Getting Started as a Provider
Experienced assisted living providers and entrepreneurs contemplating entering the field often ask the same questions:
- What is assisted living?
- Is it different than independent living and other housing with services establishments?
- Is it licensed by the State of Michigan?
- What is an adult foster care home?
- What is a home for the aged?
- Where can I get more information?
These questions as well as dozens more are presented to Michigan Assisted Living Association professionals every week. The purpose of this publication is to provide general answers to these questions. It should not be used as a sole source of guidance.
What is Assisted Living?
The term "assisted living" is simply a marketing term. It is not defined in any Michigan law or regulation. Its origin relates to efforts to market alternatives to institutional living arrangements. For example, the term "assisted living" is typically used to identify alternatives to traditional institutional long term care settings such as nursing homes, state psychiatric hospitals and other similar facilities. The term is used broadly. It is often used interchangeably with other terms such as independent living, senior housing, retirement community, housing with services establishments and more. It can be confusing to providers and consumers.
Because assisted living is used so loosely and is not defined by any state law or regulation, it means different things to different people. For some, assisted living means a large apartment building in which senior citizens receive a variety of supports and services such as meals, transportation and laundry. For others, it may reflect a living arrangement in which three adult females with developmental disabilities share a single family dwelling licensed as an adult foster care group home. Others may associate assisted living with settings offering very extensive services to frail elderly persons in need of 24-hour supervision and protection as well as assistance with medications, bathing, grooming, dressing, transferring in and out of bed and much more.
Existing assisted living providers and companies entering the field struggle to understand all of the possible variations and how they relate to the various state licensing standards. The models vary greatly depending on the needs of persons served, the number of persons served, physical plant characteristics, the relationship between the landlord and the entity providing care, and the level and intensity of the services provided. Some models must be licensed. Some do not need a license. In some cases it is not an easy distinction to make.
Who Lives in Assisted Living?
More than 45,000 adult persons of all ages live in more than 5,000 state licensed assisted living settings across Michigan. Thousands more live in a variety of unlicensed settings.
Pursuant to Michigan law, the licensed settings have a program statement that defines, in great detail, the eligibility criteria used for admission and the types of services provided. The program statement defines the population served as well as the array of available services. Persons that typically reside in assisted living in Michigan are:
- Person who are elderly
- Persons with dementia and/or Alzheimer's related conditions
- Persons with developmental disabilities
- Persons with psychiatric disabilities
- Persons with physical disabilities
- Persons with traumatic brain injuries
How is assisted living regulated in Michigan?
In Michigan, the Department of Human Services (DHS), Bureau of Child and Adult Licensing (BCAL) is charged with the responsibility for licensing and monitoring assisted living facilities that provide a combination of housing and services that require licensure. The BCAL central office is located at 7109 W. Saginaw, 2nd Floor, P.O. Box 30650, Lansing, MI 48909-8150, phone: 517-335-6124. Information about BCAL and its standards can also be obtained at www.michigan.gov/afchfa.
There are two types of licensed facilities in Michigan. They are adult foster care (AFC) homes and homes for the aged (HFAs).
Adult Foster Care Homes
Adult foster care homes are licensed by BCAL pursuant to the Adult Foster Care Facility Licensing Act, Public Act 218 of 1979. Under Michigan law, an adult foster care facility is defined as a:
Governmental or nongovernmental establishment that provides foster care to adults. Adult foster care facility includes facilities and foster care family homes for adults who are aged, mentally ill, developmentally disabled, or physically handicapped who require supervision on an ongoing basis but who do not require continuous nursing care. MCL 400.703(4)
The definition of foster care is a key component of the statutory provision. "Foster care" means:
The provision of supervision, personal care, and protection in addition to room and board, for 24 hours a day, 5 or more days a week, and for 2 or more consecutive weeks for compensation. MCL 400.704(6)
Similarly, the definitions of "personal care," "protection" and "supervision" must be observed:
"Personal care" means personal assistance provided by the licensee or an agent or employee of the licensee to a resident who requires assistance with dressing, personal hygiene, grooming, maintenance of a medication schedule as directed and supervised by the resident's physician, or the development of those personal and social skills required to live in the least restrictive environment. MCL 400.706(1)
"Protection" means the continual responsibility of the licensee to take reasonable action to insure the health, safety, and well-being of a resident, including protection from physical harm, humiliation, intimidation, and social, moral, financial and personal exploitation while on the premises, while under the supervision of the licensee or an agent or employee of the licensee, or when the resident's assessment plan states that the resident needs continuous supervision. MCL 400.706(4)
"Supervision" means guidance of a resident in the activities of daily living, including all of the following:
- Reminding a resident to maintain his or her medication schedule, as directed by the resident's physician.
- Reminding a resident of important activities to be carried out.
- Assisting a resident in keeping appointments.
- Being aware of a resident's general whereabouts even though the resident may travel independently about the community. MCL 400.707(7)
In summary, if all of the following services are provided 24 hours per day, 5 or more days per week for 2 or more consecutive weeks, the facility must be licensed as an adult foster care home:
- room and board
- personal care and
When interpreting and enforcing this statutory basis, BCAL insists on licensure where all of the services are provided by a single entity. When more than one legal entity is involved, licensure may not be required. For example, if ABC, Inc. provides all of the above referenced items other than personal care but the residents contract with a separate legal entity such as XYZ Home Health Care, Inc. for personal care, the setting may not require licensure.
There are four types of adult foster care homes:
- Family homes for 1 to 6 persons: The licensee (the individual who has legal responsibility for the home) is generally the primary caregiver and lives in the home. This is the only category where the licensee is required to live in the home. These homes are typically single family dwellings in residential neighborhoods or rural areas. The homes generally provide private or semi-private bedrooms, semi-private bathrooms and family style common areas for social, dining and recreational activities.
- Small group homes for 1 to 6 persons: The licensee may be an individual, partnership, corporation or limited liability company. Staffing is provided on a 24-hour basis by the licensee and/or qualified staff. These homes typically are also single family residences as described above.
- Small group homes for 7 to 12 persons: These larger homes vary greatly in design and accommodations. Many are large single family residences while some are uniquely designed multi-occupancy buildings with private suites or apartment-style living arrangements.
- Large group homes for 13 to 20 persons: These homes tend to have the greatest number of variations in floor plan and accommodations. A growing number of them offer studios or private apartment-like units. Sometimes the units have kitchen efficiencies and private living areas. Some facilities are part of a community of several large group homes located on one piece of property. For example, some developments have "twin twenties" on one parcel of land. This means that two or more homes licensed for 20 or more are located on one piece of property.
These facilities typically serve the elderly, while retaining a home-like environment. For example, one building on the site may serve a more independent older population, while another addresses the needs of individuals with Alzheimer's or the frail elderly. This approach facilitates the compatibility of residents and the availability of specialty services.
To locate AFC homes in your area, there is a facility "look up" tool at www.michigan.gov/afchfa.
Licensed Homes for the Aged
Again, BCAL also licenses homes for the aged. The statutory authority is the Michigan Public Health Code MCL 333.20106. Size is the single most distinguishing characteristic of a home for the aged in contrast to an adult foster care home. A home for the aged is an assisted living program that serves individuals 60 years of age or older in a setting serving 21 persons or more. (The facility may be smaller only if it is attached to a nursing home.) Younger persons may be admitted to an HFA with BCAL advance approval. There are more than 180 licensed homes for the aged statewide.
Pursuant to state law a home for the aged is a:
Supervised personal care facility, other than a hotel, adult foster care facility, hospital, nursing home, or county medical care facility that provides room, board, and supervised personal care to 21 or more unrelated nontransient individuals 60 years of age or older. Home for the aged includes a supervised personal care facility for 20 or fewer individuals 60 years of age or older if the facility is operated in conjunction with and as a distinct part of a licensed nursing home. MCL 333.20106(3)
In reviewing the HFA statute it is important to note the following definitions developd through administrative rules:
"Activities of daily living" means activities associated with eating, toileting, bathing, grooming, dressing, transferring, mobility and medication management. R 325.1901(2)
"Assistance" means help provided by a home or an agent or employee of a home to a resident who requires help with activities of daily living. R325.901(4)
"Medication management" means assistance with the administration of a resident's medication as prescribed by a licensed health care professional. R325.1901(14)
"Room and board" means the provision of housing and meals to meet the needs of the resident. R325.1901(20)
"Supervised personal care" means guidance of or assistance with activities of daily living. R325.1901(22)
"Supervision" means guidance of a resident in the activities of daily living, and includes all of the following:
- Reminding a resident to maintain his or her medication schedule in accordance with the instructions of the resident's licensed health care professional as authorized by R333.17708.
- Reminding a resident of important activities to be carried out.
- Assisting a resident in keeping appointments.
- Being aware of a resident's general whereabouts as indicated in the resident's service plan, even though the resident may travel independently about the community.
- Supporting a resident's personal and social skills. R325.1901(23)
Homes for the aged range in design from shared rooms to private bedrooms to suites to fully appointed apartments. To locate HFAs in your area there is a facility "look up" tool at www.michigan.gov/afchfa.
BCAL strictly interprets and enforces the provisions of the Public Health Code that govern homes for the aged. In summary, a home for the aged license is required when room, board and supervised personal care is provided to 21 or more unrelated nontransient individuals, 60 years of age or older. Unlike adult foster care, the HFA statute has no requirements regarding the length of time care is provided.
The state of Michigan has promulgated administrative rules that govern adult foster care homes and homes for the aged. These administrative rules are commonly also referred to as licensing rules and can be located at www.michigan.gov/afchfa.
The licensing rules interpret the licensing statutes mentioned earlier. The rules provide, in great detail, the licensee's obligations relating to many aspects of overall operations such as:
- Administrator and staff training, competencies, qualifications and good moral character, as well as personnel policies.
- Physical plant characteristics such as the availability of bathrooms, bathing facilities, common areas, laundry facilities, kitchen/cooking facilities, bedroom square footage and much more.
- Admission and discharge policies and procedures as well as resident care agreements (leases and service contracts).
- Financial and administrative capabilities.
- Emergency preparedness.
- Environment, health and building maintenance.
How Are HFA and AFC Licensees and Staff Screened for Good Moral Character?
Under Michigan law, persons hired in positions with regular direct access to consumers or their property, financial information, medical records, treatment information, or any other identifying information are subject to an extensive background check law since April 2006. The background check includes fingerprinting, state police record checks and the review of various registries to determine whether an individual has been convicted of a crime that makes him or her unsuitable to work with vulnerable adults.
The criminal background check law governing AFC homes is P.A. 29 of 2006 MCL 400.701. The law governing HFA homes is P.A. 28 of 2006 MCL 333.20106. Both can be located at www.legislature.mi.gov.
Can BCAL Inspect Unlicensed Facilities?
BCAL has the statutory authority to inspect unlicensed settings to determine whether they should be licensed. BCAL exercises this right on a regular basis. BCAL works closely with other agencies such as Adult Protective Services in an effort to protect vulnerable adults statewide.
If BCAL inspects an unlicensed facility after receiving a complaint or scheduling a more random review, BCAL has extensive policies and procedures that govern the inspection process. If it is determined that a facility should be licensed, BCAL staff informs the operator of its findings and conclusions. BCAL further informs the operator of the statutory and administrative rule requirements. The operator is officially advised to cease providing care immediately or apply for a license within 30 days.
If the operator continues to operate and does not apply for a license within 30 days, BCAL will take official action including involvement of the State Attorney General's Office and/or removal of the residents.
Where can I get more information?
For more information please contact:
Michigan Assisted Living Association
15441 Middlebelt Road
Livonia, MI 48154
Toll Free: 800.482.0118
Michigan Department of Human Services
P.O. Box 30037
Lansing, MI 48090