The Basics of the Residential Licensing Process Presented by

The Basics of the Residential Licensing Process Presented by The Bureau of Residential Facilities Licensing

Arizona Department of Health Services Cara Christ M.D., Director Division of Public Health Licensing Colby Bower, Assistant Director Health Care Institution Licensing Kathryn McCanna, Branch Chief Bureau of Residential Facilities Licensing Harmony Duport, Bureau Chief

Office Locations and Phone Numbers Phoenix office: 150 N. 18th Ave., Suite 420 PHONE: 602-364-2639 FAX: 602-324-5872 Tucson office: 400 W. Congress St., Suite 116 PHONE: 520-628-6965 FAX: 520-628-6991 Website: www.azdhs.gov/residentialfacilities Email: [email protected]

Purpose of the Bureau of Residential Facilities Licensing (BRFL) Mission Statement: – “To protect the health and safety of Arizonans by providing information, establishing standards, and licensing and regulating health and child care services” To promote and protect public health through a comprehensive compliance system

Bureau of Residential Facilities Licensing (BRFL) BRFL Licenses and regulates: – Residential Healthcare Facilities Assisted Living Centers and Homes Behavioral Health Residential Facilities BRFL also licenses and regulates: – – – – Adult Foster Care Homes Adult Day Health Care Facilities Behavioral Health Respite Homes Adult Behavioral Health Therapeutic Homes

Does NOT license or regulate: -Child Foster Care Homes Does license, but does NOT monitor: -Developmentally Disabled Group Homes* These facilities are licensed and regulated by the Department of Economic Security (DES) *the term “group home” is typically used by DES, not DHS

Review various types of facilities to assist potential providers in determining what kind of facility they want to own and operate Review application requirements Provide overview of Initial Compliance Inspection and licensing process Assist in navigating the Bureau’s website and provide additional resources

Licensing of Residential Facilities is governed by the Arizona Revised Statutes (“A.R.S.”), primarily: Title 36: Public Health and Safety, Chapter 4: Health Care Institutions Reference to a statute generally uses this format: A.R.S. § 36-401.A.1 or A.R.S. § 36-401(A)(1) Statutes are law, and authorize the Department to adopt regulations or rules which govern Health Care Institutions.

Rules are contained in the Arizona Administrative Code (“A.A.C.”), primarily: Title 9: Health Services, Chapter 10: Department of Health Services Health Care Institution Licensing Reference to a rule generally uses this format: R9-10-803.A.3.a Rules are broken down into Articles specific to each type of facility.

Rules Governing Residential Facilities Article 1: General Article 7: Behavioral Health Residential Facilities Article 8: Assisted Living Facilities (Including Homes, Centers and Adult Foster Care Homes) Article 11: Adult Day Health Care Facilities Article 16: Behavioral Health Respite Homes Article 18: Adult Behavioral Health Therapeutic Homes

BRFL Website Download and print the Articles specific to your subclass from our website: http://www.azdhs.gov/licensing/residentialfacilities/index.php#providers-home Articles 7, 8, 11, 16, and 18 are effective July 1, 2014 Article 1 is effective January 1, 2015

Definitions

Definition of Health Care Institution (A.R.S. § 36-401.A.21) "Health care institution" means every place, institution, building or agency, whether organized for profit or not, that provides facilities with medical services, nursing services, behavioral health services, health screening services, other health-related services, supervisory care services, personal care services or directed care services and includes home health agencies as defined in section 36-151, outdoor behavioral health care programs and hospice service agencies

Definition of Assisted Living Facility (A.R.S. § 36-401.A.8) "Assisted living facility" means a residential care institution, including an adult foster care home, that provides or contracts to provide supervisory care services, personal care services or directed care services on a continuous basis

Assisted Living Facilities Assisted Living Home: 10 residents or fewer Usually in a home in a residential neighborhood Assisted Living Center: 11 residents or more Usually in a commercial building

Definition of Adult Foster Care Home (A.R.S. § 36-401.A.5) “Adult foster care home" means a residential setting that provides room and board and adult foster care services for at least one and no more than four adults who are participating in the Arizona long-term care system and in which the sponsor or the manager resides with the residents and integrates the residents who are receiving adult foster care into that person’s family. (Adult foster care services means supervision, assistance with eating, bathing, toileting, dressing and medications)

Residents in Assisted Living Facilities/Adult Foster Care may have: Mild limitations: General supervision only, no hands-on care Physical limitations: Hands-on care Physical and/or cognitive deficits requiring assistance with self-administration of medications or medication administration Severe cognitive deficits such as Alzheimer’s disease

Levels of Care – Assisted Living Supervisory care services: 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 prescribed medications Personal care services: 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 nurse who is licensed pursuant to title 32, chapter 15 or as otherwise provided by law Directed care services: programs and services, including supervisory and personal care services, that are provided to persons who are incapable of recognizing danger, summoning assistance, expressing need or making basic care decisions

Definition of Adult Day Health Care Facility (A.R.S. § 36-401.A.4) “Adult day health care facility" means a facility that provides adult day health services during a portion of a continuous twenty-four hour period for compensation on a regular basis for five or more adults not related to the proprietor. (Adult day health services means a program that provides supervision, activities, personal care, , meals and health monitoring in a group setting)

Definition of Behavioral Health Residential Facility (R9-10-101.29) “Behavioral health residential facility" means a health care institution that provides treatment to an individual experiencing a behavioral health issue that: -Limits the individual’s ability to be independent, or -Causes the individual to require treatment to maintain or enhance independence

Definition of Behavioral Health Respite Home (R9-10-101.30) “Behavioral health respite home" means a residence where respite care services, which may include assistance in the self-administration of medication, are provided to an individual based on the individual’s behavioral health issue and need for behavioral health services. (A documented agreement with a collaborating health care institution that establishes the responsibilities of the behavioral health respite home is required)

Definition of Adult Behavioral Health Therapeutic Home (R9-10-101.10) “Adult Behavioral health therapeutic home" means a residence that provides room and board, assists in acquiring daily living skills, coordinates transportation to scheduled appointments, monitors behaviors, assists in the self-administration of medication, and provides feedback to a case manager related to behavior for an individual 18 years of age or older based on the individual’s behavioral health issue and need for behavioral health services and may provide behavioral health services under the clinical oversight of a behavioral health professional. (A documented agreement with a collaborating health care institution that establishes the responsibilities of the adult behavioral health therapeutic home is required)

Behavioral Health Residential Facilities Provide services to people whose primary need for services is related to: – Substance Abuse FYI according to R9-10-808(F), a “Mental Disorder” DOES NOT include Alzheimer’s disease, other dementia or Traumatic Brain Injury (TBI)

Location, Location, Location. Facilities need to work with local jurisdiction to obtain approval before applying for a license (Local jurisdiction City building codes and permits agency) Additionally Assisted Living Centers (11 or more residents) and Adult Day Health Care Facilities are required to go through ADHS’s Architectural Review process before applying for a license.

Key personnel An Assisted Living Facility must have a Certified Assisted Living Manager who is responsible for the assisted living services provided -Certified by Arizona Board of Nursing Care Institution Administrators and Assisted Living Facility Managers Board (NCIA)

Key personnel A Behavioral Health Residential Facility must have a Behavioral Health Professional (BHP) who must be available to oversee the behavioral health services provided and an administrator must be responsible for the services provided BHP Psychiatrist, psychologist, physician, registered nurse practitioner licensed as an adult psychiatric nurse or an individual licensed under A.R.S. Title 32 Chapter 33, whose scope of practice allows the individual to independently engage in the practice of behavioral health. Administrator Defined by facility policies and procedures

The Application Process

Change of Ownership CHOW If you are purchasing or leasing a facility that is already licensed as a Residential Facility, this is referred to as a “CHOW” ARS §36-422.D: The current licensee must notify the Department in writing at least 30 days prior to the planned change of ownership and ensure services are not interrupted The new owner must submit an initial application and must NOT begin operating until the Department issues a license to the new owner Civil money penalties ( ) will be considered and assessed if the Department does not get notification of a “CHOW”

Application forms Download and print from our website: http://azdhs.gov/licensing/residential-facilities/i ndex.php#providers-application-forms The application must be complete before the Bureau will conduct an inspection and issue the license – DO NOT leave anything blank. Use “N/A” if something does not apply to your facility – Submit ALL required documents

Not required for corporations or LLCs Only required for AL Centers and Adult Day Health Care Facilities

Filling out the initial application

Filling out the initial application Either Print and complete with a pen OR Complete on computer and then print

Name of Facility (owner) Actual physical address of the facility Address that you want the mail to be delivered to Facility’s number Email required Only select one

Sole proprietor, LLC, corporation, as above the licensee Can be alternate contact number (not at facility) Required

Attach additional pages if needed

Attach additional pages if needed Such as: level of care, behavioral care, medication administration, etc Marking yes allows us to ask for additional information Complete section III or section IV, not both

Fees

Submitting your application Once the application is submitted, you will receive a letter telling you that your application is either complete or incomplete – A complete application will be forwarded to a supervisor (team lead) to be assigned to a surveyor who will contact you to schedule the inspection – An incomplete application will prompt our administrative staff to contact you (in writing) requesting the information needed to complete your application

Timeframes The Department has 120 days (total) to issue the license. This is broken down by: Administrative review 30 days Substantive review 90 days Overall 120 days or the facility’s application may be considered withdrawn

But, the Department has a goal to get you licensed a lot sooner than that! ARE YOU READY?

The Initial Compliance Inspection

Are you ready? Surveyor contacts you to review initial checklist and schedule the inspection Inspection typically takes about 3-4 hours depending on: -Size of the facility -Completeness and organization of facility documents Compliance with the rules is key!

Ready means . Required policies and procedures are developed and documented Key personnel are secured and personnel records are compiled Physical plant and environmental standards are met and the facility is ready to accept a resident!

Policies & Procedures (“P&Ps”) Policies and Procedures go hand-in-hand to clarify WHAT your organization wants to do and HOW to do it!

Policies & Procedures (“P&Ps”) Policy Clear simple statement of intent of what your organization wants to do, a set of principles to guide decisions and achieve outcomes. Procedure The steps to put the policy in to action, who will do what, what steps they need to take, what forms or documents to use.

ADHS does not approve P&P’s!! Policies and procedures will vary between facilities because they reflect the values, approaches and commitments of an organization

Key personnel and personnel records For Assisted Living Facilities . -Manager -Manager’s Designee For Behavioral Health Residential Facilities -Behavioral Health Professional -Administrator -Registered Nurse (RN) -Registered Dietician (RD) -Behavioral Health Technician/Behavioral Health Paraprofessional

Key personnel and personnel records For Adult Foster Care Homes . -Sponsor -Sponsor Designee For Adult Day Health Care Facilities . -Administrator -Registered Nurse -Nurse

Key personnel and personnel records For Behavioral Health Respite Homes/Adult Behavioral Health Therapeutic Homes -Provider -Back up Provider (for BH Therapeutic Homes) -Contract with outpatient treatment center

Physical plant and environmental standards For Assisted Living Facilities and Adult Foster Care Homes . -One bedroom set up per requirements -Common areas furnished and ready for residents For Behavioral Health Residential Facilities -All bedrooms set up per requirements -Common areas furnished and ready for residents

Onsite at Initial Compliance Inspection Notice of Inspection Rights (“Entrance Letter”) - will be reviewed first. Regardless of subclass, the form is the same. Please read carefully. Ask Surveyor if any questions or concerns

Onsite at Initial Compliance Inspection Review of P&P and other facility documents Review of personnel records Facility tour of environment and measure bedrooms Interviews (if needed) You must be READY to take residents

Onsite at Initial Compliance Inspection Accompany the Surveyor and ask questions Take notes during the survey Exit interview to discuss findings – Areas of non-compliance will be reviewed and technical assistance may be discussed and documented

Initial Compliance Inspection There are three possible outcomes 1. The facility is in compliance and the surveyor completes the inspection, recommends a license and a license is issued. 2. The applicant is missing a few small items (copy of a document, a specific policy, etc.) and the surveyor gives a deadline to the applicant to submit the missing information. Once the additional information is received, a license is recommended and issued. 3. The facility is not ready (no P&P’s no furnishings, no staff, etc.) and the surveyor ends the inspection. The inspection will be re-scheduled.

Licensure after Initial Inspection If you have no deficiencies: A “No-Deficiency” Statement of Deficiencies (SOD) is written License issued when all remaining fees paid 2-5 business days Staff will contact you when license is ready Provider can mail in fees and Department will mail license or provider can pick-up license and submit remaining fees due at that time.

Paying remaining fees due The fee remittance form is available on our website – Calculate remaining licensing fees owed – Submit fees to the Department in the form of a cashier’s check, money order, business check or personal check All fees must be paid before the license will be issued

Licensure after Initial Inspection If you are found not ready and the inspection is terminated: After 120 days, the application is considered withdrawn

So Be ready!!! Receive your license and post it on the wall, so you can begin operating and accepting residents! FYI The Department does not assist you in finding residents, nor do they refer residents to your facility.

Interpretation of “Health Care Institution” If a facility has had no residents (has not provided health-related services) for more than 12 months prior to the date the Department’s Surveyor arrives to conduct a compliance inspection, the Department may deny the renewal application.

Renewing your license Renewal applications are due to the Bureau no later than 60 days prior to the expiration date on the license. An application received 59 or fewer days prior to the license expiration date will result in the assessment of a civil penalty of 250.00 for a first offense. Subsequent offenses will result in higher penalties. If an application is not received prior to the expiration date of the license, the facility may be considered closed. If such a facility is still providing services, enforcement action may be taken, as the facility is providing unlicensed care.

Renewing your license You are responsible for ensuring that your renewal application is submitted on time. When a completed renewal application and all fees are received, the Department will mail you your new license. Hang the original license on the wall at the time of the effective date. Renewals are done online! Register for an account, so you can renew your license online! https://licensing.azdhs.gov/LicensingOnline/RES

To make changes to your license Submit a written request to the Department identifying the type of change you are requesting -Bed increase/decrease -Change in level of care -Adding a service such as: Personal Care for BH Behavioral Health Services for AL Do NOT implement the change until an amended license is issued!!

Resources

Resources Bureau of Residential Facilities Licensing Websites: http://azdhs.gov/licensing/residential-facilities/index.php -Frequently Asked Questions -Links to rules and statutes -License application and renewal forms -How to prepare a Plan of Correction (“POC”) www.azcarecheck.com – Includes facility information, including survey history and enforcement actions

Resources For Information on Certified AL Managers and Caregiver Training Programs Arizona Board of Examiners of Nursing Care Institution Administrators and Assisted Living Facility Managers: Phone: (602) 364-2273 Website: www.aznciaboard.us

Resources For Adult Foster Care Home support Foundation for Senior Living: Phone: (602) 285-1800 Website: www.fsl.org

Resources For information on contracts Arizona Health Care Cost Containment System (AHCCCS): Phone: (602) 417-4000 or 1-800-654-8713 Website: www.azahcccs.gov AHCCCS monitors the contracts for the Regional Behavioral Health Authorities (RBHAs)

Resources For Assisted Living resident advocacy DES Long-Term Care Ombudsman: Phone: (602) 542-6454 Website: www.azdes.gov A representative from the Ombudsman programs visits residents in Assisted Living facilities periodically to ensure resident’s desires and needs are met.

Resources For general resource information Community Information and Referral Services Phone: 2-1-1 or (602) 263-8845 x100 Website: www.211arizona.org

Resources For Foster Parenting or DDD Group Homes DES Department of Child Safety (DCS Foster care): Phone: 1-877-KIDS-NEEDU (1-877-543-7633) Website: www.azdes.gov/ DES Department of Developmental Disabilities (DDD): Phone: (602) 542-0419 or (866)-229-5553 Website: www.azdes.gov/

Two locations Phoenix office: 150 N. 18th Ave., Suite 420 PHONE: 602-364-2639 FAX: 602-324-5872 Tucson office: 400 W. Congress St., Suite 116 PHONE: 520-628-6965 FAX: 520-628-6991 Website: www.azdhs.gov/residentialfacilities Email: [email protected]

QUESTIONS?

THANK YOU Nicole Morong Team Leader Lynn O’Malia Surveyor Deanna Adams Surveyor [email protected] 602-364-2639 www.azdhs.gov