431-2555 or 1-800-675-3591 The OOLTC supports people receiving MN Facility licensed services in these MN settings: Types • Nursing homes (skilled nursing facilities, SNFs) • Assisted Living (AL) and Housing with Services (HWS) settings • Hospice clients • Adult foster homes • Licensed home care clients in private homes • Medicare beneficiaries with hospital access or hospital discharge concerns Three Ombudsman Words: Mission Statement 1. Educate and 2. Empower To empower, educate, and advocate consumers alongside Minnesotans who are to receiving long-term care services 3. Advocate and supports to ensure their rights for are upheld. themselves. . Residents have the right to complaint or file grievances to their homecare or assisted living provider. Residents . It is illegal, a misdemeanor, for anyone to Have a Right retaliate when a resident does assert their to Use rights to ask for help of an Ombudsman. Ombudsman . If a resident fears retaliation or believes they are being retaliated against they can: Services • make a report to the Minnesota Adult Abuse Reporting Center (MAARC) and • ask for advocacy services from the OOLTC. Prevention Work & Systemic Advocacy

. Supporting resident and family . Work with regulators, legislators councils and others to institute systemic . Unannounced visits to facilities change . Consultations with residents, family, and facility staff . Elder Care and Vulnerable . Partnerships with MDH survey Adult Act of 2019 and complaint teams, DHS, local OOLTC was a key advocate for APS teams, Senior LinkAge reforms to the assisted living Line, provider groups, and many laws in Minnesota. others . Community education events 144G Establishes Strong Consumer Protections The new license establishes strong consumer protections for assisted living residents: • Requires facilities to sit down and meet with residents before issuing a notice of termination of housing and services, and to collaborate with the resident in identifying reasonable accommodations to avoid the termination; • Prohibits retaliation by a facility for an assisted living resident or family member who asserts their rights under the law; • Allows a resident to appeal a termination; Strong Consumer Protections cont.. The new license establishes strong consumer protections for assisted living residents: • Requires facilities to coordinate a resident’s relocation to a safe location and appropriate service provider; • Requires a clinical nurse supervisor on staff; and • Requires facilities to always have sufficient staffing to meet the scheduled and reasonably foreseeable unscheduled needs of each resident 24 hours a day. Rights Related to License Type Assisted Living License Assisted Living with Dementia Care • May provide care to those with • May have secured dementia care dementia if they can meet needs unit • You may have to move if your • Must provide specialized dementia needs exceed the new license care services type *Notice requirements apply • Staff must have specialized training • You have a right to receive in dementia care advanced notice of any changes • You have a right to receive advanced in services notice of any changes in services My Housing with Services Provider is closing…

My housing provider is closing, what do I need to know? • You may have to move. • If you receive home and community-based services, your case manager must be notified. • You have a choice in where you go and what services you choose to receive from your next provider. • You have a right to a coordinated transfer if you receive assisted living services. My HWS Provider is closing…I must be notified

. Provider must give advance written notice (no later than May 31, 2021) of its intent to no longer provider home care/assisted living services. . Notice must include: • the date when the HWS provider will no longer provide housing with services; • the name, date, e-mail address, and phone number of a person connected to the HWS establishment whom you can contact to discuss the notice; • the contact information to the Office of Ombudsman for Long-Term Care and Office of Ombudsman for Mental Health and Developmental Disabilities; My HWS Provider is closing…my rights as a Tenant You have rights as a tenant under MN Landlord Tenant Law: • You cannot be forcibly removed/evicted; • Your landlord cannot retaliate against you for your good faith effort to enforce your rights as a tenant; or • Your landlord cannot physically lock you out from your rental unit or otherwise prevent you from living there without a court order. My Housing Provider is transitioning… My housing provider is transitioning to the new assisted living license. How does this affect me?

• You have the right to advanced The following links provide other important notice if the services provided to rights that could apply: you are being reduced, limited • Addendum to 2020 Home Care, Assisted Living and or changed. Housing with Services Laws (www.health.state.mn.us/facilities/regulation/homecare • You have the right to advanced /docs/providers/alldecchanges.pdf) notice if the cost you pay for • 144A.44 Home Care Bill of Rights services will change or if the (www.revisor.mn.gov/statutes/cite/144A.44) provider will no longer accept • 144A.441 Assisted Living Bill of Rights Addendum certain payment types. (www.revisor.mn.gov/statutes/cite/144A.441) • 144A.442 Assisted Living Clients; Service Termination (www.revisor.mn.gov/statutes/cite/144A.442) Rights Related to Assisted Living Licensure What happens during the My facility is changing their transition time? services and/or cost, how does • If your housing provider is transitioning this affect me? to the new license, your care and • You have the right to receive advanced services should not be disrupted notice of any changes in service • You continue to have the right to receive provided or changes to the cost of care and services in the manner service provided promised in your service plan. • You have a right to receive advanced • You continue to have the right to have notice if your payer type is no longer trained and competent staff provide your being accepted care What if I don’t receive notice by May 31, 2021? . You may not be required to receive notice if your housing provider is pursing the new license and not changing services, cost, or accepted payment type. . A notice of change in services, cost or accepted payment type may not need to be 60 days in duration. . Contact your housing manager or facility leadership to find out if they intend to pursue the license or change services. . If you still have questions: • Contact the Office of Ombudsman for Long-Term Care • Contact the MN Department of Health What if I live in a Public Housing Setting?

• Some facilities operated by the Housing and Urban Development (HUD) and/or the Federal Housing Administration (FHA) can continue to provide housing and services to its residents and are not required under the law to obtain the new assisted living facility license. • Contact your housing manager and ask them if the facility will be applying for the new assisted living license. • If you still have questions, please call the Office of Ombudsman for Long-Term Care. Contact Information Maisie Blaine, Ombudsman Specialist [email protected] (651) 431-8842

OOLTC Intake Line 651-431-2555 or 1-800-675-3591 Answered 8:00 - 4:30, Monday - Friday P.O. Box 64971, St. Paul MN 55164-0971

Office of Ombudsman for Long-Term Care A Free and Confidential Service of the MN Board on Aging Website: https://mn.gov/board-on-aging/; Email: [email protected] ”Giving Voice to Those Seldom Heard” https://mn.gov/omhdd/ Main Office: 651-757-1800 Toll Free: 1-800-657-3506 Andrea Strobel-Ayres RO Supervisor

[email protected] 651.757.1808 OMHDD in Minnesota

 Established in 1987  Independent State Agency  Appointed by the Governor  Policy set by Legislature  NOT a Regulatory Agency  NOT DHS  10 Regional Offices Mission Statement

…promote the highest attainable standards of treatment, competence, efficiency and justice for persons receiving services for mental health, developmental disabilities, chemical dependency or emotional disturbance. Who we serve

Minnesotans with concerns or questions for themselves, clients, family, friends, regarding: • mental health • developmental disabilities • chemical dependency • emotional disturbance This includes children and adults. What is an Agency, Facility or Program

Agency: the divisions, officials or employees of the Departments of Human Services, Health or Education, local school districts, or county social service agencies that monitor, provide or regulate services or treatment to clients of the OMHDD Facility or Program: a residential or non-residential program or an acute care inpatient facility that provides clients with services or treatment, that is required to be licensed, certified, or registered by DHS, DOH, or MDE Why Call the Ombudsman?

Any person may call with:  A concern or complaint about services  A question about client rights  A question about an action of an agency or program  A question about access to services or service options  A question about the laws and rules that apply to services  A question about guardianship or conservatorship  A general question concerning services Things the Ombudsman can do

 Mediate or advocate on behalf of a client or group of clients  Consult with providers about policies, practices and procedures  Gather and analyze information  Conduct reviews and investigations  Review serious injuries and death reports  Examine records  Visit programs  Recommend corrective actions, issue reports and monitor results  Identify systemic issues and need for legislative action Priority Issues

 Practices that diminish client dignity, respect, productivity, community integration or independence  Concerns about health, safety and welfare  Situations of abuse or neglect  Quality of care or services received  Violation of client rights  Access to appropriate services  Suspension or Termination of services  Clients’ opportunities to direct and make choices about where they live, work and socialize Other matters appropriate for review

Actions of an agency, facility or program that:  may be contrary to law or rule  may be unreasonable, unfair, oppressive, or inconsistent with a policy or order of an agency, facility or program  may be mistaken in law or arbitrary in the ascertainment of facts  may be unclear or inadequately explained, when reasons should have been revealed Serious Injury Reviews

 Timely, appropriate medical care  Coordination of care and follow up services  Appropriate treatment planning and risk management  Medication changes  Access to appropriate residential options and supports  Adequacy of existing policies/practice/protocols  Evidence of injury prevention efforts  Staff training  Compliance with state laws, rules and relevant policies  Trends or clusters of similar system issues Questions? ”Giving Voice to Those Seldom Heard” https://mn.gov/omhdd/ Main Office: 651-757-1800 Toll Free: 1-800-657-3506 ALL Website

Assisted Living Licensure (www.health.state. mn.us/facilities/ regulation/ assistedliving/

80 Any Questions?

81 Thank you.

Lindsey Krueger - [email protected]

WWW.HEALTH.MN.GOV