The purpose of this Section is to establish standards for
Alzheimer's/Dementia Care Units and to establish criteria for the Units, which
provide Alzheimer's/Dementia patients or residents with a positive quality of
life, consumer protection and maximum individualized care that promotes rights,
dignity, comfort and independence in the least restrictive environment.
Adherence to these rules does not exempt the facility from
complying with its licensing or registration rules. These rules are in addition
to the facility's licensing rules.
23.A.
Definitions
For the purposes of this Chapter, the following words will
have the meanings indicated:
23.A.1.
"Alzheimer's/Dementia Care Unit" means a unit that provides
care/services in a designated, separated area for patients and residents with
Alzheimer's Disease or other dementia that is able to be locked, segregated or
secured to limit access by a resident outside the designated or separated
area.
23.A.2.
"Dementia" means a clinical syndrome characterized by a decline in
mental function of long duration in an alert individual. Symptoms of dementia
include memory loss and the loss or diminution of other cognitive abilities,
such as learning ability, judgment, comprehension, attention and orientation to
time and place and to oneself. Dementia can be caused by such diseases as:
Alzheimer's Disease, Pick's Disease, Amyotrophic Lateral Sclerosis (ALS),
Parkinson's and Huntington's Disease, Creutzfeldt-Jakob Disease, multi-infarct
dementia, etc.
23.B.
Alzheimer's/Dementia Care Unit Program Disclosure
23.B.1. Disclosure Required
An entity that offers to provide or provides care for
individuals with Alzheimer's disease or a related disorder through an
Alzheimer's/Dementia Care program shall disclose the form of care or treatment
it provides that distinguishes it as being especially applicable to or suitable
for those individuals. The disclosure must be made to the Department and to any
individual seeking placement within an Alzheimer's/Dementia Care Unit or the
individual's guardian or other responsible party. The Department shall examine
and verify the accuracy of all disclosures as part of an entity's license
renewal procedure.
23.B.2.
Disclosure Content
The disclosure must explain the additional care provided in
the Alzheimer's/Dementia Care Unit and include, at a minimum:
a. The program's written statement of its
philosophy and mission that reflect the needs of individuals afflicted with
dementia;
b. The process and
criteria for placement in, or transfer or discharge from the program;
c. The process used for the assessment and
establishment of a plan of care and its implementation, including the methods
by which the plan of care evolves and remains responsive to changes in an
individual's condition;
d. The
program's staff training and continuing education practices;
e. Documentation of the program's physical
environment and design features appropriate to support the functioning of
cognitively impaired adult individuals;
f. The frequency and types of individuals'
activities provided by the program;
g. A description of family involvement and
the availability of family support programs;
h. An itemization of the costs of care and
any additional fees; and
i. A
description of security measures provided by the facility.
23.C.
Standards for
Alzheimer's/Dementia Care Units
23.C.1. Physical Design, Environment and
Safety
A home-like environment is encouraged for design of
Alzheimer's/Dementia Care Units. The design and environment of a unit shall
assist residents in their activities of daily living, enhance their quality of
life, reduce tension, agitation and problem behaviors, and promote their
safety.
a. Physical Design
In addition to the physical design standards required for
the facility's license, an Alzheimer's/Dementia Care Unit shall include the
following:
1. Adequate multipurpose
rooms for dining, group and individual activities and family visits;
2. Secured outdoor space and walkways which
allow residents to ambulate, but prevent undetected egress;
3. High visual contrasts between floors and
walls and doorways and walls in resident use areas. Except for fire exits, door
and access ways may be designed to minimize contrast to obscure or conceal
areas the residents should not enter;
4. Floors, walls and ceilings shall be
non-reflective to minimize glare;
5. Adequate and even lighting which minimizes
glare and shadows and is designed to meet the specific needs of the residents;
and
6. A staff work area which
includes a communication system such as a telephone or two-way voice actuated
call system and space for charting and storage for resident records.
b. Physical Environment and Safety
The Alzheimer's/Dementia Care Unit shall:
1. Provide freedom of movement for the
residents to common areas and to their personal spaces. The facility shall not
lock residents out of or inside their rooms;
2. Assure that all assistive equipment
maximizes the independence of individual residents;
3. Label or inventory all residents'
possessions;
4. Provide comfortable
seating in the common use areas;
5.
Encourage and assist residents to decorate and furnish their rooms with
personal items and furnishing based on the resident's needs, preferences and
appropriateness;
6. Individually
identify residents' rooms and assist residents in recognizing their rooms with
appropriate and personal items; and
7. Only use a public address system in the
unit (if one exists) for emergencies.
c. Egress Control
1. The Alzheimer's/Dementia Care Unit shall
develop policies and procedures to deal with residents who may wander. The
procedures shall include actions to be taken in case a resident
elopes;
2. If locking devices are
used on exit doors, as approved by the building codes agency and the Office of
the State Fire Marshal having jurisdiction over the facility, then the locking
device shall be electronic and release when the following occurs:
(a) Upon activation of the fire alarm or
sprinkler system;
(b) Power failure
to the facility; or
(c) Bypassing a
key button/key pad located at exits for routine use by staff for
service.
3. If the unit
uses keypads to lock and unlock exits, then directions for their operation
shall be posted on the outside of the door to allow individuals access to the
unit. However, if the unit is a whole facility, then directions for the
operation of the locks need not be posted on the outside of the door. The units
shall not have entrance and exit doors that are closed with non-electronic
keyed locks, nor shall a door with a keyed lock be placed between a resident
and the exit.
d. Waivers
1. All physical plant construction or
conversion waivers for existing Alzheimer's/Dementia Care Units
are to be submitted in accordance with Section 2.1. of these regulations.
2. Any new
construction or bed conversions for Alzheimer's/Dementia Care Units approved
after the effective date of these regulations are not eligible for
waivers.
23.
C.2. Staffing and Staff Training Every effort must be made to
provide residents with familiar and consistent staff members in order to
minimize resident confusion. All direct care staff assigned to the
Alzheimer's/Dementia Care Unit shall be specially trained to work with
residents with Alzheimer's Disease and other dementias.
a. Staffing
Only staff trained as specified in Subsections (2)(b) and
(2)(c) of this rule shall be maintained and assigned to the unit. Staffing
shall be sufficient to meet the needs of the residents and outcomes identified
by the individual care plan and sufficient to implement the full day and
evening care program. Staffing levels on the night shift will depend on the
sleep patterns and needs of residents (without control of sleep by
medications). Staffing shall be sufficient to enable each resident to maximize
their functioning, self-care and independence.
b. Training
1. Pre-Service Training
The goals of training and education for staff of
Alzheimer's/Dementia Care Units are to enhance staff understanding and
sensitivity toward the unit residents, to allow staff to master care
techniques, to ensure better performance of duties and responsibilities and to
prevent staff burnout. The trainer(s) shall be qualified individuals with
experience and knowledge in the care of individuals with Alzheimer's disease
and other dementias. The facilities shall provide a minimum of eight (8) hours
of classroom orientation and eight (8) hours of clinical orientation to all new
employees assigned to the unit. In addition to the usual facility orientation,
which would include such topics as basic resident rights, confidentiality,
emergency procedures, infection control, facility philosophy related to
Alzheimer's dementia care, wandering/egress control, the eight (8) hours of
classroom orientation should also include the following topics:
(a) A general overview of Alzheimer's disease
and related dementias;
(b)
Communication basics;
(c) Creating
a therapeutic environment;
(d)
Activity focused care;
(e) Dealing
with difficult behaviors; and
(f)
Family issues.
2.
Inservice Training
Ongoing in-service training shall be provided to all medical
and non-medical staff who may be in direct contact with residents of the unit.
Staff training shall be provided at least quarterly. The facility will keep
records of all staff training provided and the qualifications of the
trainer(s). Any training provided under the Alzheimer's/dementia curriculum may
be credited toward the required twelve (12) hours of training/contact hours for
CNAs. At least four (4) of the following topics shall be trained each quarter,
so that after six months, staff will have been trained on all of the topics
listed. Inservice training will be more comprehensive that what was provided
during pre-service orientation.
(a) An
overview of Alzheimer's disease and related dementias, to include possible
causes, general statistics, risk factors, diagnosis, stages and symptoms, and
current treatments and research trends;
(b) Communication, to include communication
losses that result from Alzheimer's/dementia, non-verbal communication
techniques (i.e. body language, facial expressions and touch), techniques to
enhance communication, validation as an approach to communication and
environmental factors that affect communication. Any training provided under
the Alzheimer's/dementia curriculum may be credited toward the required twelve
(12) hours of training/contact hours for CNAs;
(c) Creating a therapeutic environment, to
include safety issues, effective and ineffective strategies for providing care
(do's and don'ts), background noise, staff behavior, consistency, wayfinding
and temperature;
(d)
Activity-focused care, to include personal care (dressing, bathing and
toileting), nutrition and dining, structured leisure (gross motor activities,
social activities, crafts, sensory enhancement, outdoor activities, spiritual
activities, normative activities, and music - see also Section 23.C.5. -
Therapeutic Activities) and sexuality;
(e) Dealing with difficult behaviors, which
should include strategies to deal with common behavioral issues such as
wandering, sundowning, catastrophic reactions, combativeness, paranoia,
ignoring self-care; and
(f) Family
issues, such as grief, loss, education and support.
23.C.3. Admission and
Discharge
Facilities with Alzheimer's/Dementia Care Units shall have a
written policy of preadmission screening, admission and discharge procedures.
Admission criteria shall require, at a minimum, a physician's diagnosis of
Alzheimer's Disease or other dementia. The policy shall include criteria for
moving residents from within the facility, into or out of the unit. When moving
a resident within the facility, or transferring a resident to another facility
or placement, the facility shall take into account the resident's welfare. When
a resident is moved into or out of the unit from within the facility, measures
shall be taken by the facility to minimize confusion and stress resulting from
the move. For those persons undiagnosed upon admission, but exhibiting signs
and symptoms of dementia, the facility shall be required to have a diagnostic
workup completed within forty-five (45) days following admission. The admission
policy shall include criteria for moving residents from within the facility,
into or out of the unit.
23.C.4. Assessments and Individual Care Plans
Specific methods and interventions to be used to accomplish
the desired outcomes shall be disclosed in the care plan. Interventions used
may include support groups, recreational therapy, occupational therapy,
physical therapy and a variety of treatment modalities as indicated by the
resident's particular needs. Outcomes for the individual care of each resident
shall include:
a. Promoting remaining
abilities for self-care;
b.
Encouraging independence while recognizing limitations;
c. Providing safety and comfort;
d. Maintaining dignity by respecting the need
for privacy, treating the resident as an adult and avoiding talking as if the
resident is not present; and
e. Any
issue of a psychosocial nature related to the resident's preferred manner of
living and receiving care.
23.C.5 Therapeutic Activities
Therapeutic activities can improve a resident's eating and
sleeping patterns; lessen wandering, restlessness and anxiety; improve
socialization and cooperation; delay deterioration of skills; and improve
behavior management. To this end, all facilities with Alzheimer's/Dementia Care
Units shall provide for activities appropriate to the needs of the individual
residents. The following types of individual or group activities shall be
offered at least weekly:
a. Gross motor
activities (e.g., exercise, dancing, gardening, cooking, etc.);
b. Self-care activities (e.g., dressing,
personal hygiene/grooming, etc.);
c. Social activities (e.g., games, music,
reminiscing, etc.);
d. Crafts
(e.g., decorations, pictures, etc.);
e. Sensory enhancement activities (e.g.,
auditory, visual, olfactory and tactile stimulation, etc.);
f. Outdoor activities, weather permitting
(e.g., walking outdoors, field trips, etc.);
g. Spiritual activities;
h. Normative activities (e.g., domestic
tasks, household chores, etc.); and
i. Therapeutic activities (e.g.,
music)
23.C.6. Social
Services A social worker or an assigned staff person shall provide social
services to the resident and support to family members.
a. The socialization of a resident shall be
incorporated in the resident's care plan.
b. The provision of support to the resident's
family, including formation of family support groups, shall be offered by the
facility if there are no such support groups available within a reasonable
distance (e.g., ten-mile radius) from the facility.
c. Every effort shall be made by the facility
to maintain close positive relationships between family members and the
resident, unless it would be injurious to the resident.
