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Executive Office of Elder Affairs - SCR Exemption Instructions And Application

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CHARLES D. BAKER
Governor
The Commonwealth of Massachusetts
Executive Office of Elder Affairs
One Ashburton Place, 5th Floor
Boston, Massachusetts 02108
KARYN E. POLITO
Lieutenant Governor
ELIZABETH C. CHEN, PhD, MBA, MPH
Secretary
INSTRUCTIONS
Special Care Residence (SCR) Staffing Exemption Application
In accordance with the Massachusetts Assisted Living Regulations 651CMR 12.00;
651 CMR Section 12.06(5)(c) allows certified Assisted Living Residences (ALRs) to request an
exemption from the Special Care Residence (SCR) staffing requirements set forth in 651 CMR
12.06(5)(b). Specifically, the EOEA Secretary has the authority to grant an exemption allowing
one staff member and one “Floater” to be on duty during an overnight shift if it is determined
that:
• The physical design of the SCR is conducive to the provision of sufficient care to all
residents;
• Staff members possess the means to conduct immediate communication with each other;
• The exemption request is not based on a fluctuation in Residence occupancy or level of
care need; and
• The safety and welfare of Residents are not compromised.
651 CMR 12.02 defines a Floater as, “[a] staff member of the Residence who is available on an
ad hoc basis to assist in times of unusually heavy workload or emergency situations and is not
specifically assigned to a group of Residents or unit.”
Exemptions will only be considered appropriate in situations where the physical design and
layout of the Residence can accommodate a modified staffing structure while still ensuring that
there is sufficient staff to meet all Residents’ needs.
All ALRs interested in applying for an exemption to SCR staffing requirements must complete
an application. Prior exemption status is not a guarantee of continued exemption; the ability of
the ALR to continue to preserve resident safety in the SCR with altered staffing levels will be
reviewed by EOEA during each compliance review. EOEA will review all complete applications
submitted and respond in writing.
Completed applications should be submitted electronically to the EOEA Assisted Living
Certification Unit using the following email address:
ALRHelp@MassMail.State.MA.US.
Tel: (617) 727-7750
Fax: (617) 727-9368
www.mass.gov/elder
Page 2 of 6
MA Assisted Living Residence: Application for SCR Staffing Exemption
EXECUTIVE OFFICE OF ELDER AFFAIRS
Assisted Living Certification Unit
www.mass.gov/elder
APPLICATION: Special Care Residence Staffing Exemption
Initial: Renewal:*
* 651 CMR 12.03(2)(g), Applications for renewal Certification must also include a statement that the data
required by 651 CMR 12.04(13), information documenting all substantial changes to the operating plan
prior to the effective date, and all other information required by EOEA, have been submitted.
A. GENERAL INFORMATION
1. Date of Application:
2. ALR Name and Address:
3. ALR Certification Profile:
a. Traditional Units:
b. Number of Special Care
Residences:
4. As of the date of Application:
Current Occupancy
TRADITIONAL
UNITS
SPECIAL CARE
UNITS (SCR)
# Units Occupied
# Single Occupancy
# Double Occupancy
Number of Units per SCR: SCR #1:
SCR #2
:
SCR #3
:
SCR #4
:
SCR #5
:
Page 3 of 6
MA Assisted Living Residence: Application for SCR Staffing Exemption
5. Using the table below, identify the number of times the listed scheduled and unscheduled care
needs were provided to Residents during the 11:00 pm to 7:00 am hours in the week prior to
the date of the application being completed.
Scheduled or Unscheduled Care Need
Frequency
Provided to
Traditional
Residents
Frequency
Provided to SCR
Residents
2-person assist
scheduled medication assistance
PRN medication assistance
scheduled ADL care (including repositioning)
unscheduled care (including: addressing falls, behavioral
issues, awake Residents, incontinence care, etc.)
6. For the 11:00 pm to 7:00 am shift only: provide below the dates over the past 90 days on
which the SCR(s) was staffed with greater than the minimum number of 2 Resident Care Staff
on the 11:00 pm to 7:00 am shift. For renewal applicants, please identify any dates when staff
exceeded the amount allowed under the exemption.
B. COMMUNICATION PROTOCAL
1. Describe the systems currently in place and utilized by staff to communicate on a regular and
emergency basis.
a. Will the systems be modified if the exemption to the staffing requirements is granted?
YES: NO:
If yes, please describe.
Page 4 of 6
MA Assisted Living Residence: Application for SCR Staffing Exemption
C. STAFFING
1. Describe the process utilized by the ALR to assess the staffing levels needed on an ongoing basis
including the methods and measures that the ALR uses to ensure that the staffing is sufficient at all
times (e.g., how residents are assessed for changes in condition, level of acuity, functional status,
etc.).
2.
Has the ALR utilized contracted “Agency” staff (contracted providers)
in the past 12 months?
YES: NO:
If yes, the average number of days per month “Agency” staff was working:
7:00 a.m.-3:00 p.m.:
3:00 p.m.-11:00 p.m.:
11:00 p.m.-7:00 a.m.:
3. Is Agency Staff used on all three shifts? YES: NO:
If no, please identify the shift(s) exempt:
4. Is Agency staff used 7 days of the week? YES: NO:
If no, please identify the day(s) exempt:
5. Please attach a written policy on the use of Agency Staff, if applicable.
D. OPERATIONS
1. Assuming the exemption were granted, describe the operational plan that would be utilized if
a Resident-specific emergency occurred in the ALR and the Floater was busy?
2. Assuming the exemption were granted, describe the disaster and emergency plan that
would be utilized during a building-wide emergency if there was only one staff person
dedicated to the SCR?
Page 5 of 6
MA Assisted Living Residence: Application for SCR Staffing Exemption
3. Describe the current responsibilities and routine of overnight staff in the traditional Assisted
Living and SCR(s)?
4. Assuming the exemption were granted, describe how these responsibilities and routine of
overnight staff in the traditional Assisted Living and SCR will
change?
5. Does the SCR utilize emergency call buttons/pull cords in the SCR?
YES: NO:
If yes, how many residents in the past 12 months have demonstrated consistent ability to
use the system? Provide information on the shortest and longest recorded response times;
please explain the reason for delayed response.
6. Describe the time it takes to do a round of hourly checks and how was this determined?
Page 6 of 6
MA Assisted Living Residence: Application for SCR Staffing Exemption
7. Describe the availability of video monitoring in ALR-both SCR and traditional.
D. PHYSICAL SPACE
Attach a detailed, easy-to-read floor plan the Assisted Living Residence. The floor plan should include
a scale to indicate all the dimensions of the residence. The plan should also clearly indicate the location
of each of the following spaces within the ALR:
Traditional AL units and the capacity for each unit
Special Care Residences and the capacity for each unit
Designated work area of overnight staff for both the Traditional / SCR units
All common area
Wellness office/nursing stations
All s
tairs and/or elevators
All points of egress
Proposed location of Floater(s) if granted an exemption
E. CONTACT INFORMATION
Person who can answer questions related to this application.
Name:
Title:
Phone:
Email:
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Completed 10 May 2020

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