Levels of Care in Assisted Living

Levels of Care in Assisted Living

Each senior living community chooses the services it is willing to offer to its residents.  Assisted living communities must obtain licensure from the state or county where the community is located for the services it offers.  Codes and regulations as well as state laws dictate the maximum levels of care a provider may offer.  Fire and city codes can affect the level of care which may be provided in a specific community.  Each city has varying levels of regulations and interpretations of fire codes impacting communities in the ways their buildings are laid out and used.

Assisted living communities are regulated by the State and inspections occur on a regular basis.  These inspections are unannounced and are extremely thorough.  Some people would consider the inspections to be “over the top” or overly invasive into the workings of the community.  A major short-coming of the inspection process is the fact that it is merely a snapshot in time of that community.  A circumstance may have presented itself just the day before and the community’s administrator hasn’t had the time to deal with the issue.  If the state comes in for their inspection that day… the issue could be a major fault or at the very least a problem logged.  To think that everything operates perfectly 24-hours a day, 365-days a year is unrealistic.  For this reason, a state survey may give insight into the operation of an assisted living community, or it may paint a highly unrealistic and sometimes “unfair” picture of the operation.

The inspection is specifically looking for problems as they relate to care, policies and actions of the community and staff. Any variance from the laws, codes or regulations will likely result in an infraction, citation or action on the part of the state.  The assisted living community must submit a plan of correction and resolve the concern.  Infractions found and noted by a state inspection are part of every community’s history.  Most all senior living communities receive infractions at one point or another, so don’t be overly alarmed if you see that a provider has one or more infractions.  What is more important is that the problem was resolved.

Because the state can revoke a license or place a community on “stop placement,” (the community cannot admit additional residents until the state removes the stop placement) it’s understandable that providers are fearful of these unannounced state inspections.  What makes this type of regulation so difficult is that most all of the laws, codes and regulations are subject to interpretation, and it is only the individual inspector’s interpretation which is given the most merit.  Some inspectors are lenient; others interpret the laws quite differently.  Some inspectors are adept at knowing if a resident has memory loss, other inspectors are not, and therefore during their interviews with residents, they may write down things in their report which are documented as truths in a report taken from information given by someone with dementia.

Assisted living providers are required by law to “self-report” specific incidents to regulatory agencies.  For instance, if a resident falls, they must report this to a state hotline. (A Mandatory Reporter is any person who works with older adults. Mandatory Reporters must call an 800 number to identify specific concerns as outlined by the state). Consumers are also encouraged to report concerns; however, the state only takes action if they determine the complaint is based on suspected abuse, neglect, exploitation, violation of resident rights or violation of codes and laws.  In other words, a family member who calls to complain about the decision or action of a manager or employee may simply be noted and ignored by the state.  Problems a consumer, older adult or their responsible party has with management or operations of an assisted living community are much better discussed with the management of the assisted living community.  The state regulates these providers, but it does not act as a mediator in disputes or disagreements. (The Ombudsman in your area may be of support to an older adult in regards to resident’s rights.)

When a report is filed by a Mandatory Reporter, or in instances where anyone from the public files a complaint, an Investigation Nurse or Social Worker from the state may be sent to the community for investigation.  The investigation can continue as long as it takes for the regulatory agency to define the concern and make a determination as to what action should be taken, if any.

Most assisted living communities employ one or more nurses, and the nurse manager likely has a large impact on which services are and aren’t extended.  As the nurse is a licensed individual, his or her license is at stake if an error occurs in the community.  As quality nurses are hard to find, consumers may find that it is the nurse rather than the manager or owner who is defining levels of care offered within a building.

Assisted living providers are charged with providing a favorable quality of life for residents while minimizing risk.  If a resident or their legal representatives chooses to continue living in an assisted living community even though the resident is at risk (for instance, if a resident is at risk for falling), then the assisted living community will likely write a contract with the older adult, documenting that the community is doing all that it can to keep the older adult safe; however the older adult wishes to assume their own risk by continuing to live in the assisted living community rather than moving to a higher level of care.

Assisted living is not skilled nursing care, and it is important for consumers to recognize the fact that assisted living is intended to provide services to individuals who do not require one-on-one care.  Most assisted living communities’ staff in a way that provides one caregiver to monitor and serve anywhere from ten to forty residents; and in the evening and overnight, the ratios may be more like one caregiver for every fifty or more residents.  Therefore, residents living in assisted living shouldn’t have the need for someone to be looking out for them 24-hours a day.

Assisted living is designed on a social model, where meals and activities offer interaction and a means for the community and staff to monitor the wellness of residents in a group setting.  Beyond the social aspects of assisted living are scheduled and routine rounds or specific plans to serve a specific resident within a given period of time.  It is for this reason that people who have needs which can be served on a scheduled basis do well in assisted living.  For instance, someone who needs help with a shower or getting dressed is not at risk if the caregiver shows up twenty minutes later than planned.  However, someone who has random needs which arise unexpectedly throughout the day or night may not necessarily be living in the appropriate environment to receive the care they need.

The older adult’s wishes also affect what services are extended.  It is the resident’s right to accept or refuse services.

For the most part, assisted living communities are willing to provide services to older adult as long as they are not at risk for injury to themselves, other residents or staff.  Each community must make daily decisions as to how much care they are able to extend.  These decisions are often based on the talents and quantity of staff available as well as the overall needs of all of the residents combined as a population.

Each community should disclose to consumers prior to admission which services they do and do not offer.  Keep in mind that this document is written in a way which is highly conservative. For instance, the provider may offer a diabetic-sensitive diet; however, the disclosure form may state that they don’t.  The community may do this because they may offer special events where snacks and drinks are provided.  Because they cannot guarantee that a diabetic resident will not help themselves to a piece of cake or a glass of punch, the provider is likely to opt to be more conservative and state that they do not offer a diabetic diet.

The best way to determine what services are and are not offered is to speak with the nurse or manager in charge of resident care.  And if there is a change in staffing in this position, it would be wise to review your plan of care with this new individual.  His or her willingness to accept and manage risk will greatly affect the assisted living community’s willingness to extend continuing care to an older adult.