Skilled Care
in Assisted Living Facilities
W. Tom Geary Jr. MD
wt.geary@adph.state.al.us
September 15, 2010
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Skilled Care in the ALF/SCALF
• Skilled nursing care is health care given
when a person needs skilled nursing staff
(registered nurse (RN) or licensed practical
nurse (LPN)) to manage, observe, and
evaluate care.
• Skilled nursing care requires the involvement
of skilled nursing staff in order to be given
safely and effectively.
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Skilled Care in the ALF/SCALF
“The goal of skilled nursing care is to help
improve the patient's condition or
to maintain the patient's condition and
prevent it from getting worse.”
Aetna Clinical Policy Bulletin:
Skilled Home Health Care Nursing Services
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Skilled Care in the ALF/SCALF
“In determining whether a service requires
the skills of a nurse, consider both the
inherent complexity of the service, the
condition of the patient and accepted
standards of medical and nursing
practice.”
Information Bulletin 03-2 MHC-40 (for coverage of skilled home health services
in Minnesota)
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Skilled Care in the ALF/SCALF
In Alabama:
• Skilled nursing services are services rendered in
accordance with the Alabama Nurse Practice Act
(Code of Alabama, 1975, §§ 34-20 et. Seq.) and
Alabama Administrative Code (Chapter 610)
Alabama Board of Nursing.
• Skilled Nursing services are provided pursuant to
physician orders as part of a prescribed plan of
care
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Skilled Care in the ALF/SCALF
• Alabama Board of Nursing Chapter 610-X-6
• Standards of Nursing Practice
• (18) Assess individual competency when assigning selected
components of nursing care to other health care workers
including but not limited to:
• (a) Knowledge, skills and experience.
• (b) Complexity of assigned tasks.
• (c) Health status of the patient.
Author: Alabama Board of Nursing.
Statutory Authority: Code of Alabama, 1975, §§ 34-212(c)(21), 34-21-25(b).
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Skilled Care in the ALF/SCALF
Nurses must exercise good judgment when assigning tasks to unlicensed personnel:
• (4) Tasks delegated to unlicensed assistive personnel may not include tasks that
require:
• (a) The exercise of independent nursing judgment or intervention.
• (b) Invasive or sterile procedures.
(i) Finger sticks are not an invasive or sterile procedure within the meaning of
these rules.
(ii) Peripheral venous phlebotomy for laboratory analysis is not an invasive or
sterile procedure within the meaning of these rules.
• (c) The assistance with medications except as provided in Chapter 610-X-7.
• (5) Supervision shall be provided to individuals to whom nursing functions or
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responsibilities are delegated or assigned.
• (6) The practice of licensed practical nursing shall be directed by a registered nurse
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or physician or dentist.
• (7) A licensed practical nurse or unlicensed individual may not supervise, direct, or
evaluate the
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nursing care provided by the registered nurse.
Author: Alabama Board of Nursing
Statutory Authority: Code of Alabama, 1975, §§ 34-21-1(3)(b), 34-21-2(a)(21), 34-21-2(c)(6).
History: Filed November 23, 2009. Effective December 28, 2009. 610-X-4
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Skilled Care in the ALF/SCALF
610-X-7-.06 Alabama Department of Mental Health Residential Community
Programs
(4) The specific delegated tasks shall not require the exercise of independent
nursing judgment or intervention. Specific tasks that require independent
nursing judgment or intervention that shall not be delegated include, but
are not limited to:
(a) Catheterization, clean or sterile.
(b) Administration of injectable medications, with the exception of injectable
medications for anaphylaxis such as the Epi-pen®.
(c ) Calculation of medication dosages other than measuring a prescribed
amount of liquid medication or breaking a scored tablet.
(d ) Tracheotomy care, including suctioning.
(e) Gastric tube insertion, replacement, or feedings.
(f ) Invasive procedures or techniques.
(g) Sterile procedures.
(h) Ventilator care.
(i) Receipt of verbal or telephone orders from a licensed prescriber.
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Skilled Care in the ALF/SCALF
ALF rules: 420-5-4-.06-(6)-(b)
An assisted living facility shall not admit nor
once admitted shall it retain a resident who
requires medical or skilled nursing care for an
acute condition or an exacerbation of a
chronic condition which is expected to
exceed 90 days unless:
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Skilled Care in the ALF/SCALF
1. The individual is capable of performing and
does perform all tasks related to his or her own
care; OR
(this means that the individual is at all times
capable of and actually does perform all tasks
related to the skilled need but may have a need
for a professional to initiate and replace the
device or process and provide the training and
initial observations – for example: a Foley
(bladder) catheter or implanted pain infusion
pump)
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Skilled Care in the ALF/SCALF
2. The individual is incapable of performing some
or all tasks related to his or her own care due to
limitations of mobility or dexterity BUT the
individual has sufficient cognitive ability to
direct his or her own care AND the individual is
able to direct others and does direct others to
provide the physical assistance needed to
complete such tasks, AND the facility staff is
capable of providing such assistance and does
provide such assistance.
(this includes limitation due to visual impairment)
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Skilled Care in the ALF/SCALF
The definition of what constitutes skilled care by
any objective standard is constantly changing:
it is a “moving target”.
• In 1950 anyone would have been amazed to see a
person with Lou Gehrig’s disease just using
oxygen at home or in a boarding home.
• Today it is not unusual to see such a person in
their own home receiving skilled care for years
with a tracheostomy on ventilator care!
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Skilled Care in the ALF/SCALF
• Many residents in assisted living use oxygen in
association with a CPAP machine at night. As long
as the resident can and does manage his or her
CPAP and oxygen, this is acceptable.
• By the same token, no one would claim that it is
not skilled care requiring training and expertise to
apply CPAP with oxygen to a person who can not
provide any verbal feedback or directions
regarding the process.
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Skilled Care in the ALF/SCALF
• We expect and allow the resident to use a
mechanical nebulizer with appropriate
medications for updraft treatments to control
asthma or COPD.
• But adding medication(s) to the nebulizer
chamber and setting up the updraft
equipment with a mask or oral inhaler for use by
another person who can not direct the process is
skilled nursing and/or skilled respiratory therapy
care.
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Skilled Care in the ALF/SCALF
Since the administration of pulmonary medications
by nebulizer is a medication administration issue,
a licensed nurse may provide this delivery system
in an ALF, or in a SCALF for residents who are
cognitively unable to do this for themselves
Unlicensed personnel can not manage the
nebulizer treatments for residents who can not
direct their own care.
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Skilled Care in the ALF/SCALF
• Some facilities have an automated
defibrillator on the wall, similar to those in
every airport, for use by non-professional
personnel in the event of sudden cardiac
arrest.
• If any licensed health care facility has such a
device we expect the staff to be trained in the
use of the equipment.
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Skilled Care in the ALF/SCALF
• Some facilities have small, portable pulse-Ox
oxygen saturation monitors for use by nonprofessional staff in obtaining vital signs. This is
appropriate when coupled with the same degree
of training and experience that is customary for
nursing assistants in monitoring vital signs with
blood pressure devices, thermometers, checking
the heart rate, and training in what constitutes
normal values and “panic” values for results.
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Skilled Care in the ALF/SCALF
• Allowing these sophisticated devices and
procedures in the assisted living facility is
surely a step forward. But this raises questions
about other new processes and procedures:
Why not allow anything in the ALF/SCALF if
the FDA allows the equipment and/or the
process in the home setting?
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Skilled Care in the ALF/SCALF
Home Health and Consumer DevicesInformation from the FDA web site
• FDA regulates medical devices that consumers
use themselves without professional medical
assistance in the same way as they regulate other
medical devices. But the agency also focuses on
how people can use these devices safely and
effectively.
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Skilled Care in the ALF/SCALF
Risks such as infection or injury still exist with
these products and everyone--FDA, the health
professionals that prescribe the products, and
consumers--have a role to play in prevention.
Use in the assisted living means that the facility
assumes a great deal of the responsibility for
the safety and effectiveness of these products
and devices.
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Skilled Care in the ALF/SCALF
• The FDA is also developing educational
materials on the safe use of these devices.
• There are no clear regulations for complex
medical devices used in the home.
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Skilled Care in the ALF/SCALF
The CDC has targeted Assisted Living Facilities as
a high risk area for transmission of Hepatitis B from
the use of finger stick blood sugar monitors for
multiple residents without disinfecting the
glucometer itself after each use.
MMWR March 11, 2005 / 54(09);220-223
Transmission of Hepatitis B Virus Among Persons Undergoing Blood Glucose Monitoring in Long-Term--Care Facilities --Mississippi, North Carolina, and Los Angeles County, California, 2003—2004
Assisted Living Center B, Los Angeles County, California
“Of the nine patients who had daily exposure to fingerstick procedures performed
by nursing staff, eight had acute HBV infection, compared with none among
the seven residents who performed their own fingersticks.”
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BOX 1. Recommended practices for preventing patient-to-patient transmission
of hepatitis viruses from diabetes-care procedures in long-term–care
Settings
A. Diabetes-care procedures and techniques
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Prepare medications such as insulin in a centralized medication area; multidose insulin vials
should be assigned to individual patients and labeled appropriately.
Never reuse needles, syringes, or lancets.
Restrict use of fingerstick capillary blood sampling devices to individual patients.
Consider using single-use lancets that permanently retract upon puncture.
Dispose of used fingerstick devices and lancets at the point of use in approved sharps
containers.
Assign separate glucometers to individual patients. If a glucometer used for one patient must
be reused for another patient, the device must be cleaned and disinfected. Glucometers and
other environmental surfaces should be cleaned regularly and whenever contamination with
blood or body fluids occurs or is suspected.
Store individual patient supplies and equipment, such as fingerstick devices and glucometers,
within patient rooms when possible.
Keep trays or carts used to deliver medications or supplies to individual patients outside
patient rooms. Do not carry supplies and medications in pockets.
Because of possible inadvertent contamination, unused supplies and medications taken to a
patient’s bedside during fingerstick monitoring or insulin administration should not be used
for another patient.
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BOX 1. Recommended practices for preventing patient-topatient transmission of hepatitis viruses from diabetes-care
procedures in long-term–care Settings
B. Hand hygiene and gloves
• Wear gloves during fingerstick blood glucose monitoring, administration of
insulin, and any other procedure involving potential exposure to blood or body
fluids.
• Change gloves between patient contacts and after every procedure that
involves potential exposure to blood or body fluids, including fingerstick blood
sampling. Discard gloves in appropriate receptacles.
• Perform hand hygiene (i.e., hand washing with soap and water or use of an alcoholbased hand rub) immediately after removal of gloves and before touching other
medical supplies intended for use on other patients.
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BOX 2. Recommended medical management, training, and oversight measures to prevent
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patient-to-patient transmission of hepatitis viruses from diabetes-care procedures in
longterm–care settings
Regularly review patient schedules for fingerstick blood glucose sampling and insulin
administration and reduce the number of percutaneous procedures to the minimum
necessary for appropriate medical management of diabetes and its complications.
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Ensure that adequate staffing levels are maintained to perform all scheduled diabetes-care
procedures, including fingerstick blood glucose monitoring.
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Consider diagnosis of acute viral hepatitis infection in patients with illness that includes
hepatic dysfunction or elevated liver transaminases (serum alanine aminotransferase and
aspartate aminotransferase).
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Provide a full hepatitis B vaccination series to all previously unvaccinated staff members with
exposure to blood or body fluids. Check and document postvaccination titers 1–2 months
after completion of the vaccination series.
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Establish responsibility for oversight of infection control activities. Investigate and report any
suspected case of newly acquired bloodborne infection.
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Require staff members to know standard precautions and demonstrate proficiency in taking
these precautions with procedures involving potential blood or body fluid exposures.
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Provide staff members who perform percutaneous procedures with infection-control training
that includes practical demonstration of aseptic techniques and instruction regarding
reporting exposures or breaches. Conduct annual retraining of all staff members who
perform procedures with exposure to blood or body fluids.
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Assess compliance with infection-control recommendations (e.g., hand hygiene or glove
changes) by periodic observation of staff and tracking use of supplies.
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Skilled Care in the ALF/SCALF
• The bureau recommends that glucometers be
reserved for use by one individual.
• Monitoring of blood sugars by finger-stick
monitoring is skilled care.
• The resident must be able to do all aspects of
their own finger-stick blood sugar
determination and interpretation - or have
this performed by a nurse.
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Skilled Care in the ALF/SCALF
• However, there may be rare instances where the
resident is cognitively intact but unable, due to
limitations of mobility, dexterity, or vision, to
perform his or her own fingerstick glucose
determinations. If that resident is able at all times
to direct the care assistant in all aspects of the
physical assistance need to complete the
procedure and the facility staff is capable of and
does provide such assistance, the resident may
remain in an assisted living facility without a
nurse to perform the blood glucose
determinations.
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Skilled Care in the ALF/SCALF
• Capable of providing the such assistance means
that there is documentation that all facility
staff/care assistants who assist the resident are:
1. Trained in performing finger-stick blood glucose
determinations
2. Trained in the use, calibration, and maintenance
of the glucometer
3. Educated, trained, and current with all the OSHA
and CDC requirements for procedures which
involve exposure to blood and body fluids
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Skilled Care in the ALF/SCALF
• Let’s look at a some examples of care
interventions from the simple to the more
complex.
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Skilled Care in the ALF/SCALF
1. First Aid is not considered skilled care – the
management of simple cuts, abrasions and
skin tears; minor bug bites and stings, poison
ivy exposure; minor burns; the Heimlich
Maneuver; CPR
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Skilled Care in the ALF/SCALF
• First Aid may be rendered by an unlicensed
person or by the resident to him/her self.
• We require the staff to have training in CPR and
expect them to perform CPR in the event of
sudden unexpected cardiopulmonary arrest.
• In the event of an emergency I would hope that
even a visitor trained in first aid would come to
the aid of anyone in acute distress.
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March 2007 Talking About Disaster: Guide for Standard Messages First Aid Contents-1
Produced by the American Red Cross
First Aid Kit Contents
*ACFAS MINIMUM RECOMMENDED FAMILY KIT CONTENTS
Assemble a first aid kit to include in your Disaster Supplies Kit and one for each vehicle.
Additional items may be added to personalize or customize this kit.
Family First Aid Kit Content Suggested Use
Absorbent Compress 5x9 dressing
Cover and protect open wounds
Adhesive Bandages (Assorted Sizes)
Cover and protect open wounds
Adhesive Tape (cloth) 1”
To secure bandages or splints
Antibiotic Ointment packets (approx 1 g)
Anti-infection
Antiseptic wipe Packets
Wound cleaning/germ killer
Aspirin (Chewable) 81 mg
For symptoms of a heart attack**
Blanket (Space Blanket)
Maintain body temperature for sh ock
CPR Breathing Barrier (w/one-way valve)
Protection during rescue breathing or CPR
Instant Cold Compress
To control swelling
Gloves (large), disposable, non-latex
Prevent body fluid contact
Hydrocortisone Ointment Packets (approx 1 g)
External rash treatment
Scissors
Cut tape, cloth, or bandages
Roller Bandage 3” (individually wrapped)
Secure wound dressing in place
Roller Bandage 4” (individually wrapped)
Secure wound dressing in place
Sterile Gauze Pad 3x3
To control external bleeding
Sterile Gauze Pad 4x4
To control external bleeding
Thermometer, Oral (Non-Mercury/Non-Glass)
Take temperature orally
Triangular Bandage
Sling or binder/splinting
Tweezers
Remove splinters or ti cks
First Aid Instruction booklet Self explanatory
*ACFAS is the American National Red Cross Advisory Council on First Aid and Safety
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Workplace First Aid Cabinet for Food Services Industry Contents Include:
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(2) 1" x 3" Visible Blue Bandage (25) Bandages
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(1) Knuckle Visible Blue Bandage (20) Bandages
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(1) Fingertip Visible Blue Bandage (20) Bandages
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(5)2" x 2" Gauze Pads - Packs of 2
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(5)3" x 3" Gauze Pads - Packs of 2
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(1)2" Gauze Roll Bandage - 2" Roll
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(1)1 3" Gauze Roll Bandage - 3" Roll
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(1)Elastic Wrap Bandage - 2" x 5 yd.
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(1)40" Triangular Sling/Bandage
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(1)5" x 9" Trauma Pad
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(20)Alcohol Cleansing Pad Pads
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(20)Antiseptic Cleansing Wipe Wipes
(10)First Aid/Burn Cream Packs
(10)First Aid Antibiotic Ointment Packs
(6)Burn Relief Gel - 3.5 gm. Packs
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(1)Eye Wash - 1 oz. Bottle
(10)Moleskin - 2" Squares
(1)CPR Face Shield paired with Gloves
(2)Pair of Vinyl Gloves
(1)First Aid Tape - 1/2" x10 yd. Roll
(1)Cloth First Aid Tape - 1" x 5 yd. Roll
(50)Bandage Protectant/Finger Cot
(1)Nickel Plated 4 1/2" Scissor
(1)Stainless Steel 3" Tweezer, Slanted
American Red Cross Emergency First Aid Guide
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March 2007 Talking About Disaster: Guide for Standard Messages First Aid Contents-1
Produced by the American Red Cross
First Aid Kit Contents
*ACFAS MINIMUM RECOMMENDED FAMILY KIT CONTENTS
Assemble a first aid kit to include in your Disaster Supplies Kit and one for each vehicle.
Additional items may be added to personalize or customize this kit.
Family First Aid Kit Content Suggested Use
Absorbent Compress 5x9 dressing
Cover and protect open wounds
Adhesive Bandages (Assorted Sizes)
Cover and protect open wounds
Adhesive Tape (cloth) 1”
To secure bandages or splints
Antibiotic Ointment packets (approx 1 g)
Anti-infection
Antiseptic wipe Packets
Wound cleaning/germ killer
Aspirin (Chewable) 81 mg
For symptoms of a heart attack**
Blanket (Space Blanket)
Maintain body temperature for sh ock
CPR Breathing Barrier (w/one-way valve)
Protection during rescue breathing or CPR
Instant Cold Compress
To control swelling
Gloves (large), disposable, non-latex
Prevent body fluid contact
Hydrocortisone Ointment Packets (approx 1 g)
External rash treatment
Scissors
Cut tape, cloth, or bandages
Roller Bandage 3” (individually wrapped)
Secure wound dressing in place
Roller Bandage 4” (individually wrapped)
Secure wound dressing in place
Sterile Gauze Pad 3x3
To control external bleeding
Sterile Gauze Pad 4x4
To control external bleeding
Thermometer, Oral (Non-Mercury/Non-Glass)
Take temperature orally
Triangular Bandage
Sling or binder/splinting
Tweezers
Remove splinters or ti cks
First Aid Instruction booklet Self explanatory
*ACFAS is the American National Red Cross Advisory Council on First Aid and Safety
34
Skilled Care in the ALF/SCALF
Once the treatment is beyond First Aid
--and usually by this time the physician is involved-there must be a licensed nurse providing all skilled care
including the supervision of dressings and any other
treatments.
• Care assistants may provide and assist with
application of ice/cold packs for residents who have
a sprain or minor joint pain.
• Care assistants may not provide or apply hot packs
due to concern for burns in the elderly.
• Residents who are cognitively intact may use their
own heating pad.
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Skilled Care in the ALF/SCALF
2. Wound care and dressing changes.
Nurses (RN or LPN) in the ALF or SCALF can apply
dressings as ordered with or without topical
medication(s) for a skin injury such as a skin tear
or scrape, or a laceration, a surgical wound, or a
small pressure ulcer. All of these conditions are
expected to resolve in less than 90 days.
This may be the facility nurse or the Home Health
nurse.
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Skilled Care in the ALF/SCALF
If a wound fails to heal in 60 days, the facility
must give the resident and sponsor a 30 day
discharge notice. It could still heal at day 89 – but
its not very likely.
It is obvious that something more significant is
going on when a wound is not healing in 60 days.
In those situations a higher level of care is
needed for further assessment of the wound and
the overall physiologic status of the resident.
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Skilled Care in the ALF/SCALF
• Wound care involves much more that just
removing and reapplying the dressing every
day or every few days.
• Comprehensive Wound Assessment and Care
involves: Assessing the character of the tissue,
drainage, necrosis and infection in the wound
base, tunneling, status of the surrounding skin
(integrity, infection); circulation; concurrent
medical conditions; effects of medication;
nutrition; activity
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Skilled Care in the ALF/SCALF
• All of these parameters are important to the
process and require specialized training for
nurses (Beyond Basic Training).
• Why can’t the Home Health nurse who is a
certified WOCN be the one to provide
comprehensive wound care beyond 90 days in
the ALF or SCALF?
• No ALF or SCALF facility is staffed with fulltime, professionally trained personnel from
each discipline to provide this level of
integrated care and oversight.
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Skilled Care in the ALF/SCALF
There are many specialized mechanical devices
which are marketed to assist in wound healing
and are applied to wounds continuously to:
• Negative pressure wound care
• Electronic current therapies
• Sequential intermittent pneumatic
compression (IPC) device
All of these have potential serious side effects
and require continuous trained personnel for
monitoring and represent skilled care that is
inappropriate in the ALF/SCALF.
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Skilled Care in the ALF/SCALF
• Intermittent wound therapies that are applied
early in the care of a wound ( <90 days) during
a visit by the Home Health Nurse and
removed at the time the nurse leaves are
acceptable in the ALF or SCALF.
• Examples: LED laser light therapy, MIRE
(Monochromatic Infrared Energy) at the
specific wave length of 890 nm, Hydrotherapy
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Skilled Care in the ALF/SCALF
3. What about pulsed electromagnetic devices
for bone healing in nonunion fractures?
• Currently, a number of electrical bone growth
stimulators (EBGS) devices and ultrasound
devices have been approved by the FDA for
treating nonunion fractures.
• The noninvasive EBGS are portable, battery
operated devices applied to the area for as
long as 12-24 hours daily.
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Skilled Care in the ALF/SCALF
These devices are acceptable in the ALF or
SCALF as an aid to healing of fractures and
return to normal mobility.
In the SCALF there may be few residents who would benefit
from such therapy and who could tolerate this without
becoming noncompliant with such a device attached to a
limb for hours and hours every day for weeks.
Overall, EBGS is considered safe and well tolerated. No major
side effects or complications have been reported in the
literature.
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Skilled Care in the ALF/SCALF
4. Ostomy Care
This type of care can be safely done by any
alert and mentally intact person who is
intellectually and emotionally willing and able
to learn how to manage his or her own
ostomy. The teaching is done by a nurse
specially trained in wound and ostomy
therapy (WOCN).
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Skilled Care in the ALF/SCALF
• In the setting of the hospital, home health,
and nursing home, only nurses with training
and experience care for ostomies.
• Nursing assistants, CNA’s, family members,
and sitters never provide ostomy care in any
licensed health care setting.
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Skilled Care in the ALF/SCALF
• If a resident is able to provide all of his/her own
ostomy care, that person is acceptable for
assisted living. If the resident can and does direct
the staff who are trained in ostomy care to do all
the care, that resident may remain in assisted
living.
• If that resident becomes unable to provide all of
their own care or, because of cognitive decline
they become unable to continuously direct and
monitor the care for their ostomy, that person is
no longer appropriate for any assisted living
facility.
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Skilled Care in the ALF/SCALF
• The care assistants must have training in the
infection control aspects of ostomy care as
well as the mechanics of performing ostomy
bag changes. The resident must continue to
provide all of the technical assessment of the
site and the function of the ostomy and be
able to report any problems with the function
of the ostomy.
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Skilled Care in the ALF/SCALF
5. Urinary Catheter
Bladder catheter management requires skilled
nursing care to insert and change the catheter.
If the resident in a regular ALF is able to manage
the catheter and the tubing and the urine bag –
then there is not a problem with home health
nurses providing intermittent skilled care beyond
90 days to change the catheter or obtain the
occasional urine culture.
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Skilled Care in the ALF/SCALF
If a resident is unable, for whatever reason, to
understand how to manage the catheter and
tubing that resident is ineligible for assisted living.
For example, the resident is constantly pulling on
the catheter causing bladder irritation, or is
contaminating the building with a leaking
catheter bag, or is unable to understand that
back-flow of cloudy urine into the bladder and a
twisted and obstructed catheter represent major
infection risk factors.
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Skilled Care in the ALF/SCALF
6. Condom Urinary catheters for male
residents:
The care and management of condom catheters
requires training and experience. If a resident
is capable of applying and managing his own
catheter, this is acceptable in an assisted
living facility.
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Skilled Care in the ALF/SCALF
• Use of condom catheters is associated with the
potential for serious problems:
1. Twisting and obstruction to the flow of urine
2. Maceration of the skin when flow is blocked
3. Vascular obstruction at the base of the penis if
applied too tightly or additional taping is applied
to maintain position. This can lead to ischemic
necrosis of the penis.
4. Frequent displacement with loss of control of
urine
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Skilled Care in the ALF/SCALF
• For these reasons, the use of condom
catheters for residents who are unable to
apply ad manage this themselves is not
appropriate or allowed in assisted living
facilities.
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Skilled Care in the ALF/SCALF
7. Swallowing Dysfunction – Thickened Liquids and
puree Diets
• The management of swallowing dysfunction
requires both an analysis by a speech therapist –
and
• The careful observation and monitoring of every
aspect of every meal, snack, and drink that a
resident takes.
• There are slowly progressive cognitive and
neuromuscular changes in the elderly that affect
swallowing – from decline in memory to arthritic
and osteoporotic changes of the spine.
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Skilled Care in the ALF/SCALF
Swallowing is a complicated neurological reflex that involves a
well orchestrated sequence of three major phases.
• Oral phase:
1. This begins in the mouth with the coordinated action of
muscles involved with chewing and the formation of a food
bolus = a small and soft mass of food.
2.This is followed by the transfer of this food bolus towards
the pharynx.
• Pharyngeal phase: the bolus triggers an automatic
sequence of movements of several small muscles that then
work together to channel the food into the esophagus.
• Esophageal phase: the food bolus enters the esophagus
"food pipe" which finally brings food to the stomach.
All this must occur while preventing food or liquid particles
from entering the lungs.
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Skilled Care in the ALF/SCALF
• Preparation and monitoring of special puree diets
and thickened liquids requires coordinated
interaction between a dietician and the dietary
staff on a frequent basis.
• The department invariably finds problems with
the preparation and delivery of thickened liquids.
• In addition, the normal and expected progression
of the resident’s pathologic process must be
anticipated and the plan altered based on
continued speech therapy assessment.
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• Special positioning - both voluntary on the
part of the resident, and with special
equipment - is often necessary to provide safe
and effective swallowing. This requires a
trained and experienced person to implement
the positioning correctly at every meal.
• Assisted living facilities are not staffed to
provide this level of specialized care.
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Skilled Care in the ALF/SCALF
• Residents who require speech therapy and
dietary modification with a puree diet due to
swallowing dysfunction and risk for aspiration
are inappropriate for assisted living.
• The Bureau would be willing to review and
approve the delivery of this level of skilled
care in specific situations that may arise in
assisted living facilities that meet all the
criteria reviewed in the last few slides.
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Skilled Care in the ALF/SCALF
• Dietary modification because of difficulty with
dentures or chewing problems are
appropriate and acceptable in any assisted
living facility. There should be an order for this
and it must be part of the care plan.
• We believe that in nearly every such situation
there should be an assessment of the
resident’s problem to eliminate any serious
and progressive diseases.
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8. Feeding tubes
• If a resident has an enterostomy feeding tube
(PEG, G-Tube, J-Tube) and is able to personally
maintain the tube and do his/her own feedings,
medication administration and flushes, and local
care – then the resident can be admitted and
remain in the assisted living facility.
• Such a resident would require a professionally
trained person to change the tube on a regular
basis.
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Skilled Care in the ALF/SCALF
When a person cannot maintain her/his own
enterostomy tube, the feeding must be provided by a
licensed nurse who has special training, experience, and
supervision in the care and management of tubes:
• Medication administration and delivery by tube
•
•
Skin condition at the entry site
Positioning of the tube and documentation that
the tube is in the correct location to receive tube
feeding
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Skilled Care in the ALF/SCALF
• Inadvertent displacement or removal of the tube
during bathing and positioning
• Dealing with obstruction
• Complications related to a specific feeding
formula (such as diarrhea)
• Positioning to prevent aspiration
• Leakage of gastric contents around the tube
• Routine tube replacement
• Condition of the tube itself
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Skilled Care in the ALF/SCALF
• Assisted Living Facilities are not staffed around
the clock by personnel who are trained and
qualified to provide enteral nutrition
including all the professional observations and
assessment necessary to do this safely.
• Thus: this skilled nursing care is not allowed in
a SCALF or in an ALF for a person who can not
personally perform all aspects of such care.
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9. Continuous IV fluid administration
The department recently (2008) responded to a
request to allow IV fluid administration in an ALF
during an outbreak of viral gastroenteritis.
ADPH would be willing to discuss and give
individual approval for the the short-term
administration of IV fluids to residents if there
has been an assessment by the physician and
there is an RN in attendance 24 hours a day
during the infusion.
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Skilled Care in the ALF/SCALF
In addition there must be advanced preparation for
safe and appropriate IV fluid care:
1. Policy and Procedure for IV fluid administration
2. Physician orders for the IV, any laboratory
testing required, VS, pulse oximetery
3. Written agreement with the outside provider(s)
defining duties and responsibilities
4. Staffing requirements including continuous RN
care and supervision during infusion (the RN
can’t also serve as a Care Assistant)
5. Rescue equipment and medications immediately
available - primarily Oxygen
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Skilled Care in the ALF/SCALF
10. Hoyer Lift – Patient Lifters
The use of a mechanical lift generally indicates
that a resident is incapable of independently
transferring from bed to chair.
Such patient lifters were primarily developed
to prevent injury to the care attendants doing
heavy lifting in the skilled care environment.
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Skilled Care in the ALF/SCALF
Patient lifts of all types and brands are complex
pieces of equipment that require continuous
maintenance and use in accordance with
manufacturer’s specifications and
recommendations.
This mandates initial training of staff and
continued competency assessment in order
that this not present a danger to residents.
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Skilled Care in the ALF/SCALF
The Bureau of Health Provider Standards gets
reports of Hoyer-type lift injuries nearly every
month. These reports generally originate from
the Skilled Nursing Home environment and
many of these result in serious harm.
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Skilled Care in the ALF/SCALF
There are falls from the sling, falls due to
tipping over of the lift itself, skin tears, burns,
blunt trauma when hit by the swinging metal
arm, as well as injury from striking objects
while suspended and swinging in the lift sling.
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Skilled Care in the ALF/SCALF
The Bureau feel very strongly that use of such
equipment represents skilled care and has no
place in a Specialty Care Assisted Living Facility
and almost no place in a regular ALF.
However, there might be a rare instance in a
regular ALF facility that is constructed and
organized to accommodate a patient lift in which
a specific resident with a qualifying disability
might be appropriate for a patient lift.
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Skilled Care in the ALF/SCALF
If the individual is capable of performing and does
perform all tasks related to the use of the lift, or
The individual is incapable of performing some or
all tasks related to the use of the patient lift due
to limitations of mobility or dexterity BUT the
individual has sufficient cognitive ability to direct
his or her own care AND the individual is able to
direct others and does direct others to provide
the physical assistance needed to use the patient
lift, AND
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Skilled Care in the ALF/SCALF
the facility staff is capable of providing such
assistance and does provide such assistance,
AND once transferred out of bed to a mobility
device the resident is independent with
mobility and toileting –
the use of a Hoyer-type Lift would be
acceptable, IF all documentation is in place.
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Skilled Care in the ALF/SCALF
For these conditions to be met (specifically the facility
staff is capable of providing such assistance) it is
obvious that there must be advanced preparation for
safe and appropriate care using a patient lift.
1. Policy and Procedure describing the use of the lift by
the staff
2. Policy for inspection, maintenance, and repair of the
lift, sling, and attachments
3. Training for all staff in the correct use of the lift
4. Continued competency assessment for all staff at
reasonable intervals
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Skilled Care in the ALF/SCALF
• It is the philosophy of the Bureau of Health
Provider Standards that the care each resident
receives meets the standard of care based on
the resident’s health needs and does not vary
depending on the particular location or facility
in which the resident resides.
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Skilled Care in the ALF/SCALF
• This means, for example, that a nursing home
which provides IV antibiotic therapy must
adhere to the basic standards of care that the
hospitals in the state follow.
• The same requirements should apply to the
any assisted living facility.
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Skilled Care in the ALF/SCALF
11. Allowing the administration of IV antibiotics
and other IV medications in the assisted
living setting is undoubtedly skilled care.
ADPH is considering a request to allow this
under specific, individual circumstances.
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Skilled Care in the ALF/SCALF
The procedure as presently conceived and
implemented requires the delegation of postinfusion assessment and care to facility staff.
• This is not allowed at present.
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Skilled Care in the ALF/SCALF
• The Bureau is aware that there are doctors,
home health agencies, IV infusion therapy
companies, and facilities that have provided
this type of skilled care in the recent past.
• This is an issue of defining the standard of
safety and care for IV therapy in licensed
assisted living facilities.
• What is allowed in the home or doctor’s
office is different from what is acceptable in a
licensed health care facility.
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Skilled Care in the ALF/SCALF
• There is an unwritten assumption on the part
of the physician when prescribing devices and
skilled care to be delivered in the patient’s
home.
• The assumption is that the patient and/or
the family member will be capable and very
highly motivated to learn everything they
can about the device or process to ensure a
good outcome.
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Skilled Care in the ALF/SCALF
When it is obvious to the medical staff that
the patient is unable to understand and
provide his or her own care and is
unsupported by family to accomplish the
desired care in the home, other
arrangements are made.
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Skilled Care in the ALF/SCALF
Whether one is talking about home IV
parenteral nutrition care for a spouse or child
with Crohn’s disease, or a patient doing his or
her own ostomy care, the individual and family
have specific characteristics:
1. Very personal stake in outcome
2. Intense commitment to be successful
3. Availability for in-depth training,
observation, and extensive practice
4. 24 hour availability.
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Skilled Care in the ALF/SCALF
• The job description and work schedule for
personnel in any assisted living is quite
different from “family member” in the home
setting.
• The employees are virtually all good people
who want to work with the elderly and want
to do a good job.
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Skilled Care in the ALF/SCALF
• The reality is that they work their shifts and go
home. They can’t take their work home with
them.
• They have their own (and at times urgent)
problems, often relating to their own and
their family member’s health issues.
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Skilled Care in the ALF/SCALF
• The rules do not allow family members, even
family members who are medical
professionals, to come in to an assisted living
facility and provide skilled medical or nursing
care or medication administration on a
routine basis to their own family members unless they are an employee of the facility.
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Skilled Care in the ALF/SCALF
The rules are written to protect the vulnerable
elderly residents in assisted living facilities and
prevent pressure from residents, family
members, doctors, church and corporate
organizations, and others from forcing the
assisted living facilities (ALF and SCALF) in
Alabama into becoming poorly performing,
poorly staffed, poorly equipped, (Mini)Skilled
Nursing Homes.
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