The world of elder care is fraught with rules, regulations and requirements. The myriad of complex laws that apply to different types of senior housing often make an already difficult decision even more challenging, but for good reason: residents’ safety and well-being.
There are federal regulations in place for long-term care facilities that are certified by the Centers for Medicare and Medicaid Services (CMS), licensing standards and additional Medicaid regulations enacted on the state level, and unique in-house rules that individual communities elect to follow. All these policies and procedures are used to calculate costs for services, set staffing ratios and training requirements, determine when care plans must be updated, define the level of care a facility can provide, and much more.
Assisted living is an intermediate level of long-term care that varies widely by state, so gaining even a cursory understanding of some of the unique rules these providers must follow will be invaluable when making senior living decisions. Be certain to research rules and requirements specific to the state where an aging loved one is seeking care. Once you’ve narrowed down your search, carefully read a facility’s contract or admission agreement for detailed information on their policies and protocols.
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The Band-Aid Application Ban
Most assisted living facilities (ALFs) do not provide any medical care, but some are specifically licensed to provide “limited health care services,” which are carefully regulated. For example, ALFs in the state of Rhode Island are not allowed to provide even basic wound care, such as the application of a Band-Aid, unless they obtain a limited health services license from the state’s Center for Health Facilities Regulation. From there, the wound treatment must be ordered by a physician and administered by a qualified, licensed staff member, such as a certified nursing assistant (CNA), a licensed practical nurse (LPN) or a registered nurse (RN).
While this regulation may seem frivolous, it clearly defines and controls what level of care an assisted living community can legally provide. Compared to skilled nursing facilities, which provide around-the-clock skilled nursing care, ALFs follow less strict staffing, licensing and training requirements. It’s important to educate yourself on what medical care services a particular community can provide—especially when accounting for future changes in your loved one’s condition—before making the decision to move them there. -
Care Plan Management
Many states require assisted living staff to conduct a comprehensive needs assessment of each resident upon admission to develop a written care plan. In Georgia, this must be done within 14 days of an elder’s admission, and the personalized plan must be reevaluated at least once a year (or every three months for those residing in specialized memory care units) and whenever a resident’s care needs change.
In California, ALFs, memory care units, and continuing care retirement communities (CCRCs) are all referred to as residential care facilities for the elderly (RCFEs). When it comes to care planning, state regulations specify that RCFEs must also include an assessment of an aging adult’s “likes and dislikes and interests and activities, to determine if the living arrangements in the facility will be satisfactory, and to suggest the program of activities in which the individual may wish to participate.”
It’s important to inquire about prospective facilities’ care plan policies. You should be able to receive a written copy of a loved one’s current plan at any time and request care team meetings to discuss any issues and potential changes. -
Medication Adherence Mandates
Residents have the right to control their receipt of medical services based on informed decision making, and this includes medications. However, ALF residents in Idaho must take their medications as prescribed by a doctor or risk being discharged. A facility must document medication refusal, contact the resident’s physician and authorized family member(s)/legal representative(s) to work on a solution. Ultimately, though, Idaho’s regulations state that “refusal of treatment does not relieve the facility of its obligations” under a resident’s plan of care. If a reasonable solution isn’t reached, ALFs are not required to retain residents who endanger their own health. -
The Continuous Medical Care Threshold
In most states, if a senior requires access to around-the-clock skilled nursing care, then their care needs exceed what can be legally provided in an assisted living community and they are not suitable for admission. The exact definition of skilled nursing services may vary from state to state, and some ALFs may be able to offer residents increased help with certain medical tasks, such as medication management, insulin administration and blood glucose testing, at an increased cost. However, even facilities that employ licensed/certified nursing staff are not allowed to admit residents who require full-time medical care. If your loved one requires 24/7 skilled care, hiring around-the-clock home health care services or seeking placement in a memory care unit or nursing home is probably a better fit for their needs. -
The Leisure Activities Requirement
Assisted living communities in Georgia require residents to be capable of participating in the social and leisure activities they provide. Obviously, staff members cannot demand that your loved one actually engage in community programs and events, but it’s often advisable to encourage an elder to pursue an active social life when moving to senior living. -
CPR Exemptions
There is a great deal of controversy surrounding the effectiveness and advisability of cardiopulmonary resuscitation (CPR) on elderly and frail individuals. State laws regarding the provision of CPR in certain long-term care settings and mandatory CPR training for staff vary, especially when it comes to facilities that provide no or limited medical services like independent living facilities and ALFs. Some years ago, an independent living facility in California came under intense scrutiny when a nurse refused to give a dying woman CPR.
Individual assisted living facilities may have the option to legally enact “no-CPR” policies in states that permit this. For example, Georgia regulations stipulate that ALF staff members do not have to perform CPR if a resident becomes unresponsive and it is apparent that any effort to revive them would be futile (i.e., their body is stiff, their skin is blue/grey, they are cool to the touch).
When it comes to emergency resuscitation efforts for seniors, the best way to avoid confusion is to encourage your loved one to engage in advance care planning using documents like do-not-resuscitate (DNR) orders, living wills or even physician orders for life-sustaining treatment (POLST). Also, be sure that you fully understand the policies and procedures a particular ALF has regarding CPR and DNR orders.
Of course, state regulations for assisted living and rules at individual facilities vary widely. Furthermore, some of these may not directly affect your loved one or the care they receive. However, being aware of the complex policies that govern assisted living will help you search for senior living, determine which questions to ask when evaluating potential providers, and avoid confusion and problems after a loved one moves in.
Sources: Licensing Assisted Living Residences (216-RICR-40-10-2) (https://rules.sos.ri.gov/regulations/part/216-40-10-2); Ga. Comp. R. & Regs. R. 111-8-63: RULES AND REGULATIONS FOR ASSISTED LIVING COMMUNITIES (http://rules.sos.state.ga.us/gac/111-8-63)