oversight

Assisted Living: Quality-of-Care and Consumer Protection Issues in Four States

Published by the Government Accountability Office on 1999-04-26.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                 United States General Accounting Office

GAO              Report to Congressional Requesters




April 1999
                 ASSISTED LIVING
                 Quality-of-Care and
                 Consumer Protection
                 Issues in Four States




GAO/HEHS-99-27
      United States
GAO   General Accounting Office
      Washington, D.C. 20548

      Health, Education, and
      Human Services Division

      B-278340

      April 26, 1999

      The Honorable Charles Grassley
      Chairman, Special Committee on Aging
      United States Senate

      The Honorable John Breaux
      Ranking Minority Member, Special Committee on Aging
      United States Senate

      The Honorable Ron Wyden
      United States Senate

      Assisted living facilities are becoming an increasingly popular setting for
      providing long-term care through a combination of housing, personal
      support services, and health care. Consumer demand is expected to grow
      significantly as the projected number of elderly Americans needing
      long-term care doubles to nearly 14 million over the next 20 years. The
      provider and investment communities have responded to this growing
      demand by increasing the supply of assisted living facilities throughout the
      country in recent years, and Fortune magazine identified assisted living as
      one of the top three potential growth industries for 1997.1 Unlike nursing
      homes, most assisted living is paid for privately by individuals and their
      families. However, many states are exploring whether assisted living can
      be a cost-effective alternative to nursing home care for some residents,
      and they are expanding the use of Medicaid and other federal and state
      sources of funds to help pay for care.2 In addition, many states are
      examining their role in regulating this industry, and, according to the
      National Conference of State Legislatures, 32 states plan to consider
      legislation related to assisted living during 1999.

      While interest in assisted living has grown among consumers, the
      investment community, and state governments, concerns about quality of
      care and consumer protection in assisted living have been raised in recent
      media accounts and other reports. As we discussed in an earlier report,
      little is known about whether consumers are able to make informed
      choices about their care or about the nature and extent of problems that

      1
       Precise numbers of facilities and residents are difficult to obtain because there is no generally
      accepted definition of assisted living and no systematic means of counting these facilities. Estimates of
      the current number of assisted living beds range from 800,000 to 1.5 million.
      2
       Medicaid is the joint federal and state health financing program for low-income families and aged,
      blind, and disabled people. Those who receive long-term care under Medicaid include the elderly,
      persons with physical disabilities, and persons with developmental disabilities.



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                   may be occurring in assisted living.3 To help the Congress better
                   understand these issues, you asked us to (1) describe the residents’ needs
                   and the services provided in assisted living facilities, (2) determine the
                   extent to which facilities provide consumers with information sufficient to
                   help them choose a facility that is appropriate for their needs, (3) describe
                   state approaches to the oversight of assisted living, and (4) determine the
                   type and frequency of quality-of-care and consumer protection problems
                   they identify.

                   To address these issues, we studied four states that have a range of
                   experiences with assisted living—California, Florida, Ohio, and Oregon.
                   Specifically, we (1) analyzed responses to a mail survey from 622 assisted
                   living facilities concerning the services they provide and the needs of the
                   residents they serve; (2) evaluated written marketing materials and
                   contracts of 60 facilities for completeness, clarity, and consistency with
                   selected state statutes and regulations; (3) interviewed state officials in the
                   four states and reviewed relevant state statutes, regulations, guidance, and
                   policy manuals; and (4) analyzed information on the quality-of-care and
                   consumer protection problems identified by the state licensing and
                   ombudsmen agencies in each state, for calendar years 1996 and 1997, for a
                   random sample of 753 facilities and the adult protective services agency in
                   Florida and Oregon.4 We also visited 20 assisted living facilities in the four
                   states and interviewed facility administrators, staff, and more than 90
                   residents or family members. In this report, we do not evaluate the
                   effectiveness of the state agencies’ oversight of assisted living facilities.
                   See appendix I for a more detailed discussion of our methodology. We
                   conducted our study from June 1997 through March 1999 in accordance
                   with generally accepted government auditing standards.


                   Assisted living facilities provide a growing number of elderly Americans
Results in Brief   with an alternative to other types of long-term care, such as nursing
                   homes, and many facilities serve a vulnerable population with significant
                   care needs. To make informed choices among various facility options,
                   consumers need clear and complete information on facility services, costs,
                   and policies. However, in many cases, assisted living facilities in the four
                   states we studied are not routinely providing prospective residents with
                   information sufficient for them to select the setting most appropriate for

                   3
                    See Long-Term Care: Consumer Protection and Quality-of-Care Issues in Assisted Living
                   (GAO/HEHS-97-93, May 15, 1997).
                   4
                    We sent our mail survey to 955 randomly selected facilities of 2,652 potential providers of assisted
                   living in the four states. We received responses from 721 facilities, or 75 percent of those we surveyed,
                   622 of which identified themselves as providers of assisted living services.



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their needs. Consumers also need assurance that facilities provide
high-quality care and protect consumers’ interests. All four states license
assisted living facilities and provide oversight through periodic inspections
and complaint investigations. Licensing, ombudsmen, and adult protective
services (APS) agencies identified some assisted living facilities with
quality-of-care and consumer protection problems during 1996 and 1997,
such as inadequate care, insufficient staffing, medication errors, abuse,
and improper discharge.

Within the parameters of state regulations, assisted living facilities in the
four states serve a wide range of resident needs in a variety of residential
settings. The 622 facilities that responded to our survey include small
homes providing meals, housekeeping, and limited assistance for as few as
2 residents as well as large, multilevel communities that provide or arrange
for a variety of specialized health and related care for as many as 600
residents; the average size is 63 beds. The average monthly rate residents
pay in the facilities we surveyed ranges from less than $1,000 to more than
$4,000, and although the majority of facilities serve only a private pay
market, 40 percent reported receiving Medicaid or other public funds to
care for one or more residents, primarily in Florida and Oregon. As for the
residents’ needs, a majority of the facilities reported that more than half
their residents need staff assistance with bathing and medications, and
94 percent reported serving some residents who are cognitively impaired.
Facilities vary widely in the level of care they choose to provide and in the
extent to which they allow residents to remain in a facility as their needs
increase. For example, about half of the facilities would admit or retain a
resident who has an ongoing need for nursing care while half would
discharge a resident who developed that need.

Given the wide variation in what is labeled assisted living, consumers
shopping for an appropriate facility must rely primarily on providers for
information. However, we found that the providers do not always give
consumers information sufficient to determine whether a particular
assisted living facility can meet their needs, for how long, and under what
circumstances. Marketing material, contracts, and other written material
provided by facilities are often incomplete and are sometimes vague or
misleading. Only about half of the facilities reported that they provide
prospective residents with such key written information as the amount of
assistance residents can expect to receive with medications, the
circumstances under which the cost of services might change, or when
residents might be required to leave if their health changes. In addition,
only about one-third provide a description of the qualifications of facility



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staff or information on the services that are not available. Moreover, while
contracts are an important source of written information about a facility
and its services, only 25 percent of the facilities routinely provide these
documents to prospective residents before they decide to apply for
admission.

All four states have licensing requirements that must be met by facilities
that provide assisted living services. Each of these states inspects or
surveys assisted living facilities to ensure that they comply with
regulations, yet they vary in the frequency and content of inspections. For
example, California requires inspections annually, Ohio at least every 15
months, and Oregon every 2 years. Florida’s requirements vary depending
on the level of assisted living provided—from every 2 years for facilities
providing standard assisted living services to twice a year for those
providing more extensive nursing care, referred to as extended congregate
care (ECC) facilities. The state licensing agencies also respond to
complaints they receive related to potential violations of state regulations.
In addition to the state licensing agency, other state agencies have a role in
the oversight of assisted living facilities. In all four states, the state
long-term care ombudsman agency may investigate and resolve complaints
involving residents of long-term care facilities including those providing
assisted living. In Florida and Oregon, APS agencies also investigate
complaints or allegations involving residents of assisted living facilities.

Given the absence of any uniform standards for assisted living facilities
across the states and the variation in their oversight approaches, the
results of state licensing and monitoring activities on quality-of-care and
consumer protection issues also vary, including the frequency of identified
problems. However, using available state licensing surveys and reports
from other oversight agencies in these four states, we determined that
more than one-fourth of the facilities we reviewed were cited by state
licensing, ombudsman, or other agencies for five or more quality-of-care or
consumer protection related deficiencies or violations during 1996 and
1997. Eleven percent of these facilities were cited by the state agencies
with 10 or more quality-of-care or consumer protection related
deficiencies or violations during this same time period. Most of the
problems identified were related to quality of care rather than consumer
protection. While data were not available to assess the seriousness of each
identified problem, many problems seemed serious enough to warrant
concern. Frequently identified problems included facilities (1) providing
inadequate or insufficient care to residents, such as inadequate medical
attention after an accident; (2) having insufficient, unqualified, and



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             untrained staff; (3) not providing residents the appropriate medications or
             storing medication improperly; and (4) not following admission and
             discharge policies required by state regulation. According to state officials,
             factors that contributed to these problems included insufficient numbers
             of staff, inadequate staff training, high caregiver staff turnover, and low
             caregiver staff pay rates.


             Assisted living is usually viewed as a residential care setting for persons
Background   who can no longer live independently. It is designed to respond to the
             needs of individuals who require help with activities of daily living (ADL)
             but who may not need the level of skilled nursing care provided in a
             nursing home. However, there is no uniform assisted living model, and
             considerable variation exists in what is labeled an assisted living facility.
             Assisted living facilities are similar to board and care homes in that both
             may monitor a resident’s care needs and condition and may assist with
             some ADLs and other needs such as medication administration. According
             to assisted living advocates, however, what may not be evident in board
             and care is that assisted living emphasizes residents’ autonomy, their
             maximum independence, respect for individual resident preferences, and
             the ability to meet residents’ scheduled and unscheduled needs for
             assistance. Moreover, assisted living facilities may sometimes admit or
             retain residents who meet the level-of-care criteria for admission to a
             nursing home.

             Most residents pay for assisted living out of pocket or through other
             private funding. However, in some states, public funds are available to pay
             for assisted living care for some low-income residents who may be at risk
             of institutionalization. For example, some states are attempting to control
             rising Medicaid costs by using assisted living as an alternative to more
             expensive nursing home care. While all states pay for nursing home care
             under Medicaid, according to the National Academy for State Health
             Policy, 32 states use Medicaid to reimburse for services in assisted living
             or board and care facilities for more than 40,000 Medicaid beneficiaries.5
             This represents an increase from 22 states that did so as recently as 1996,
             and several states are currently considering legislation to allow the use of
             Medicaid funds for assisted living.

             To help pay for assisted living services for Medicaid-eligible residents,
             states typically use Medicaid waivers, specifically the Home and

             5
              For further information, see State Assisted Living Policy: 1998 (Portland, Me.: National Academy for
             State Health Policy, June 1998), prepared under contract to the Office of the Assistant Secretary for
             Planning and Evaluation of the Department of Health and Human Services.



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                        Community Based Services Waiver.6 Medicaid waivers allow the states to
                        reimburse assisted living facilities for services such as personal care and
                        homemaker services that may not be covered by the states’ regular
                        Medicaid programs. However, these payments do not cover room and
                        board. In assisted living, the room and board portion may be paid by a
                        combination of individual resident payments, residents’ Supplemental
                        Security Income (SSI), and optional state payments. Through these
                        waivers, the states may choose to provide specific services only to defined
                        groups, such as elderly persons at risk of institutionalization, instead of to
                        all beneficiaries who meet Medicaid’s eligibility criteria, which would be
                        required under Medicaid without a waiver. In contrast, a few states pay for
                        services in assisted living facilities through the personal care option under
                        the Medicaid state plan. State plan services are an entitlement, and all
                        beneficiaries who meet Medicaid’s eligibility criteria can receive
                        government-funded medical assistance.

                        The states have the primary responsibility for licensing and overseeing
                        care furnished to assisted living residents, and few federal standards or
                        guidelines govern assisted living.7 Some states have set very general
                        criteria for the type of resident who can be served and the maximum level
                        of care that can be provided, while other states have set more specific
                        limits in these areas, such as not serving residents who require 24-hour
                        skilled nursing care. In general, state regulations tend to focus on three
                        main areas—requirements for the living unit, admission and retention
                        criteria, and the types and levels of services that may be provided.
                        However, the states vary widely on what they require.


                        There is no typical assisted living facility or resident, and within the limits
Facility Services and   of state regulation, facilities have considerable flexibility to decide what
Resident Needs Vary     residents they will serve and the types of services they will provide. The
Widely                  assisted living facilities responding to our survey range from small,
                        free-standing, independently owned homes with a few residents to large,
                        multilevel, corporately owned communities caring for several hundred
                        residents. They also serve a wide range of resident needs, with some
                        providing only meals, housekeeping, and limited personal assistance while
                        others provide or arrange for a range of specialized health and related
                        services. The facilities also vary in the extent to which they will admit


                        6
                         Sec. 1915(c) of the Social Security Act.
                        7
                         For further information on federal programs’ responsibility related to assisted living, see Long-Term
                        Care: Consumer Protection and Quality-of-Care Issues in Assisted Living (GAO/HEHS-97-93, May 15,
                        1997).



                        Page 6                                                             GAO/HEHS-99-27 Assisted Living
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                             residents with certain needs and whether they will retain residents as their
                             needs change, referred to as aging in place.


A Wide Range of Facilities   The assisted living facilities in the four states include providers of a variety
Provide Assisted Living      of types, sizes, and costs. The vast majority of the 622 facilities that
                             responded to our survey, 93 percent, primarily serve the frail elderly.8
                             About two-thirds of the facilities in the four states are run as for-profit
                             organizations, ranging from a high of 86 percent in Oregon to a low of
                             45 percent in Ohio. In California, Ohio, and Oregon, most assisted living
                             facilities are part of a corporation that owns or operates multiple facilities,
                             while in Florida most are independently owned and operated. The
                             facilities vary widely in size and structure as well. The facilities in our
                             survey range from as small as 2 beds to as large as 600 beds. On average,
                             the facilities have 63 beds. Although some facilities are freestanding, about
                             57 percent are part of a multilevel facility or community that offers other
                             levels of care, such as nursing home care or independent apartments
                             without services. Some providers also offer different types of specialized
                             care within assisted living. For example, about 20 percent of the assisted
                             living facilities reported that they have a special assisted living unit for
                             residents with dementia; the units’ average size is 23 beds.

                             The average monthly rate residents pay for basic and additional services in
                             these four states varies widely, ranging from less than $1,000 per month
                             for general assisted living in some facilities to more than $4,000 per month
                             for special dementia care in others. Among the facilities responding to our
                             survey, about one-third have an average rate for general assisted living of
                             less than $1,500 per month, about one-third between $1,500 and $2,000,
                             and one-third more than $2,000. Although the market for assisted living is
                             primarily among seniors who can afford substantial private payments for
                             their care, many facilities serve some low-income residents who receive
                             government assistance. About 40 percent of the facilities overall reported
                             that they receive Medicaid or other forms of public assistance or subsidy
                             to provide care to one or more residents. The use of public funds to
                             subsidize assisted living care varies among the states. In Florida and
                             Oregon, two states that pay for assisted living care under a Medicaid
                             waiver, 43 and 86 percent of facilities, respectively, reported receiving
                             public funds to pay for care for some of their residents. In contrast,
                             27 percent of the facilities in Ohio and 28 percent in California receive
                             some public subsidy.

                             8
                              The remaining 7 percent of the survey respondents primarily serve persons with developmental
                             disabilities, mental illness, or other special needs.



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Assisted Living Facilities                A wide variety of services are available to residents in assisted living.
Provide or Arrange for a                  Some services may be provided by a facility with its own staff or by staff
Variety of Services                       under contract to the facility. In other cases, the facility may arrange with
                                          an outside provider to deliver services, with the residents paying the
                                          provider directly, or residents may arrange and pay for services without
                                          the facility being involved at all. As shown in table 1, the assisted living
                                          facilities in our survey usually provide or arrange for housekeeping,
                                          laundry, meals, transportation to medical appointments, special diets, and
                                          assistance with medications. Many facilities also provide or arrange for
                                          skilled nursing services, skilled therapy services, and hospice care for
                                          their residents. More specialized services, such as intravenous (IV) therapy
                                          and tube feeding, are least likely to be available.

Table 1: Services Available to
Residents in Assisted Living Facilities                                       Provided or         Resident must make
                                                                             arranged for                independent              Service not
                                          Service                               by facility            arrangementsa                available
                                          Housekeeping                                    98                              0                 0
                                          Meals                                           98                              0                 0
                                          Laundry                                         97                              1                 0
                                          Special diets                                   93                              0                 5
                                          Supervision of
                                          self-medication                                 93                              1                 4
                                          Storage and
                                          administration of oral
                                          medication                                      92                              1                 5
                                          Transportation                                  87                              2                 6
                                          Storage and
                                          administration of
                                          injectable medication                           78                              4                15
                                          Skilled therapy                                 66                            15                 13
                                          Hospice                                         60                            17                 17
                                          Skilled nursing                                 41                              9                44
                                          IV therapy                                      20                              5                75
                                          Tube feeding                                    15                              3                81
                                          Note: Numbers are percentages of facilities in our survey. They may not add to 100 percent
                                          because some facilities did not respond to all items on the survey.
                                          a
                                           Some facilities allow residents to receive the service but require that they make independent
                                          arrangements for the service with an outside provider such as a home health agency.




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Facilities Serve a Wide                    Assisted living is generally considered to be a residential setting designed
Range of Resident Needs                    to respond to the needs of persons who require some oversight or help
                                           with activities of daily living but who may not need the level of skilled care
                                           provided in a nursing home. We found considerable variation among
                                           facilities and among the four states in the needs of residents they serve.
                                           Facilities we visited serve some residents who are completely
                                           independent, have some residents with severe cognitive impairment, or
                                           have some who are bedridden and require significant amounts of skilled
                                           nursing care.

                                           Residents of assisted living facilities typically need the most assistance
                                           from facility staff with medications and bathing. As shown in table 2, more
                                           than half of all facilities reported that more than 50 percent of their
                                           residents need assistance with these activities. Assistance with dressing
                                           and toileting or incontinence care were the next most frequently cited
                                           ADLs. Assistance was reported to be needed least with feeding,
                                           transferring, and ambulation.9 The highest level of need for staff assistance
                                           with ADLs was reported among facilities in Oregon and those in Florida
                                           licensed as extended congregate care facilities.10


Table 2: Percentage of Facilities in Which More Than Half of Residents Need Staff Assistance With Activities of Daily Living
                                                                                                         Floridaa
ADL need                                        Total    California           Ohio         Oregon               AL            LNS             ECC
Medication dispensing                               53            68             56              78              29              53               37
Bathing                                             52            49             52              58              41              50               62
Dressing                                            34            34             32              33              29              24               42
Toileting                                           20            18             15              29              21              11               27
Ambulation                                          11            11               8             15              13               9                8
Transferring                                         6             3               4               6              9               0               10
Feeding                                              2             2               1               1              3               3                4
                                           a
                                            Florida assisted living licensing categories include standard assisted living (AL), limited nursing
                                           services (LNS), and extended congregate care (ECC).




                                           9
                                            These findings are consistent with national studies of assisted living resident needs. The Assisted
                                           Living Federation of America’s (ALFA) 1996 survey found similar percentages of residents needing
                                           assistance with bathing (64 percent), dressing (46 percent), toileting (33 percent), transferring
                                           (15 percent), eating (10 percent), and medication dispensing (70 percent).
                                           10
                                            Florida has four assisted living licensing categories: standard assisted living (AL), limited nursing
                                           services (LNS), extended congregate care (ECC), and limited mental health (LMH). We did not include
                                           LMH in our analysis.



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                       In addition to needing assistance with activities of daily living, residents of
                       assisted living facilities often have some degree of cognitive impairment.11
                       They may suffer from significant short-term memory problems, be
                       disoriented all or most of the time, have difficulty making decisions, or be
                       diagnosed with Alzheimer’s disease or some other form of dementia. Their
                       service needs may include behavior monitoring and management,
                       orientation, and reminders or cueing to perform daily tasks. Most facilities
                       in the four states have some residents who are cognitively impaired;
                       however, they range widely in terms of the percentage of their residents
                       with cognitive impairment. More than half of the facilities reported that at
                       least 25 percent of their residents have cognitive impairment, and
                       one-quarter of the facilities reported that more than 50 percent of their
                       residents are cognitively impaired. This ranges from a low of 20 percent of
                       facilities in Oregon to a high of 38 percent among extended congregate
                       care facilities in Florida.


Most Assisted Living   Almost all the assisted living facilities we surveyed reported that they
Facilities Monitor     provide some form of oversight to monitor and supervise their residents.
Residents’ Condition   Their oversight responsibilities include monitoring changes in residents’
                       health and physical or cognitive functioning, as well as notifying a
                       resident’s physician, family, or other responsible person when the
                       resident’s condition changes. About 90 percent of the facilities also
                       reported that their oversight includes regular health or wellness checks by
                       a nurse or other licensed health professional and supervision of residents
                       by staff on a 24-hour basis.12 The only significant variation among the
                       states in terms of oversight is on the issue of 24-hour supervision. While all
                       facilities in Oregon reported that they provide 24-hour supervision by
                       awake staff, only about two-thirds of facilities licensed as standard
                       assisted living in Florida do so.13 (See table 3.)




                       11
                         ALFA’s 1996 survey found 48 percent of residents in assisted living with cognitive impairments.
                       12
                        State regulations generally require the presence of staff on-site 24 hours a day in assisted living. In
                       some small facilities, however, they do not require that staff be awake at all hours.
                       13
                        The Florida standard assisted living category includes a large number of very small facilities. Forty
                       percent are licensed for 12 or fewer residents, 20 percent for 6 or fewer.



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Table 3: Percentage of Facilities Providing Oversight to Residents of Assisted Living Facilities
                                                                                                                        Floridaa
Type of oversight                                  All    California           Ohio         Oregon               AL            LNS             ECC
24-hour supervision of residents by
awake staff                                        90              94             96             100              69            100                90
Monitoring changes in residents’
condition or functioning                          100            100              99             100            100             100                100
Notification of physician or family when
changes in condition are noted                    100            100              99             100            100             100                100
Regular health or wellness checks
provided by a health professional                  91              91             91              90              89             97                91
                                            a
                                             Florida assisted living licensing categories include standard assisted living (AL), limited nursing
                                            services (LNS), and extended congregate care (ECC).




Support for Aging in Place                  Assisted living is often promoted as supporting the concept of “aging in
                                            place” that allows residents to remain in a facility as their health condition
                                            declines or their needs change. The ability of residents to age in place is
                                            reflected in a facility’s admission and discharge criteria or its rules
                                            governing who it will permit to move in and when they may be required to
                                            leave. Facilities responding to our survey vary in terms of resident needs
                                            they will accept on admission, and they also vary in terms of the degree to
                                            which they will retain residents who develop certain needs or conditions
                                            after being admitted.

                                            As shown in table 4, more than 75 percent of the facilities reported they
                                            admit residents who have mild to moderate memory or judgment
                                            problems, are incontinent but can manage on their own or with some
                                            assistance, have a short-term need for nursing care, or need oxygen
                                            supplementation. Less than 10 percent of the facilities admit residents who
                                            are bedridden, require ongoing tube feeding, need a ventilator to assist
                                            with breathing, or require IV therapy. Although some facilities might not
                                            admit residents with a particular need or condition, they do not
                                            necessarily discharge them if they develop that need. In Oregon, for
                                            example, most facilities indicated that they will not admit someone who is
                                            bedridden, but half would typically retain that individual if he or she
                                            becomes bedridden while a resident.




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Table 4: Percentage of Facilities That
Support Aging in Place as Reflected in                                                                Facility would typically
Their Admission and Discharge                                                                                Not admit
Criteria                                 Resident condition                                          Admit   but retain   Discharge
                                         Has mild to moderate memory or judgment
                                         problems                                                       98            2           1
                                         Lacks bladder control but can manage own
                                         incontinence supplies                                          95            4           2
                                         Lacks bowel control but can manage own
                                         incontinence supplies                                          82            8          10
                                         Requires oxygen supplementation                                80            7          14
                                         Has a short-term need for nursing care or
                                         monitoring by a licensed nurse                                 76           12          12
                                         Lacks bladder control but needs assistance to
                                         manage incontinence                                            75            9          15
                                         Requires a wheelchair to get around                            73           18          10
                                         Requires assistance to transfer from bed to chair
                                         or wheelchair                                                  59           16          25
                                         Lacks bowel control but needs assistance to
                                         manage incontinence                                            59           13          28
                                         Requires colostomy or ileostomy care                           49           12          40
                                         Requires the use of an indwelling urinary catheter             47           13          40
                                         Wanders                                                        39            9          52
                                         Has severe memory or judgment problems                         37           15          48
                                         Has an ongoing need for nursing care or
                                         monitoring by a licensed nurse                                 34           10          56
                                         Requires intravenous medication or therapy                      9            0          91
                                         Requires a ventilator to assist with breathing                  7            5          88
                                         Requires tube feeding on an ongoing basis                       6            7          88
                                         Is confined to bed for 22 or more hours a day                   4           19          77
                                         Note: Percentages may not add to 100 because of rounding.



                                         There is also considerable variation across the states in admission and
                                         discharge criteria, some of which results from regulatory limits on
                                         allowable conditions or services in assisted living facilities, the facilities’
                                         choice of whom to serve, and the particular services they choose to
                                         provide or make available. Facilities in Oregon are more likely to admit or
                                         retain residents with a higher level of need than facilities in the other
                                         states. For example, 95 percent of the Oregon facilities admit people
                                         requiring assistance to transfer from bed to chair or wheelchair while only
                                         35 percent of the California facilities admit people with this need.




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                          Given the variation in what is labeled assisted living, consumers must rely
Consumers May Lack        primarily on information supplied to them by the providers. In order to
Enough Information        compare facilities and choose one that best meets their needs, prospective
to Select a Facility      residents should receive information about facility services, costs, and
                          policies in writing. However, we found that written material often does not
That Meets Their          contain key consumer information or is not routinely provided to
Needs                     prospective residents to use as an aid in decisionmaking. Moreover, in
                          some cases the written material that is provided to consumers is unclear
                          or inconsistent. As a result, consumers may not be receiving information
                          sufficient to determine whether a particular assisted living facility can
                          meet their needs, for how long, and under what circumstances.


Consumers Rely on         Nursing homes are subject to extensive federal regulations that prescribe
Information Provided by   detailed standards for their operations and services. In contrast, assisted
Facilities                living facilities are regulated by the states and usually have considerable
                          flexibility to determine what services they will provide and what level of
                          resident need they will serve. As a result, facilities vary widely, and
                          consumers must rely primarily on information providers supply to identify
                          a facility that meets their needs and preferences.

                          Prospective residents may obtain information to aid in their
                          decisionmaking in a variety of ways, including facility tours, personal
                          interviews, personal recommendations, and written materials. Most
                          residents we interviewed had had the assistance of a family member,
                          usually an adult child, in identifying possible facilities, and they had often
                          relied on the advice of family, friends, or health professionals in making
                          their decisions. Residents often mentioned the facility tour along with
                          interviews with management, staff, and other residents as important
                          means of obtaining information to make their decisions. Providers
                          indicated that written marketing material and sample resident contracts
                          are also useful sources of consumer information.


Much Information          To help consumers compare facilities and select the most appropriate
Considered Key by         setting for their needs, key information should be provided in writing and
Consumer and Industry     in advance of their application for admission. However, we found that
                          written material often does not contain key information, and facilities do
Groups Is Not Routinely   not routinely provide prospective residents with important documents
Provided in Writing       such as a copy of the contract, sometimes called a resident agreement, to
                          use as an aid in decisionmaking. According to consumer advocates and
                          provider associations, consumers need to know about the services that



                          Page 13                                            GAO/HEHS-99-27 Assisted Living
    B-278340




    will be provided, their costs, and the respective obligations of both the
    resident and the provider.14 Specifically, this information should include

•   the cost of the basic service package and what is included such as room,
    board, supervision, amenities, and personal care;
•   the availability of additional services such as skilled nursing care or
    therapy services, who will provide them, and their cost;
•   the circumstances under which costs may change, such as when care
    needs increase;
•   how the facility monitors resident health care needs, including
    requirements for regular health examinations, and how the facility
    coordinates with a resident’s physician;
•   the qualifications of staff who provide personal care, medications, and
    health services;
•   discharge criteria, such as when a resident may be required to leave the
    facility because health or need for supervision changes, and what
    procedures will be followed for resident notification and relocation; and
•   grievance procedures, including the resident’s right to challenge decisions
    about care.

    The majority of the facilities responding to our survey said that they
    generally provide prospective residents with written information about
    many of their services and costs in advance of a resident’s choosing to
    apply for admission. However, as shown in table 5, less than half indicated
    that they provide written information in advance on discharge criteria and
    staff training and qualifications or a description of services not covered or
    available from the facility. Only about half indicated that they provide
    information on the circumstances under which the cost of services might
    change, their policy on medications, or their practice for assessing or
    monitoring residents’ needs.




    14
      Advocacy and provider associations we consulted to help identify key consumer information
    included AARP, the American Association of Homes and Services for the Aging, the American Bar
    Association Commission on Legal Problems of the Elderly, the American Health Care Association, the
    Assisted Living Federation of America, the Consumer Consortium on Assisted Living, the Consumers
    Union, and the United Seniors Health Cooperative.



    Page 14                                                         GAO/HEHS-99-27 Assisted Living
                                     B-278340




Table 5: Percentage of Facilities
Reporting That They Provide Key      Informationa                                                                              Facilitiesb
Written Information to Prospective   Description of services included in the basic rate                                                78
Residents
                                     Cost of the basic service package                                                                 73
                                     Statement of residents’ rights and responsibilities                                               73
                                     Description of services available beyond the basic rate                                           70
                                     Description of complaint or grievance procedure                                                   65
                                     Cost of additional services                                                                       63
                                     Policy on medication assistance or administration                                                 56
                                     Facility practice for assessing or monitoring resident needs                                      53
                                     Circumstances under which costs may change                                                        49
                                     Discharge criteria related to change in health status                                             47
                                     Description of services not covered or not available                                              39
                                     Description of staff training and qualifications                                                  31
                                     a
                                      Key information includes that identified by consumer advocates and provider associations as
                                     important for consumers to have in order to choose a facility appropriate for their needs.
                                     b
                                      Survey respondents indicating that they provide information in writing and, in the case of the
                                     contract, in advance of a resident’s choosing to apply for admission.



                                     The contract or resident agreement is an important source of written
                                     information and, in some cases, may be the only place where certain key
                                     points such as discharge criteria or circumstances when costs may change
                                     are addressed. However, most providers indicated that they do not
                                     routinely make a copy of the contract available to prospective residents to
                                     aid in their decisionmaking. Only one out of four of the facilities we
                                     surveyed indicated that they routinely provide a copy of the contract to
                                     consumers before they make their decision to apply for admission. About
                                     65 percent of the respondents said they would provide a copy if requested,
                                     and 10 percent said they do not provide contracts to prospective residents.

                                     We also reviewed the contents of a sample of contracts, marketing
                                     materials, and other written information from 60 of the facilities that
                                     responded to the survey.15 These written materials almost always include
                                     information about the services available from a facility and, in the
                                     contract, some discussion of discharge criteria. However, the written
                                     materials we reviewed rarely mention staffing, medication policies, or
                                     grievance procedures. Only one in three contain information about
                                     services not covered or not available, the facility practice for monitoring

                                     15
                                       We reviewed written material provided by 60 of the facilities that responded to the survey as
                                     providers of assisted living—10 each from California, Ohio, and Oregon and 10 from each of the three
                                     licensing categories in Florida.



                                     Page 15                                                           GAO/HEHS-99-27 Assisted Living
                               B-278340




                               resident needs, or the circumstances under which the cost of services
                               might change.


Written Information May        In addition to lacking important content, the facility contracts, marketing
Be Unclear or Misleading       material, and other written information that we reviewed are sometimes
                               vague or misleading. To the extent that contracts and other written
                               material contain information on key points, we examined them to
                               determine whether the information is clear and understandable and
                               whether marketing materials and contracts are consistent with each other
                               and with relevant requirements of state regulations. Contracts range from
                               a one-page standard form lease to a detailed 55-page document that
                               includes multiple attachments. Some are written in very fine print, while
                               others are prepared in large easy-to-read type. Some contracts are
                               complex documents written in specialized legal language while others are
                               not. Marketing and other written material provided by facilities also varies
                               widely from a one-page list of basic services and monthly rent to multiple
                               documents of more than 100 pages.

                               While most facilities use written materials that are specific and relatively
                               clear in the points they cover, we found written materials from 20 of the 60
                               facilities, or 33 percent, that contain language that is unclear or potentially
                               misleading, usually concerning the circumstances under which a resident
                               can be required to leave a facility. Contracts and other written materials
                               are often unclear or inconsistent with each other or with requirements of
                               state regulation regarding how long residents can remain as their needs
                               change, resident notification requirements, or other procedural
                               requirements for discharge. Some examples follow.

                           •   The marketing material used by one Florida facility is potentially
                               misleading in specifying that a resident “can be assured if health changes
                               occur, we can meet your needs. And you won’t have to deal with the
                               hassles of moving again.” However, the contract specifies a range of
                               health-related criteria for immediate discharge, including “changes in [the
                               resident’s] physical or mental condition, supplies, services or procedures
                               . . . that [the facility] by certification, licensure, design, or staffing cannot
                               provide.”
                           •   In another Florida facility, the marketing material states that the facility is
                               committed to helping individuals to live at the facility “for the rest of their
                               lives by . . . adapting services and care plans to meet the needs of each
                               person.” The facility contract, however, states that the facility may
                               terminate the agreement immediately “if the Resident requires services



                               Page 16                                              GAO/HEHS-99-27 Assisted Living
                          B-278340




                          which are outside the scope of those services which the facility is licensed
                          to provide” or if the facility “determines that the discharge of the Resident
                          is appropriate for the Resident’s welfare or for the welfare of other
                          Residents.” Florida law states that “any resident who is determined by the
                          medical review team to be inappropriately residing in a facility shall be
                          given 30 days’ written notice to relocate unless the resident’s continued
                          residence in the facility presents an imminent danger to the health, safety,
                          or welfare of the resident.”
                      •   The contract of a California facility lacks specific information about
                          discharge requirements, stating only that the facility “reserves the right by
                          action of its Board of Directors to dismiss Resident for what is, in the
                          judgement of the Board, good and sufficient cause.” Moreover, the
                          contract makes no mention of state regulations that specify criteria for
                          discharge or eviction.
                      •   The contract of an Oregon facility is inconsistent with requirements of
                          state regulation regarding notification of residents before their discharge.
                          Oregon regulations specify that residents may not be asked to leave
                          without 14 days’ written notice and may be asked to leave only in specified
                          circumstances, such as when the facility cannot meet the residents’ needs
                          with available support services or required services are not available. In
                          contrast, the contract states that “the resident shall be required to
                          immediately vacate the Premises . . . [if] the Resident requires medical or
                          nursing care of a higher level or degree than may be available at [the
                          facility].”


                          Each of the four states we studied has licensing requirements that must be
The States Use a          met by most facilities that provide assisted living services.16 Some states
Range of Approaches       have created a specific licensing category called “assisted living” while
to Oversee Assisted       others license and regulate assisted living under existing residential care
                          standards. All states inspect or survey assisted living facilities to ensure
Living Facilities         that they comply with regulations for quality of care and consumer
                          protection, yet unlike annual nursing home inspections, they vary in the
                          frequency and content of inspections and the range of enforcement
                          mechanisms available to ensure compliance. The state licensing agencies
                          also respond to complaints they receive related to potential violations of
                          state regulations. In addition to the state licensing agency, other state


                          16
                           California and Ohio may have some facilities that advertise themselves as “assisted living facilities”
                          but do not provide a level of care that is required by state law to be licensed. For example, a facility
                          may call itself an assisted living facility but provide only an apartment and one meal per day but no
                          direct care or no supervision of personal care or medical needs and, therefore, it does not meet the
                          criteria that require it to be licensed by the state. In Florida and Oregon, any facility that holds itself
                          out as an assisted living facility must be licensed by the state.



                          Page 17                                                               GAO/HEHS-99-27 Assisted Living
                           B-278340




                           agencies have a role in the oversight of assisted living facilities. In the four
                           states we studied, the state ombudsman agency may investigate and
                           resolve complaints involving residents of long-term care facilities,
                           including those providing assisted living.17 In two of the four states we
                           studied, Florida and Oregon, APS agencies also investigate complaints or
                           allegations related to abuse, neglect, or exploitation involving residents.


State Requirements for     Most facilities that provide assisted living services must meet licensing
Assisted Living Facility   requirements in the four states we studied. Regulations that address
Licensing Vary             quality of care and consumer protection generally cover such areas as
                           admission and discharge criteria, the type and level of services that can be
                           provided, staffing levels and training, as well as resident rights and
                           consumer access to information.18 However, the four states vary in how
                           they define these requirements and the level of detail with which they
                           describe them.

                           Florida and Oregon have created a specific licensing category and
                           requirements for assisted living facilities, while California and Ohio
                           generally license them under existing residential care facility regulations.19
                           In addition, Florida has four subcategories of assisted living licensure,
                           depending on the types and levels of care that can be provided. These
                           include facilities that provide standard assisted living services, limited
                           nursing services, and extended congregate care for residents needing
                           more care than can be provided in an LNS facility.20

                           Three of the four states we studied have established specific criteria that
                           define who can be admitted to an assisted living facility, and all four states
                           have criteria that specify when a resident must be discharged. In addition,
                           all four states have rules governing the process for resident admission and
                           discharge. For example, regulations in California and Florida generally
                           require that a person needing 24-hour skilled nursing care or supervision
                           cannot be admitted to a facility and must be discharged if he or she

                           17
                             In California and Oregon, the ombudsman investigates and resolves complaints only in licensed
                           long-term care facilities. In contrast, ombudsmen in Florida and Ohio may respond to complaints in
                           both licensed and unlicensed facilities.
                           18
                             The regulations also cover minimum space for the resident’s living unit and building and safety
                           standards that we have not covered in this report.
                           19
                            According to state officials, the Oregon regulations that apply to assisted living were recently revised
                           effective April 1, 1999. Not all assisted living facilities in Ohio are licensed as residential care. Some are
                           unlicensed, and some may be licensed as adult care facilities or homes for the aged.
                           20
                             Florida has another assisted living licensing category called limited mental health that we did not
                           include in our study. Facilities with this licensing type serve three or more mental health residents.



                           Page 18                                                                GAO/HEHS-99-27 Assisted Living
B-278340




develops such a need. In contrast, Oregon regulations allow facilities the
most flexibility in deciding who they will serve. For example, Oregon
regulations allow residents to remain in a facility as their health condition
declines or their needs change, provided the facility can continue to meet
their needs.

With respect to resident admission, all states require facilities to conduct
an initial assessment of a resident’s health, functional ability, and needs
for assistance. Except for Florida, the states we studied require all
facilities to develop a plan of care to address the identified needs.21 In
California, the initial assessment must include a physical examination of
the resident, tests for contagious and infectious diseases, documentation
of prior medical services and history and current medical status, a record
of current prescribed medications, identification of the resident’s physical
limitations to determine his or her capability to participate in the facility’s
programs, and a determination of the person’s ambulatory status.

Concerning resident discharge, all states generally require that facilities
provide residents with sufficient advance notice of discharge or eviction,
ranging from 14 to 30 days, except in certain emergency situations where
continued residence would jeopardize the health or safety of the resident
or others in the facility. In addition, all state regulations specify certain
rights and procedures for residents to appeal or contest a facility’s
decision to discharge them.

State regulations have similar requirements for the types and the levels of
services that assisted living facilities must provide residents. In addition to
basic accommodations that include room, board, and housekeeping, all
the states require assisted living facilities to provide residents with certain
basic services, including (1) assistance with ADLs, (2) ongoing health
monitoring, and (3) either the provision or the arrangement of medical
services, including transportation to and from those services as needed.

State regulations for assisted living differ with respect to the level of
skilled nursing or medical care that facilities can provide to residents and
the circumstances under which it can be provided. For example, California
regulations contain a list of services that facility staff are generally not
allowed to provide, including catheter care, colostomy care, and
injections. According to state officials, the care for such conditions in
California assisted living facilities is normally provided through a contract

21
 Florida requires the development of a plan of care for residents in an ECC and residents under the
Medicaid waiver.



Page 19                                                           GAO/HEHS-99-27 Assisted Living
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between a resident and a home health agency. With a few exceptions, Ohio
regulations limit skilled nursing care to residents who need it only on a
part-time, intermittent basis and restrict it to no more than 120 days per
year.22 Oregon, in contrast, has no explicit restrictions on the types or
levels of care that facility staff can provide, except that certain nursing
tasks must be either assigned or delegated to a caregiver by a registered
nurse.

Although all states require facilities to provide some degree of supervision
with medications, they differ in the degree to which facility staff can be
directly involved in administering medications to residents. For example,
in Oregon, unlicensed, nonprofessional staff can administer medications
to residents if they have appropriate authorization, training, and general
supervision. However, in Florida and Ohio, only staff specifically licensed
or certified to administer medications may do so. In California, facility
staff may not administer medications to residents but may only assist
residents to take medication themselves. The rules governing medications
can limit a resident’s ability to continue residing in a facility if he or she is
unable to manage his or her own medications and licensed or certified
staff are not available.

Requirements for staff levels, qualifications, and training also vary among
the states. Florida’s regulations require facilities to maintain a minimum
number of full-time staff, based on the total number of residents, while
regulations in California and Ohio require that the number of staff be
sufficient to meet the needs of residents. In contrast, Oregon provides no
specific guidance on how many staff are needed to provide for the
residents’ needs. The regulations in all four states specify minimum
qualifications for the education and training of facility administrators, and
they generally require that caregivers receive training for the personal care
services they are to provide. Only Florida’s regulations specify the amount
and content of training that caregiver staff must receive.

State regulations also generally contain consumer protection provisions
governing resident contracts, criminal background checks for staff, and
residents’ rights, including resident participation in decisionmaking. All
four states require that facilities enter into contracts with residents.
Although the contracts typically include provisions related to residents’
rights, services to be provided, charges, and refund policies, state
requirements differ in the level of detail they require in the agreements.

22
  Exceptions include (1) supervision of special diets, (2) applications of dressings, and (3) medication
administration, which facilities can provide on an ongoing basis if they have the appropriate skilled
staff.



Page 20                                                             GAO/HEHS-99-27 Assisted Living
                             B-278340




                             California, Florida, and Oregon have explicit requirements in regulations
                             for criminal background checks of facility administrators, and all four
                             states require such checks for direct care staff.


State Inspections of         All four states are responsible for conducting periodic inspections or
Assisted Living Facilities   surveys of facilities to ensure that they comply with licensing
Vary                         requirements, yet they vary in the frequency and content of those
                             inspections and in the range of enforcement mechanisms that can be used
                             to correct problems. In each of the four states, licensing agencies conduct
                             periodic inspections or surveys to ensure compliance with regulations.
                             The licensing agency in California is required to inspect facilities annually,
                             and the licensing agency in Ohio is required to inspect facilities every 15
                             months. Florida and Oregon survey facilities at least once every 2 years.23
                             Facilities in Florida licensed as limited nursing services are to be
                             inspected at least once a year for compliance with LNS regulations, and
                             facilities licensed to provide extended congregate care are to be inspected
                             at least twice a year for compliance with ECC regulations. One of these
                             visits may be made in conjunction with the state’s biennial standard
                             assisted living survey. Licensing authorities in all four states also conduct
                             investigations in response to complaints they receive regarding the
                             services and care provided to facility residents.

                             The content of periodic state surveys is driven primarily by the
                             requirements in state regulations. To assist licensing staff in interpreting
                             the regulations, Florida and Ohio have developed detailed guidelines,
                             similar to those used for nursing home inspections, that cover most
                             aspects of regulated facility practice. In contrast, licensing staff in
                             California and Oregon use a checklist that covers a subset of the
                             regulations and focuses on a few selected elements.24

                             The licensing survey process generally includes meeting with the facility’s
                             administrator, touring the facility, reviewing facility and resident records,
                             and interviewing residents and staff. A complaint survey can include
                             interviews with the resident, staff, and other relevant persons and a review
                             of facility records. When deficiencies are found, facilities are given the
                             opportunity to correct them. The four states we visited use a variety of


                             23
                               While Oregon has historically conducted biennial inspections to coincide with the expiration of the
                             2-year license, the licensing agency officials said they have increased the frequency of inspections of
                             all assisted living facilities to at least once a year.
                             24
                               According to state officials, Oregon’s checklist is intended to focus on selected elements related to
                             resident care.



                             Page 21                                                             GAO/HEHS-99-27 Assisted Living
                             B-278340




                             means to ensure that facilities correct deficiencies. These include
                             requiring a written plan of correction, reinspection of facilities to verify
                             compliance, civil monetary penalties, restrictions on admissions, criminal
                             sanctions, or license revocation, although not all states use all these. For
                             example, in Florida, a facility with severe or repeated deficiencies with
                             respect to medications or dietary services may be required to add a
                             consultant pharmacist or dietitian to its staff until problems are resolved.


Ombudsmen and Adult          In addition to the state licensing agency, other state agencies play a role in
Protective Services Also     the oversight of assisted living facilities. In the four states we examined,
Provide Oversight of         the state ombudsman agency has a role in overseeing the quality of care
                             and consumer protection of residents. The ombudsmen are intended to
Assisted Living Facilities   serve as advocates to protect the health, safety, welfare, and rights of
                             elderly residents of long-term care facilities and to promote their quality of
                             life. One of their primary responsibilities is to investigate and resolve
                             complaints of residents in long-term care facilities, such as nursing homes,
                             board and care homes, and assisted living facilities.25

                             Typically, ombudsmen receive complaints from residents, family, friends,
                             and facility staff or they initiate a complaint based on their own
                             observation. The complaints name the facility and describe the problem
                             and the resident involved. The ombudsman assigned to that facility
                             generally interviews the resident within a certain period of time to gather
                             additional information about the complaint, to assure the resident that his
                             or her identity will remain confidential unless he or she indicates
                             otherwise, and to request permission to investigate the complaint.26 The
                             ombudsmen may also need to gather additional information by
                             interviewing physicians and other health practitioners, facility staff, other
                             residents, or family members and reviewing resident records. If the
                             resident gives permission, then the ombudsmen can try to resolve the
                             complaint with the appropriate facility staff. Depending on the state and
                             the nature of the complaint, ombudsmen may refer the complaint to
                             another agency, such as the state licensing agency or adult protective
                             services.


                             25
                              Ombudsmen also (1) visit facilities to educate the administrator, staff, and residents about the
                             ombudsman program; (2) distribute program materials; and (3) offer educational and training
                             programs. For example, Oregon ombudsmen have participated in an assisted living association’s
                             monthly training sessions of facility administrators and staff.
                             26
                               If the resident is unable to provide written or verbal consent because of functional or cognitive
                             limitations, then the ombudsmen follow certain guidelines on who can give consent, especially in
                             cases involving access to medical files.



                             Page 22                                                            GAO/HEHS-99-27 Assisted Living
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Ombudsmen in Florida are also required to inspect each facility annually
to evaluate the residents’ quality of care and quality of life. The inspections
provide ombudsmen an opportunity to (1) talk to residents, (2) inspect the
facility and residents’ rooms, (3) identify the level of resident privacy, and
(4) check certain safety requirements. Upon completion of the inspection,
the ombudsmen discuss any problems with the facility administrator and
negotiate a resolution. Any unresolved problems are referred to the
licensing agency.

In some states, APS has oversight responsibility for assisted living
residents. In two of the four states we studied, Florida and Oregon, APS
agencies have authority to investigate complaints or allegations related to
abuse, neglect, or exploitation involving residents.27 In general, the APS
agencies are responsible for (1) investigating a complaint or allegation,
(2) determining the immediate risk to the person and providing necessary
emergency services, (3) evaluating the need for and referrals for ongoing
protective services, and (4) providing ongoing protective supervision. The
investigations typically include interviewing the victim, alleged
perpetrator, and witnesses separately to obtain their accounts of what
occurred and obtaining relevant documents and other physical evidence to
determine whether abuse, neglect, or exploitation has occurred.

Florida’s and Oregon’s Medicaid-funded residents receive additional
oversight from case managers. Both of these states’ Medicaid programs
require case management for residents who receive assisted living services
under the Medicaid waiver. Case managers meet periodically with
residents, their facility administrator, or facility staff and discuss the
residents’ needs, changes in what services they require, and any other
additional issues related to the care plan. In Oregon, the Medicaid Fraud
Control Unit within the Office of the Attorney General has investigated
cases involving residents of assisted living facilities that receive Medicaid
funding.28 The Oregon Attorney General’s office has also been active in
educational and training sessions to ensure that residents of assisted living
facilities are provided good-quality care.




27
  In California and Ohio, the APS agencies’ authority is limited to investigating problems involving
persons not residing in “institutions” or “facilities.” However, in these two states, complaints related to
abuse, neglect, and exploitation of residents in assisted living facilities may be investigated by the
licensing agency or the ombudsman agency.
28
  The Florida Medicaid Fraud Control Unit has the authority to investigate cases involving assisted
living facility residents in Medicaid-funded facilities. However, as of late February 1999, no
investigations of assisted living facilities had taken place.



Page 23                                                              GAO/HEHS-99-27 Assisted Living
                                         B-278340




                                         Given that states vary in their licensing requirements for assisted living
States Identify                          facilities and in their approaches to oversight, the type and frequency of
Quality-of-Care and                      quality-of-care and consumer protection problems identified by the states
Consumer Protection                      may not fully portray the care and services actually provided. However,
                                         using available state licensing surveys and reports from ombudsmen and
Problems in Assisted                     APS agencies, we determined that 27 percent of the facilities in the four
Living Facilities                        states were cited for 5 or more quality-of-care or consumer protection
                                         related problems, and 11 percent for 10 or more problems, during 1996 and
                                         1997.29 The most commonly cited problems were related to quality of care
                                         and included inadequate care and staffing and medication issues.
                                         According to state officials, factors that contributed to these problems
                                         included insufficient numbers of staff, inadequate staff training, high
                                         caregiver staff turnover, and low caregiver staff pay rates. Thirty-eight
                                         percent of the facilities in the four states were not cited for any
                                         quality-of-care or consumer protection related problems during this
                                         period.


Some Facilities Have Been                Twenty-seven percent (200 of 753) of the assisted living facilities for which
Cited for Deficient Care                 we requested state agency data were cited for 5 or more quality-of-care or
Practices and Inadequate                 consumer protection related problems by state oversight officials during
                                         1996 and 1997, while 11 percent (86 of 753) of these facilities had 10 or
Consumer Protection                      more problems during this same time period. As shown in table 6, most of
                                         the problems identified by the oversight agencies were related to quality of
                                         care. While data were not available to assess the seriousness of each
                                         identified problem, many problems seemed serious enough to warrant
                                         concern.

Table 6: Percentage of Facilities With
Quality-of-Care and Consumer                                                     Facilities with verified problems
Protection Related Problems Identified   Number of            Quality of care or
by Licensing, Ombudsman, and APS         problems          consumer protection                Quality of care        Consumer protection
Agencies in the Four States
                                         5 or more                                27%                        22%                             3%
                                         10 or more                               11                           9                             0
                                         Note: Number of facilities = 753.




                                         29
                                           Our analysis includes quality-of-care or consumer protection related problems (1) cited during each
                                         facility’s most recent licensing survey or (2) verified by state licensing, ombudsman, or APS agencies
                                         for the period 1996 and 1997. The quality-of-care problems related to resident care, services,
                                         medications, staffing and training, and outcomes of care. The consumer protection problems related to
                                         contracts, consumer disclosure and financial issues, tenant-landlord issues, resident access to
                                         information, and resident participation in decisionmaking.



                                         Page 24                                                           GAO/HEHS-99-27 Assisted Living
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The number and type of problems identified in assisted living facilities
often depend on a number of factors that may be unique to each state. For
example, facilities in states with more licensing standards, more frequent
inspections, or more agencies involved in oversight may be likely to have
more problems identified.30 (Appendix III contains frequencies of the four
states’ licensing deficiencies and verified ombudsman complaints and
Florida’s and Oregon’s verified APS allegations.)

The most common problems, as shown in table 7, that licensing and
ombudsman agencies cited in the four states concerned inadequate care,
staffing, and medication. Other frequently cited problems involved
resident care plans and assessments; admission, discharge, and
level-of-care issues; billing charges; and abuse. These problems included
instances in which a facility was found to be providing inadequate care to
residents as well as instances in which a facility did not demonstrate the
capacity to provide sufficient care. For example, staffing problems
included cases in which a resident suffered harm as a result of an
insufficient number of staff in the facility, as well as cases in which
facilities had no documentation to substantiate that required caregiver
training had been provided.




30
  Appendix I discusses the methodology we used to analyze the state data, and appendix III describes
the limitations of the data.



Page 25                                                          GAO/HEHS-99-27 Assisted Living
                                             B-278340




Table 7: Types of Quality-of-Care and Consumer Protection Issues Most Frequently Identified by Licensing and
Ombudsman Agencies in the Four States, 1996-97
                   California                   Florida                       Ohio                         Oregon
         Licensing      Ombudsman        Licensing           Ombudsman         Licensing      Ombudsman          Licensing        Ombudsman
Rank     deficiencies   complaints       deficiencies        complaints        deficiencies   complaints         deficiencies     complaints
1        Inadequate     Inadequate       Staffing or         Inadequate        Care plans or Admission,          Care plans or Inadequate
         care           care             training            care              assessments discharge, or         assessments care
                                                                                             level of carea
2        Medication     Admission,       Medication          Billing or        Inadequate                        Medication       Staffing or
                        discharge, or                        chargesb          care                                               training
                        level of carea
3        Admission,     Abuse            Care plans or Abuse                   Medication                        Inadequate       Billing or
         discharge, or                   assessments                                                             care             chargesb
         level of carea
4        Staffing or    Billing or       Admission,     Staffing or            Staffing or                       Staffing or      Medication
         training       chargesb         discharge, or training                training                          training
                                         level of carea
5        Care plans or Staffing or       Contractsb                            Access to                         Abuse            Care plans or
         assessments training                                                  informationb                                       assessments
                                             Note: Includes only types of problems cited at least five times across all facilities we sampled in
                                             each state during the 2-year period. Blank cells indicate that no additional type of deficiency or
                                             complaint was cited more than four times. All problems are related to quality of care unless noted
                                             otherwise.
                                             a
                                             Problem may be related to either quality of care or consumer protection.
                                             b
                                                 Problem is related to consumer protection.



                                             Deficiencies and complaints related to inadequate care in the four states
                                             most frequently dealt with such problems as residents not receiving
                                             adequate access to physicians and other medical care or treatment for
                                             symptoms, such as pressure sores. For example, in one California facility,
                                             staff neglected to call “911” after a resident fell and injured her head.
                                             Instead, they gave the resident aspirin, and several hours later she was
                                             found in a comatose state, and she died 3 days later. In an Oregon facility,
                                             a resident’s catheter was to be irrigated daily; however, records indicated
                                             that the irrigation had not been done for approximately 6 weeks.
                                             Subsequently, the resident was sent to the emergency room and diagnosed
                                             with a urinary tract infection. An Ohio facility failed to notify a resident’s
                                             physician that the resident had fallen at least 22 times and sustained head
                                             injuries. In that same facility, another resident fell 32 times over a 6-month
                                             period and was not evaluated for possible transfer to another facility for
                                             closer supervision.




                                             Page 26                                                           GAO/HEHS-99-27 Assisted Living
    B-278340




    The second most frequently cited problem area included issues related to
    staff qualifications and training and facilities having sufficient staff to care
    for the residents. For example, in a Florida facility, staff had not received
    any training in personal hygiene care or proper infection control
    procedures, which could result in exposure to a wide range of viruses and
    bacterial infections, including influenza and hepatitis. In Oregon, family
    members routinely assisted residents by changing soiled garments because
    the facility had insufficient staff.

    The third most frequently cited problem area concerned medication-
    related deficiencies and complaints, such as not providing residents
    prescribed medication, providing them the wrong medication, or storing
    medication improperly. An Oregon facility was found to have numerous
    medication problems, including (1) staff inconsistently and inaccurately
    transcribing a physician’s medication orders to the resident’s medication
    administration records, (2) medications often being borrowed or shared
    between residents, (3) one staff member signing out narcotics but another
    staff member on a different shift administering them to residents, and
    (4) unlicensed caregivers altering residents’ prescription labels. In a
    California facility, staff failed to provide psychiatric medication to a
    resident for 20 days.

    Other commonly cited problems dealt with care plans and admission,
    discharge, and level-of-care issues. In one case, a Florida facility was cited
    for having four residents who had more care needs than an assisted living
    facility is allowed by state law. One of these residents required a special
    mechanical lift to transfer from bed to wheelchair, and the resident’s room
    was on the second floor, which could prove extremely difficult to evacuate
    in an emergency. The three other residents were unable to respond to
    questions and had heavy care needs; they were all located on the second
    floor, which made them also incapable of evacuating in case of an
    emergency.

    Oregon APS verified 48 cases of abuse in 21 of the 83 assisted living
    facilities over the 2-year time period. Oregon APS also found numerous
    cases of inadequate care, problems with care plans and assessments, and
    medication issues. For example,

•   Investigators found a resident who had a serious stage III decubitus ulcer
    on her foot and three other open skin areas. The decubitus was not being
    treated or documented, and no physician had been notified.




    Page 27                                            GAO/HEHS-99-27 Assisted Living
    B-278340




•   A resident was left on the toilet for 2 hours because the caregiver forgot to
    return to the resident’s room and a call light was not within reach. Only
    one caregiver was scheduled for the night shift to care for 30 residents,
    some of whom had need for a high level of care.
•   Staff ordered a resident’s medications from a new pharmacy, but the
    medications received were the wrong ones. Methyldopa, a heart
    medication, was sent instead of Levodopa, a medication for Parkinson’s
    disease. The error was not detected by the medication aides for 2 months.
    The medication mix-up was finally discovered by the admitting physician
    when the resident was hospitalized with low blood pressure and fever.

    In Florida, the APS agency verified 39 cases of abuse in 25 assisted living
    facilities and 103 cases of neglect in 32 facilities. Florida cases included
    the following.

•   A 90-year-old resident was admitted to a hospital with a stage IV pressure
    ulcer and found to be dehydrated and poorly nourished.
•   A resident did not receive his medications over several days, resulting in
    the resident’s having a seizure and being hospitalized. The facility had
    contacted the pharmacy several times for the medication, but the
    pharmacy did not deliver it because the pharmacy had run out of its
    supply. The facility and the pharmacy were both found negligent.
•   A resident who was at the facility for respite care fell, bruising her face.
    Later that day, the resident was found nonresponsive and was transported
    to the emergency room. The physician diagnosed a hematoma that was
    inoperable because of her severe vein disease, and she subsequently died.
    The administrator admitted that he should have sought medical treatment
    after the resident’s fall.

    In addition to the other state agencies, the Oregon Attorney General’s
    Office investigated three cases involving residents of assisted living
    facilities during 1996 and 1997. For example, the Office’s Medicaid Fraud
    Control Unit investigated a case involving a resident with end-stage renal
    disease who was receiving dialysis treatments and was on a special diet.
    However, the facility had no certified or trained dietitian available, and the
    resident was not receiving proper nutrition. In another case, the Oregon
    Financial Fraud Unit investigated the death of a resident in an Alzheimer’s
    secured unit. The resident had exited the unit through a window,
    subsequently dying of exposure and hypothermia. The unit qualified as
    “secure” under the applicable regulations, but the windows were easily
    opened wide enough for a person to pass through.




    Page 28                                            GAO/HEHS-99-27 Assisted Living
              B-278340




              State officials attributed the most common problems identified in assisted
              living facilities to insufficient staffing and inadequate training. Inadequate
              care and medication issues were most frequently attributed to shortage of
              staff and inadequate staff training. The officials also cited high staff
              turnover rates and low pay rates for caregiver staff. When facilities do not
              have adequate numbers of staff, then residents may be more likely to
              receive inadequate ADL assistance or have their call lights left unanswered
              or have inadequate assistance in case of an emergency. Furthermore, if
              facilities do not adequately train their staff, residents’ medication may be
              improperly administered, the facility may experience widespread
              infections, or staff may injure or harm the residents through improper
              lifting or bathing techniques.


              As a growing number of elderly Americans reach the point where they can
Conclusions   no longer live independently, many look to assisted living facilities as a
              viable, homelike setting to meet their long-term care needs. Currently, the
              assisted living industry is regulated by states and predominantly funded by
              private resources. However, as the states increase the use of Medicaid to
              help pay for assisted living, the contribution of federal financing will grow
              as well. These trends will likely focus more attention from consumers,
              providers, and the public sector on where assisted living fits on the
              continuum of long-term care, on the standards the states use to ensure
              quality of care and protect consumers, and on the approaches the states
              use to ensure compliance with those standards.

              With attention on assisted living facilities growing, our work in four states
              suggests that two issues are likely to be at the forefront of discussions
              about potential oversight needs. First, many assisted living facilities are
              not routinely providing prospective residents with key information they
              need in advance so they can compare what several facilities offer and
              determine whether a facility is appropriate for their needs. Second, it is
              apparent that residents of a number of assisted living facilities are
              encountering problems with quality of care or consumer protection, which
              in some cases can have a serious effect on their health. State regulators,
              providers, consumer advocates, and the federal government will need to
              be attentive to these problems as they surface and will need to consider
              what additional steps, if any, may be advised to best ensure that adequate
              quality of care and consumer protections are in place.




              Page 29                                            GAO/HEHS-99-27 Assisted Living
                  B-278340




                  We obtained comments on the draft report’s section on state oversight
State and Other   from officials representing licensing and ombudsman agencies in the four
Comments          states we studied and also from Florida’s and Oregon’s APS and Medicaid
                  agencies and Medicaid Fraud Control Unit. We also obtained comments on
                  our draft report from expert reviewers and representatives of provider
                  associations. All reviewers suggested technical changes, which we
                  included in the report where appropriate.

                  The expert reviewers, who are nationally known researchers in the
                  assisted living field, were Catherine Hawes, Ph.D., Senior Research
                  Scientist at the Myers Research Institute, and Robert L. Mollica, Ed.D.,
                  Deputy Director of the National Academy for State Health Policy.
                  Generally, they commented that the report is balanced, should help
                  consumers and policymakers think more carefully about the potential of
                  assisted living to meet the needs of the frail elderly, and should be useful
                  to states as they review their regulations and monitoring activities for
                  assisted living facilities.

                  The provider associations that reviewed and provided comments on the
                  draft report included the American Association of Homes and Services for
                  the Aging, the American Health Care Association, and the Assisted Living
                  Federation of America. In general, these reviewers reiterated the
                  importance of clear and complete information to help consumers select an
                  appropriate assisted living facility. With regard to our findings on
                  quality-of-care and consumer protection issues, they noted the importance
                  of better understanding the seriousness of verified problems and the
                  states’ approaches to addressing and resolving them.




                  Page 30                                           GAO/HEHS-99-27 Assisted Living
B-278340




As agreed with your office, unless you publicly announce the report’s
contents earlier, we plan no further distribution for 30 days. We will then
send copies to interested congressional committees and members and
agency officials and will make copies available to others on request. If you
or your staff have any questions about this report, please call me at
(202) 512-7118 or John Hansen, Assistant Director, at (202) 512-7105.
Major contributors to this report are listed in appendix IV.




Kathryn G. Allen
Associate Director, Health Financing
  and Public Health Issues




Page 31                                          GAO/HEHS-99-27 Assisted Living
Contents



Letter                                                                                              1


Appendix I                                                                                         34
Scope and
Methodology
Appendix II                                                                                        37
Our Survey of
Assisted Living
Facilities
Appendix III                                                                                       50
Additional
Information on
Quality-of-Care and
Consumer Protection
Problems in Four
States
Appendix IV                                                                                        55
Major Contributors to
This Report
Tables                  Table 1: Services Available to Residents in Assisted Living                 8
                          Facilities
                        Table 2: Percentage of Facilities in Which More Than Half of                9
                          Residents Need Staff Assistance With Activities of Daily Living
                        Table 3: Percentage of Facilities Providing Oversight to Residents         11
                          of Assisted Living Facilities
                        Table 4: Percentage of Facilities That Support Aging in Place as           12
                          Reflected in Their Admission and Discharge Criteria
                        Table 5: Percentage of Facilities Reporting That They Provide              15
                          Key Written Information to Prospective Residents




                        Page 32                                         GAO/HEHS-99-27 Assisted Living
Contents




Table 6: Percentage of Facilities With Quality-of-Care and                24
  Consumer Protection Related Problems Identified by Licensing,
  Ombudsman, and APS Agencies in the Four States
Table 7: Types of Quality-of-Care and Consumer Protection                 26
  Issues Most Frequently Identified by Licensing and Ombudsman
  Agencies in the Four States, 1996-97
Table I.1: GAO Assisted Living Study Sample                               34
Table III.1: California’s Frequency of Quality-of-Care and                51
  Consumer Protection Problems by Agency, 1996-97
Table III.2: Florida’s Frequency of Quality-of-Care and Consumer          52
  Protection Problems by Agency, 1996-97
Table III.3: Ohio’s Frequency of Quality-of-Care and Consumer             53
  Protection Problems by Agency, 1996-97
Table III.4: Oregon’s Frequency of Quality-of-Care and Consumer           54
  Protection Problems by Agency, 1996-97




Abbreviations

ADL        activities of daily living
AL         standard assisted living
ALFA       Assisted Living Federation of America
APS        adult protective service
ECC        extended congregate care
IV         intravenous
LMH        limited mental health
LNS        limited nursing services
SSI        Supplemental Security Income


Page 33                                        GAO/HEHS-99-27 Assisted Living
Appendix I

Scope and Methodology


                                       Our study focused on four states with a range of experiences with assisted
                                       living facilities—California, Florida, Ohio, and Oregon. We chose these
                                       states because they have a large number of assisted living facilities and
                                       represent four distinct regions of the country. We selected Florida and
                                       Oregon because they have an assisted living licensing category and use
                                       Medicaid waivers to reimburse assisted living facilities for covered
                                       services for Medicaid-eligible residents. We used two methods to identify
                                       potential facilities. In all four states, we included the facilities that are
                                       members of trade associations that represent assisted living facilities.31 In
                                       the two states with an assisted living licensing category, Florida and
                                       Oregon, we also included facilities that were licensed as of 1997.

                                       To identify the facilities’ services and their residents’ needs, we conducted
                                       a mail survey of 955 randomly selected facilities of 2,652 identified
                                       facilities in the four states. We received responses from 721 facilities, or
                                       75 percent of those we surveyed; 622 of those identified themselves on the
                                       survey as providers of assisted living services.32 See table I.1 for details
                                       on the study sample by state. We also visited five facilities in each of the
                                       four states, met with facility administrators and staff, and interviewed
                                       more than 90 residents or family members.

Table I.1: GAO Assisted Living Study
Sample                                                                                                          Number of assisted living
                                                                   Number of                                      facilities GAO analyzed
                                                                     potential       Number of assisted            for quality-of-care and
                                                               assisted living           living facilities          consumer protection
                                       State                         facilities        returning survey                             issues
                                       California                            387                         134                                150
                                               a
                                       Florida                            1,939                          276                                370
                                       Ohio                                  243                         140                                150
                                       Oregon                                 83                          72                                  83
                                       Total                              2,652                          622                                753
                                       a
                                        Florida assisted living licensing categories include standard assisted living, limited nursing
                                       services, and extended congregate care.



                                       To determine whether prospective residents and their families receive
                                       sufficient information to make an informed decision about which facility

                                       31
                                        The associations were the American Association of Homes and Services for the Aging, the American
                                       Health Care Association, and the Assisted Living Federation of America.
                                       32
                                         We excluded from our analysis 32 respondents from Florida and Oregon that were identified as
                                       assisted living facilities by their association membership but were not licensed by the state as assisted
                                       living facilities. Of the remaining 689, we excluded from our subsequent analysis 67 respondents that
                                       indicated on the survey that they do not provide or arrange for any assisted living services.



                                       Page 34                                                             GAO/HEHS-99-27 Assisted Living
Appendix I
Scope and Methodology




to enter, we (1) asked several assisted living industry experts, including
experts at AARP, the American Association of Homes and Services for the
Aging, the American Health Care Association, and the Assisted Living
Federation of America, to identify the kinds of information that would be
useful to potential residents and their families in selecting an assisted
living facility; (2) obtained information from our mail survey of assisted
living facilities on which of these items they usually provide and in what
form; and (3) evaluated written marketing materials and contracts of 60
facilities for completeness, clarity, and consistency with pertinent state
statutes and regulations.

To determine how the states oversee assisted living facilities, we
interviewed state officials in the four states and reviewed relevant state
statutes, regulations, guidance, and policy manuals. We did not evaluate
the effectiveness of the state agencies’ oversight of assisted living
facilities. To determine the type and frequency of quality-of-care and
consumer protection problems the four states identified in assisted living
facilities, we analyzed information obtained from the state licensing and
ombudsmen agencies in each state, and the adult protective services (APS)
agency in Florida and Oregon, for the period from January 1, 1996, through
December 31, 1997, for a randomly selected sample of 753 of the 955
facilities that received our survey. See table I.1 for detail on the sample by
state. We examined each facility’s most recent licensing survey and all
complaint investigations for the facility that had resulted in deficiencies or
complaints the state had verified concerning quality of care or consumer
protection. We assessed the reliability of the state data by testing multiple
data elements to confirm their expected relationships to one another and
by testing individual data elements for specific attributes. We consider the
states’ data to be reliable for the purpose of this study. However, the
results of our study cannot be projected to all assisted living facilities in
these states.

We considered the deficiencies or complaints that concerned resident
care, services, medications, staffing—levels, training, qualifications—and
outcomes of care to be quality-of-care problems. We considered the
deficiencies or complaints related to contracts, consumer disclosure and
financial issues, tenant-landlord issues, and resident access to information
and participation in decisionmaking to be consumer protection problems.
We did not analyze deficiencies or complaints that dealt with resident
rights, quality of life, administration, safety, or physical plant or
environment issues. These data may include cases that were investigated
and verified by more than one state agency. For example, a licensing



Page 35                                           GAO/HEHS-99-27 Assisted Living
Appendix I
Scope and Methodology




agency may have cited a deficiency in a facility and also referred the case
to the APS to investigate. In this case, if the APS agency also verified that
allegation, then we would have counted two problems occurring as
opposed to one. However, because of the agencies’ data limitations, we
were unable to identify when this occurred or the extent to which it
occurred. We also obtained information on factors that may have
contributed to the identified problems through interviews with officials
from the four states’ licensing, ombudsman, and APS agencies.




Page 36                                           GAO/HEHS-99-27 Assisted Living
Appendix II

Our Survey of Assisted Living Facilities




                Page 37             GAO/HEHS-99-27 Assisted Living
Appendix II
Our Survey of Assisted Living Facilities




Page 38                                    GAO/HEHS-99-27 Assisted Living
Appendix II
Our Survey of Assisted Living Facilities




Page 39                                    GAO/HEHS-99-27 Assisted Living
Appendix II
Our Survey of Assisted Living Facilities




Page 40                                    GAO/HEHS-99-27 Assisted Living
Appendix II
Our Survey of Assisted Living Facilities




Page 41                                    GAO/HEHS-99-27 Assisted Living
Appendix II
Our Survey of Assisted Living Facilities




Page 42                                    GAO/HEHS-99-27 Assisted Living
Appendix II
Our Survey of Assisted Living Facilities




Page 43                                    GAO/HEHS-99-27 Assisted Living
Appendix II
Our Survey of Assisted Living Facilities




Page 44                                    GAO/HEHS-99-27 Assisted Living
Appendix II
Our Survey of Assisted Living Facilities




Page 45                                    GAO/HEHS-99-27 Assisted Living
Appendix II
Our Survey of Assisted Living Facilities




Page 46                                    GAO/HEHS-99-27 Assisted Living
Appendix II
Our Survey of Assisted Living Facilities




Page 47                                    GAO/HEHS-99-27 Assisted Living
Appendix II
Our Survey of Assisted Living Facilities




Page 48                                    GAO/HEHS-99-27 Assisted Living
Appendix II
Our Survey of Assisted Living Facilities




Page 49                                    GAO/HEHS-99-27 Assisted Living
Appendix III

Additional Information on Quality-of-Care
and Consumer Protection Problems in Four
States
               Licensing agencies across the four states have different assisted living
               regulations—that is, the content, level of detail, and coding schemes for
               their assisted living licensing regulations all differ. Similarly, Florida’s and
               Oregon’s APS agencies have different allegation categories that they assign
               problems to. A problem or deficiency in one state may have one regulation
               requirement or allegation category, whereas another state may have four
               relevant regulatory requirements or allegation categories for the same
               problem. Therefore, the frequencies of licensing deficiencies should not be
               compared across states, and neither should frequencies of APS allegations
               be compared between Florida and Oregon. Only the ombudsman agencies
               across the four states use the same categories for complaints, which
               allows for the possibility of comparing the findings across the states.
               Furthermore, because of the inconsistencies with how licensing and APS
               agencies categorize deficiencies or allegations across the states, no
               comparisons should be made across the ombudsman, licensing and APS
               data.




               Page 50                                            GAO/HEHS-99-27 Assisted Living
                                         Appendix III
                                         Additional Information on Quality-of-Care
                                         and Consumer Protection Problems in Four
                                         States




Table III.1: California’s Frequency of
Quality-of-Care and Consumer                                                               Licensing                    Ombudsman
Protection Problems by Agency,                                                      Number of Number of Number of Number of
1996-97                                  Problem                                     facilities problems facilities problems
                                         Quality of care
                                         Abuse                                                                              15                22
                                         Admission, discharge, or level of
                                         care                                                 25             39             12                29
                                         Care plans or assessments                            18             27              7                 8
                                         Inadequate care                                      28             53             23                40
                                         Medication                                           25             43              8                10
                                         Neglect                                               1              1              2                 2
                                         Nutrition or special diet needs                                                     2                 2
                                         Restraints
                                         Staffing shortages, qualifications,
                                         or training                                          26             33              8                11
                                         Other
                                         Consumer protection
                                         Access to information                                 1              1              4                 4
                                         Billing or charges                                                                 10                15
                                         Contracts                                             3              3              3                 3
                                         Criminal background checks                           11             12
                                         Exploitation                                                                        4                 4
                                         Other                                                 5             11              5                 6
                                         Note: Number of facilities = 150. Numbers cannot be compared or aggregated across the
                                         licensing and ombudsman agency columns. A blank cell indicates that the agency database had
                                         no facilities with deficiencies in this problem category. These data may include cases that were
                                         investigated and verified by more than one state agency. However, the agencies’ data limitations
                                         left us unable to identify when this occurred or the extent to which it occurred. Also, problems
                                         classified under the category of “admission, discharge, or level of care” may be related to either
                                         consumer protection or quality-of-care issues.




                                         Page 51                                                          GAO/HEHS-99-27 Assisted Living
                                          Appendix III
                                          Additional Information on Quality-of-Care
                                          and Consumer Protection Problems in Four
                                          States




Table III.2: Florida’s Frequency of Quality-of-Care and Consumer Protection Problems by Agency, 1996-97
                                         Licensing                     Ombudsman                                        APS
                                Number of        Number of           Number of            Number of           Number of           Number of
Problem                          facilities       problems            facilities           problems            facilities          problems
Quality of care
Abuse                                                                            6                   9                  25                     39
Admission, discharge, or
level of care                           65                118                    5                   5
Care plans or assessments              115                201                    2                   2
Inadequate care                         44                 51                  19                  29
Medication                             116                266                    5                   5
Neglect                                                                                                                 32                103
Nutrition or special diet
needs                                   38                 49                    3                   3
Restraints                              38                 38                    4                   4
Staffing shortages,
qualifications, or training            151                393                    5                   7
Other                                   28                 28
Consumer protection
Access to information                   55                 76                    5                   5
Billing or charges                       4                  5                  13                  13
Contracts                               72                 82                    1                   1
Criminal background checks
Exploitation                                                                     3                   3                   1                      1
Other                                   55                 73                    1                   1
                                          Note: Number of facilities = 370. Numbers cannot be compared or aggregated across the
                                          licensing, ombudsman, and APS agency columns. A blank cell indicates that the agency
                                          database had no facilities with deficiencies in this problem category. These data may include
                                          cases that were investigated and verified by more than one state agency. However, the agencies’
                                          data limitations left us unable to identify when this occurred or the extent to which it occurred.
                                          Also, problems classified under the category of “admission, discharge, or level of care” may be
                                          related to either consumer protection or quality-of-care issues.




                                          Page 52                                                          GAO/HEHS-99-27 Assisted Living
                                   Appendix III
                                   Additional Information on Quality-of-Care
                                   and Consumer Protection Problems in Four
                                   States




Table III.3: Ohio’s Frequency of
Quality-of-Care and Consumer                                                         Licensing                    Ombudsman
Protection Problems by Agency,                                                Number of Number of Number of Number of
1996-97                            Problem                                     facilities problems facilities problems
                                   Quality of care
                                   Abuse                                                                               3                3
                                   Admission, discharge, or level of
                                   care                                                  3              3              6                6
                                   Care plans or assessments                            17             25              1                1
                                   Inadequate care                                       8             14              1                2
                                   Medication                                            8             12
                                   Neglect                                                                             2                2
                                   Nutrition or special diet needs                       4              4
                                   Restraints                                            2              2
                                   Staffing shortages, qualifications,
                                   or training                                           9             10              3                3
                                   Other                                                 2              2
                                   Consumer protection
                                   Access to information                                 6              6
                                   Billing or charges                                    2              2              2                3
                                   Contracts
                                   Criminal background checks
                                   Exploitation
                                   Other                                                 2              2              2                2
                                   Note: Number of facilities = 150. Numbers cannot be compared or aggregated across the
                                   licensing and ombudsman agency columns. A blank cell indicates that the agency database had
                                   no facilities with deficiencies in this problem category. These data may include cases that were
                                   investigated and verified by more than one state agency. However, the agencies’ data limitations
                                   left us unable to identify when this occurred or the extent to which it occurred. Also, problems
                                   classified under the category of “admission, discharge, or level of care” may be related to either
                                   consumer protection or quality-of-care issues.




                                   Page 53                                                          GAO/HEHS-99-27 Assisted Living
                                         Appendix III
                                         Additional Information on Quality-of-Care
                                         and Consumer Protection Problems in Four
                                         States




Table III.4: Oregon’s Frequency of Quality-of-Care and Consumer Protection Problems by Agency, 1996-97
                                       Licensing                     Ombudsman                                         APS
                               Number of        Number of           Number of            Number of           Number of           Number of
Problem                         facilities       problems            facilities           problems            facilities          problems
Quality of care
Abuse                                   2                  6                    4                   7                  21                     48
Admission, discharge, or
level of care                                                                 10                  14                    2                      2
Care plans or assessments              34                 86                  11                  18                   13                     18
Inadequate care                        15                 26                  26                  74                   26                     50
Medication                             24                 33                  10                  20                    9                     17
Neglect                                                                         4                   4                  14                     16
Nutrition or special diet
needs                                                                           6                   8                   5                      7
Restraints                                                                      2                   2
Staffing shortages,
qualifications, or training            10                 12                  20                  59                    1                      1
Other
Consumer protection
Access to information                                                           5                   6
Billing or charges                                                            15                  27                    1                      1
Contracts                                                                       1                   1                   1                      1
Criminal background checks
Exploitation                                                                    2                   3                   3                      3
Other                                                                           4                   5                   5                      5
                                         Note: Number of facilities = 83. Numbers cannot be compared or aggregated across the
                                         licensing, ombudsman, and APS agency columns. A blank cell indicates that the agency
                                         database had no facilities with deficiencies in this problem category. These data may include
                                         cases that were investigated and verified by more than one state agency. However, the agencies’
                                         data limitations left us unable to identify when this occurred or the extent to which it occurred.
                                         Also, problems classified under the category of “admission, discharge, or level of care” may be
                                         related to either consumer protection or quality-of-care issues.




                                         Page 54                                                          GAO/HEHS-99-27 Assisted Living
Appendix IV

Major Contributors to This Report


               John C. Hansen, Assistant Director, (202) 512-7105
               Eric R. Anderson, Senior Evaluator
               Connie Peebles Barrow, Senior Evaluator
               Ann V. White, Senior Evaluator
               David W. Bieritz, Evaluator
               George Bogart, Attorney-Adviser
               Susan Lawes, Senior Social Science Analyst (Survey Specialist)
               Elsie Picyk, Senior Evaluator (Computer Science)
               Joan Vogel, Senior Evaluator (Computer Science)




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