216 R.I. Code R. 216-RICR-40-10-1.22

Current through November 7, 2024

Section 216-RICR-40-10-1.22 - Licensing Procedures, Definitions, and Conditions for Resident-Directed Homes

1.22.1Purpose

A. Section 1.22 of this Part establishes requirements to implement the provisions of R.I. Gen. Laws § 23-17-44(e). For the purpose of this Part, the expansion of the bed capacity of a nursing facility pursuant to R.I. Gen. Laws § 23-17-44(e) shall be designated as a "Resident-directed Home."

1.22.2Scope

A. Only those nursing facilities that propose to adopt a resident-directed model of care in accordance with the following provisions of this Part shall be licensed to expand their bed capacity:

1. Except for any variance(s) granted pursuant to §1.20.2 of this Part, the provisions of § 1.22 of this Part shall be in addition to other applicable provisions of this Part.

2. A nursing facility that adopts a resident-directed home model of care shall have such a designation listed on the nursing facility's license. No separate license shall be issued by the Department for a bed expansion and adoption of the model, as provided in this Part.

3. A nursing facility may implement resident-directed home model of care either in its existing nursing facility setting, in campus-based homes or in-home settings within the community.

4. Only nursing facilities licensed in Rhode Island are eligible to expand under the culture change initiative.

5. Any nursing facility seeking to expand its licensed bed capacity under this initiative, that will result in an expenditure that meets or exceeds the criteria for determination of need review under R.I. Gen. Laws §23-15 - 2(10)(ii), shall be required to receive approval under R.I. Gen. Laws Chapter 23-15.

6. Each residential area of a resident-directed Home shall have a minimum of six (6) and a maximum of twelve (12) residents.

1.22.3Application for a Resident-directed Home

A. The Department shall develop an open and competitive process for a resident-directed Home and Requests for Applications for a resident-directed Home, to determine the licensure of expansion beds for a culture change initiative, the form and content of which shall be determined as the Department shall deem appropriate.

B. Complete Application Required. Only applications that the Department has determined to be complete shall be eligible for review. An applicant who submits an incomplete application shall receive written notification from the Department regarding the specific deficiencies and shall be allowed to resubmit a revised application to address these deficiencies within the timeframes stipulated in the Request for Applications.

C. Approval Not Implied. The announcement of an open application period does not imply that the Department will approve any or all of the submitted applications, even if the number of beds requested in the application(s) is less than the total number of available beds. The Department reserves the right to deny, or request modifications to, any and all applications consistent with its duly established statutory and regulatory authority.

D. Decision. After completion of the review process, the Department shall issue a decision granting or denying an application for a resident-directed Home. The decision of the Department is final, unless judicial review is sought in accordance with §1.21.2 of this Part.

E. Acceptance of the Department's decision by the applicant includes acceptance of all conditions attached thereto. Failure to comply with all conditions attached to the approval may result in the Department canceling or withdrawing an approval in accordance with §1.21.2 of this Part.

F. Cancellation or Withdrawal of an Approval. The Department may cancel or withdraw an approval for good cause. The Department shall provide written notification to the applicant detailing the basis for cancellation or withdrawal of an approval. Within thirty (30) days from the date of notification, the applicant shall provide written justification to the Department as to why the approval should not be canceled or withdrawn. Upon receipt of this written justification or following the expiration of the allowed thirty (30) day period, the Department shall render a decision, as applicable. The decision of the Department is final, unless judicial review is sought in accordance with §1.21.2 of this Part.

G. Application(s). Applications shall only be accepted during an open application period announced by the Department. The frequency of an open application period shall be determined by the Department.

H. Application for a resident-directed Home shall be on forms provided by the Department and shall include, but not be limited to, the following criteria:

1. A non-returnable, non-refundable application fee as set forth in Part 10-05-2 of this Title, Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health;

2. The legal name and license number of the applicant, as stated on the current nursing facility license issued by the licensing agency;

3. The total number of beds requested in the resident-directed Home application;

4. Estimated total capital expenditures, including construction and financing, and all other capital costs to implement the resident-directed Home;

5. Projected incremental annual operating expenses, for the start-up year and two (2) full years following implementation of the resident-directed Home;

6. Written evidence of financing commitment from a qualified lender for the capital expenditures to construct the resident-directed Home and working capital requirements for the first twelve (12) months of operation;

7. If no debt financing is involved, evidence that the applicant has sufficient capital to fund the proposed construction of the resident-directed Home and working capital requirements for the first twelve (12) months of operation;

8. The proposed physical address of the resident-directed Home, including a scale drawing showing the spatial relationship to the licensee's existing nursing facility;

9. A building/floor plan (to scale), prepared in accordance with §1.19.1 of this Part, including any proposed variances, and ensuring;

a. The floor plan shall demonstrate that residents' rooms are constructed around a central, communal, family-style living area where residents and staff may socialize, prepare meals, and dine together;

b. The central communal area shall, at a minimum, include:

(1) A living room seating area;

(2) An open residential-style full kitchen capable to prepare and cook resident meals;

(3) A dining area large enough for a single table, where possible, serving all residents in the home plus two (2) staff members;

c. Provide a private bedroom for each resident;

(1) Rooms shall only be shared at the request of a resident to accommodate a spouse, partner, family member, or friend;

(2) A spouse, partner, family member or friend who does not meet medical criteria for placement in the resident-directed Home may reside in the room assigned to the individual who is admitted to the resident-directed Home and who does meet the medical criteria for admission, and the nursing facility may charge room and board (and other appropriate nursing facility charges) for the spouse, partner, family member or friend who does not meet medical criteria for admission;

(3) Each resident room shall have a full, accessible private bathroom that contains at a minimum, a toilet, sink, and shower, and

(4) The entrance for each resident room shall be visible from the central communal area.

d. Be designed to be fully independent, handicapped accessible, and have overhead lift tracks that run from the bed into the bathroom in each resident bedroom.

e. Includes a secured exterior patio, garden or other outdoor space that:

(1) Allows residents to ambulate, with accommodations for assistive devices such as wheelchairs or walkers;

(2) Provides for outdoor activities;

(3) Provides seating for each resident-directed Home to protect from sun and elements under a covered area; and.

(4) Where feasible, provide a space to accommodate limited overnight guests

f. Projected staffing, by staffing classifications, for the entire nursing facility, and separately for the resident-directed Home, for the start-up year and two (2) full years following implementation of the resident-directed Home;

g. A written operations manual that describes in detail the operational systems and structure that will support and facilitate that resident-directed and person-centered care is provided to residents of the resident-directed Home, and minimally includes the following components:

(1) Procedures for the establishment, training, and operationally maintaining the following:

(AA) Routinely, at least fifty percent (50%) of direct-care staff qualified as Universal Workers;

(BB) Self-directed work team(s), assigned to the day-to-day management of the resident-directed Home; and

(CC) Personnel scheduling practice of consistent assignment of direct-care staff, as defined in this Part.

(2) Procedures for the implementation of a learning culture for staff and residents that identifies and facilitates participation by the residents in making personal and group choices in the operation of the resident-directed Home;

(3) A policy for the provision of person-centered services at the highest level of care required by a resident;

(4) A policy for the provision of services to Medicaid residents at the Medicaid reimbursement rate;

(5) Such other information or documents as deemed relevant by the Department

I. Review Criteria. The Department shall use an open and competitive process to determine the licensure of expansion beds under this culture change initiative and shall evaluate applications in accordance with the criteria and considerations contained in this Part.

J. Such evaluation shall be based upon a review of the items submitted in accordance with §1.22.3(I) of this Part. The Department may also consider any prior experience with, or knowledge of, the applicant's provision of long-term care services and licensure record.

K. Additionally, in reviewing resident-directed Home applications, the Department shall consider the applicant's regulatory compliance history, available quality and performance measurements, including resident and family satisfaction reports, and the impact of the licensure of expansion beds on the regional distribution of, and access to, nursing facility beds in Rhode Island. In analyzing the statewide impact of the expansion beds, the Department may consider any available plans or studies related to the geographical distribution of nursing facility beds, including measures of bed need, levels-of-care, and accessibility.

L. Certificate of Need Review. A resident-directed Home, whose implementation requires prior Certificate of Need review and approval pursuant to R.I. Gen. Laws Chapter 23-15 shall, within one (1) year of the approval date of the application for a resident-directed Home, submit a Certificate of Need application in a form deemed acceptable by the Department. Failure to submit an application within the specified time frame may result in the Department canceling or withdrawing an approval in accordance with §1.22.3(F) of this Part.

M. Approved Applications. All nursing facilities whose resident-directed Home applications are approved by the Department and whose implementation shall not require a prior Certificate of Need review and approval, shall comply with the following conditions:

1. The applicant shall implement the project at or under the total proposed cost;

2. The applicant shall complete the project in accordance with the proposed application;

3. The applicant shall provide information to the Department upon request; including results of studies and/or reports describing the resident-directed Home's "lessons learned" with innovative approaches to long term care, such as the culture change model of care;

4. The applicant shall obtain needed zoning approval(s) within one (1) year of the date of approval of the application;

5. The applicant shall execute a contract to initiate construction within one (1) year of the date of approval of the application and expeditiously initiate development;

6. The applicant shall file a summary progress report, including a description of costs incurred, with the Department at three (3) month intervals from the date of final Department decision until full implementation;

7. The applicant shall comply with all applicable laws, codes and Regulations unless a variance therefrom shall have been granted by the appropriate agency; and

8. Any other factors deemed relevant by the Department.

1.22.4Additional Organization and Management Requirements for a Resident - Directed Home

A. In addition to the requirements of §§ 1.5 through 1.19 of this Part, the following is required for a resident-directed Home:

1. Governing Body of Other Legal Authority: The governing body or other legal authority, through the Administrator, shall be responsible for ensuring the management and operation of the resident-directed Home routinely conforms to resident-directed and person-centered practices as defined in this Part.

2. Quality Improvement: Monitoring and review of the resident-directed Home shall be added to the review criteria for the nursing facility's Quality Improvement Plan.

3. For QI issues related to the resident-directed Homes, a member of the resident-directed Home's self-directed work team shall participate on the Home's Quality Improvement Committee.

B. Administrator

1. The Nursing Home Administrator is responsible for establishing the organizational supports and operational structure for a resident-directed Home that ensures and facilitates the control and management of the day to day activities and flow-of-life in the home is resident-directed and coordinated through self-directed work teams with appropriate medical and nursing other professional supports as would be provided in any private home or residential environment.

2. Include a central administration unit for the resident-directed Home that does not contain or utilize commercial and institutional elements and products such as physical nursing stations, medication carts, hospital or office type florescent lighting, acoustical tile ceilings, institutional style railings and corner guards, room numbering, labeling and signage that would not normally be found in a private home setting. Where Regulations require specific institutional elements, every effort shall be made to provide the institutional elements in a manner that is consistent with a private home environment (e.g., residential wall sconces used for required nurse call lights). Where Regulations require specific institutional elements, every effort shall be made to provide the institutional elements in a manner that is consistent with a resident-directed environment.

C. Personnel

1. Staffing model for a resident-directed Home shall be by consistent assignment.

2. Staffing of self-directed work teams for a resident-directed Home shall be scheduled based on the service needs of the residents and adjusted as needed to continually meet the needs of residents at all times, and should be determined for each individual resident-directed Home and not the nursing facility as a whole.

a. Self-directed work teams shall be composed of universal workers and any support staff consistently assigned to the functions of the resident-directed Home and responsible for the general administrative day-to-day activities and work functions for the home, and

b. Self-directed work teams shall collaborate with and include residents, residents' family members, and guardians in the decision making regarding the flow and content of daily living and coordination of all resident's care needs.

3. Staff Training: In addition to any State or Federal training requirements pertaining to long term care facilities, or training deemed appropriate by the nursing facility, each universal worker in a resident-directed Home shall annually and/or as needed receive in-service training on topics directly related to:

a. Resident-directed and person-centered care practices;

b. Communication and workplace conflict management; and

c. Self-directed work teams.

D. Resident Care Services

1. All resident care services shall be person-centered in their development and implemented with a full commitment to the resident-directed Home being a restraint-free environment.

2. Professional services (i.e., physician, nursing, dietetic, social, and specialized rehabilitative) shall be organized and provided by or arranged by the nursing facility for residents of the resident-directed Home and at the convenience of the residents and coordinated with the Home's self-directed work teams, similar to services that would be provided to residents in their private home; either as outpatient, or home nursing care.

a. Professional services provided in the nursing facility by licensed nursing facility staff shall not be construed as providing "outpatient" or "home nursing care" services for the residents of the resident-directed Home for purposes of health care facility licensing.

b. The nursing facility's Dietary Manager and/or consulting Dietitian shall provide staff of the resident-directed Home with consultation and in-service in the development of resident-directed menus, meal planning, and meal preparation.

E. Nothing in this Part shall prohibit the consumption of foods that are:

1. Prepared outside the resident-directed Home by family, acquaintances, or social organization, such as churches, schools, etc.;

2. Grown in or on the grounds of the resident-directed Home by residents and/or staff for residents; or

3. Prepared by appropriately licensed local retail or established eating establishments.

F. The resident-directed Home shall have at least one (1) lift motor and separate slings for each resident who requires use of a lift.

G. Environmental and Maintenance Services

1. The resident-directed Home should be designed to provide for normal housekeeping and laundry services from within the home, however, as needed or as circumstance require, such services may be provided for under the umbrella of the nursing facility's available services in terms of emergency support services; including the adoption or inclusion in the nursing facility's emergency operations plan.

H. Physical Environment

1. The resident-directed Home shall:

a. Have built-in safety features (e.g., magnetic locks on cabinets with chemicals or knives) to allow all areas of the house, including the kitchen, to be accessible to the residents during the majority of the day and night.

b. Utilize a wireless communication and notification system that shall provide for escalation of response if a signal is unanswered for a designated period of time. The signal shall be repeated and sent to other staff who were not designated to receive the original signal.

(1) Wired call or alert systems and overhead paging shall not be permitted.

c. Provide ample natural light in each habitable space provided through exterior windows.

d. Provide staff and public access to bathroom facilities.

2. Have available at least one (1) portable functional fire extinguisher accessible in the kitchen area. All fire extinguishers shall be installed, inspected and maintained in accordance with applicable National Fire Protection Association (NFPA) standards.

216 R.I. Code R. 216-RICR-40-10-1.22

Amended effective 7/3/2022
Amended effective 8/25/2022
Amended effective 10/2/2023, exp. 1/30/2024(Emergency)
Amended effective 3/7/2024