Can Assisted Living Manage Incontinence in California?

The National Institute on Aging describes urinary incontinence as leaking urine by accident. It is more common in older people, especially women, and the institute says it can often be stopped or controlled. That is a reason to ask the doctor about it before assuming nothing can be done.

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, lists incontinence of bowel or bladder as a restricted health condition, which means a home may care for it under the terms of section 87625, titled Managed Incontinence. Our guide to health conditions assisted living can accept has the full list.

Section 87625 lets a home accept or keep a resident who has a manageable bowel or bladder incontinence condition when it can be managed with any of four things: self care by the resident, a structured bowel or bladder retraining program, a program of scheduled toileting at regular intervals, or the use of incontinence care products.

This is one of the few restricted conditions where caregivers do most of the hands-on work. Helping a person to the bathroom, giving reminders, changing a brief and washing are personal care, which is what an RCFE is licensed to provide. The regulation gives a licensed professional three specific jobs.

Health and Safety Code section 1569.39 defines an appropriately skilled professional as a person trained and licensed to perform the procedure a physician has prescribed, such as a registered nurse or licensed vocational nurse. For incontinence, section 87625 adds that the professional should have training and experience in the care of older people with bowel or bladder problems.

Section 87625 makes the home responsible for a list of protections. Several are about dignity as much as hygiene:

• Residents who can benefit from scheduled toileting are assisted or reminded to go to the bathroom at regular intervals, rather than being diapered.
• Residents are checked during the times they are known to be incontinent, including during the night.
• Residents are kept clean and dry, and the home stays clear of odors from incontinence.
• Skin exposed to urine and stool is evaluated regularly for breakdown.
• Privacy is given when care is provided.
• Fluids are not withheld to control incontinence.
• A resident is not catheterized to control incontinence for the convenience of the home.

The personal rights in Title 22 back this up. Section 87468.1 gives residents the right to be accorded dignity in their relationships with staff, and section 87468.2 gives residents of privately operated homes the right to a reasonable level of personal privacy in personal care and assistance. If care falls short and raising it with the home does not fix it, complaints about a licensed home go to California's Community Care Licensing Division, and in an emergency call 911.

The regulation uses the word manageable and does not draw a line by how often accidents happen or whether they involve bowel, bladder or both. In practice the limits come from other rules and from the home itself.

One is skin. The rule requires regular checks of skin exposed to urine and stool so that breakdown is caught. Stage 1 and 2 pressure injuries are restricted conditions that need a physician or licensed professional, and stage 3 and 4 are prohibited, as wound care in assisted living explains. Another is overall dependence: a person who depends on others to perform all activities of daily living is on the prohibited list in section 87615. A catheter or ostomy brings its own rules, covered in catheters and ostomies in assisted living.

A home is also never required to accept a particular person. A home may decline someone whose toileting or night care needs more staff than it has. Where a state rule is the obstacle, section 87616 lets the home ask the Department of Social Services for a written exception, and a home with a hospice care waiver needs no separate exception for a terminally ill resident whose hospice care plan addresses the condition. Section 87633 lists turning and incontinence care to prevent skin breakdown among the training topics for staff caring for a resident on hospice.

Start from the assumption that supplies are a family cost. Medicare states that Original Medicare does not cover incontinence supplies or adult diapers, and that some Medicare Advantage plans offer extra benefits, so check with the plan. Ask the doctor and any other insurer what is covered for your parent.

Homes do not all handle supplies the same way. Ask whether the family brings them, the home orders them and bills the cost, or they are part of the monthly rate. Ask, too, whether incontinence care changes the care level and with it the monthly fee, and where each charge appears in the contract. Our guide to the admission agreement explains what that document has to spell out.

Use your nose and your eyes first. The rule that residents be kept clean and dry and the home kept clear of incontinence odors gives you something to check in the first minute of a visit. Then ask:

• How often do you check residents overnight, and how many staff are awake?
• Do you use scheduled toileting, and how do you keep track of it?
• Who decides which products a resident uses, and who buys them?
• Does incontinence care change the care level or the monthly fee?
• How do you protect privacy in a shared room?
• How do you check skin, and who is told when you see redness?
• At what point would you say you can no longer manage my mother's needs?

Hamssa Benrekia is a senior living placement specialist in Torrance with a background in hospice, palliative care and home health. Families often find this subject hard to raise, and she can ask the direct questions with you. She helps families in the South Bay and Harbor area look for a licensed board and care home or assisted living community that says it can meet a parent's needs, and she goes on the tours. To talk it through, contact Hamssa, or start with the California Assisted Living Placement Guide.