1. Florida’s New Assisted Living Rule
Presented by
Laura Manville
Agency for Health Care Administration
Health Quality Assurance
Field Operations

2. Objectives Review the recent changes to 58A-5 FAC
Review changes in assistance with self-administration of medication
Review ALF residency requirements
Review new training requirements for ALF staff and implementation of the changes
Review and discuss recent assisted living regulatory reform, including background screening requirements

3. Definitions 58A
Anti-Embolism Stockings and Hosiery - clarification added
Assistance with Transfer– defined and clarified, language added
Day Care Participant – defined
Glucose Meter or glucometer – defined
Local fire safety authority – defined
Nursing Assessment – clarification and language added
Pill organizer – defined
Universal Precautions – clarification and language added

4. Assistance with tube feeding Monitoring of blood gases
Admission Procedures, Appropriateness of Placement and Continued Residency Criteria – 58A
Residents admitted to ALFs with Standard, LNS or LMH licenses may NOT require:
Artificial airway management, except as provided through the use of a CPAP or bipap machine
Assistance with tube feeding
Monitoring of blood gases
Management of post-surgical drainage tubes and wound vacuum devices
Administration of blood products in the facility

5. Admission Procedures, Appropriateness of Placement and Continued Residency Criteria (cont’d)
Treatment of surgical incisions or wounds, unless the incision or wound and underlying condition have been stabilized and a plan of care has been developed. The plan must be maintained in the resident’s record.

6. Admission Procedures, Appropriateness of Placement and Continued Residency Criteria (cont’d)
In addition, residents admitted to ALFs holding only standard and/or LMH licenses may NOT require any of the following services:
Hemodialysis and peritoneal dialysis performed in the facility
Intravenous therapy performed in the facility
Not require 24-hour nursing supervision
Not require skilled rehabilitation services

7. LNS - Admission and Continued Residency Criteria – 58A-5.0181
Facilities with a Limited Nursing Services license (LNS) may provide nursing care to residents:
Not requiring 24-hour nursing supervision
Who are enrolled in hospice
Who require intravenous therapy performed in the facility
Who require hemodialysis and peritoneal dialysis performed in the facility

8. ECC - Admission and Continued Residency Criteria – 58A-5.0181
Facilities with an Extended Congregate Care (ECC) license may admit residents:
Enrolled in Hospice
Requiring assistance with PEG tube feeding
Requiring dialysis performed at the facility
Administration of intravenous therapy/ blood products performed at the facility
Meet admission and continued residency criteria in 58A (5)

9. Resident Care Standards– Social and Leisure Activities 58A-5.0182 (2)
Clarifies that as part of consulting with residents regarding activities, one of the methods includes a monitored suggestion box.

10. Resident Care Standards– Rights and Facility Procedures 58A-5
Resident Care Standards– Rights and Facility Procedures 58A (6) FAC
Specifies that a facility must have a written procedure for allowing residents to recommend changes to facility policies and procedures.
Clarifies language that residents may be required to clean their own apartments/areas if the facility rules and contract include such a requirement.

11. In the presence of the resident, reading the label ALOUD
Medication Practices – FS, 58A FAC Assistance with Self-Administration of Medication
Includes:
Bringing medication in previously dispensed, properly labeled container to the resident
In the presence of the resident, reading the label ALOUD
Opening the container
Removing the prescribed amount of medication
Closing the container

12. Assistance with Self-Administration of Medication (cont’d)
Placing oral dosage in resident’s hand or another container
Applying topical medication
Returning medication container to proper storage and documenting on MOR

13. Assist with nebulizers
Assistance with Self-Administration of Medication includes - New Duties per statute and rule
Assist residents with insulin pens by dialing the prescribed amount to be injected and handing the pen to the resident for self-injection
Only insulin syringes that are prefilled with the proper dosage by a pharmacist or a manufacturer may be used
Assist with nebulizers
Use a glucometer to perform blood glucose testing

14. Examples of Prefilled Insulin Pens
Injection equipment (e.g., insulin pens, needles) should never be used for more than one person

15. Apply and remove anti-embolism stockings and hosiery
Assistance with Self-Administration of Medication - New Duties per statute and rule
Assist residents with oxygen nasal cannulas and continuous positive airway pressure (CPAP) devices, excluding the titration of the oxygen levels (NOT DIALING SETTINGS)
Apply and remove anti-embolism stockings and hosiery
Placement and removal of colostomy bags, excluding the removal of the flange or manipulation of the stoma site
Measurement of blood pressure, heart rate, temperature, and respiratory rate

16. Medication Practices – 58A-5.0185 FAC
Medication Administration – removes language including glucose testing. Also, clarifies language requiring documentation of unusual reactions to medication.
Medication Records – Clarifies and cleans up language requiring the record to be updated each time the medication is offered or administered.

17. Medication Practices – 58A-5.0185 FAC
Medication Labeling and Orders – clarifies that any changes in direction for use for medications that the facility is administering or assisting with administration for must be accompanied by an order. Orders can be written, faxed or electronic.
New directions for medications must be recorded in the record and the facility can place an “alert” label or get a revised label from the pharmacist.

18. Medication Practices – 58A-5.0185 FAC
Over the Counter (OTC) Products – A facility may now keep a stock supply of OTC products for multiple resident use.
When providing an OTC product to a resident, the name and amount provided must be recorded in the MOR.
All OTC products must be stored in a locked container or secure room in a central location.
All OTC products must be labeled with the medication name, date of purchase and a notice that the medication is part of the stock supply.

19. Medication Practices – 58A-5.0185 FAC
OTC products prescribed by a health care provider for a resident, excluding the facility’s stock supply, must be labeled with the resident’s name and manufacturer’s label for use.
A health care provider’s order for OTC products is not required when a resident self-administers his or her medications, or when unlicensed staff provides assistance with self-administration of medication.
A health care provider’s order is required when a nurse provides assistance.

20. Staffing Standards – 58A-5.019 (3)
Adds language clarifying that daycare participants AND respite residents must be included in the calculation of minimum required staffing levels in the facility.

21. Staff Training Requirements – Preservice Orientation – 58A-5.0191
New employees who are not Core trained must receive a 2-hour preservice orientation prior to interacting with residents.
Must cover resident rights, the facility’s license type, services offered by the facility

22. Staff Training Requirements – Preservice Orientation (cont’d)
Employee and administrator sign a statement documenting completion of orientation.
Statement is maintained in employee’s record.

23. Staff Training Requirements– Staff In-Service Training 58A-5.0191
Adds language indicating that the facility must use its infection control policies and procedures when training staff for the 1hour in-service infection control training.
Adds language indicating the facility must use its abuse prevention policies and procedures when offering required training on recognizing and reporting abuse, neglect and exploitation.

24. Staff Training Requirements – First Aid and CPR – 58A-5.0191
Staff with current CPR certification must have documentation that required the student to demonstrate, in person, that he or she is able to perform CPR.
Training must be approved by the American Red Cross, American Heart Association, the National Safety Council or an organization whose training is accredited by the Commission on Accreditation for Pre-Hospital Continuing Education.
2015 statutory changes and rule update removed conflict previously indicating that a nurse was considered to meet the criteria for CPR.

25. Staff Training Requirements - Assistance with Self-Administration of Medication - 58A-5.0191
Trained unlicensed staff who currently have the 4-hours of required training as of the effective date of the rule (May 10, 2018) must receive an additional two hours of training that focuses on the additional duties allowed prior to assisting with these duties.
Going forward, the requirement for new staff assisting with self-administration of medications is 6 hours of training.

26. Staff Training Requirements - Assistance with Self-Administration of Medication (cont’d)
Trained staff who have the required 6 hours of training must receive a minimum of 2 hours of continuing education every year and it may be provided online.
All medication training, including the additional two hours required to perform the new duties, must be provided by a registered nurse or pharmacist.

27. Limited Mental Health (LMH) – 429.075 FS 58A-5.029 FAC
Facilities intending to admit one or more mental health residents must have an LMH license.
Specific language was added to clarify requirements regarding missing documentation requested by the facility from the appropriate party regarding the resident and the information that must be documented.
Language was added requiring that community living support plan be updated annually or in the event of a significant change.

28. Limited Nursing Services (LNS) – 58A-5.031
Removes the list of specific nursing services and allows a facility with an LNS license to perform nursing services to residents who do not require 24-hour nursing supervision and residents enrolled in hospice who require 24-hour supervision.

29. Assisted Living Regulatory Reform
SB 622
Effective July 1, 2018

30. Assisted Living Regulatory Reform
Prohibits an assisted living facility from operating for more than 120 days without a qualified administrator.
Requires a new assisted living facility administrator to complete core requirements within 90 days of the date of employment (including training and passing the exam).
Modifies the definition of “personal services,” which closes a loophole in unlicensed activity. This change reduces the burden of proof for personal services – one or more personal services to include direct physical assistance with or supervision of activities of daily living (ADLs), self-administration of medication or similar services.

31. Assisted Living Regulatory Reform (cont’d)
Also related to unlicensed activity, the reform bill clarifies exemptions for assisted living licensure:
Includes exemptions for entities licensed by the Agency for Persons with Disabilities, a mental health facility, nursing homes, inpatient hospice, homes for special services, intermediate care facilities, and transitional living facilities.
Establishes requirements for proof of permanent residency and entitlement to exemption.
Exemption does not apply to previously licensed providers whose license was revoked or renewal was denied or voluntarily relinquished.

32. Assisted Living Regulatory Reform (cont’d)
Removes a statutory conflict related to resident records – requires a facility to provide records within 14 days after a request related to a current resident.
Aligns Agency inspection requirements with the Health Care Licensing Procedures Act by removing survey frequency language from every 24 months and adding language for monitoring visits in s , F.S; and
Removing the language “during any calendar year in which no survey is conducted, the agency shall conduct at least one monitoring visit of each facility cited in the previous year for a class I or class II violation, or more than three uncorrected class III violations” from s , F.S.
A new service not previously provided can be charged immediately to the resident without a 30 days notice.

33. Assisted Living Regulatory Reform (cont’d)
Closes loopholes related to unlicensed assisted living facilities:
Includes additional language for entities that own, rent, or otherwise maintain a building for operating unlicensed.
Eliminates 10 days to correct unlicensed activity.
Makes technical changes to the assisted living facility bill of rights by providing specifics as to what access to “adequate and appropriate health care” actually means and removing redundant language related to Agency inspections.

34. Regulatory Reform – Background Screening
Also part of SB 622, effective July 1, 2018
Amends and Chapter 435, F.S.
Requires background screening for any person who is a controlling interest, any contractors with a licensee or provider who work for 20 hours or more per week and have access to client funds, property or living areas.
The contractor’s employer or the licensee may retain the evidence of screening.

35. Background Screening - Reminders
Retained fingerprints must be renewed every five years.
To retain fingerprints, renewals must be completed through the Clearinghouse Results Website.
Facilities are required under statute to maintain the Employee Roster .
Listing employees on the roster is the only way to ensure notification of disqualifying arrest.

36. Contact information: Laura Manville Health Facility Evaluator Supervisor