Adult Day Services Rules Guidance

Compliance requires the agency to have a written protocol for participants to exit timely.  If a participant needs additional assistance to exit timely, the type of assistance and the manner in which the client will be assisted should be in written form in the participants file or other location as designated by the agency. Using a wheelchair to evacuate a participant that lacks mobility or fails to respond appropriately to a drill is an example of an acceptable protocol. (2) The adult day services center shall have written emergency procedures and have a posted plan for evacuation of participants, staff, volunteers, and visitors in case of fire or other emergencies such as storms, flooding, and chemical emergencies. (c)The center shall develop a written protocol for when a participant fails to exit timely or respond appropriately to the drill. The protocol shall include notification to family/responsible party. (4) Participants shall take part in program development and activity planning to the extent possible. This requirement is only applicable to multiple ADS centers operated at the same location. The licensee would be limited to two centers at that location and the center’s responsibility plan would need to enumerate who was in charge when the director was not present. As written, this requirement is not applicable to multiple ADS centers operating under one licensee at different locations. This section includes provisions for allowing an individual to request a waiver from exclusion from access to an adult day services center. Generally, waiver hearings are scheduled approximately once per month and sometimes more frequently if volume requires. The exclusion letter issued to an applicant includes detailed instructions about how to submit a request for a waiver. All requests for a waiver must be submitted in writing to the Director of Child and Adult Care Licensing and must include a letter explaining why the applicant is requesting a waiver and the completed Adult Day Care Services Criminal/Juvenile History & State Registry Review Disclosure Form. The applicant may also submit letters of reference; however, it is not required. An advisory committee reviews the request and makes a recommendation to the Director of Child and Adult Care Licensing. The Director of Child and Adult Care Licensing makes the final determination. The 2020-2025 Dietary Guidelines for Americans are available at: Current Dietary Guidelines | health.gov . The ADS Child and Adult Care Food Program handbook is available at: https://www.fns.usda.gov/cacfp/adult-day-care-centers (5) All medications shall be stored in a container, labeled with the participant’s name, the name of the medication, dosage strength, frequency, method of administration, prescribing physician, and special instructions. Effective June 1, 2019, and going forward, licensing staff will cite for non-compliance on ALL rules (pre-existing and new) and will follow regular policy and procedures for citing violations and legal enforcement actions. Staff training requirements are based upon the licensing year rather than the calendar year. Also, note that the training described in item one (1) may be conducted in-house and does not necessarily require an outside third party vendor to deliver the training. (1) Criminal Background and Abuse Registry Disclosures and Reviews; Fingerprinting Requirements. (a) The following persons are required to undergo a criminal background check and registry reviews before having access to any adult day services center: (1) Any person who owns or operates an adult day services center and has significant contact with participants; (2) Any person who applies to work in an adult day services center as an employee, director or manager; and Compliance requires agencies to have a blood pressure cuff and a scale to weigh participants. The term 'scale' should have been listed as a separate required piece of safety equipment. (4) Staff Records (d) An employment record for each employee and volunteer used to meet ratios shall include the following: (2) Signed and completed criminal history disclosure form; Compliance requires all staff members working in an adult day services center receive a criminal background check.  When fingerprinting is completed, DHS completes a comprehensive background check of all applicable records including criminal records, juvenile records, and administrative history. All background check elements described within this section are included in the comprehensive background check done through the TDHS system. (13) Safety Equipment (d) Blood pressure cuff or scale; and 1240-07-10-.07 Program 1240-07-10-.13 Medication Compliance requires the agency have all participants and/ or responsible party and an agency representative sign and date all plans, revisions, updates, and changes. If the agency determines additional parties such as additional agency representatives need to also be included in the plan, the agency may, upon their discretion, have other agency representatives involved in the plan sign and date the plan as well. As provided in item (1), agencies must have a written policy that outlines what is appropriate for the agency based upon the qualifications of staff available. The level of medication assistance is based upon the qualifications of available staff. (2) Each record shall contain, at a minimum, the following information regarding the participant: (e) A copy of any power of attorney, any health care proxy, any advanced care directive, and any physician’s orders for scope of treatment (POST) involving the participant; (7) Multiple Adult Day Services Centers Operated by a Licensee at the same location. (2) Each record shall contain, at a minimum, the following information regarding the participant: (g) A pre-enrollment assessment, which shall include: 2. Basic health history to include: current medical diagnosis, current prescription and non-prescription medications (see 1240-07-10-.13), standing orders, physical disabilities or medical conditions requiring specific modes of care and/or adaptive devices (including allergies and special dietary requirements), and evidence of a TB screening if required based on current Department of Health guidelines; (3) The record for each participant shall also include the participant’s individualized plan. (d) All plans, including all revisions, updates, changes, etc. shall be signed and dated by all involved parties. If any party refuses to participate in the planning process and/or sign the plan, the plan must include a statement of this along with a brief explanation of reason for refusal. (1) General Staff Requirements. (f) In the absence of the director, an assistant director or other staff member shall act in the place of the director, and all staff shall be notified of this designation. The available indoor space is used to determine the maximum number of participants that a program can serve at any one time. The required staff to participant ratios are based on the actual number of participants present at any one time rather than the overall agency capacity. 1240-07-10-.12 Staffing and Supervision (8) Requests for waivers from exclusion from access to an adult day services center. (6) Responsibility of Center for Supervision of Participants. (e) Required Staff:Participant Ratios. 1. The center shall have a plan that enables staff, in an emergency situation, to access additional staff who can respond quickly in order to maintain the required staff:participant ratio. 2. The minimum required staff:participant ratio must be met during special activities such as outings in order to provide adequate supervision for the participants during these activities. 1240-07-10-.08 Participants’ Records (1) Criminal Background and Abuse Registry Disclosures and Reviews; Fingerprinting Requirements. (b) Requirements for Disclosure of Criminal/Juvenile and Administrative History and Fingerprinting. (1) The center shall have a written policy which allows a participant to self-medicate or which allows staff to supervise or provide assistance to the participant for this purpose in accordance with any requirements set by the participant’s health care practitioner. (2)Appropriate assistance or supervision by staff includes reading labels, opening bottles, reminding participants to take medication, checking the self-administered dose against the dosage shown on the prescription, observing the participant while taking medication, reassuring participants that he/she is taking the correct dosage, and reporting any noticeable changes in the condition of a participant to a physician and/or to the responsible party. “Any person who applies to work” means anyone who applies and is accepted for employment, but the check must be completed prior to beginning employment. (3) The record for each participant shall also include the participant’s individualized plan. (b) Participant records shall show evidence of regular communication with the participant and/or responsible party about the individualized plan including changes to the plan and other pertinent information. Compliance requires a designated person to be in charge in the absence of the director. Whoever is designated by the agency shall be communicated to all agency staff. The main intent is to ensure that someone is placed in charge in the absence of the director and that staff know about the designated person. The agency can determine the criteria for selecting the individual(s). (2) Each record shall contain, at a minimum, the following information regarding the participant: (a) Acknowledgment of receipt of participant bill of rights; (9) Restraints (d) Locked restraints and chemical restraints are prohibited. (3) Training. (a) Staff shall complete orientation and eight (8) hours of annual training relevant to the performance of their duties recognized by the Department. 1. At least 50% of all training hours completed must be a “live” presentation in a classroom, one-on-one or group Technical Assistance (TA) session, or similar “in person” setting. 2. The additional 50% of total training hours to meet licensing rules can come from online, CD-ROM, video, self-study, including correspondence, in-house or director/staff led training (maximum of 4 hours annually), or any combination thereof. An employee or volunteer used to meet the ratios must complete a disclosure form prior to being fingerprinted. After being fingerprinted, the technician will give you a receipt. The agency must attach the receipt to the disclosure form and keep the form with attached receipt in the agency staff records. Compliance requires serious incidents be reported by calling the hotline.  It is the agency’s responsibility to gauge whether or not an incident is serious.  If in doubt, call. A description of the incident may also be emailed to the Child Care Hotline or Adult Day Services mailbox instead of calling the Child and Adult Care Complaint Hotline: ChildCareHotline.DHS@tn.gov AdultDayServices.DHS@tn.gov According to Tenn. Comp. R. & Regs.1240-07-10-.15 (6) (a)2, a serious incident includes reports made to Adult Protective Services; however, adult day services providers should only report referrals made to APS if it is *related* to an occurrence at the adult day services center. TDHS is only concerned with referrals that potentially affect the operations of the adult day services center, and not incidents in the participant's home or otherwise. Nutritional needs shall be met in accordance with the Dietary Guidelines for Americans published by the U.S. Department of Health and Human Services and the Department of Agriculture and in accordance with each caregiver’s instructions and physician’s orders, if applicable. 1240-07-10-.03 Definitions Compliance requires a routine schedule for participants that allows for a variety of physically and mentally stimulating activities.  Daily schedules should allow for rest periods as needed. Participants are allowed to choose whether or not they participate in the activities.  Rest shall be allowed throughout the day as needed for each participant.  Allowing rest periods in recliners/easy chairs at any time a participant wants to rest is an example that meets the activity rest requirement. (6) The center shall notify the Department of all serious incidents the same day of the incident by contacting the Child and Adult Care Complaint Hotline at 1-800-462-8261. The failure to report may be a basis for the summary suspension, revocation or denial of the center’s license to operate. (a) Serious incidents, include, but are not limited, to the following: The available indoor space is used to determine the maximum number of participants that a program can serve at any one time. The staff to participant ratios are based on the actual number of participants present at any one time rather than the overall agency capacity. An agency’s enrollment may exceed licensed capacity; however, an adult day services facility may never exceed licensed capacity. (2) Responsibility for Providing Fingerprint Sample; Prohibition of Contact with Participants Prior to Completion of Criminal History Review. (c)Failure to Complete or Disclose Information on Criminal Disclosure Form. There are many exceptions to a physical restraint. The main exceptions are based on an individual's ability to self release the device, the medical need for a restraint, or temporary prompting, comforting, assisting, or redirection need for physical holding. If, for example, an individual in a wheelchair does not have the ability to maintain posture without a lap belt, the lap belt may be used if the belt is easily released by the individual, and/or, needed to maintain posture while eating to prevent choking. If, for example, an individual with dementia is wandering or exit seeking, staff may physically hold the hand of a member to comfort and redirect the individual away for the exit and return to an activity. If, for example, an individual need to use a 'geri-chair' to eat, or to sit and recline comfortably, the tray is easily self-released, also excluding the chair as a restraint. Additional temporary exceptions are made for the safety of the individual as well as for transportation (seat-belts/wheelchair belts, etc). Compliance requires a routine schedule for participants that allows for a variety of physically and mentally stimulating activities.  Daily schedules should allow for rest periods as needed. Participants are allowed to choose whether or not they participate in the activities.  Rest shall be allowed throughout the day as needed for each participant.  Allowing rest periods in recliners/easy chairs at any time a participant wants to rest is an example that meets the activity rest requirement. In addition, note that the unstructured passive leisure activities mentioned in item (e) would also qualify as rest periods. (7) Contents of the Adult Day Services Program.(d) The following activities shall be offered daily: physical exercise, rest, social interaction, learning opportunities, mental stimulation, and, if needed, personal care. These social, educational and life-enrichment activities may include, but are not limited to, the following: arts, crafts, music, pet therapy, outings, current events, memory-enhancing activities, history, games, puzzles, cards, physical activity, reminiscence sessions, movies, guest speakers, and presentations, discussions about feelings, and appropriate recreational activities. Compliance requires the agency have regular communication with the participant and/or responsible party. Some possible times for communication include any time the plan changes or anytime a change is made to pertinent information that may change the participant’s plan. In addition, communication may happen on a schedule based on the agency’s policy (i.e. monthly, quarterly, biannually); written communication is acceptable.  The specific frequency for regular communication is not stated within the rule. (6) The center shall notify the Department of all serious incidents the same day of the incident by contacting the Child and Adult Care Complaint Hotline at 1-800-462-8261. The failure to report may be a basis for the summary suspension, revocation or denial of the center’s license to operate. (a) Serious incidents, include, but are not limited, to the following: (2) Reports made to Adult Protective Services or law enforcement or anytime it is necessary to call 911; The Tennessee Department of Health does not require nor recommend routine TB screening or testing either at hire or new enrollment or routinely afterward, for staff, volunteers or participants of adult day services centers. Compliance requires an agency to maintain a copy of any existing power of attorney, health care proxy, advanced care directive, and any POST. 1240-07-10-.15 Health and Safety Compliance requires participant involvement in the planning of their own activities. Depending on the cognitive ability of the participant, some may be unable to actively participate in the planning of their own activities.  Quarterly or semi-annual participant council meetings are an example of an activity that fulfills the requirement for participants to take part in program development and activity planning. Licensed Capacity. The designated maximum number of participants permitted in the care and supervision of a licensed adult day services center as determined by the Department based upon available indoor space and staff: participant ratios. Licensed capacity shall be designated on the license. 1240-07-10-.11 Food Service (e) Although leisure activities comprise an integral part of the adult day services program, activities which are limited to passive participation, including watching television, reading, etc. shall comprise no more than 20% of the center’s planned activity schedule. 1240-07-10-.04  Requirements for Licensure as an Adult Services Center Compliance requires each person receiving a criminal background check to complete an Adult Day Care Services Criminal/Juvenile History & State Registry Review Disclosure Form.   While the disclosure form is not necessary when having prints completed, the disclosure form is required for licensing and should be included in the employee files. The disclosure form is available on the TDHS website: https://www.tn.gov/content/dam/tn/human-services/hs/hs-2680-ADSDisclosureForm.pdf 1240-07-10-.10 Physical Facility Compliance requires each participant receive a bill of rights.  The bill of rights shall include all items listed within this section of the rules.  The format and any additional items the agency includes above licensing requirements is decided by the agency. Agencies are free to develop a participant bill of rights in their own wording utilizing the principals within this section (see example of participant bill of rights submitted by an agency in the Appendix). The participant bill of rights shall be shared with the responsible party/primary family caregiver in instances where the participant has dementia. 1240-07-10-.12  Staffing and Supervision 1240-07-10-.09 Criminal Background and State Registry Review Procedures Compliance requires the container medications are stored in to be labeled with the above mentioned information.  The type of the container used is the decision of the agency. The container does not have to be a pill bottle. It is acceptable to add the required information to whatever container is being provided by the responsible party.