HEALTHCARE FACILITY REGULATION Presented by: Elaine Wright Director, Personal Care Home Program

Fire Safety Symposium June 21, 2016 Regulations for Personal Care Homes/Assisted Living Facilities Community Living Arrangements and Adult Day Centers Fire Safety Symposium June 21, 2016 (n) “Written plan of care” means the specific set of written instructions which have been determined necessary, usually by a registered professional nurse, to implement the written orders of the attending physician or an advanced practice registered nurse or physician assistant working under a nurse protocol agreement or job description respectively. Facility is required to - Maintain a copy of the written plan of care for the individual with a disability which has been developed by a licensed healthcare professional pursuant to written orders of an attending physician, or an advanced practice registered nurse or physician assistant working under a nurse protocol agreement or job description respectively. (d) Determine that the written plan of care provided specifies the health maintenance activities to be performed, the frequency of training and evaluation for the proxy caregiver and the kinds of changes in the written plan of care that would necessitate additional training for the proxy caregiver. (d) Ensure that a written plan of care is developed for the individual with a disability by a licensed healthcare professional in accordance with the written orders of an attending physician, an advanced practice registered nurse or physician’s assistant working under a nurse protocol agreement or job description respectively, and that such plan of care specifies the frequency of training and evaluation requirements for the proxy caregiver and when additional training will be required for new duties added to the written plan of care for which the proxy caregiver has not been previously trained. The licensed facility must either use the written plan of care form made available by the Department or another form containing all the required elements. (e) Ensure that the written plan of care is implemented by appropriately trained proxy caregivers who have been specifically designated by the individual with a disability or the legally authorized representative. (f) Maintain documentation of the specific training that was provided on the health maintenance activities that the proxy caregiver performs. The documentation must include a competency-based skills checklist completed by the licensed healthcare professional. The checklist must reflect that the proxy caregiver has personally demonstrated to the satisfaction of the licensed healthcare professional the necessary knowledge and skills to perform safely the specific health maintenance activities. (g) Maintain supporting documentation reflecting that the employee or contractor serving as the proxy caregiver has the basic qualifications as represented, e.g. no findings of abuse, neglect or exploitation entered against the individual in the nurse aide registry, a satisfactory report of motor vehicle driving record where the proxy caregiver may be transporting clients and a satisfactory criminal records check where required by other rules applicable to the specific licensed facility. (h) Maintain written evidence of satisfactory performances on initial and annual skills competency determinations utilizing skills competency checklists which have either been made available by the department or developed and completed by appropriately licensed healthcare professionals. The competency-based skills checklists must reflect a testing of the knowledge and observation of the skills associated with the completion of all of the discrete tasks necessary to do the specific health maintenance activity in accordance with accepted standards of care.

DCH Mission ACCESS RESPONSIBLE HEALTHY Access to affordable, quality health care in our communities Responsible health planning and use of health care resources Healthy behaviors and improved health outcomes First … The Mission of the Department of Community Health is … Access

AGENDA Introduction Licensure Requirements Residents – Admission/Retention Criteria Waiver or Variance Requirements Fire Safety Inspections and Reports Complaints Questions (f) an acknowledgement that proxy caregivers are not licensed healthcare professionals and do not have the same education and training as licensed healthcare professionals. Therefore, there may be additional health risks associated with receiving this care from proxy caregivers who may not recognize an important change in the individual’s medical condition requiring assessment and/or treatment; (g) an acknowledgment that the individual with a disability, or the legally authorized representative consents and is willing to take such risks; (h) that the informed consent is conditioned upon the proxy caregiver(s) being determined by an appropriately qualified licensed healthcare professional to have the knowledge and skills necessary to perform safely the specific health maintenance activities listed on the consent; (i) a statement that the informed consent for any proxy caregiver designated to deliver health maintenance activities may be withdrawn orally or in writing by the individual with a disability or the legally authorized representative by informing the proxy caregiver and any licensed facility through which the proxy caregiver may be operating; and (j) an authorization for such health maintenance activities to be provided which is signed and dated by the individual with a disability or the legally authorized representative.

Definition PCH/ALC – residence that provides Housing Meals and one or more: Personal services, i.e. assistance with eating, bathing, grooming, dressing, toileting, or supervision of medications To two or more adults unrelated to owner by blood or marriage ALC 25 or more, structure of the bldg., enough staff to evacuate all to point of safety requires CMA to administer medication

Definition-2 Community Living Arrangement (CLA) – same but for DBHDD population Service differences Admission differences DBHDD verifies the residence will exclusively serve DBHDD residentially-funded consumers Usually 2-4 consumers only .

Definition - 3 ●Adult Day Care Social Model ●Adult Day Health Care Medical Model ●Effective January, 2015 ●Services to 3 or more participants, requires licensure If serving exclusively the developmentally disabled- exempt Had informal rules advisory workgroup that met 4 times … We concluded with a town hall meeting

Licensure Requirements Permit is required when Housing, food service and personal services are provided to two or more residents Exemptions - boarding homes, host homes, care of family members or one resident, shelters - Referral to local inspectors, i.e. planning, zoning, business license, etc. - Referral to fire department 3 or more day care participants Investigate unlicensed personal care homes

Application requirements Electrical Inspection Fire Safety Inspection CRC for owner/administrator Proof of possession of property ID affidavit Local zoning approval Floor plan HFRD on-site Inspection

Fire Safety Inspection ● Inspection, required of each PCH, regardless of size with occupancy load ● From fire department having jurisdiction ● 7+ Residents - Fire Safety Inspection from State Fire Safety Inspector (or local fire authority) ● 2-6 Residents – possible Private Fire Safety

Residents Personal Care Home should admit and retain only residents who Are 18 years of age or older Do not require restraints, isolation, confinement Are not bed bound Do not require continuous nursing care and services Do not require more care than the PCH can provide

Residents-2 PCH residents must be Ambulatory Resident has ability to self-preserve with minimal assistance, i.e. staff assist in transferring and respond to verbal directions to self-propel to exit Resident has ability to move from place to place by propelling wheelchair or using walker

Residents ● Must meet admissions criteria ● Retention criteria is same as admissions criteria

Variences and Waivers Definition Waiver Variance Waiver regulations provide for exceptions to rule Provisions of rules can be waived Provisions of law cannot be waived

Waiver/Varience Process Policy Forms Provider identifies rule(s) to be waived Submits to HFR Place the request on the Rules Waiver Register maintained by SoS for 15 days Open for public comment Waiver policy available on website. Identify rule – tell us why you’re requesting it, what you plan on doing in lieu of meeting the rule. Variance – the particular rule or regulation that is the subject of the variance request should not be applied as written because strict application of the rule would cause undue hardship. There should be adequate standards affording protection for the health, safety and care of the residents and these standards will be met in lieu of the exact requirements of the rule or reg in question. Waiver – the Department may dispense entirely with the enforcement of a rule or regulation by granting a waiver upon a showing by the applicant that the purpose of the rule or regulation is met through equivalent standards affording equivalent protection for the health, safety, care and rights of the residents. 2. List the specific rule(s) (citations) for which variance or waiver is being requested (e.g. 290-5-35-.15(1) (c): 3. Action requested (check one): Variance or Waiver (A variance is a request to permit some variation from the literal requirements of the rule. A waiver is a request to dispense with compliance with the rule entirely with no alternative standards proposed to be met for the specific rule to be waived.) 4. What are the facts that support a claim of substantial hardship? How do they justify the variance or waiver: 5 What alternative standards do you agrees to meet instead of the rule: 6. Explain how the alternative standards will afford adequate protection for the public health, safety and welfare: 7. Explain the reason why the variance or waiver requested would serve the purpose of the underlying statute: 8. The length of time that the variance or waiver is requested to last:

Process-2 Request is on website for 15 days Meet internally to review Review facility’s compliance history Review facility’s waiver history Review specific documentation sent To include Fire Safety Approval Form

Process -3 For waiver of HFRD admission criteria, info includes 1. Date of admission of resident 2. Current physical exam 3. Floor plan - indicate resident’s room, exits/ramps and escape routes identified 4. Current staffing schedule/sitter schedule 5. Copy of the last 3 fire drills 6. Hospice Plan of Care, if applicable 7. A statement from the appropriate fire official

Process-4 Written statement from fire authority Levels of care Not an evaluation of the resident Not a recommendation re waiver Asking for a FS evaluation, given information regarding resident population/location etc. Asking for feedback

Fire Safety Approval Form

Process -5 Review and make recommendation Have sufficient information? Physician report match HFR assessment? HFR evaluates based on compliance with rules

Process -6 Make waiver/variance decision Establish conditions Changes in resident status Care and services Fire safety Admissions Staffing Other services Changes in Ownership

Process-7 Follow-up on subsequent surveys Is facility meeting conditions of waiver? Are there care issues? Additional residents who do not meet the admission/retention criteria Review fire drills

Rule Requirements HFR may require repeat fire safety inspection of any PCH If physical plant undergoes substantial repair, renovations, additions If HFR believes residents may be at risk If there is a substantial increase in the amount of personal assistance offered to residents Keyed Locks

HFR Surveyos Are NOT fire inspectors Rely on fire safety inspections Conduct initial inspections Review policies and procedures Review disaster preparedness plans Review fire safety inspection Survey for HFR rules Facility should have no residents

HFR Surveyors-2 Conduct annual inspections Review changes in policies and procedures Review changes in disaster preparedness plan Survey for ORS rules Review fire drill reports Observe / interview residents Determine resident needs Review staffing schedules

HFR Surveyors-3 Conduct complaint investigations Focused inspections based on allegations Complaints regarding inappropriate residents Result in violations being cited Facility must submit plan of correction Follow-up visit must confirm compliance Negative outcome for resident or failure to achieve or maintain compliance may result in adverse actions

HFR Surveyors -4 Primary role re Fire Safety Identify potential problems/issues Make appropriate referrals as needed

Referral to Fire Safey When obvious fire safety violations Keyed locks/Blocked egress etc When there are questions about FS compliance e.g. drills do not show complete evacuation When four or more inappropriate residents When evacuation times exceed 13 minutes When we’re considering waiver request re admission/retention

Fire Drills Review fire drills on survey If questions, may suggest fire drill monitored by local fire department If questions, may request to be notified of time of next fire drill Excessive evacuation time will result in violations cited and POC by facility

Referral to HFR Allegations that facility is operating without a permit Questions regarding facility’s staffing Questions regarding abuse, neglect or exploitation Issues regarding care and services If residents are improperly placed If evacuation times cannot be met Improperly placed – may need NH and are in ALC or PCH. Not meeting evacuation times – we can survey for residents meeting the admission/retention criteria and sufficient staffing. Recently, we had a facility where a fire started in the water heater which was located in the basement of the facility. The six residents were evacuated to safety and 911 was called. The county Fire Marshall , Building Inspector, and Police Detective inspected the facility as a result of the fire. Multiple fire code violations and building code violations were issued. The Fire Safety report stated that the facility had five days to relocate residents or correct all fire code violations. The Fire Safety Report listed violations which included: multiple electrical issues; structural issues; an open breaker hooked to ceiling light fixture; air conditioning unit blocking a second means of escape; dryer not vented to the outside; no separation between the basement and the first floor and no fire detection system in the basement. Ten people were living in the home. The Fire Marshall had approved the home for six residents. Short version – facility did not correct the fire safety violations. We were on-site with APS to relocate the residents. Facility closed.

QUESTIONS???

Contact information Main number 404-657-5850 Applications/Waivers Director: Yolanda Smith yfsmith@dch.ga.gov 404-657-1511 Complaint number 1-800-878-6442 or 404-657-5726

Contact Information PCH program Elaine Wright, Director ehwright@dch.ga.gov 404-657-5856 Managers Roxanne Cade: rcade1@dch.ga.gov 404-657-4074 Shirley Rodrigues: serodrigues@dch.ga.gov 404-657-4302 Karen Brown: klbrown1@dch.ga.gov 404-657-3817