Assisted Living Facility
The Division of Public Health Licensing Services, Bureau of Residential Facilities Licensing, licenses assisted living facilities. Regulations have been in effect since November 1998. The licensure category consolidates the previous six licensure categories for residential care institutions into a universal assisted living license. This license is sub-classified based on size and level of services provided. All facilities are required to comply with resident rights, food service requirements, administration requirements, abuse reporting, and resident agreements. Training requirements vary depending upon level of care. Physical plant requirements vary depending upon size.
Legislative and Regulatory Update
In 2019, Arizona completed a rulemaking, effective January 8, 2019, to clarify that the implemented pest control program in a health care institution must comply with requirements in A.A.C. R3-8-201(C)(4). Arizona also completed a rulemaking, effective October 1, 2019, that eliminated renewal licensure for health care institutions and stated that a health care institution license remains valid unless subsequently suspended or revoked by the Department or the health care institution fails to pay a licensing fee by a specified due date. Arizona enacted SB 1244 to modify the training requirements for assisted living facilities to include training that is consistent with those for in-home direct care workers. The law specifies that a person who has successfully completed the training and competency requirements developed by the state for in-home direct care workers satisfies the training requirements for assisted living caregivers, with an exception for medication administration training. The statute requires conforming regulations be issued on or before June 1, 2020. HB 2529 (2018) was enacted to create new disclosure requirements from referral agencies to prospective assisted living residents regarding any business relationship between the referral agency and the assisted living facility and related fees. The bill also imposes civil penalties on referral agencies for failure to comply. Also, in 2018, Arizona implemented new opioid prescribing and treatment requirements applicable to all health care institutions, including assisted living facilities. See A.A.C. R9-10-120.
Assisted Living Facility means a residential care institution, including Adult Foster Care, that provides or contracts to provide supervisory care services, personal care services, or directed care services on a continuing basis.
Facility Scope of Care
There are three licensed levels of care. “Supervisory Care Services” means general supervision, including daily awareness of resident functioning and continuing needs, the ability to intervene in a crisis, and assistance in the self-administration of medications. “Personal Care Services” means assistance with activities of daily living that can be performed by persons without professional skills or professional training and includes the coordination or provision of intermittent nursing services and the administration of medications and treatments by a licensed nurse. A facility licensed to provide Personal Care Services may not accept or retain residents unable to direct their own care. “Directed Care Services” means programs and services provided to persons who are incapable of recognizing danger, summoning assistance, expressing need, or making basic care decisions.
Third Party Scope of Care
Residents in Assisted Living Facilities may also receive nursing services or health-related services from a licensed home health agency, licensed hospice service agency, or private duty nurse.
Admission and Retention
A facility must not accept or retain a resident who requires physical or chemical restraints; medical services; nursing services, unless the facility complies with specified requirements; behavioral health residential services; or services that the assisted living facility is not licensed or able to provide.
Before or at the time of a resident’s acceptance by a facility, the manager must provide a copy of: (1) the residency agreement that includes information such as a list of services to be provided, list of services available at an additional fee, policy for refunding fees, and policy and procedure for terminating residency; (2) resident’s rights; and (3) the policy and procedure on health care directives.
Square Feet Requirements
Facilities must comply with all local building codes, ordinances, fire codes, and zoning requirements. Private resident bedrooms must be a minimum of 80 square feet and shared resident bedrooms must provide a minimum of 60 square feet per resident, not including a closet or bathroom.
Residents Allowed Per Room
A maximum of two residents is allowed per bedroom, with very limited exceptions, which are specified in regulations.
Shared bathrooms are permitted with at least one full bathroom with a toilet and bathtub or shower for every eight residents.
Medication administration is permitted by licensed nurses. Certified assisted living managers and trained caregivers may also provide medication assistance to residents and may provide medication administration with a physician order and proper training. The state has specific requirements for opioid prescribing and treatment. Residents in facilities licensed to provide Personal Care Services or Directed Care Services may not be bed bound, have stage III or IV pressure sores, or require continuous nursing services unless the resident is under the care of a licensed hospice service agency or continuous nursing services are provided by a private duty nurse. Assisted living facilities licensed to provide Personal Care Services may also not admit or retain residents who are unable to direct self-care. Additionally, these facilities may only retain residents who are bed bound or have stage III or IV pressure sores in limited specified circumstances.
A resident assessment and service plan must be initiated at the time of resident move-in and completed within 14 days of acceptance. The service plan must be updated every three months for directed care, every six months for personal care, and annually for supervisory care. Service plans must be updated, for any resident, with any change of condition. For a resident who requests or receives behavioral care from the assisted living facility, an evaluation must occur within 30 days before acceptance or the resident begins receiving behavioral care. An evaluation must occur again at least once every six months throughout the duration of the resident’s need for behavioral care.
All facilities must follow either local jurisdiction requirements or state rules, whichever are more stringent. Under state rules, if a center (assisted living center is 10 beds or more) is licensed for personal or directed care services, it must have a fire alarm system installed according to the National Fire Protection Association (NFPA) 72: National Fire Alarm Code (Chapter 3, Section 3-4.1.1(a)), and a sprinkler system installed according to NFPA 13 standards, or have an alternative method to ensure residents’ safety approved by the local jurisdiction and granted an exception by the Department. Fire inspections must be conducted no less than every 36 months by a local fire department or state fire marshal. State rules for homes require an all-purpose fire extinguisher with a minimum of a 2A-10-BC rating, serviced every 12 months.
Smoke detectors are to be installed according to the manufacturer’s instructions in at least the following areas: bedrooms, hallways that adjoin bedrooms, storage and laundry rooms, attached garages, rooms or hallways adjacent to the kitchen, and other places recommended by the manufacturer. Smoke detectors must be in working order and inspected as often as recommended by the manufacturer. Smoke detectors may be battery operated. However, if more than two violations of an inoperative battery-operated smoke detector are cited in a 24-month period, the licensee is subject to ensuring the smoke detector is hard-wired into the electrical system.
Assisted living facilities must have a designated manager who is responsible for daily operations. The regulations require that sufficient staff must be present at all times to provide services consistent with the level of service for which the facility is licensed. There are no staffing ratios.
Managers must be at least 21 years of age and certified as assisted living facility managers.
All staff must be trained in first aid and CPR specific to adults. Caregivers must: be at least 18 years of age; be trained at the level of service the facility is licensed to provide; and have a minimum of three months of health-related experience. Caregivers, which are staff who provide supervisory care services, personal care services, or directed care services to a resident, must have specified qualifications, such as completing a caregiver training program or having a nurse’s license. Assistant caregivers must be at least 16 years of age. Their qualifications, skills, and knowledge are based on the types of services to be provided and acuity of residents receiving services.
Facility staff, including assisted living managers and administrators, providing supervisory, personal, or direct care in the facility must be fingerprinted and maintain a valid fingerprint clearance card. Individuals contracted directly by residents are not required to have a card.
Entity Approving Continuing Education Program
The Board of Examiners of Nursing Home Administrators and Assisted Living Facility Managers approves CE programs for certified managers. staff who provide supervisory care services, personal care services, or directed care services to a resident, must have specified qualifications, such as completing a caregiver training program. Assistant caregivers must be at least 16 years of age.
Qualifications, skills, and knowledge are based on the types of services to be provided and acuity of residents receiving services.
Medicaid Policy and Reimbursement
Services are covered through the Arizona Long-Term Care System (ALTCS) program, which operates under a Medicaid 1115 demonstration waiver. Managed care plans contract with individual facilities to pay for services.
Arizona, Senate Bill 1244 https://www.azleg.gov/legtext/54leg/1R/bills/SB1244P.pdf
Arizona Administrative Code, Title 9, Chapter 10, Article 1: General. http://apps.azsos.gov/public_services/Title_09/9-10.pdf
Arizona Administrative Code, Title 9, Chapter 10, Article 8: Assisted Living Facilities. http://apps.azsos.gov/public_services/Title_09/9-10.pdf
Arizona Administrative Code, Title 9, Chapter 10, Article 1: General, Opioid Prescribing and Treatment.http://apps.azsos.gov/public_services/Title_09/9-10.pdf
Arizona Department of Health Services website: Bureau of Residential Facilities Licensing, Provider Information, with links to licensing tools and resources.http://www.azdhs.gov/als/residential/providers.htm
Arizona Department of Economic Security, Division of Health Care Services: Arizona Long Term Care System.https://des.az.gov/services/disabilities/developmental-child-and-adult/altcs-homeHouse Bill 2529 https://legiscan.com/AZ/text/HB2529/2018