Licensure Terms
Assisted Living Facility

General Approach
The Delaware Department of Health and Social Services (DHSS), Division of Long
Term Care Residents Protection, licenses assisted living facilities (ALFs) that offer living
arrangements to medically stable persons who do not require skilled nursing services
and supervision.
Adult Foster Care. The state licenses two types of adult foster care (called rest
homes)–family care homes and residential care homes (RCHs)–which provide room
and board and personal care services for 2-3 residents who can no longer live
independently and/or who need supervision and a family living situation. Family care
homes can provide a higher level of care than can RCHs, but when admitted,
individuals must be able to perform all activities of daily living (ADLs) and selfadminister medications.
Regulatory provisions for adult foster care settings are not
included in this profile but a link to the provisions can found at the end.
This profile includes summaries of selected regulatory provisions for ALFs.
The complete regulations can be viewed online using the links provided at the end.

Assisted living is a special combination of housing, supportive services,
supervision, personalized assistance, and health care designed to respond to the
individual needs of those who need help with ADLs and/or instrumental activities of daily

Resident Agreements
Prior to executing a contract, which includes financial and non-financial
components, residents must receive a statement of all charges. Financial components
include: service rates and ancillary charges; billing and payment policies; criteria for
additional charges as needs change; the process for changing the rates; and the party
responsible for handling finances, obtaining equipment/supplies, arranging services not
covered by the contract, and disposing of belongings.

Non-financial components include: basic and optional services; optional services
provided by third parties; residents’ rights and obligations; grievance procedures;
occupancy provisions, such as policies concerning modifications to the resident’s living
area; procedures for changing the resident’s accommodations (relocation, roommate,
number of occupants in the room); transfer procedures; security; temporary absence
policy; interim service arrangement during an emergency; staff members’ right to enter
a resident’s room; discharge policies and procedures; and facility obligations.

Disclosure Provisions
Facilities must make a financial disclosure statement available to the public.
Facilities offering special care for persons with dementia must disclose the
philosophy of care; the population served; the admission and discharge process and
criteria; the assessment, care planning, and care implementation process; the staffing
plan and training policies; physical environment and design features; resident activities;
family roles; psychosocial services; nutrition and hydration services; policies on
wandering; and costs.

Admission and Retention Policy
Facilities may not admit people with a range of medical conditions, including those
who: (1) require more than intermittent or short-term nursing care; (2) require skilled
monitoring, testing, and adjustment of medications and treatments; (3) require
monitoring of a chronic unstable medical condition; (4) are bedridden more than 14
days; (5) have Stage III or IV pressure sores; (6) require a ventilator; (7) require
treatment for a disease or condition that requires more than contact isolation; (8) have
an unstable tracheotomy or a stable tracheotomy of less than 6 months’ duration;
(9) require an intravenous or central line; (10) wander to the extent that facilities cannot
provide adequate supervision or security arrangements; or (11) pose a threat to
themselves or others.
Resident-specific waivers may be granted to allow facilities to temporarily care for
people with excluded conditions for up to 90 days, as long as services are provided by
appropriate health professionals. These restrictions do not apply to residents under the
care of a licensed hospice program.

Facilities must provide assistance with ADLs; laundry and housekeeping; access
to appropriate health care and social services, as described in resident service
agreements; opportunities for social interaction and leisure activities that promote the
physical and mental well-being of each resident; and arrangements for emergency

Service Planning
A registered nurse (RN) must complete the state’s Uniform Assessment Instrument
(UAI) prior to admitting an individual and it must be updated within 30 days of
admission, annually, and following a change in condition. The UAI collects information
about the applicant’s/resident’s physical condition, medical status, and psychosocial
needs. This information determines whether applicants meet criteria for admission/
retention, level of care criteria (for Medicaid-eligible applicants), and whether the facility
can meet their service needs.
Facilities must develop a service agreement with each resident to describe what
services will be provided, who will provide the services, when the services will be
provided, how the services will be provided, and, if applicable, the expected outcome.
The service agreement includes a risk agreement.
A managed or negotiated risk agreement is a signed document between a resident
and the facility–and any other involved party–that describes mutually agreeable actions
for balancing the resident’s choices and independence with the facility’s requirement to
oversee residents’ health and safety. Only residents who are capable of making choices
and decisions and understanding consequences may enter into a managed/negotiated
risk agreement.

Third-Party Providers
Third-party providers are defined as any party, other than the facility, that furnishes
services/supplies to a resident. Third-party providers, including family members, must
be specified in the resident’s service agreement.

Medication Provisions
Facilities must establish and adhere to written medication policies and procedures
that specify processes for obtaining, documenting, storing, and administering
medications. Residents may self-administer or receive assistance with self administration of medications,
or have medications administered to them.
An RN must review medications within 30 days of admission for residents who
self-administer medications to: (1) assess their cognitive and physical ability and need
for assistance; (2) ensure that medications have been received and properly labeled
and stored; and (3) determine the presence of adverse side effects.
Staff who complete a Board of Nursing-approved medication training program,
called Assistance with Self-Administration of Medication, in accordance with the state’s
Nurse Practice Act, may provide assistance with self-administration of medications.
Assistance includes holding the container, opening the container, and assisting the
resident in taking the medication (other than by injection), following the directions of the
original container, and documenting in the medication log that each medication has
been taken.
An adult family member/support person, as identified in the resident’s contract and
service agreement, may provide help with prescription or non-prescription medication.
The family role in the care of a resident receiving specialized care for memory
impairment must be disclosed in the service agreement.
A required quarterly pharmacy review includes a review of residents’ medication
regimens and writing a report describing any irregularities.

Food Service and Dietary Provisions
Facilities must ensure that three meals, snacks, and prescribed food supplements
are available during each 24-hour period, 7 days per week. A dietician or nutritionist
must ensure that menus are nutritionally adequate.

Staffing Requirements
Type of Staff. Every ALF must have a director, who has overall responsibility for
managing the facility to ensure that all statutory and regulatory requirements are met,
and resident assistants who provide direct care services. Facilities licensed for 25 or
more beds must have a full-time nursing home administrator. Facilities licensed for 5-24
beds must have a part-time nursing home administrator on-site and on-duty at least 20
hours a week. Each facility with four beds or fewer must have a full-time, on-site house
manager who is responsible for daily operations; the director of the facility must be on
site at least 8 hours a week.
Every ALF must have a director of nursing who is an RN. The director of nursing
must be full-time in facilities licensed for 25 or more beds, and on-site and on-duty at
least 20 hours a week in facilities licensed for 5-24 beds, and on site at least 8 hours a
week in a facility with four beds or fewer.
The ALF must have a staffing plan that specifies supervisory responsibilities,
including the person responsible in the director’s absence. All direct care staff must be
familiar with the service agreement for each resident for whom they provide care. At
least one staff person must be on site 24 hours per day who is qualified to administer
medication and/or assist with self-administration of medication, and has knowledge of
emergency procedures, basic first-aid, cardiopulmonary resuscitation, and the Heimlich
Staff Ratios. No minimum ratios. Facilities must provide a sufficient number of
staff who are adequately trained, certified, or licensed to meet residents’ needs and to
comply with applicable state laws and regulations. At least one awake qualified staff
person must be on site 24 hours per day.

Training Requirements
Orientation is required for regular and temporary resident assistants. It must cover
several topics, including fire and life safety and emergency disaster plans; infection
control; basic food service; first-aid and the Heimlich maneuver; job responsibilities;
residents’ health and psychosocial needs; the assessment process; use of service
agreements; resident rights and reporting of abuse, neglect, and mistreatment; and
hospice services. A minimum of 12 hours of annual training must be provided.
Provisions for Apartments and Private Units
Living units may be single-occupancy or double-occupancy; no more than two
residents may share a room. Bathrooms must be available to residents either in their
individual living units or in an area accessible to each resident. There must be at least
one bathroom for every four residents. Residents must have access to a microwave or
stove/conventional oven, refrigerator, and sink in their own living unit and/or a readily
accessible central kitchen. Bedrooms and all bathrooms used by residents, except in
specialized care units for memory impairment, must be equipped with an intercom or
other mechanical means of communication for emergencies.

Provisions for Serving Persons with Dementia
Dementia Care Staff and Facility Requirements. No provisions identified.
Dementia Staff Training. Facilities that provide direct health care services to
persons diagnosed with dementia must provide dementia-specific training each year to
health care providers, who must also participate in continuing education programs. The
training must cover topics relevant to dementia care, including communicating with
persons diagnosed with various forms of dementia; their psychological, social, and
physical needs; and required safety measures.

Background Checks
Facilities must obtain a report of each employee’s entire criminal history record
from the Delaware Bureau of Identification and a report from DHSS regarding its review
of any report of any person’s entire federal criminal history record. Facilities must also
comply with the state’s mandatory drug testing law for all employees. The licensing
agency may impose civil money penalties for violations of the criminal background
check and drug testing laws.

Inspection and Monitoring
Facilities are surveyed annually. When investigating abuse, neglect, mistreatment,
or financial exploitation reports, the Division may make unannounced visit(s) to the

Public Financing
The Delaware Diamond State Health Plan Plus is a Medicaid managed long-term
care program, which is currently being implemented throughout the state through an
1115 demonstration waiver. The program covers services provided in assisted living.

Room and Board Policy
In 2015, the state pays a maximum optional state supplement of $140 to
Supplemental Security Income recipients who reside in ALFs; Medicaid-eligible
residents are allowed to keep a $131 personal needs allowance. Family
supplementation is allowed