2800 Regulatory Compliance Guide - FINAL 03.01.2015
Bureau ofHumanServicesLicensingRCGAdult Residential LicensingEGULATORYOMPLIANCEUIDEA Tool for AssistedLiving ResidenceRegulators, Operators,and Stakeholders55 Pa. Code Chapter 2800March 1, 2015 EditionHS 2095 5/18
IntroductionWhat is Assisted Living?Chapter 2800 identifies assisted living residences as “a significant long-term carealternative to allow individuals to age in place,” and goes on to read that residents ofassisted living residences “will receive the assistance they need to age in place anddevelop and maintain maximum independence, exercise decision-making and personalchoice.” This begs the question, alternative to what? A private residence, a personalcare home, a skilled nursing facility, or all three, or something else entirely?Assisted living is not meant to be an alternative to care in any one particularlocation. It is an alternative to the primary method of providing care to older adults. Itis not uncommon for older adults to receive care in a variety of settings; such settingsmay include their own homes, personal care homes, domiciliary care homes, acute carehospitals, rehabilitation facilities, and skilled nursing facilities. Importantly, residency insuch settings is not always linear. Older adults do not move from home to personal careto skilled nursing in a direct path. Older adults are frequently moved back-and-forthfrom setting to setting for short-term and long-term lengths of stay depending on theirimmediate care needs. Not only does this prohibit a consistent sense of “home” at anyone location, it all but eliminates a person’s right to choose his or her own manner ofliving. Assisted living residences are meant to reduce the need for residents to leave thecommunity in order to receive care for chronic or acute conditions. This is madepossible by allowing assisted living residences to directly provide health and medicalservices that other non-skilled community settings may not provide directly.Additionally, many elements of Chapter 2800 address residents’ rights to selfdetermination and choice in the manner in which such care is provided.To be clear: Chapter 2800 is not meant to supplant care in a person’s privatehome, a personal care home, or any other out-of-home residential care setting. Manypeople live in such settings for the duration of their adult lives, and consider them to behome, and nothing prohibits non-assisted living residential settings from arranging thetype of care needed to permit aging in place. In short, assisted living is exactly whatChapter 2800 says it is: an alternative.2
How to Use the Regulatory Compliance GuideThis guide has been developed to provide clearer explanations of the regulatory requirements of55 Pa. Code Chapter 2800 to help assisted living residence operators provide safe environmentsand effective services to residents through regulatory compliance, and to help regulators protectresidents by conducting consistent and comprehensive inspections. It provides a detailedexplanation of each regulatory requirement, including expectations for compliance, guidelines formeasuring compliance, and the primary benefit of the requirement.Each regulation that can be measured during an inspection is included in the RCG and isaccompanied by clarifying information. The illustration below shows how regulations arepresented and how inspectors and residences can effectively use the RCG.This area lists the regulation exactlyas it appears in Chapter 2800.The “Discussion” section providesinformation about applying theregulation, including referencing otherregulations and applicable narratives.The “Inspection Procedures” sectiondescribes how inspectors maymeasure compliance with theregulation.The “Primary Benefit” sectionexplains how the regulation protectsresidents’ health, safety, and wellbeing.16f2800.16(f) - The residence shall keep a copy ofthe report of the reportable incident or condition.Discussion: Copies of all reports must be retained.Retention of the incidents in residents’ records is inaccordance with § 2800.252(10), but remember thatreportable incidents must be reviewed in aggregate as partof the residence’s quality management process pursuant to§ 2800.26(b)(1).Inspection Procedures: Inspectors will verify that copiesare retained. If necessary, inspectors will compare theresidence’s record of reports with those received by theregional office.Primary Benefit: Permits residences to review reports toidentify and address patterns of incidents and conditions thatmay otherwise be a source of harm to residents.3
“Residence”The RCG uses the word “residence” and “community” interchangeably to aid in readability. Forexample, the “resident-residence contract” is referred to as the “residence-community contract.”“Recommended”Throughout the RCG, you will repeatedly see the words “recommended” or “stronglyrecommended.” These words indicate that what you are reading is a suggestion based on bestpractices, not a regulatory requirement. Failure to follow a recommendation will not result in aregulatory violation.“Admission Date” Versus “Move-In Date”Multiple regulations (including but not limited to regulations relating to resident-communitycontracts, medical evaluations, assessments, and support plans) require certain events to occurbefore, after, or on the date of admission. Residences occasionally use the term “admission” torefer to the date a contract is signed, the date an admission fee is paid, or the date a residentmoves personal items such as furniture into the residence.The Department interprets“admission date” to mean the first day the resident resides in the residence. As such, the datethe resident begins to live at the residence is the date from which regulatory timeframes relatingto admission should be met.Grace Periods“Annually” as used throughout this guide means at least once every 12 months. A 15-day flexor grace period is allowed for any item that has a time requirement of one year or more. Thisincludes, but is not limited to: Medical evaluations (§ 2800.141) Fire-safety inspections and supervised fire drills (§ 2800.132(b)) Documentation of evacuation times and fire-safe areas (§ 2800.132(d)) Completion of ANNUAL Resident Assessments (§ 2800.225(a)(1))Unless there is a specific grace period or timeline specified in the applicable section, a 5-day flexor grace period is allowed for any item that has a time line of less than one year. This does notapply to the following: Inspecting fire extinguishers (§ 2800.131(f)) Conducting fire drills (§ 2800.132(a)) § 2800.25(a) § 2800.25(h) § 2800.51-52 § 2800.224(a) § 2800.231(c)4
Inspection ProceduresPlease note that the “inspection procedures” are guidelines, and the specific means of measuringcompliance with a regulation may differ depending on circumstances specific to the residenceand the nature of the regulatory violation.Repeated ViolationsA repeated violation is noncompliance with the same regulation number (to the most finite letteror number) on the violation report (VR) from at least the prior 12 months of VRs, to include thelast renewal inspection and all VRs issued since the last renewal inspection.Source of InspectionCompliance with regulations can be measured through three methods: “Site” – Direct observation during an on-site inspection. This includes direct observationusing all 5 senses. Site observations include the physical inspection of staff offices andprivate living quarters of staff persons or others living in the residence to assurecompliance with building-wide requirements such as the prohibition of portable spaceheaters and other unsafe practices that may be in violation of the regulations. “Records” – Inspection of written documents. This includes the inspection of writtenmaterials, electronic transmissions, photographs and other paper or verbal materials. “Interview” – Asking questions of residents, staff persons, families and others todetermine compliance. This includes unsolicited information provided orally, informalconversations and formal questioning.5
PART I:Regulations,Discussion,and InspectionProcedures6
PART I: INDEX OF REGULATIONS BY TOPICTo learn more about a particular topic, please review the applicable regulations.Regulations and regulatory clarifications are listed on the following pages in numericalorder as they appear in 55 Pa.Code Ch. 2800.TOPICAbuse ReportingAccess to Residence by DHS (formerly DPW), AAA, etc.APPLICABLE REGULATIONS15a-d5a1-4, 5bPersonal Care Needs23a-bActivities221a-cActivity Space98-99Administrator Qualifications53 a-hAdministrator Staffing56Administrator ms101a-rBlocked Exits121-123Certificate of Occupancy / Fire Safety Approval14a-dCommunications/Phone90-91Community Services222Complaints made by Residents or Family44a-gCriminal History Checks51-52Dining Room104a-eDirect Care Staff Qualifications54a-cDirect Care Staffing57-62Direct Care Training65a-iElevators97Emergency Medical Plan143a-bEmergency Preparedness107a-dExit SignsExteriorFinancial Management for Residents133100a-b20a, 20b1-10Fire Drills132a-jFire Extinguishers131a-fFire Official Notice124First Aid KitFirst Aid/CPR TrainingFlammable Material96a-c63125a-b7
TOPICFood serviceFurnitureHeat SourcesHospice ServicesLaundryAPPLICABLE REGULATIONS103a-j95126-12929105a-gMaximum Capacity13bMedical Evaluations141a-bMedications - Administration181-182Medications - Errors/Reactions188-189Medications - Labeling184a-cMedications - Prescriptions186a-cMedications - Records187a-dMedications - Resident Education191Medications - Storage183a-gMedications - Training190a-cNutrition/Meals161-164Other Laws and Regulations11a, 18Outings and Offsite Services21Personal Hygiene24PetsPosting License and VRQuality ManagementRecord le Incidents16b-fResident Records224-227Resident Records - Access254a-cResident Records - Content252Resident Records - Requirements251a-eResident Records - Retention253a-dResident Rights - Deprivation Prohibited43a-bResident Rights - List of Rights42a-zResident Rights - Notification41a-eResident-Residence Contract25a1-2, 25b, 25c1-13, 25d-hRestraints and Safe Management TechniquesSanitation, Surfaces, and EquipmentSpecial Care Units - Admission201-20281-882318
TOPICAPPLICABLE REGULATIONSSpecial Care Units - Discharge235Special Care Units – DHS (formerly DPW) Notice239Special Care Units - Locks/Alarms233Special Care Units - Physical Environment232Special Care Units - Program237Special Care Units - Resident Care234Special Care Units - Staff Training236Securing Health Care142a-dService Description223a-bService Termination228a-hSmoke Detectors130a-iSSI Recipients27a-eSwimming AreasTobaccoTraining ges106144a-d66a-c171b-d1989a-e10892-949
PART IGENERAL PROVISIONSInspections and Licenses3d2800.3(d) – The assisted living residence shall post the current license, a copy of the current licenseinspection summary issued by the Department and a copy of this chapter in a conspicuous andpublic place in the assisted living residence.Discussion: A “licensing inspection summary” is the Violation Report (VR) with a plan of correction approved bythe Department. The Department interprets “most current version” to mean: The VR that was issued with the most current license, and Any additional VRs issued between the most current license and the receipt of the next license.If there is no VR since there are no violations, the VR does not need to be posted. A “copy of this chapter” meansthe “blue book,” 55 Pa.Code § 2800.These items must be displayed in a public area of the residence, such as a public bulletin board in the residence’sentryway, in a manner easily visible and accessible to all residents and visitors.Inspection Procedures: Inspectors will view the area where the required items are posted to determine if theyare accessible to all residents and guests without assistance from staff.Primary Benefit: Permits residents, families, and visitors to learn about applicable regulations and the regulatorycompliance status of the residence and the residence’s plan to correct any violations found.10
Access5a12800.5(a)(1) - The administrator, administrator designee or staff person designated under §2800.56(c) (relating to administrator staffing) shall provide, upon request, immediate access to theresidence, the residents and records to: Agents of the Department.5a22800.5(a)(2) - The administrator, administrator designee or staff person designated under §2800.56(c) (relating to administrator staffing) shall provide, upon request, immediate access to theresidence, the residents and records to: Representatives of the area agency on aging.5a32800.5(a)(3) - The administrator, administrator designee or staff person designated under §2800.56(c) (relating to administrator staffing) shall provide, upon request, immediate access to theresidence, the residents and records to: Representatives of the Long-Term Care OmbudsmanProgram.5a42800.5(a)(4) - The administrator, administrator designee or staff person designated under §2800.56(c) (relating to administrator staffing) shall provide, upon request, immediate access to theresidence, the residents and records to: Representatives of the protection and advocacy system forindividuals with disabilities designated under the Protection and Advocacy for Individual RightsProgram of the Vocational Rehabilitation and Rehabilitation Services Act (29 U.S.C.A. § 794e), theProtection and Advocacy for Individuals with Mental Illness Act (42 U.S.C.A. §§ 10801-10851), andthe Developmental Disabilities Assistance and Bill of Rights Act (42 U.S.C.A. §§ 15041-15043).5a52800.5(a)(5) - The administrator, administrator designee or staff person designated under §2800.56(c) (relating to administrator staffing) shall provide, upon request, immediate access to theresidence, the residents and records to: The resident’s designated person, if so requested by theresident. The access to records under this paragraph is limited to the records of the resident.Discussion: An agent of the Department is any individual authorized by the Department to enter, visit, inspect,or investigate regulatory issues in assisted living residences. A representative of the area agency on aging isany individual authorized by the area agency on aging to enter, investigate, or provide services in assisted livingresidences. A representative of the Long-Term Care Ombudsman Program is any individual authorized by theLong-Term Care Ombudsman Program to enter, investigate, or provide services in assisted living residences. Arepresentative of the protection and advocacy system for individuals with disabilities program is anyindividual authorized by the program to enter, investigate, or provide services in assisted living residences. InPennsylvania, this system is currently administered by the Disability Rights Network of Pennsylvania, 1414 CameronStreet, Second Floor, Harrisburg, Pennsylvania 17103-1049, telephone number (717) 236-8110.In the case of access to residents who are not currently at the residence, access should be granted as soon theresident can return to the residence. Access must be provided to all areas of any building accessible to residentsand to areas where harmful materials may be stored.Resident records must be kept on site; other records may be kept off-site as long as such storage permitsimmediate access regardless of the day or time of the request.Inspection Procedures: “Immediate” means a reasonable period of time depending on the request. Forexample, it’s reasonable to expect a residence to produce a resident’s support plan within 10 minutes during regularbusiness hours, but unreasonable to expect off-site staff records to be delivered within 10 minutes at 2:00 AM.Primary Benefit: Allows the Department to measure compliance with all regulations. Allows area agency on agingthe ability to fulfill their legal mandate to protect older adults. Provides ombudsmen with the access necessary topromote and protect resident rights. Provides advocates with the access necessary to protect the rights of residentswith disabilities.11
5b2800.5(b) - The administrator, administrator designee or staff person designated under §2800.56(c) shall permit community service organizations and representatives of community legalservices programs to have access to the residence during visitation hours or by appointment for thepurpose of assisting or informing the residents of the availability of services and assistance. Aresident or a resident’s designated person if so authorized may decline the services of thecommunity service organization or the community legal service program.Discussion: This requirement is closely related to § 2800.222, which requires residences to encourage residentsto use social and community services available in the community.Inspection Procedures: Inspectors will interview the administrator, staff of the residence, and representatives ofcommunity service organizations who may be present at the residence or who file complaints with the Department.Primary Benefit: Allows service organizations to provide information to residents who may benefit from theirservices, and allows the residence to ensure compliance with § 2800.222.12
GENERAL REQUIREMENTSProcedural Requirements for Licensure or Approval of Assisted Living Residences11a2800.11(a) - Except for § 20.32 (relating to announced inspections), the requirements in Chapter20 (relating to licensure or approval of facilities and agencies) apply to assisted living residences.Discussion: Assisted living residences are licensed in accordance with the licensing procedures established by 55Pa.Code Chapter 20. Residences are strongly encouraged to review Chapter 20, which is available on theDepartment’s website. Knowledge of Chapter 20 is required by regulation for administrators – see § 2800.53(f).Inspection Procedures: If a violation of Chapter 20 is suspected, inspectors will cite only in consultation with theregional director and BHSL headquarters.Primary Benefit: Chapter 20 contains additional regulatory requirements, including the allowable reasons fordenial, revocation, or nonrenewal of a license.Maximum Capacity13b2800.13(b) - The maximum capacity specified on the license may not be exceeded.Discussion: “Maximum capacity” means the total number of residents who require assisted living services that theresidence is permitted to serve. The maximum capacity is different from the number of people who may reside in aresidence as determined by the residence’s certificate of occupancy. See “Certificates of Occupancy and MaximumCapacity” in the “Regulatory Issues and Frequently-Occurring Situations” section for more information. Occupantsof the residence who do not need assisted living services (sometimes referred to as “independent” residents) arenot counted when determining if the residence’s maximum capacity has been exceeded. However, becausemaximum capacity is determined in part by square footage and by the number of sinks, toilets, and showers in theresidence, the total number of persons living in a residence must be considered when determining compliance withother regulations (such as living unit square footage, number of toilets, and the like).Inspection Procedures: Inspectors will verify the total number of persons who reside in the residence. If thenumber of residents who require assisted living services exceeds the maximum capacity as specified on the license,a violation exists.Primary Benefit: Protects from overcrowding and ensures that the number of people living in the residence doesnot exceed toilet, bathing or hand-washing facilities necessary to maintain sanitary conditions.13
Fire Safety Approval14a2800.14(a) - Prior to issuance of a license under this chapter, a written fire safety approval fromthe Department of Labor and Industry, the Department of Health
Additionally, many elements of Chapter 2800 address residents’ rights to self-determination and choice in the manner in which such care is provided. To be clear: Chapter 2800 is not meant to supplant care in a person’s private home, a personal care home, or any other out-of-home residential care setting. ManyFile Size: 1MB
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