What is California Code of Regulations Title 22
Residential Care Facilities for the Elderly (RCFEs) in California, which encompass Assisted Living, Board and Care Homes, Memory Care, and Continuing Care Retirement Communities (CCRCs), are highly regulated with a robust body of laws and regulations. They are regulated under a code called California Code of Regulations Title 22. Title 22 lays out how RCFEs must operate, what they are allowed to do, and the oversight process.
Probably the biggest issue for potential assisted living residents in Los Angeles with Title 22 is the prohibition on insertions. In lay terms, Title 22 prohibits unskilled staff from administering any care service that penetrates the body. This would include insulin injections, glucose monitoring, enemas, and catheters. Those treatments can only be administered by “appropriately skilled professionals.”
Regulation Impact on Diabetics
This clearly is the biggest problem for insulin-dependent diabetics. Diabetes is one of the fastest-growing chronic diseases in the world. The CDC estimates that 37 million people in the US had diabetes in 2022. Around 31% of those people take injectable insulin.
Most RCFEs in Los Angeles, particularly board and care homes, do not have what’s considered “appropriately skilled professionals” on staff. To provide these services, the family needs to get a prescription for a home health nurse, but home health is not going to visit 3 or 4 times/day in the case of a sliding-scale diabetic.
Title 22 requires that a resident must be able to perform glucose testing and injections by his/herself, as well as be able to set the dosage. Staff can assist in this process using a “hand-over-hand” technique. If a skilled professional, such as an LVN or RN is available, the RCFE may choose to provide this service but many choose not to do so even when a skilled professional is on duty.
There are two other categories of conditions that are restricted under Title 22.
Prohibited Conditions are conditions such as “staph” infections that are absolutely not permitted in a residential care setting. The other type of prohibited conditions, like feeding tubes or Stage 3 and 4 pressure sores, may be allowable but only under medical supervision from a hospice or home health organization. Restricted conditions are those that are allowable if the resident is mentally and physically able to perform care for his/herself or is under the supervision of an “appropriately skilled professional.”
Prohibited Conditions
Some facilities have received waivers to provide care for these conditions under the guidance of hospice or home health services.
(1) Stage 3 and 4 pressure injuries
2) Gastrostomy tubes
(3) Naso-gastric tubes
(4) Staphylococcus aureus (“staph”) infection or other serious infection
(5) Residents who depend on others to perform all activities of daily living for them
(6) Tracheostomies.
Restricted Conditions
Generally, the resident must be physically and mentally able to perform all aspects of the procedure him/herself, or care must be performed by an appropriately skilled professional.
(1) Administration of oxygen
(2) Catheter care
(3) Colostomy/ileostomy care
(4) Contractures as specified
(5) Diabetes
(6) Enemas, suppositories, and/or fecal impaction removal
(7) Injections
(8) Intermittent Positive Pressure Breathing Machine
(9) Stage 1 and 2 pressure injuries
(10) Wound care.
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