Residential Care Facilities for the Elderly (RCFE) provide care, supervision and assistance with activities of daily living to persons 60 years of age and over. RCFEs may also be known as assisted living communities, retirement homes and board and care homes. They can range in size from six beds or less to over 100 beds. The residents in these facilities require varying levels of personal care and supervision. RCFEs, as a licensed residential long-term care (LTC) option, are voluntarily chosen by an individual who does not need 24-hour nursing care, but does require some daily assistance. By definition, “RCFE” is used as both a licensure category within California and a general reference to facilities under this license type, which include board and care homes and assisted living facilities. In California, these facilities are licensed by the Community Care Licensing Division (CCLD) of the California Department of Social Services. RCFEs are predominantly for-profit, privately- owned entities and can range from residential homes to facilities that resemble apartments. They can be freestanding or integrated with skilled nursing facilities or independent housing complexes. Some offer semi-private accommodations, such as shared rooms, while other facilities offer private apartments.
Relative to nursing facility regulations, RCFEs exercise considerable flexibility in determining the populations they serve and the care provided. Within California, 75 percent of the residents of an RCFE must be age 60 or older must have needs that are compatible with those of other residents in the facility. RCFE residents often have functional and cognitive impairments that limit their ability to independently accomplish activities of daily living (ADLs), such as bathing, grooming and dressing. At a minimum, RCFEs are required to provide or coordinate the following services:
- Safe and healthy living accommodations and services;
- Sufficient staff available 24 hours a day to provide oversight and meet the scheduled and unscheduled needs of residents;
- Provision of oversight and supportive services, such as assistance with ADLs;
- Coordination of health-related services (e.g., medication administration services, treatments, wound care, etc.) provided by outside entities licensed to provide this type of care;
- A planned activities program that includes social and recreational activities appropriate to the interests and capabilities of residents;
- Three nutritious, well-balanced meals as well as snacks made available daily;
- Regular observation of the residents’ physical and mental condition;
- Housekeeping and laundry; and
- Arrangements to meet health needs, including transportation.
RCFEs may admit residents with conditions requiring incidental medical services when the residents can either manage the condition themselves or with outside help from a medical professional. These include conditions requiring injections, such as with diabetes, or those requiring oxygen administration. To provide additional types of care beyond the scope of what can generally be provided, RCFEs must request special permission from CCLD, which has oversight responsibility for RCFEs, and meet certain regulatory requirements. For example, RCFEs with a Hospice Waiver may provide end-of-life care to assist in carrying out an individual’s wish to die in their own residence. Certain health conditions may restrict individuals from using RCFEs. For example, facilities may not admit or retain anyone with a communicable disease, serious infections, or anyone requiring around-the-clock skilled nursing care.
The average assisted living resident nationally is an 86 year old female who is ambulatory, but needs assistance with about two ADLs.
RCFEs employs a variety of professional, paraprofessional, and supportive staff, including administrators, direct care workers, activity directors, food service managers, and housekeeping staff. Due to the non-medical nature of RCFEs, they are not required to have medically-trained personnel, such as nurses or physicians, on staff. For care beyond an RCFE’s scope of practice, the facilities contract with other entities such as home health or hospice agencies to provide these services. At a minimum, staff must meet age requirements, which are 21 years of age for administrators and 18 years of age for other staff, and pass a criminal background check to be eligible to work in an RCFE. Administrators are subject to additional educational requirements that increase with the number of beds a facility contains. For example, an administrator of an RCFE with 15 beds or less must possess a high school diploma or equivalent, while an administrator of an RCFE with 50 or more beds must possess at least two years of college, three years experience providing residential care to the elderly, or equivalent education and experience as approved by the licensing agency. Administrators must also complete a 40-hour training course and pass an exam in order to be certified. Other staff are subject to specific training requirements depending upon their position. Regulations governing RCFEs do not specify staff-to-resident ratios, but state that “personnel shall at all times be sufficient in numbers, and competency to provide the services necessary to meet resident needs.”
RCFEs are part of the continuum of care, providing a vital option of housing with services for seniors who want to remain in the community, but need more support and socialization than they may be able to affordably receive while living in their own home. The first members of the baby boomer generation turn 65 in 2011 and it is expected that California’s senior population will nearly double by 2030. As such, the demand for RCFEs will likely increase.