Assisted Living National Program Guidelines 2019 to 2020

1. Introduction

1.1 These guidelines set out the delivery requirements and standards for funding recipients of the Assisted Living program that have a funding agreement with Indigenous Services Canada (ISC) (formerly Indigenous and Northern Affairs Canada).

1.2 This document will be in effect as of April 1, 2019 and replaces the Assisted Living National Program Guidelines published in fiscal year 2018 to 2019.

1.3 This document is to be read in conjunction with the funding agreement signed by the funding recipient, as well as ISC's regional office program manuals or guidance. These documents provide information about provincial and territorial services, supports and rates to help funding recipients align the delivery of services and supports with those of provincial and territorial programs, where applicable. These documents can be requested using contact information in section 14.

For funding recipients working on Disabilities initiative projects, this document should be read in conjunction with their ISC approved proposal and work plans.

1.4 Where ISC has entered into agreements with the provinces, the obligations set out in the agreements, and as amended from time to time, are to be read first and take precedence over the delivery requirements and standards of the Assisted Living program, as explained in this document.

• In Ontario, the Memorandum of Agreement Respecting Welfare Programs for Indians guides ISC's reimbursement to the Government of Ontario for social services cost-shared in accordance with the agreement. This agreement (referred to informally as the "1965 Agreement" or the 1965 "Indian Welfare Services Agreement"), supports cost-sharing of the Assisted Living program delivered in First Nations communities under the overall management oversight and responsibility of the Government of Ontario: Homemakers Services.
• In Alberta, the Arrangement for the Funding and Administration of Social Services (referred to informally as the "1991 Alberta Reform Agreement") guides ISC's reimbursements to Alberta for social services that the Government of Alberta delivers to First Nations individuals who are ordinarily resident on reserve in the Province of Alberta.
• Other bilateral or tripartite agreements or memoranda of understanding may be developed in collaboration with and must first be approved by ISC Social Policy and Programs Branch.

2. Objective

The Assisted Living program is a component of Canada's social safety net meant to align with similar provincial and territorial programs.

The objective of the Assisted Living program is that in-home, group-home and institutional care supports are accessible to eligible low-income individuals to help maintain their independence for as long as possible in their home communities. This residency-based program provides funding to First Nations, provinces and Yukon Territory on an annual basis through negotiated funding agreements for non-medical social supports, as well as training and support for service delivery so that seniors and persons with disabilities can maintain functional independence within their home communities.

3. Expected outcomes

The ultimate outcome for the Assisted Living program is that eligible individuals have the ability to maintain functional independence within their home communities. In order to achieve this, the Assisted Living program also supports the development of capacity of First Nations communities to deliver assisted living social support services, to address and overcome barriers to the delivery of these services, and to provide the social support component of in-home care, adult foster care, and institutional care.

4. Funding recipients

A funding recipient means an individual or entity that has met the eligibility criteria of the program and has signed a funding agreement with ISC to deliver an initiative (program, service or activity).

4.1 Eligibility criteria

Eligible funding recipients for the delivery of in-home care, adult foster care and institutional social supports are:

• band councils of First Nations bands recognized by the Government of Canada
• tribal councils
• provinces
• Yukon Territory
• indigenous communities and organizations
• political and treaty organizations
• municipal governments or agencies
• private businesses, organizations or agencies
• volunteer, not-for-profit and non-governmental organizations

Eligible funding recipients for the delivery of projects and activities under the Disabilities Initiative are:

• band councils of First Nations bands recognized by the Government of Canada
• tribal councils
• indigenous communities and organizations
• political and treaty organizations
• volunteer, not-for-profit and non-governmental organizations
• educational institutions

4.2 Assessment criteria for funding recipients

In order to receive funding for the Assisted Living program, the following criteria will be assessed.

To deliver the In-Home Care component, funding recipients must have:

• operational processes and procedures for the delivery of services that are consistent with this document and with programs, standards and guidelines of the reference province or territory
• established management and accountability processes and procedures for program funding
• documentation to confirm that in-home care services provided to a client are a part of the client's care plan based on assessed needs

For Adult Foster Care and Institutional Care components, funding recipients must:

• operate according to the licensing and accreditation guidelines applicable to the facility type of the reference province or territory
• maintain up-to-date documentation confirming that adult foster care or institutional care services provided to a client is a part of a client's care plan based on assessed needs
• ensure that the care services for which the care facility is invoicing do not exceed Types I and II care as defined in Health Canada's (1973) Federal Classification System for Institutional Care or equivalent

Additional information to help with the determination of comparability to programs and services of the reference province or territory can be found in section 16.

5. Program recipients, clients and individuals

A program recipient is referred to as a client or an individual throughout this document. A client is the ultimate beneficiary of assisted living services. An individual has not yet been determined as eligible for service (for example, during the application and eligibility determination phase).

Once an individual has been found eligible or approved to receive services through the Assisted Living program, they become a client.

5.1 Eligibility requirements

5.1.1 For in-home care, adult foster care and institutional components, clients must be:

• ordinarily resident on reserve
• formally assessed by a designated social service or health professional using the care assessment criteria recognized by ISC as requiring one or more eligible supports
• unable to obtain such services themselves or access other federal, provincial or territorial sources of support, as confirmed by an assessment covering employability, family composition and age and financial resources available to the household

5.1.2 Ordinarily resident on reserve

Ordinarily resident on reserve means that a client has, at the time of applying for a care assessment, demonstrated that he or she:

• lives on reserve and does not maintain a primary residence off reserve

or

• is off reserve primarily to obtain required medical care or social service support because there is no comparable service available on reserve, and lived on reserve immediately prior to receiving the medical care or social support

5.1.3 A student who is registered and attending a secondary or post-secondary institution or training program and who is in receipt of education funding from the federal government, a band or Indigenous organization continues to be considered ordinarily resident on reserve if he or she:

• maintains a residence on reserve

or

• is a dependent of a parent or legal guardian that maintains a primary residence on reserve

or

• returns to live on reserve with parents, guardians, caregivers or maintainers during the year, even if they live elsewhere while attending school or working at a temporary job

5.1.4 Services provided to individuals residing off reserve may only be funded when:

• the individual meets the definition of ordinarily resident on reserve at the time of applying for a care assessment
• the service provided is in an institutional care or adult foster care facility that meets the conditions described in section 4.2 of this document

Funding for in-home care services is not provided for individuals ordinarily residing off reserve.

5.1.5 Residency status is determined at the time an individual applies for assessment and follows the client until he or she no longer requires assisted living social supports

5.2 Minimum required documentation for clients

Funding decisions require that the administrators collect and keep information that supports the eligibility of the expenditures and the management of a client's circumstances. Refer to the applicable funding agreement for the specific requirements of record keeping.

In accordance with the record keeping requirements set out in the funding agreement, administrators are required to keep information that is collected from all current and prospective clients, whether or not they are eligible for services, including:

• completed applications
• incomplete applications
• all supporting documentation provided during the application process

5.3. The types of information that are used to assess and confirm the needs and eligibility of an individual and their related expenditures are:

• application forms refer to section5.4.1 of this document
• authorization forms used to confirm the individual's information
• documentation confirming and supporting the verification of the identity of the individual
• documentation verifying the residency of the individual refer to section 5.4.2 in this document
• documentation verifying the household income
• all supporting documentation for program expenditures: receipts, invoices, cancelled cheques, log of care services and formal assessment and care plan documenting the supports and services provided
• for adult foster care and institutional care, documentation demonstrating that the care home or facility operates according to the licensing and accreditation guidelines of the reference province or territory: refer to section 5.4.8 in this document
• the funding recipient's general ledger and supporting accounting records
• working papers, lists, system reports and any other information necessary to complete each ISC reporting requirement
• pay lists used to create monthly assisted living benefit payments and cheques

In addition, administrators are required to verify and cross reference the funding recipient's information from other programs to the individual's application, to ensure that there is no duplication of supports and benefits, when considered as a whole. The types of information to consider include:

• schedule of salary and honoraria paid to elected officials and band employees,  including any individuals who are paid to provide services
• income assistance pay lists used to create monthly income assistance benefit payments and cheques
• post-secondary education lists and nominal rolls

5.4 Documentation for program management activities

There are several key activities that form the overall management of program expenditures. The minimum requirements for documenting key program management activities are outlined in detail below.

Additional ISC regional office requirements for documenting key program management activities may also apply. Please contact your regional office to confirm whether additional requirements apply.

When determining an individual's eligibility for the Assisted Living program, the administrator must:

• obtain authorization from the individual to verify with the Income Assistance Program whether or not the individual is in receipt of income assistance benefits
• once authorized, verify and document any income assistance benefits received at the time the individual applies for assisted living services or supports
• include notes and other supporting documentation in the individual's file to confirm that the individual meets the requirements listed in this document

When the individual is not in receipt of income assistance benefits at the time of applying for assisted living supports or services, the verifications of eligibility outlined in sections 5.4.4 and 5.4.5 of this document must be completed and documented in the individual's file before providing any assisted living services to the individual.

5.4.1. Application form

An application must be completed in full and contain all of the following information and supporting documentation before issuing benefits to the individual:

• full name of the individual and the individual's family members: refer to section 5.4.3 of this document
• date of birth for the individual and individual's family members (ages listed is not acceptable)
• signatures of the individual or legal guardian and the date of the signatures as per ISC regional office formats and procedures
• an address or other indication of on reserve residency: refer to section 5.4.2 of this document
• a declaration that the information provided is accurate to the best of the individual's knowledge signed and dated by the individual or legal guardian

Applications must be updated annually or as changes in financial circumstances and need for assisted living social supports require.

5.4.2. Primary residence

The administrator must confirm that the individual is ordinarily resident on reserve before issuing benefits. The requirements for ordinarily resident on reserve are set out in this document.

Documentation containing the current home address for the individual and each dependent must be kept in the individual's file.

The documentation must contain the current home address on at least one of the following pieces of information:

• utility bill
• income documentation such as a pay stub or other information slip for government programs such as Old Age Security, Guaranteed Income Supplement, Canada Pension Plan and Employment Insurance
• bank statement
• income tax assessment or information slips for the most recent year
• lease agreement
• tenancy agreement
• residency verification provided by the a band council's housing department
• driver's license or vehicle registration
• vendor invoices
• school records: current registrations
• declaration of residency signed by a landlord

When the documentation listed above cannot be obtained, a band council resolution verifying the individual's residency on reserve may be accepted by ISC. However, there must be evidence on file that other sources of identification are unavailable.

5.4.3. Identity verification

Within 60 days of the date of the initial application, the administrator must confirm the identity of the individual as listed in the application and ensure that copies of each person's identification are placed on file. The individual applying for assistance has up to 60 days to provide proof of identification for the individual and legal guardian if applicable.

If after 60 days of the date of initial application, the individual has not provided identity documentation for the individual and legal guardian if applicable, he or she will be ineligible to receive benefits. However, if the individual demonstrates that he or she is actively pursuing the missing identity documentation, the administrator may extend the 60 day period until it is received. In this situation, it is important that the administrator note in the individual's file the efforts made by the individual to obtain the missing documentation.

5.4.4. Financial needs assessment

A clear demonstration of financial need, taking into consideration all financial resources available to the individual and household, must be obtained from the individual prior to issuing benefits to the individual.

This means that prior to issuing benefits the administrator must verify the individual's financial need by:

• completing and documenting an assessment of all financial resources, including income, assets, savings and investments, available to the individual and household
• verifying official documentation to fully support the assessment of financial need

The financial needs assessment must include copies and verification of the supporting documentation for the individual and household:

• at the time of approving the application
• when the assessment is updated annually or sooner when there is a change in circumstances, including a break in assistance

5.4.4.1 Budget and decision sheets

Budget and decision sheets must:

• be completed in full, listing the individual's and dependent spouse's financial resources and needs
• be available for review during the on-site review
• have a numerical amount entered for each line item, including a zero (0) where there are no amounts

5.4.5. Documentation to support the financial need assessment

The following documentation, supporting the financial need assessment must always be in the file:

• documentation showing amounts received from employment insurance or showing that the individual and dependent spouse are not eligible for benefits
• documentation showing amounts received for Guaranteed Income Supplement, Old Age Security or Canada Pension Plan or showing that the individual or spouse is not eligible for these benefits, when it appears that the individual or dependent spouse could be eligible for one or more of these benefits
• current bank account statement if the individual or dependent spouse have a bank account
• current and complete income tax assessments, showing total income and deductions, or information slips for the most recent year

In addition to the mandatory documentation described above, the following additional sources of documentation can be used to document the individual and his or her family circumstances:

• last pay cheque
• record of employment
• confirmation of the recipient's payroll or employee list
• Canada Child Benefit Notice
• confirmation with the province or other First Nations social programs to determine if the individual is receiving income assistance and assisted living benefits from the province or another First Nations social program (for example, case notes, email, letter or standard form)
• confirmation of funding for post-secondary education, funding amounts included

5.4.6. Formal assessment for non-medical social support

The formal assessment for non-medical services (original or a copy of the original) must be on file and must be completed by a health or social professional and include the following:

• the name of the individual
• the name of the person authorized by the reference province or territory statutes and regulations to perform a formal assessment for non-medical social support services (for example, a physician, nurse practitioner, registered nurse, licensed practical nurse, registered social worker)
• the date and signature of the designated social services or health professional
• formal letterhead or form used by the person authorized by the reference province or territory statutes and regulations to perform a formal assessment for social support services
• a precise statement about the non-medical social supports services required
• the period of time that the individual is eligible for non-medical social support services, (for example, start and finish date covering the period that individual social support services are eligible)
• the types and amount of non-medical individual social support services required

5.4.7. Expenditure documentation

Expenditures require supporting documentation and information.

When reimbursing expenditures, the following requirements apply:

• the expenditure must match the amount identified on the receipt, invoice, purchase order, chit or statement (original or copy of original) that is kept on file
• the file documentation must demonstrate that the amount paid is eligible as per this document
• for each receipt, invoice, purchase order, chit or statement that contains an individual's name, the name on the document must match the name of the individual or a legal guardian if applicable
• the non-medical social support services on the invoice (log of services provided and paid for) be identified in the individual's care and support plan based on the formal assessment of needs
• for adult foster care and institutional care, documentation must be provided to verify that services do not exceed Types I and II care, federal classification or equivalent

5.4.8. Licensing and accreditation guidelines

For adult foster care and institutional care, documentation confirming that the care home or facility operates according to the licensing, recognition or accreditation guidelines of the relevant province or territory is required.

Examples of documentation include a copy of the license provided by the reference province or territory or a letter from the province or territory confirming that the facility meets licensing standards.

6. Activities

6.1 There are 3 components available through the Assisted Living program.

6.1.1 All 3 program components respond to 3 distinct and progressively intensive care needs:

• in-home care (such as meal programs and housekeeping)
• adult foster care (not established in all regions) (such as care in a group home setting)
• institutional care for Types I and II levels of care (such as care provided in provincially licensed residential facilities)

Type I and II levels of care: the definitions of care are based on the Report of the Working Party on Patient Care Classification to the Advisory Committee on Hospital Insurance and Diagnostic Services (1973) and The Memorandum of Understanding Regarding the Delineation of Responsibility Between the Medical Services Branch of the National Health and Welfare (now Health Canada) and the Indigenous and Northern Affairs Canada (now Indigenous Services Canada) for Adult Care for Elderly, Disabled and Handicapped Indians (1984).

Type I care is residential care for persons requiring primarily supervision and assistance with daily living activities and social and recreational services: 30 to 90 minutes therapeutic and personal care or supervision daily.

Type II care is extended care for persons requiring availability of personal care on a 24-hour basis, under medical and nursing supervision: 90 to 150 minutes care or supervision.

Additional information to help with the determination of comparability to programs and services of the reference province or territory can be found in section 16.

6.1.2 Funding recipients who deliver the Assisted Living program receive resources to support the administration of the program

6.1.3 For disabilities initiative projects to improve the coordination and accessibility of existing disability programs and community services to persons living on reserve, eligible activities for funding recipients are set out in the funding recipient's approved work plan or proposal

7. Expenditures

ISC funds the Assisted Living program supports and services for clients that are aligned with the requirements outlined in this document and with the eligibility criteria and rates established by the reference province or territory. Assisted living funding can be used for eligible service delivery expenditures.

7.1 Guiding principles

Where it is not clear whether or not a particular service would be eligible for funding under the Assisted Living program, the following guiding principles should be considered:

• services are intended to be aligned with those provided by the reference province or territory for clients subject to a financial needs test. This includes services for which a person with sufficient means would be expected to pay out-of-pocket. For example, the Assisted Living program would fund attendant care as an eligible item under in-home care to the same extent as would the reference province or territory on the basis of an income test
• the maximum amount payable to any funding recipient with respect to any client is the actual costs of the eligible expenditures associated with that client for in-home care, foster care and institutional care consistent with the reference provincial or territorial programming
• administrators are required to verify and cross reference the funding recipient's information from other programs (for example, income assistance) to the client's application, to ensure that there is no duplication of supports and benefits, when considered as a whole
• for assisted living in-home care, services should apply to care in the client's home and community environment (for example, housekeeping), but not care of the client directly (for example, nursing care)
• the amounts should always be reasonable in the circumstances in which the services are provided. Hourly rates may include incidental costs (for example, transportation and supplies). In all cases, expenditures must be supported by documentation and information as listed in section 5.4.7 of this chapter
• Assisted Living program funding, including service delivery funding, cannot be used for capital expenditures such as the construction of care facilities

7.2 The in-home care component provides funding support for non-medical support services

These services include:

• meal programs, meal planning and preparation
• day programs
• attendant services: this could include services such as accompanying a client to an appointment or while shopping, but does not include care of the client directly, for example, bathing and dressing
• short-term respite care as defined by the reference province or territory
• group care
• laundry
• ironing
• mending
• carrying water
• chopping and carrying wood
• home management which may include making beds, dusting, washing dishes, sweeping, wiping counter tops, vacuuming, taking out the garbage, scrubbing a bathroom or floor, washing walls or shampooing carpets
• minor home maintenance such as fixing a door knob or attaching a railing along stairs
• non-medical transportation

7.3. The adult foster care component provides funding support for supervision and care to individuals unable to live on their own due to physical, cognitive or psychological limitations and who do not need continuous medical attention

Before client expenses in adult foster care can be reimbursed, eligible funding recipients must verify that the adult foster home:

• charges provincial or territorial daily rates
• operates according to the licensing or accreditation guidelines of the reference province or territory

7.4. The institutional care component of the program provides funding support for individuals requiring Types I and II care in institutions operating according to provincial or territorial laws and standards both on and off reserve

7.4.1. Provinces and territories are responsible for providing funding for higher levels (for example, Types III, IV and V) of institutional care on and off reserve

7.4.2. Co-payment and user fees

Clients residing in an institution are expected to pay the provincial or territorial government established co-insurance or user fee for care, maintenance, clothing and personal expenses to the extent that they are financially able to do so. This may require using or assigning income received from alternate income-support programs (for example: Old Age Security, Guaranteed Income Supplement, Canada Pension Plan, Employment Insurance, and personal income from all sources).

7.4.3 Eligible institutional care expenditures:

• standard accommodation in accordance with the reference province's definition of institutional care
• meals, including therapeutic diets
• food
• laundry
• necessary emergency and routine treatment supplies
• professional social services, as needed, in accordance with assessed client needs
• programs for social and recreational activities
• clothing
• special diets
• age allowance
• personal living allowance
• guide dogs

7.4.4 Eligible service delivery expenses

Eligible expenditures to support the administration of the Assisted Living program are:

• salaries, wages and benefits
• travel

• transportation
• training for professional or paraprofessional administrators and case workers
• related office costs
• activities related to collecting and managing data required for program management
• monitoring, planning, reporting and evaluation
• maintaining and upgrading program management systems
• developing operational policy and related documents, and delivery options to encourage local integration, where possible, of education, health and social services needed to effectively deliver and administer the Assisted Living program
• developing and implementing case management protocols, including the following:
  • structured client assessments
  • referrals
  • re-assessment and counselling
  • training
  • professional support for Administrators and case managers

7.4.5. For the proposal-based disability initiative, eligible program expenditures are set out in the approved work plan or proposal referred to in the funding agreement

8. Funding

8.1 Maximum amount of funding

The maximum amount of funding to be provided to a funding recipient in a fiscal year is set out in the funding agreement signed by the funding recipient.

8.2 Stacking limits and duplication of funding

The maximum funding that will be provided to a funding recipient are 100% of the eligible costs associated with a particular program (activity, initiative or project) to be funded.

A funding recipient is required to declare any and all sources of funding for the program that are expected to be received or that are received, including all funding from the Government of Canada and from provincial, territorial, and municipal governments. Annual financial reporting must show all sources of funding received.

Provision for repayment will be made when ISC's contribution is in excess of $100,000 and when funding from all sources exceeds eligible expenditures. Funding recipients must provide ISC with information showing the amount to be repaid and the basis for calculating that amount. The reimbursement should be proportionate to ISC's contribution, expressed as a percentage of the total funding obtained by the funding recipient from all government sources for that program.

9. Reporting requirements and monitoring and oversight activities

9.1 The reporting requirements (program and financial reports) and their respective due dates are listed in the recipient's funding agreement, and details on these requirements are available in the Reporting Guide.

9.2 All funding recipient reporting requirements are subject to monitoring and oversight activities to determine the accuracy of the information provided to ISC.

10. Personal information

10.1 The collection and use of personal information and other records for the purposes of program compliance reviews will be limited to what is necessary to ensure program delivery requirements are met, in accordance with the Privacy Act.

10.2 ISC is responsible for all information and records in its possession. The confidentiality of the information will be managed by ISC in accordance with the Privacy Act and other related policies on privacy. Funding recipients are responsible for the protection of personal information per the privacy legislation, regulations and policies that govern them up to the point that it is transferred to ISC.

10.3 Funding recipients shall develop and implement by-laws, policies and procedures to protect personal information, collected in the course of complying with the program delivery requirements, from unauthorized access, use, or disclosure.

11. Accountability

11.1 ISC is committed to providing assistance to recipients in order for them to effectively carry out obligations set out in this document and funding agreements.

11.2 Funding recipients must deliver the programs in accordance with the provisions of their funding agreement and the program delivery requirements outlined in this document while also ensuring that the necessary management controls are in place to manage funding and monitor activities. Funding recipients are required to exercise due diligence when approving expenditures and must ensure that such expenditures are in accordance with the eligible expenditures set out in this document.

11.3 Funding recipients have a responsibility to ensure that program administrators are properly trained and possess the skills and knowledge to deliver the programs.

12. Official languages

Funding recipients are responsible for providing access to services in both English and French in compliance with the requirements of Part IV of the Official Languages Act.

13. Definitions

13.1 For the purposes of this document, the definitions in the Indian Act and the funding agreement apply.

13.2 Additional definitions

Additional definitions necessary to interpret the delivery requirements and standards set out in this document include:

• administrator: the person who has been delegated responsibility by a funding recipient to carry out functions on behalf of the funding recipient
• age of majority: the age at which a person is granted the rights and responsibilities of an adult in accordance with provincial or territorial legislation
• child: a person under the age of majority in the relevant province or territory
• family: as defined in the relevant province or territory
• client: a person who ultimately receives the benefit of programs or services funded by ISC
• funding agreement: a written agreement or documentation between the Government of Canada and a funding recipient setting out the obligations of both with respect to one or more grants or contributions
• funding recipient: an individual or entity that has met the eligibility criteria of the program and has signed a funding agreement with ISC to deliver an initiative (program, service or activity)

14. Contact information

You can contact your regional offices.

You can also write to:

Manager, Assisted Living
Indigenous Services Canada
10 rue Wellington
Gatineau, QC K1A 0H4

15. Related links

For further program information, please consult: Assisted Living Program.

16. Summary of federal classification system for institutional care

This section summarizes the Report of the Working Party on Patient Care Classification to the Advisory Committee on Hospital Insurance and Diagnostic Services (1973) and the Memorandum of Understanding Regarding the Delineation of Responsibility Between the Medical Services Branch of the Department of National Health and Welfare, and the Department of Indian Affairs and Northern Development, now ISC, for Adult Care for Elderly, Disabled and Handicapped Indians (1984).

It is provided as a reference to help determine reasonable comparability among similar services and programs.

When it is not clear which type of care a patient falls into, the patient should be treated as the higher, more specialized type of care. For example, if it cannot be determined whether a patient is Type  II or Type III, the patient should be treated as Type III.

16.1. Generally, Type I care is required by a person who is ambulant and independently mobile, who has decreased physical or mental faculties and who primarily requires supervision and assistance with activities of daily living and provision for meeting psycho-social needs through social and recreational services. The period of time during which care is required is indeterminate and related to individual condition.

Operationally, Type I care is residential care for persons requiring primarily supervision and assistance with daily living activities and social and recreational services: 30 to 90 minutes therapeutic and personal care or supervision daily.

16.2 Type II care is required by a person with a relatively stabilized physical or mental chronic disease or functional disability who having reached the apparent limit of his recovery, is not likely to change in near future, who has relatively little need for the diagnostic and therapeutic services of a hospital but who requires the availability of personal care on a continuing 24-hour basis, with medical and professional nursing supervision and provision for meeting psychosocial needs. The period of time during which care is required is unpredictable but usually consists of a matter of months or years.

Operationally, Type II care is extended care for persons requiring availability of personal care on a 24-hour basis, under medical and nursing supervision: 90 to 150 minutes care or supervision.

16.3 Type III care is required by a person who is chronically ill or has a functional disability (physical or mental), whose acute phase of illness is over, whose vital processes may or may not be stable, whose potential for rehabilitation may be limited, and who requires a range of therapeutic services, medical management and skilled nursing care plus provision for meeting psycho-social needs. The period of time during which care is required is unpredictable but usually consists of a matter of months or years.

Operationally, Type III is chronic care for persons who require a range of therapeutic services, medical management and skilled nursing care: minimum 2.5 hours care and supervision.

16.4 Type IV care is required by a person with relatively stable disability such as congenital defect, post-traumatic deficits or the disabling sequelae of disease, which is unlikely to be resolved through convalescence or the normal healing process, who requires a specialized rehabilitative program to restore or improve functional ability. Adaptation to this impairment is an important part of the rehabilitation process. Emotional problems may be present and may require psychiatric treatment along with physical restoration. The intensity and duration of this type of care is dependent on the nature of the disability and the patient's progress, but maximum benefits usually can be expected within a period of several months.

Operationally, Type IV is rehabilitative care to restore or improve functional ability and may require psychiatric treatment along with physical restoration. When rehabilitation treatments are the primary focus of the overall treatment plan, rather than just a part of it, the type of care is definitely Type IV.

16.5 Type V is required by a person who:

• presents a need for investigation, diagnosis or for definition of treatment requirements for a known, an unknown or potentially serious condition
• is critically, acutely or seriously ill (regardless of diagnosis) and whose vital processes may be in a precarious or unstable state
• is in the immediate recovery phase or who is convalescing following an accident, illness or injury and who requires a planned and controlled therapeutic and educational program of comparatively short duration

Operationally, Type V is acute care for persons who present a need for investigation, diagnosis or treatment and who are critically, acutely or seriously ill or convalescing in rehabilitative centers and acute care hospitals.