Florida Regulatory Compliance Resources for Residential Care Facilities

Appropriateness for admission and retention in an ALF is determined by the facility’s ability to meet an individual’s needs and preferences. However, certain conditions or needs can make an individual inappropriate for admission or retention in standard or Limited Nursing Services (LNS) facilities, or in Extended Congregate Care (ECC) facilities.

To be admitted and retained, an individual must generally be capable of performing **Activities of Daily Living (ADLs)**, including transfers, with supervision or assistance. They must not require **24-hour nursing supervision**. Individuals must also be free of Stage II, III, or IV pressure sores. They should be able to participate in social and leisure activities, be ambulatory, and not display violent behavior or be a danger to self or others.

In standard and LNS facilities, residents who are **bedridden for more than 7 days** or who develop a need for 24-hour nursing supervision may not be retained. However, residents with Stage II pressure sores may remain if the facility has a limited nursing license or the resident contracts with a home health agency or Registered Nurse (RN).

Residents in ECC facilities may not be retained if they are **bedridden for more than 14 days**. Terminally ill residents may continue to reside in any ALF if it is mutually agreeable to the resident and facility, additional care is provided through a licensed hospice, and the resident is under the care of a physician who agrees their physical needs are being met.

ECC facilities promote aging in place, and continued residency is based on a comprehensive review of the resident’s physical and functional status, the ability of various parties (facility, family, friends, agencies) to provide required care, and documentation of a developed and implemented written service plan consistent with facility policy.

Several types of documentation are required for Florida ALFs according to the sources:

• Resident Agreements: The resident contract must specify the services, supplies, and accommodations provided, including those under any specialty license. It must also detail the daily, weekly, or monthly rate, notice policy for rate increases, cost of additional services, residents’ rights, duties, and obligations, refund policies, the bed hold policy, any religious affiliation and related requirements, and discharge policies and procedures.
• Dementia Care Advertising: Facilities advertising special care for persons with Alzheimer’s disease or other dementias must disclose the services that distinguish this care in advertisements or a separate document. A copy of all such advertisements or the document must be given to anyone requesting information about dementia programs and services and must be maintained in the facility’s records. The licensing agency examines these as part of the license renewal procedure.
• Medical Examination Report: Residents must have a medical examination by a physician or advanced RN practitioner within 60 days prior to admission or no later than 30 days after admission. This practitioner must provide the administrator with a medical examination report.
• Nursing Assessments: Licensed nurses employed by or under contract with a facility must routinely, or at least monthly, perform and document a nursing assessment for residents receiving physician-ordered nursing services (except medication administration). This documentation must include any substantial changes in a resident’s status.
• Service Plans: ECC facilities use managed risk agreements where facility staff discuss the service plan and resident needs with the resident and involved parties. The consequences and inherent risks of decisions are explained and reviewed periodically with the service plan, documenting changes in status and the facility’s ability to respond. A “shared responsibility” approach involves exploring options and risks within the facility to develop a service plan that best meets the resident’s needs and quality of life. Residents eligible for both MLTC and Assistive Care Services programs must have a service plan that separately identifies services provided under each program.
• Third-Party Provider Coordination: Facility policies must require third-party providers delivering services in the facility to coordinate with the facility regarding the resident’s condition and the services being provided.
• Assistance with Medication: A record must be kept of when a resident receives assistance with self-administration of medication. Assistance with self-administration by unlicensed staff requires a documented request by, and the written informed consent of, a resident or their representative. Informed consent includes advising the resident or representative that the ALF isn’t required to have a licensed nurse, that assistance may be from unlicensed personnel, and whether or not such assistance will be overseen by a licensed nurse.
• Menu Review: All regular and therapeutic menus must be reviewed annually by a licensed or registered dietitian, a licensed nutritionist, or a registered dietetic technician supervised by a licensed or registered dietitian or licensed nutritionist.
• Background Checks: Criminal history record checks, obtained through fingerprint searches, are required for ALF owners (if individuals), administrators, financial officers, and employees to check for disqualifying offenses. These checks must be re-screened every five years.
• Inspection and Monitoring Reports: Facilities are inspected before licensure and at any time deemed necessary by the licensing agency, with inspections for re-licensure conducted every 2 years. RNs or designees representing the licensing agency must visit ECC facilities quarterly and LNS facilities twice a year to monitor residents and determine facility compliance, implying associated documentation.

Florida ALFs have several staffing requirements depending on the facility type and size:

• Administrator: Every facility must be under the supervision of an administrator responsible for its operation, maintenance, staff management, and resident care. Administrators must complete the ALF core training and competency test within 90 days of employment and receive 12 hours of continuing education every 2 years.
• Direct Care Staff: Facilities must employ direct care staff. Direct care staff (other than licensed nurses, certified nursing assistants, or home health aides) have specific initial and in-service training requirements.
• First-Aid and CPR Certification: A staff member who has completed courses in **first-aid and cardiopulmonary resuscitation (CPR)** must be in the facility at all times.
• Nurses: LNS and ECC facilities must employ or contract with a **nurse** available as needed by residents. In ECC facilities, the nurse must participate in resident service plan development and perform monthly nursing assessments.
• ECC Supervisor: An ECC staff member must serve as the ECC supervisor responsible for the general supervision and service planning for the ECC program if the administrator does not fulfill this role.
• Sufficient Staff: Facilities must employ **sufficient staff** to ensure the safety and proper care of individual residents, implement emergency plans, and provide or arrange for services according to resident needs, contracts, and care standards. Adequate staff must be awake during all hours to meet scheduled and unscheduled needs.
• Minimum Staff Hours: Rules contain **minimum staff hours per week** based on the number of residents:
  • Up to 5 residents: 168 staff hours per week.
  • 6-15 residents: 212 hours.
  • 16-25 residents: 253 hours.
  • 26-35 residents: 294 hours.
  • For every 20 residents over 95: 42 additional staff hours each week (approximately one full-time employee per 20 residents).
• ECC Staffing: ECC facilities must have enough qualified staff to meet the specific needs of ECC residents and provide services established in their service plans. If service plans are not followed or needs are unmet due to insufficient staffing, facilities must immediately provide additional or appropriately qualified staff.
• Dementia Special Care Staffing: Facilities advertising special care for persons with dementia must meet specific staffing requirements:
  • 24-hour staffing capability.
  • If the facility has 17 or more residents, it must have an awake staff member on duty at all hours.
  • If the facility has fewer than 17 residents, it must have an awake staff member on duty at all hours or have mechanisms to monitor and ensure residents’ safety.
• Training: Various staff roles require specific training, including core training for administrators, in-service training for direct care staff on infection control, ADLs, resident rights, reporting abuse, and emergency procedures. Administrators and supervisors in specialty licensed facilities (ECC, LMH) require additional specialized training. Staff in dementia special care units require initial and continuing specialized training on dementia care, while staff with incidental contact need general information. All staff must receive training on resident elopement response policies.