Can Assisted Living Care for Someone With Diabetes and Insulin in California?

MedlinePlus, the National Library of Medicine's health site, describes diabetes as a disease in which blood glucose, also called blood sugar, is too high. Insulin is the hormone that moves glucose from the blood into the cells. People with type 1 diabetes need daily insulin by injection or pump, and some people with type 2 diabetes take pills, injections or both.

Assisted living communities and board and care homes, licensed in California as residential care facilities for the elderly (RCFEs), are non-medical homes. Title 22, section 87612, puts diabetes on the list of restricted health conditions: a home may care for a resident who has it, but only as section 87628 describes. The full list is in our guide to health conditions assisted living can accept.

Section 87628 says a home may accept or keep a resident with diabetes if the resident can do their own glucose testing and can take their own medication, by mouth or by injection, or has the medication administered by an appropriately skilled professional.

Two kinds of people: the resident, or an appropriately skilled professional. Health and Safety Code section 1569.39 defines that professional as someone trained and licensed to perform the procedure a physician has prescribed, such as a registered nurse or licensed vocational nurse. The law says the professional may work for a home health agency, for the resident or for the home.

Caregivers are a different matter. Title 22, section 87465, says facility staff, except those authorized by law, shall not administer injections, though designated staff may assist a resident with self-administration as needed. How that line between assisting and administering works for every kind of medication is explained in medication management in assisted living.

The table sets out the main diabetes tasks and what the regulations say about each.

MedlinePlus notes that people with type 1 diabetes, who must take insulin, also need to check their blood sugar at home, and that the health care provider says how often. In an RCFE, the regulation is built on the resident doing that check. Section 87628 does not name caregivers as people who may perform the test for a resident.

That matters most when a parent has memory loss, poor eyesight or shaky hands and can no longer manage a meter. Ask each home, plainly, who performs the test when a resident cannot, under whose direction, and how the result reaches the nurse or the doctor. Ask for the answer in writing, and ask the doctor whether your parent can still test reliably.

The general rules for restricted conditions also apply. Before admission, staff who will help must complete hands-on training from a licensed professional. The home keeps the physician's documentation of how stable the condition is and of the resident's ability to perform the procedure, and it must watch for changes in that ability and document them. Staff must be able to recognize a problem and contact the physician or the professional.

Section 87628 makes the home responsible for providing modified diets as prescribed by the resident's physician, and the food service rules in section 87555 repeat it: a modified diet a physician prescribes as a medical necessity shall be provided. The same section says snacks between meals must be made available unless the physician has limited them.

The rule turns on a physician's prescription, so a diet your mother has followed informally for years is not the same as a written order. Ask the doctor whether a diet order is appropriate and bring it to the home before move-in. Our guide to special diets in assisted living covers how homes handle them.

Then the skilled part of the care has to come from a licensed professional. Some larger communities employ nurses. Many small homes do not, and rely on a home health agency or a private nurse who visits. Title 22 requires a written agreement between the home and a home health agency that spells out the services, how often they happen and how the two will communicate.

Ask who pays for those visits. Medicare's home health benefit lists injections among the part-time or intermittent skilled nursing services it covers for people who qualify, which includes being homebound. Whether that fits a daily insulin visit for your parent is a question for the doctor and the agency. Our guide to who may give injections in an RCFE goes further into the options.

Two other rules can change the answer. Under section 87616, a home may send the Department of Social Services a written exception request when it believes it can meet a resident's needs by other means; the home applies, and the department decides. And a home with a hospice care waiver needs no separate exception for a terminally ill resident whose hospice care plan addresses the diabetes care. Even then, section 87633 says staff may not perform a procedure that the law reserves for a licensed professional.

A home is never required to accept a particular person, and each one decides what it can manage. Bring the current medication list and the doctor's orders, and ask:

• Do you have residents on insulin now, and who gives the injections?
• Is there a nurse on staff, and on which days and hours?
• If a nurse visits, which agency, how many times a day, and who pays?
• Who checks blood glucose when a resident cannot, and who is told when a reading is out of the range the doctor set?
• What do staff do, and whom do they call, when a resident shows signs of low blood sugar?
• How do you handle a physician's diet order, and can I see a week of menus?
• What would make you say my father's diabetes is more than you can care for?

Hamssa Benrekia is a senior living placement specialist in Torrance with a background in hospice, palliative care and home health. When a parent uses insulin, she can help a family in the South Bay and Harbor area look for a licensed assisted living community or board and care home that says it can manage it, and she goes on the tours with you. The home, the doctor and the state decide what a home may accept, not Hamssa. To talk it through, contact Hamssa, or start with the California Assisted Living Placement Guide.