Expanded ARCH Openings: How Nursing-Level Slots Really Work

The rule in one sentence

Under HAR 11-100.1-84, a Type I expanded ARCH (five or fewer residents) may care for no more than two residents at nursing facility level of care at a time, and a Type II expanded ARCH (six or more) for no more than 20% of its licensed capacity, unless the Department of Health allows more. Everyone else in the home must be at a lower level of care.

The rounding in the Type II row is our reading of the percentage rule; ask the home and its case manager how the department applies it to that license.

Why an open bed may not be an open slot

Families calling around after a hospital discharge often hear that a home has a bed. If your parent has been certified at nursing facility level of care, the next question has to be whether the home has a nursing-level slot. A five-bed expanded home with two nursing-level residents already has no room for a third, even with an empty bedroom, unless the department approves an exception.

The rule cuts the other way too. A parent who is not yet at nursing level can move into an expanded home's open bed. If they later decline, the department must consider letting them stay as an additional nursing-level resident, based on their best interest after consulting the family, physician, case manager, care giver and operator. That provision is why many families choose an expanded home early.

The case manager's role

Every expanded ARCH resident has a registered nurse case manager who assesses them before placement, writes an interim care plan within 48 hours and a full plan within seven days (HAR 11-100.1-88). The family chooses the case management agency with the care giver and physician. The case manager is also the person who knows which homes have nursing-level openings, because agencies work with many homes.

If you are working through a QUEST Integration health plan, the plan's service coordinator and the case management agency do much of the searching. If you are paying privately, call homes on the roster and ask the questions below.

Questions to ask an expanded home

How many residents do you have now, and how many are at nursing facility level of care? Is your license Type I or Type II? Have you ever had department approval for an additional nursing-level resident? Which case management agencies do you work with? Do you accept Med-QUEST members, and through which plans? What care can you not provide, such as two-person transfers at night or frequent suctioning?

The roster tells you the license type and capacity. On Oahu, 251 expanded homes are Type I and 34 are Type II. The answers to the rest come from the phone call.

A worked example

A daughter in Pearl City is told her mother, now certified at nursing facility level of care after a stroke, will be discharged on Friday. She finds three expanded Type I homes nearby with open bedrooms. The first already has two nursing-level residents, so it cannot take her mother without department approval. The second has one nursing-level resident and can take her. The third has none but cannot manage two-person transfers at night, which her mother needs for now.

The second home is the realistic choice. The daughter asks the hospital for the physician's level-of-care statement, the medication orders and tuberculosis clearance, and chooses a case management agency with the care giver. The case manager visits before the move and writes the interim care plan within 48 hours of admission.

What changes over time

Slots open and close as residents' needs change, move to nursing homes or pass away. A home that is full at nursing level this month may have an opening next month. If you find a home you like that is full, ask to be called when a slot opens, and keep a second option in place.

When to look at a foster family home or nursing home instead

If expanded homes near you are full at nursing level, a community care foster family home is the other home-based option for nursing-level care. Oahu has 1,111 certified, mostly two- and three-bed homes, built around Med-QUEST. If the care need is heavily skilled or short-term rehab, a nursing home is the safer first step, with a move to a home afterwards.