Assisted Living: Quality-of-Care and Consumer Protection Issues

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                       Testimony
                          Before the Special Committee on Aging, U.S. Senate

For Release on Delivery
Expected at 1:00 p.m.
Monday, April 26, 1999
                          ASSISTED LIVING

                          Quality-of-Care and
                          Consumer Protection Issues
                          Statement of Kathryn G. Allen, Associate Director
                          Health Financing and Public Health Issues
                          Health, Education, and Human Services Division

Assisted Living: Quality-of-Care and
Consumer Protection Issues

                  Mr. Chairman and Members of the Committee:

                  We are pleased to be here today to discuss quality-of-care and consumer
                  protection issues in assisted living. Assisted living facilities are becoming
                  an increasingly popular option for providing long-term care for the elderly
                  in what can be a less costly and more homelike setting than nursing
                  homes. Current estimates of the number of assisted living beds in the
                  United States range from 800,000 to 1.5 million, and consumer demand is
                  expected to grow significantly as the projected number of elderly
                  Americans in need of long-term care doubles over the next 20 years.

                  Assisted living facilities offer a combination of housing, meals, personal
                  support services, and, in some cases, health care for their residents.
                  Although most assisted living is paid for privately by individuals and their
                  families, many states are using Medicaid to fund services and care for
                  residents in assisted living facilities, and others are considering whether
                  assisted living can be a cost-effective alternative to publicly funded
                  nursing home care for some persons. At the same time as interest in
                  assisted living has grown, concerns about quality of care and consumer
                  protection in assisted living have been raised in recent media accounts and
                  other reports.

                  The information I am presenting is based on a report we are issuing to
                  your Committee today that examined assisted living in four
                  states—California, Florida, Ohio, and Oregon.1 My statement focuses on
                  four main issues:

              •   residents’ needs and the services provided in assisted living facilities;
              •   the extent to which facilities provide consumers with sufficient
                  information for them to choose a facility that is appropriate for their
              •   the four states’ approaches to oversight of assisted living; and
              •   the types of quality-of-care and consumer protection problems they

                  Our findings are based on an analysis of responses to a mail survey of
                  facilities in these four states, an evaluation of the facilities’ marketing
                  materials and contracts, interviews with state officials, a review of
                  relevant state statutes and regulations, visits to 20 assisted living facilities,
                  interviews with more than 90 assisted living residents or family members,

                  Assisted Living: Quality-of-Care and Consumer Protection Issues in Four States (GAO/HEHS-99-27,
                  Apr. 26, 1999).

                  Page 1                                                                      GAO/T-HEHS-99-111
Assisted Living: Quality-of-Care and
Consumer Protection Issues

and an analysis of state data on verified quality-of-care and consumer
protection problems in assisted living facilities.2

In brief, we found that assisted living facilities vary widely in the types of
services they provide and the residents they serve. They range from small,
freestanding, independently owned homes with a few residents to large,
corporately owned communities that offer both assisted living and other
levels of care to several hundred residents. Some assisted living facilities
offer only meals, housekeeping, and limited personal assistance, while
others provide or arrange for a range of specialized health and related
services. They also vary in the extent to which they admit residents with
certain needs and whether they retain residents as their needs change.

Given the variation in what is labeled assisted living, prospective residents
must rely on information supplied to them by facilities to select one that
best meets their needs and preferences. However, we found that, in many
cases, assisted living facilities did not routinely give consumers sufficient
information to determine whether a particular facility could meet their
needs, for how long, and under what circumstances. For example, many
facilities did not provide prospective residents with written information on
such key issues as the amount of assistance they could expect to receive
with medications, the circumstances under which the cost of services
might change, or when they could be required to leave if their health
changes. Moreover, we identified numerous examples of vague,
misleading, or even contradictory information contained in written
materials that facilities provide to consumers.

The states have the primary responsibility for the oversight of care
furnished to assisted living facility residents. All four states we reviewed
have licensing requirements that must be met by most facilities providing
assisted living services, and state licensing agencies routinely inspect or
survey facilities to ensure compliance with state regulations. However, the
licensing standards as well as the frequency and content of the periodic
inspections vary across the states. The licensing agencies also respond to
complaints they receive related to potential violations of state regulations.
In addition, the long-term care ombudsman agency in all four states and
the Adult Protective Services (APS) agency in Florida and Oregon

 We sent our mail survey to 955 randomly selected facilities of 2,652 identified 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. Our analysis of
quality-of-care and consumer protection issues was based on a review of state licensing agency
deficiencies, ombudsman complaints, and adult protective service allegations that state officials
verified in a sample of 753 facilities in these states.

Page 2                                                                            GAO/T-HEHS-99-111
             Assisted Living: Quality-of-Care and
             Consumer Protection Issues

             investigate complaints or allegations of problems 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 inspection surveys and reports from
             the other oversight agencies in the four states, we determined that the
             states cited more than 25 percent of the 753 facilities in our sample 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 for 10 or more problems during this time period. Most of the
             problems identified by the state agencies were related to quality-of-care
             rather than consumer protection issues. 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 providing inadequate or insufficient care to residents;
             their having insufficient, unqualified, and untrained staff; and their not
             providing residents appropriate medications or storing medications
             improperly. State officials attributed most of the common problems
             identified in assisted living facilities to insufficient staffing and inadequate
             training, exacerbated by high staff turnover and low pay for caregiver

             Assisted living is usually viewed as a residential care setting for persons
Background   who can no longer live independently and who require some supervision
             or help with activities of daily living (ADL) but may not need the level of
             skilled care provided in a nursing home. It is promoted by assisted living
             advocates as a long-term care setting that emphasizes residents’
             autonomy, independence, and individual preferences and that can meet
             their scheduled and unscheduled needs for assistance. Typically, assisted
             living facilities provide housing, meals, supervision, and assistance with
             some ADLs and other needs such as medication administration. However,
             there is no uniform assisted living model, and considerable variation exists
             in the types of facilities or settings that hold themselves out to be an
             assisted living facility. In some cases, assisted living facilities may serve
             residents who meet the level-of-care criteria for admission to a nursing

             Page 3                                                        GAO/T-HEHS-99-111
                        Assisted Living: Quality-of-Care and
                        Consumer Protection Issues

                        Unlike residents of nursing homes, the majority of whom receive some
                        support from Medicaid or Medicare, most residents of assisted living
                        facilities pay for care out of pocket or through other private funding.3
                        However, public sources of funding are available to help pay for services
                        for some residents. For example, some states are attempting to control
                        rising Medicaid costs by encouraging the use of assisted living as an
                        alternative to more expensive nursing home care. Currently, 32 states use
                        Medicaid funds to reimburse for services provided to Medicaid
                        beneficiaries residing in assisted living facilities.4 However, Medicaid
                        payments do not cover the cost of room and board in assisted living
                        facilities. A combination of individuals’ personal resources, residents’
                        Supplemental Security Income (SSI) payments, and optional state
                        payments pay for these costs.

                        The states have the primary responsibility for overseeing the care that
                        assisted living facilities provide residents, and few federal standards or
                        guidelines govern assisted living.5 The four states we reviewed vary widely
                        in what they require of these facilities. Generally, state regulations 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. 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.

                        A wide variety of services are available to residents in assisted living, and
Assisted Living         most facilities provide oversight to monitor and supervise their residents.
Facility Services and   These oversight responsibilities generally include providing 24-hour
Resident Needs Vary     supervision; monitoring changes in residents’ health and functioning;
                        notifying a resident’s physician, family, or other responsible person when
Widely                  the resident’s condition changes; and providing regular health or wellness
                        checks. Assisted living facilities in our survey reported that they usually

                         Medicaid is the federal-state health financing program for low-income and aged, blind, and disabled
                        people. Medicare finances health care for most Americans over age 65 and the disabled. In 1999, the
                        federal government is projected to pay $39 billion for nursing home care, mostly through Medicaid.
                         See State Assisted Living Policy: 1998 (Portland, Me.: National Academy for State Health Policy,
                        June 1998). States often use the authority available under section 1915(c) of the Social Security Act,
                        which enables them to fund nursing services in a home and community-based setting rather than in an
                        institutional setting.
                         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,

                        Page 4                                                                           GAO/T-HEHS-99-111
    Assisted Living: Quality-of-Care and
    Consumer Protection Issues

    provide housekeeping, laundry, meals, transportation to medical
    appointments, special diets, and assistance with medications. Many
    facilities also provide 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.
    Some services may be provided by facility staff or by staff under contract
    to the facility. In other cases, the facility may arrange with an outside
    provider to deliver some services, with residents paying the provider
    directly, or residents may arrange and pay for services on their own.

    We found considerable variation among facilities and among states in the
    needs of the residents they serve. The facilities we visited have some
    residents who are completely independent and ambulatory, some who
    have severe cognitive impairments, and 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. Assistance with dressing and toileting or
    incontinence care are the next most frequently cited needs, and assistance
    is needed to a lesser extent with eating, transferring, and walking. The
    highest level of resident need for staff assistance with ADLs was reported
    among facilities in Oregon and those in Florida licensed as extended
    congregate care facilities. In addition, residents often have some degree of
    cognitive impairment, such as significant short-term memory problems,
    disorientation much of the time, or Alzheimer’s disease or another form of

    The ability of residents to remain in a facility as their health declines or
    their needs change, commonly referred to as aging in place, is determined
    largely by admission and discharge criteria. There is considerable
    variation across the states in these criteria, some of which comes from
    state regulations, some the facilities’ choice of whom to serve, and some
    the particular services a facility chooses to provide or make available. For
    example, facilities in Oregon are more likely to admit and retain residents
    with a higher level of need than those in other states. Facilities responding
    to our survey vary in terms of resident needs they accept on admission and
    the circumstances under which they retain or discharge residents who
    develop certain needs or conditions after being admitted. Although some
    facilities may not admit residents with a particular need or condition, they
    do not necessarily discharge them if they develop that need. For example:

•   More than 75 percent of the facilities reported that they admit residents
    who have mild to moderate memory or judgment problems, are

    Page 5                                                       GAO/T-HEHS-99-111
                            Assisted Living: Quality-of-Care and
                            Consumer Protection Issues

                            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, and most facilities discharge residents who develop
                            these needs.
                        •   Most facilities in Oregon indicated that they do not admit people who are
                            bedridden, but half typically retain anyone who becomes bedridden while
                            a resident.

                            Given the variation in what is labeled assisted living, prospective residents
Consumers May Lack          must rely primarily on information supplied to them by facilities to select
Adequate Information        one that best meets their needs and preferences. They can obtain
to Select a Facility        information in a variety of ways, including written materials, facility tours,
                            personal interviews, and personal recommendations. However, in order to
That Best Meets Their       help prospective residents compare facilities and select the most
Needs                       appropriate setting for their needs, key information should be provided in
                            writing and in advance of their decision to apply for admission. Yet we
                            found that written material often does not contain key information;
                            facilities do not routinely provide prospective residents with important
                            documents, such as a copy of the contract, to use as an aid in
                            decisionmaking; and written materials that are available are sometimes
                            confusing or even misleading.

                            According to consumer advocates and provider associations, consumers
                            need to be informed about the services that will be provided, their costs,
                            and the respective obligations of both the resident and the provider. Such
                            information should include

                        •   the cost of the basic service package and what it includes;
                        •   the availability of additional services, who will provide them, and their
                        •   the circumstances under which costs may change;
                        •   how the facility monitors resident health care;
                        •   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, and the procedures for notifying and relocating the resident; and
                        •   grievance procedures.

                            Page 6                                                       GAO/T-HEHS-99-111
Assisted Living: Quality-of-Care and
Consumer Protection Issues

The majority of facilities responding to our survey said they generally
provide prospective residents with written information about many of
their services and costs in advance of their choosing to apply for
admission. However, as shown in figure 1, only about half indicated that
they provide information on the circumstances under which the cost of
services may change, their policy on medication assistance, or their
practice for monitoring residents’ needs, and less than half indicated that
they provide written information in advance about discharge criteria, staff
training and qualifications, or services not covered or available from the

Page 7                                                    GAO/T-HEHS-99-111
                                                       Assisted Living: Quality-of-Care and
                                                       Consumer Protection Issues

Figure 1: Percentage of Facilities Reporting That They Provide Key Written Information to Prospective Residents


Description of Basic Services

Cost of the Basic Services

Residents' Rights and Responsibilities

Other Services Available

Complaint or Grievance Procedure

Cost of Additional Services

Medication Assistance

Monitoring Resident Needs

Circumstances When Costs May Change

Discharge Criteria

Services Not Available

Staff Training and Qualifications

                                         0            10        20       30        40         50   60   70    80         90      100

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

                                                       Page 8                                                      GAO/T-HEHS-99-111
Assisted Living: Quality-of-Care and
Consumer Protection Issues

residents. Contracts range from a one-page standard form lease to a
55-page document with 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 the facilities also
vary widely from a one-page list of basic services and monthly rent to
multiple documents of more than 100 pages.

We examined written marketing materials and contracts from 60 of the
facilities that responded to our survey to determine whether they were
complete, clear, and consistent with state laws. While most of the facility
materials we reviewed were specific and relatively clear, we found that
materials from 20 of the 60 facilities contained language that was unclear
or potentially misleading, usually concerning the circumstances under
which a resident could be required to leave a facility. Contracts and other
written materials we reviewed were often unclear or inconsistent with
each other or with requirements of state regulation regarding how long
residents could remain as their needs change, resident notification
requirements, and other procedural requirements for discharge. For
example, the contract from a California facility was vague regarding the
circumstances under which a resident could be required to move. It stated
that the facility can discharge a resident for good and sufficient cause
without elaborating on what the cause might be. The contract also failed
to refer to state regulations that provide specific criteria for discharge or

As shown in figure 2, the marketing material one Florida facility uses is
potentially misleading in specifying that residents can be assured that if
their health changes, the facility can meet their needs and they will not
have to move again. However, the facility’s contract specifies a range of
health-related criteria for immediate discharge, including changes in a
resident’s condition or need for services that the facility cannot provide.
The contract of an Oregon facility is inconsistent with requirements of
state regulation regarding notification of residents before discharging
them. Oregon regulations specify that residents may not be asked to leave
without 14 days’ written notice that a facility cannot provide the services
they need. However, the facility’s contract specifies that residents can be
required to move immediately if they need more care than is available at
the facility.

Page 9                                                      GAO/T-HEHS-99-111
                                          Assisted Living: Quality-of-Care and
                                          Consumer Protection Issues

Figure 2: Examples of Unclear or Misleading Written Information

                     Facility 1                                                        Facility 2
                                     So you can be
                                     assured if health
                                     changes occur, we
                                     can meet your
                                                                                                Resident may not be
                                     needs. And you
                                                                                                asked to leave
                                     won't have to deal
                                                                                                without 14 days'
                                     with the hassles of
                                                                                                written notice stating
                                     moving again.
                                                                                                reasons for the
                                      "... It's reassuring
                                      to know that even
                                      if my needs
                                      change, I won't
                                      have to move."
  Marketing Brochure                                                 State Regulation

                                       ... may terminate
                                       this Residency
                                       immediately ...
                                                                                                ... may terminate this
                                      Due to changes in                                         agreement
                                      your physical or                                          immediately upon
                                      mental condition,                                         notice and the
                                      supplies, services                                        resident shall be
                                      or procedures are                                         required to
                                      required that ... by                                      immediately vacate
                                      certification,                                            the Premises in any
                                      licensure, design                                         one of the following
                                      or staffing cannot                                        circumstances:
          Contract                                                          Contract

                                          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. Florida and
Range of Approaches                       Oregon have created a specific licensing category and requirements for
to Oversee Assisted                       assisted living facilities, while California and Ohio license these facilities
                                          under existing residential care facility regulations. All four states have
Living Facilities

                                          Page 10                                                      GAO/T-HEHS-99-111
Assisted Living: Quality-of-Care and
Consumer Protection Issues

similar requirements regarding the type and level of services that assisted
living facilities must provide residents. In addition to basic
accommodations such as room, board, and housekeeping, all the states
require facilities to provide residents with basic services, including
assistance with ADLs, ongoing health monitoring, and either the provision
of or arrangement for medical services, including transportation to and
from those services as needed.

All four states require assisted living facilities to conduct an initial
assessment of a resident’s health, functional ability, and needs for
assistance. They also require that facilities provide residents with
reasonable advance notice of discharge or eviction, and they specify
certain rights and procedures for residents to appeal or contest a facility’s
decision to discharge them. State regulations also generally contain other
consumer protection provisions such as those governing resident
contracts, criminal background checks for staff, and residents’ rights. All
four states require that facilities enter into contracts with residents, but
they differ in the level of detail they require in these agreements. In
addition, all four states require criminal background checks for direct care
staff, and three states—California, Florida, and Oregon—require them for
facility administrators as well.

State regulations often differ, however, with respect to the level of skilled
nursing or medical care that facilities can provide to residents and in 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, such as catheter care, colostomy care, and injections.
In contrast, Oregon has no explicit restrictions on the care that facility
staff may provide, except that certain nursing tasks must be either
assigned or delegated to a caregiver by a registered nurse. In addition,
while all four 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 California, facility staff may not administer medications
but may only assist residents to take their own medications. Requirements
for staff levels, qualifications, and training also vary among the states. For
example, Florida requires facilities to maintain a minimum number of
full-time staff that is based on the total number of residents, California and
Ohio require only that the number of staff be adequate to meet the needs
of residents, and Oregon does not have any minimum staffing requirement.

Page 11                                                     GAO/T-HEHS-99-111
Assisted Living: Quality-of-Care and
Consumer Protection Issues

To ensure that assisted living facilities comply with the various licensing
requirements, all four states conduct periodic inspections or surveys of
facilities, and they may also conduct more frequent inspections in
response to specific complaints.6 However, the four states vary in the
frequency and content of assisted living facility inspections. The frequency
of required licensing inspections ranges from at least twice a year for
extended congregate care facilities in Florida to at least once every 2 years
for assisted living facilities in Oregon.7 The content of periodic state
surveys is driven primarily by the requirements in state regulations. To
assist surveyors, Florida and Ohio have developed detailed guidelines,
similar to those used for nursing home inspections. In contrast, surveyors
in California and Oregon use a checklist that covers a subset of the
regulations and focuses on a few selected elements.

In addition to the state licensing agency, other state agencies play a role in
the oversight of assisted living facilities. In the four states we examined,
the state ombudsman agency has a role in overseeing the quality of care
and consumer protection of residents in assisted living. The ombudsmen
are intended to 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.
Ombudsmen in Florida are also required to inspect each facility annually
to evaluate the residents’ quality of care and quality of life. In two of the
four states, Florida and Oregon, APS agencies are responsible for
investigating reports of alleged abuse, neglect, or exploitation of assisted
living residents; determining their immediate risk and providing necessary
emergency services; evaluating the need for and referrals for ongoing
protective services; and providing ongoing protective supervision.

 In Florida, Ohio, and Oregon, the agency with responsibility for inspecting assisted living facilities
also has responsibility for nursing homes. In contrast, responsibility for the regulation and inspection
of assisted living facilities in California rests with the Department of Social Services, while nursing
homes fall under the jurisdiction of the Department of Health Services.
 Florida has multiple categories of assisted living licensure, including standard assisted living, limited
nursing services, and extended congregate care.

Page 12                                                                            GAO/T-HEHS-99-111
                                         Assisted Living: Quality-of-Care and
                                         Consumer Protection Issues

                                         Given that the states vary in their licensing requirements for assisted living
The 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 the facilities actually provide.
                                         Facilities in states with more licensing standards, more frequent
Problems in Assisted                     inspections, or more agencies involved in oversight may be more likely to
Living Facilities                        have more problems identified and verified. Using available data and
                                         reports from state licensing, ombudsman, and APS agencies in the four
                                         states, we determined that 27 percent of the 753 facilities in our sample
                                         were cited for five or more quality-of-care or consumer protection related
                                         problems during 1996 and 1997. Most of these verified problems pertained
                                         to quality-of-care rather than consumer protection issues. As table 1
                                         shows, 22 percent of the facilities we sampled had 5 or more verified
                                         quality-of-care problems during the period, and 9 percent of the facilities
                                         had 10 or more.

Table 1: Percentage of Facilities With
Quality-of-Care and Consumer                                                             Facilities with verified problems
Protection Related Problems Identified                                       Quality of care or
by Licensing, Ombudsman, and APS                                                    consumer                                 Consumer
Agencies in the Four States              Number of problems                         protection     Quality of care           protection
                                         5 or more                                          27%                 22%                  3%
                                         10 or more                                         11                   9                   0
                                         Note: Number of facilities = 753.

                                         The most commonly cited quality-of-care problems included inadequate
                                         care, staffing, and medication issues. 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 residents suffered harm as a result of insufficient numbers of staff
                                         in the facility, as well as cases in which facilities had no documentation to
                                         substantiate that required caregiver training had been provided.

                                         Inadequate care, such as instances of residents not receiving appropriate
                                         access to physicians and other needed medical care or treatment, was the
                                         most frequently cited quality-of-care problem. For example, as illustrated
                                         in table 2, in one California facility, staff neglected to call “911” after a
                                         resident fell and injured her head. Instead, they gave her aspirin, and
                                         several hours later she was found in a comatose state. She died 3 days
                                         later. The second most frequently cited problem concerned staff

                                         Page 13                                                                     GAO/T-HEHS-99-111
                                       Assisted Living: Quality-of-Care and
                                       Consumer Protection Issues

                                       qualifications and training and facilities not having sufficient staff to care
                                       for the residents. For example, in an Oregon facility, family members
                                       routinely assisted residents by changing soiled garments because the
                                       facility did not have enough staff.

Table 2: Examples of Quality-of-Care
and Consumer Protection Problems       Issue                           Problem
                                       Quality of care
                                       Inadequate care                 Staff neglected to call “911” after a resident fell and
                                                                       injured her head. Instead, they gave her aspirin, and
                                                                       several hours later she was found in a comatose state.
                                                                       She died 3 days later.
                                       Staffing                        Because of insufficient staff, family members in one
                                                                       facility routinely assisted residents by changing soiled
                                       Medication                      Facility staff inconsistently and inaccurately transcribed
                                                                       physicians’ medication orders, often allowed sharing of
                                                                       medications between residents, signed out narcotics on
                                                                       one shift but had staff from another shift administer them,
                                                                       and allowed unlicensed caregivers to alter residents’
                                                                       prescription labels.
                                       Consumer protection
                                       Billing or discharge            A resident was told on admission that she could stay in
                                                                       the facility until she died. After living at the facility for 2
                                                                       years, she began to wander within the facility. The facility
                                                                       then issued a 2-week eviction notice stating that it could
                                                                       no longer care for her. The facility also increased her
                                                                       monthly fee from approximately $1,600 to more than
                                                                       $6,400. She moved to another facility.
                                       Contracts                       A resident contract did not contain all state-required
                                                                       elements, such as the basic daily, weekly, or monthly rate
                                                                       and a list of available services and fees not included in
                                                                       the basic rate.

                                       The third most frequently cited problem concerned medication-related
                                       issues, such as not providing residents their prescribed medication,
                                       providing them the wrong medication, or storing medication improperly.
                                       For example, an Oregon facility was found to have numerous medication
                                       problems, including (1) staff inconsistently and inaccurately transcribing
                                       physicians’ medication orders to the residents’ 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.

                                       Page 14                                                                   GAO/T-HEHS-99-111
              Assisted Living: Quality-of-Care and
              Consumer Protection Issues

              Commonly cited consumer protection problems included those related to
              circumstances under which a resident could be required to leave a facility
              for health or financial reasons and those related to provisions in resident
              contracts. For example, a resident of an Oregon facility was told on
              admission that she could stay until she died. However, the facility issued
              her an eviction notice when she began to wander within the facility, and it
              raised her monthly charge from approximately $1,600 to more than $6,400.
              In Florida, a facility was cited for not having all state-required elements in
              the resident contract, such as the basic daily, weekly, or monthly rates and
              a list of available services and fees not included in the basic rate.

              In Florida and Oregon, the two states in which APS agencies have some
              responsibility for oversight of residents in assisted living facilities, resident
              abuse was also often cited. In Oregon, the APS agency verified 48 cases of
              abuse in 21 of the state’s 83 assisted living facilities during 1996 and 1997.
              In one case, a resident was left on the toilet for 2 hours because the
              caregiver forgot to return to the resident’s room, and there was no call
              button within reach. In Florida, the APS agency verified 39 cases of abuse
              in 25 facilities and 103 cases of neglect in 32 facilities during the 2-year
              period. Florida cases included an instance in which a 90-year-old resident
              was admitted to a hospital with a stage IV pressure ulcer and found to be
              dehydrated and poorly nourished.

              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. While many
              residents may enter assisted living facilities with relatively few or minimal
              needs for supportive or health services, these needs generally increase
              with age or with declining health. Some assisted living facilities may be
              able to accommodate these changing and more intensive needs, while
              others may not. Fully understanding the strengths and limitations of
              facilities is important as consumers and their families attempt to make the
              best choice for what is often a difficult decision.

              Currently, the assisted living industry is predominantly funded by private
              resources and is licensed and regulated by the states. However, as the
              states increase their use of Medicaid to help pay for assisted living, the
              contribution of federal financing will grow as well. This trend will no
              doubt focus more attention from consumers, providers, and the public
              sector on several issues, including where assisted living fits on the
              continuum of long-term care, on standards needed to ensure quality of

              Page 15                                                        GAO/T-HEHS-99-111
           Assisted Living: Quality-of-Care and
           Consumer Protection Issues

           care and protect consumers, on appropriate approaches to ensure
           compliance with those standards, and on the adequacy of information
           available to help inform consumers’ choices and decisions.

           Mr. Chairman, this concludes my statement. I will be happy to answer any
           questions that you or other members of the Committee may have.

(101815)   Page 16                                                 GAO/T-HEHS-99-111
Ordering Information

The first copy of each GAO report and testimony is free.
Additional copies are $2 each. Orders should be sent to the
following address, accompanied by a check or money order
made out to the Superintendent of Documents, when
necessary. VISA and MasterCard credit cards are accepted, also.
Orders for 100 or more copies to be mailed to a single address
are discounted 25 percent.

Orders by mail:

U.S. General Accounting Office
P.O. Box 37050
Washington, DC 20013

or visit:

Room 1100
700 4th St. NW (corner of 4th and G Sts. NW)
U.S. General Accounting Office
Washington, DC

Orders may also be placed by calling (202) 512-6000
or by using fax number (202) 512-6061, or TDD (202) 512-2537.

Each day, GAO issues a list of newly available reports and
testimony. To receive facsimile copies of the daily list or any
list from the past 30 days, please call (202) 512-6000 using a
touchtone phone. A recorded menu will provide information on
how to obtain these lists.

For information on how to access GAO reports on the INTERNET,
send an e-mail message with "info" in the body to:


or visit GAO’s World Wide Web Home Page at:


United States                       Bulk Rate
General Accounting Office      Postage & Fees Paid
Washington, D.C. 20548-0001           GAO
                                 Permit No. G100
Official Business
Penalty for Private Use $300

Address Correction Requested