Memory care in California RCFEs: dementia rules and what to ask

Memory care is part of RCFE licensing

Many assisted living homes use the words memory care. In California, those homes are licensed as RCFEs, and the dementia rules are part of the RCFE regulations. Which extra rules apply depends on whether the home cares for residents with dementia, and whether it advertises special dementia care.

The rules apply to residents diagnosed with dementia. Mild cognitive impairment, on its own, is not treated as dementia under these rules.

Rules for every home that cares for residents with dementia

These rules apply whether or not a home calls itself memory care. Any RCFE caring for a resident diagnosed with dementia must:

• Train staff in dementia care, including hydration, nutrition, skin care, communication, therapeutic activities, behavioral challenges, the environment, and help with daily activities.
• Train staff to recognize problems that can cause or worsen behavior changes, such as dehydration, urinary tract infections, and trouble swallowing, and to recognize the effects of medications used to reduce those behaviors.
• In homes with fewer than 16 residents, have at least one staff member awake and on duty at night if a resident with dementia needs awake night supervision.
• Have an alarm or other staff alert on exterior doors and perimeter gates that residents at risk of leaving unsupervised can reach.
• Use exit alert or location tracking devices only with the prior written approval of the resident or conservator, and without violating the resident's rights.

Locked or delayed exit doors

Some homes use delayed egress devices, which delay the opening of an exit door, or lock exterior doors and perimeter gates. To do either, the home must notify licensing and have the setup approved as part of its fire clearance. Locked or delayed doors can never substitute for enough trained staff.

Staff must first try to redirect a resident who wants to leave. Where delayed egress devices are used, a resident who still wants to leave must be allowed to go with staff supervision, and the home must report each time a resident at risk leaves unsupervised: to the resident's representative right away, and to licensing by the next working day.

A home with locked exterior doors must have indoor and outdoor space where residents can wander freely and safely. For each resident, it must keep either a court order showing a conservator's authority for the placement, or a signed statement from a resident who is not conserved agreeing to the locked doors.

Staff training required by law

State law requires RCFE staff who help residents with daily activities to complete 40 hours of training, including 12 hours on dementia care. Twenty hours, including six dementia hours, must be finished before a new staff member works alone with residents. The rest must be finished within the first four weeks of employment.

Direct care staff also need in-service training on dementia care every year. These requirements apply to all RCFEs, not only homes that advertise memory care. Ask how the home meets them and what extra training, if any, it adds.

Extra rules for homes that advertise dementia care

A home that advertises or promotes special dementia care, programming, or environments must meet added rules. Its plan of operation must describe:

The home must give each prospective resident a written description of these programs and services before admission, and make it available to the public on request. If a home stops advertising dementia care, it must give residents and licensing at least 30 days' written notice.

• Its philosophy and goals for residents with dementia.
• Which areas of the home provide dementia care, and what services are offered.
• Training for the direct care staff who provide dementia care.
• Activities, such as mental stimulation, physical activity, and reminiscence.
• The physical setting, such as hallways, handrails, secured perimeters, lighting, signs, and outdoor space.
• What happens when a resident's condition changes, including the conditions that would require a move.
• How the home checks whether its program is working.

Questions to ask on a memory care tour

Use the written program description as your guide. Ask how each part works day to day.

• May I have your written dementia program description?
• How many staff are on duty during the day, evening, and night? Is someone awake all night?
• How are staff trained, and who trains them?
• What happens when a resident tries to leave? Are doors locked or delayed?
• What does a typical day of activities look like?
• How do you respond to agitation or other behavior changes before turning to medication?
• What changes in health or behavior would mean my parent has to move?
• Do you have a hospice care waiver?

Hospice care in an RCFE

A terminally ill resident can receive hospice care in an RCFE only if the home has a hospice care waiver from CDSS. The hospice agency must be Medicare-certified and licensed. The hospice and the home must agree on a written care plan that spells out who does what.

To get the waiver, the home must show it can meet the care needs of terminally ill residents and agree to add care staff if the hospice care plan requires it. Residents also have the right to choose their own hospice agency, consistent with the admission agreement. If your parent may need hospice later, ask about the waiver before you choose a home.