Chapter 9

 

Assisted Living:

Information & Resources

 

 

Overview

In general, assisted living is a combination of housing, personal care and some health services. It is intended for people who need help  with activities of daily living (eating, bathing, dressing, getting to and using the bathroom, getting in or out of a bed or chair, and walking), but who do not need round-the-clock nursing care and supervision.

Assisted Living Services usually include:

• Individual apartments.

• Meals served in a common dining area.

• Housekeeping and laundry services.

• Transportation.

• Assistance with activities of daily living. 

• Access to health and medical services.

• Medication management.

• Social and recreational activities.

• 24-hour security.

• Emergency call systems for each resident’s apartment.

There are two kinds of assisted living facilities in Indiana: licensed assisted living facilities and legally unlicensed facilities (not required by the state to be licensed).

Licensed Assisted Living Facilities

These facilities also are called residential care facilities. In these residences, facility staff may administer medications, provide some nursing services, or

do both.

You must check with the individual facility to find out which of the above services are provided.

 

Residential care facilities are licensed by the state of Indiana and must follow a specific set of regulations. The Indiana State Department of Health inspects these facilities once a year to see if they are in compliance with the regulations, and sanctions can be imposed if the facility is violating the requirements. If you have a complaint regarding care or services, you can file the complaint with the Department of Health, and the agency will investigate.

 

Legally Unlicensed Assisted Living Facilities

These facilities generally provide limited assistance with personal care, such as help with dressing and bathing. However, they do not have staff that administer medications or provide nursing services. This means that your loved one cannot receive medication administration or nursing services in this facility or must arrange with a home health agency or other caregiver to deliver these services.

These facilities are not required to be licensed. As a result, there are no regulations or standards that the facility must follow (e.g. how much training a person must have to provide care to a resident), there are no inspections by an outside entity (such as the Indiana State Department of Health), and the only place to turn if you have a complaint may be to the facility itself, to the ombudsman or to Adult Protective Services. (see Chapter 12: Addressing Problems.)

 

One of the best things you can do as a consumer is to obtain a copy of the facility’s Housing With Services Establishment Disclosure form. Both licensed and legally unlicensed assisted living facilities are required by state law to complete this form, which provides information about the facility's services and costs as well as information about ownership. The form allows you to better compare one facility to another.

An assisted living facility must provide potential residents with a copy of the form. If the assisted living facility does not give you the form, make sure to ask for it!

 

For more information about the differences between licensed and unlicensed assisted living residences, see the handout, Assisted Living Residences: Knowing the Difference Between Licensed and Unlicensed Facilities.

Important Points To Consider In Indiana

Because assisted living residences vary so much in Indiana, there is not a standard set of services that these facilities provide. The following are some points to research if you are considering assisted living for a loved one.

 

Standards/Monitoring/Oversight

While there are many good licensed and unlicensed assisted living facilities, think about whether it is important to you that the facility be held to certain established standards and that there be outside oversight and monitoring. If this is important, consider only licensed facilities.

Services

Do not make any assumptions about what will or won’t be provided. Find out exactly what services will be provided. ASK. Check the contract!

 

Below are some of the areas you might want to clarify before signing a contract.

Nursing Services

• Does the facility provide nursing services? If so, are those services provided by a nurse or by a nursing assistant/home health aide? If you learn that services from a nurse are available, find out if the nurse is on-site, and if so, for how many hours a day or per week. Don’t assume that a nurse is there 24 hours a day. Licensed assisted living facilities are required only to have a licensed nurse on call or on the premises if the facility administers medications.

Ask what the role of the nurse is. In some cases, the nurse may just be there to conduct required assessments. It is very important to find out the extent and nature of any services to be provided by a nurse.

• If no nursing services are provided, can those services be brought in? Who makes those arrangements?

Medication administration

• Does the facility provide medication administration (actually giving the medication, not just reminding the resident to take it or handing it to them to take)? If not, can that service be brought in? Who makes those arrangements?

• If facility staff does administer medications, can you use the pharmacy of your choice or order by mail?

Physician services

• Can the resident see the doctor of his or her choice?

• Would you have to arrange for your loved one to get to the doctor’s office?

• Does the residence provide transportation to doctor's appointments?

Meals

• Are meals available 7 days a week?

• How many meals are offered per day?

• Can residents eat only at designated times?

• Are special diets available?

• Do residents get a credit for meals not eaten?

• Can residents have a tray in their apartment whenever they want or only when they are sick? Is there an extra charge for trays brought to their unit?

Transportation

• Does the facility actually provide transportation or just arrange it?

• If the facility provides it:

  
  

• Where can residents be taken (just to medical appointments or on social outings or shopping too)? How far can residents be driven?

• Is there a charge for the transportation?

• How often is transportation provided (every day, three times a week, etc.)?

• Are vehicles equipped to accommodate residents with disabilities? Is the van wheelchair-accessible?

  
  

• Can residents have their own vehicles? Is there a parking fee for a car?

Housekeeping

• Does housekeeping include only light dusting and vacuuming or does it also include cleaning the bathroom and floors and emptying the trash?

• How frequent is the cleaning?

• If only light housekeeping is done, is there an extra charge for heavy cleaning?

Laundry

• Are bed linens and towels provided? Does the residence launder these items? If so, how often? Is this service included in the monthly fee?

• Is personal laundry done? Is that service included in the monthly fee? Can residents/families do the laundry if they wish?

Levels of Care

• Are different levels of care provided in the facility? If so, what are the levels of care and what services are included in each level?

• Is level of care linked to cost? Many assisted living residences have formulas for determining how much care an individual needs, and costs can go up when the level of care changes. (See Chapter 5: The Costs of Long Term Care and Paying for Services.)

• What kind of assessment of the resident is conducted? How often are assessments done?

• Who decides when a resident’s care needs change and another level of care is required? Can the decision be appealed if the resident or family disagrees with the decision?

• Can residents bring in home health agency staff or hire their own aides/personal attendants to help if their care needs increase and the facility staff can’t provide that level of care?

• Do residents have to change units or move if their needs increase?

• What are the guidelines about incontienence and care at the facility?

Service Plan/Plan Of Care

• Who develops the plan?

• Is involvement by residents and family encouraged and sought after?

• How often is the plan reviewed?

Staff

• What kind of training does staff have?

• What are the credentials of the staff who provide personal care? ? Note that even in licensed residential care facilities, staff that assist residents with personal care generally don’t have to be certified nursing assistants or home health aides; they just have to be “qualified” according to what the assisted living residence feels “qualified” means.

• Is there an on-site staff member trained and certified in life-saving techniques for heart attack and choking 24 hours a day, 7 days a week?

• Is there over-night awake staff? What are their credentials?

• What is the ratio of nursing staff to residents during the day, evening, and night?

Dementia Care

• Is there a special unit, wing or building for residents with dementia? If so, what makes it different from the rest of the facility?

• Is there special training for staff who care for residents with dementia?

• Are there special activities for residents with dementia?

• What measures are taken to prevent residents who wander from leaving the residence or unit unsupervised?

• Under what circumstances might a resident with dementia be asked or required to leave this unit?

If the residence states it has a dementia care unit, it must complete a Alzheimer's/Dementia Special Care Unit Disclosure form. This form provides information about the unit, such as staffing levels, staff training, and admissions/discharge criteria. Ask the residence to give you a copy.

Building Safety

• Does each apartment have its own sprinkler system?

• Are there hard-wired smoke detectors in each apartment?

Fees/Pricing

The way fees are calculated varies enormously from one facility to another. Use the Housing with Services Disclosure Form to help you in trying to compare “apples to apples.”

Examples of different pricing systems include:

• A flat or bundled rate. In this system, the facility estimates the average amount of care residents will need. Everyone pays the same for personal care services that are folded into the basic rent for the living unit.

• A tiered rate. A facility may offer different levels of care at different rates. The facility assesses the resident and determines what level he or she needs. The resident then pays for the cost of care at that level, even if he or she doesn’t need all the care that comes with that level.

• A flat rate plus charges per service. This is a menu-like approach where the resident pays a flat rate that includes certain set features and then pays per additional service needed. For instance, a resident might pay for help getting dressed every time that service is provided.

Other questions you should ask are:

• What is included in the rates? For instance, are utilities included (telephone, cable, water, gas, electricity)? Are maintenance and repair fees included?

• Under what conditions can monthly payments be increased? How much notice will be given?

• What happens if the resident goes to the hospital? Is payment still due? Will the bed be held? If so, what is the cost?

• Does the facility accept Medicaid? If not, will the resident have to move if he or she becomes a Medicaid recipient?

Transfer/Discharge

Do not assume that once a resident has moved into the facility, he or she can automatically “age in place” and never have to move again. In fact, that is rarely the case. The average length of stay for a resident was only 28.3 months in 2009.* If a resident in a licensed facility does not agree with the decison to be transferred, they have the right to appeal to the Indiana State Board of Health.

*National Center for Assisted Living

Ask:

• What are the criteria for transferring or discharging the resident to another facility? Under what circumstances would a resident be forced to leave?

• How much notice will be given?

• What if the resident or family disagrees with the decision?

• Will the assisted living residence staff help your loved one find another place to live?

Contract

Review the contract to see what it specifically requires the facility to do. Since legally unlicensed assisted living residences do not have to follow state requirements, the contract becomes very important because a facility can be held only to what the contract says. Make sure you understand the contract. Consider having the contract reviewed by an attorney before it is signed.

Regulation

 

Residential care facilities

As noted above, only assisted living residences that are residential care facilities are licensed and required to follow state regulations. You can access these regulations by clicking here.

 

Medicaid Waiver Providers

Some assisted living facilities are “Medicaid Waiver Providers.” This means that the facility can provide care and services to a certain number of residents who are on Medicaid and need nursing home level of care. Assisted living facilities that are Medicaid Waiver Providers must be licensed residential care facilities and must also apply the “Assisted Living Medicaid Waiver” rules to any resident whose stay is funded through a Waiver. To read those regulations, go to: FSSA Assisted Living Provider Application Packet.

Unlicensed assisted living residences

Although there are no regulations for non-licensed facilities, the contract/agreement outlines the assisted living residence’s obligations. Reading the contract will tell you what you can expect from the facility. State law requires that any facility using the term “ assisted living” to describe itself must provide certain information in the resident contract/agreement. This information includes:

• A description of the services to be included in the base rate and those available at an additional cost.

• Conditions for transfer/discharge from the residence.

• A description of how the resident will be assessed to determine his or her needs.

• Billing and payment requirements.

To learn more about what the contract must contain, go to:

Housing with Services Establishment contracts.

Rights

Residents in assisted living residences that are licensed as residential care facilities have rights under state regulations. You can learn what those rights are by going to: Residents' Rights.

Residents in assisted living facilities that are also Medicaid Waiver providers have an extra set of rights that include the right to have control over their time, space and lifestyle as long as it doesn’t disturb other residents, and the right to exercise decision making to the fullest extent possible.

 

Even though there are no regulations and therefore no residents’ rights regulations for unlicensed assisted living residences, state law gives residents a number of rights. These rights must be posted in the residence. They include:

• The right to receive a complete copy of your contract with the assisted living community.

• The right to be transferred/discharged from the residence only for the reasons stated in the contract.

• The right to participate in activities away from the community, regardless of the time, duration and distance of the activities.

• The right to have visitors and to receive family members and guests (restrictions may be applied to protect the rights of other residents).

Check the contract to see what additional rights your loved one may have.

Listing of Facilities

Assisted Living Facilities In Central Indiana

Call CICOA’s Aging & Disability Resource Center at 317-254-3660 to request a copy of a Assisted Living Facilities in Central Indiana booklet. This list both licensed and unlicensed facilities in Marion and the seven surrounding counties, including Medicaid Waiver providers.

Assisted living facilities by Area Agency on Aging and County
www.in.gov/fssa/da/3453.htm

This interactive map not only lists Assisted Living facilities by county and Area Agency on Aging service area, but also lists many other services that are available in each area.

Checklists and Guides for Choosing an Assisted Living Residence

Finding an Assisted Living Facility

Link to Met Life publication: Choosing an Assisted Living Facility
Includes an assisted living checklist and “cost calculator.”

 

Assisted Living Checklist

A checklist provided on the Aging Parents & Eldercare, a web site published by Senior Solutions of America, Inc.

 

Thinking of Moving to an Assisted Living Residence?

A guidebook published by the New York Nursing Home Coalition.

 

Comparing Assisted Living Residences

The Indiana State Department of Health offers a “Residential Consumer Report” to help consumers evaluate and compare licensed residential care facilities.

You can access the site by going to: http://www.in.gov/isdh/reports/QAMIS/resrpt/index.htm

The report contains:

• A profile of the facility that includes the name of the administrator, the name and address of the entity that holds the license, the number of beds, and more.

• Information about the facility’s past three annual inspections (surveys).

• Information about the number of complaints that have been substantiated.

These reports currently are for licensed residential care facilities that are free-standing (not part of a nursing home) only. You never should select a residential care facility solely based on a review of this report. It is very important to visit the residence yourself with your loved one, if possible, and to consult with medical/health care professionals, the long term care ombudsman, elder law attorneys, care managers and others familiar with these facilities.

Costs and Payments

(See Chapter 5 for more detailed information)

Payment

Assisted living can be paid for by:

1. Medicaid Waiver

Medicaid Waiver covers only services and does not pay for room and board.

2. Long Term Care Insurance

3. Veterans Aid and Attendance Benefit

 

4. Private pay

 

Getting Good Care For a Loved One

In addition to the information provided in Chapter 6: Getting Good Care, here are some additional steps should take when considering assisted living facilities.

Contracts and agreements are key to knowing the responsibilities of the assisted living facility and the rights of residents. Read them carefully and ask for more written information if you need it.

If your loved one’s care is paid for through a Medicaid Waiver, familiarize yourself with the Assisted Living Medicaid Waiver rules.

 

Participate in the development of the service/care plan.

 

In licensed residential care facilities, the service plan is created or reviewed after an evaluation of the resident. Evaluations must be conducted at least twice a year, upon a major change in the resident’s condition, or when requested by your loved one or you.

• If your loved one’s care is funded through Medicaid Waiver or CHOICE , the care plan will be reviewed every 90 days or when the services your loved one needs or wants change.

In unlicensed residences, assistance with personal care and medication management is often provided by a home health care agency. The agency will develop a care plan for your loved one. How often the plan is reviewed will depend on the type of care your loved one is receiving.

If your loved one is in an unlicensed residence, it is a good idea to get input from assisted living staff who see your loved one on a daily basis and can tell you if they have observed any changes or increased needs. You can then share that information with home health agency staff or any private caregivers to help in creating or revising the care plan. You will also want to make sure there is good communication between the home health agency staff/private caregivers and the assisted living residence staff.

Regardless of the type of assisted living setting, your loved one or you on your loved one’s behalf can request a service/care plan review at any time.

 

Visit as often as you can.

In addition to adding pleasure to your loved one’s day, visiting gives you an opportunity to see for yourself how he or she is doing and to send a message to staff that someone is overseeing the care.

Also, try to vary the times you visit and include evenings, weekends, and mealtimes if at all possible.

 

Monitor medication assistance or administration for your loved one.

• Ask staff to keep you informed of any issues or problems they observe if your loved one administers his or her own medications or that they experience in administering medications to him or her.

• Keep staff up-to-date on all medications your loved one is taking, including over–the-counter drugs, vitamins, and herbal supplements.

• Share any negative side effects you observe with staff and your loved one’s doctor.

For additional information about medication in assisted living facilities read Taking Medication on the ACLA web site.

 

Addressing Problems

Listed below are some approaches specific to assisted living facilities that you can take to address a problem. Be sure to read Chapter 12 for a comprehensive approach to addressing problems in all long term care settings.

 

If possible, check with your loved one to make sure he or she wants action to be taken—remember your loved one has to live in the residence 24 hours a day. In addition, try to involve your loved one as much as possible in problem resolution.

 

Fair Housing and reasonable accommodations

 

Depending on the circumstances, you may be able to use the Fair Housing Act to avoid the transfer/discharge of your loved one. The Fair Housing Act applies to people with disabilities, and this definition includes residents of assisted living residences.

 

Under The Fair Housing Act, a person with a disability is entitled to:

• “reasonable accommodation:” a change, exception, or adjustment to a rule, policy, practice, or service of a facility;
  
  or

• “reasonable modification:” a structural change to the premises of a facility if such a change would allow the person to continue to live in the residence or to better enjoy his or her living situation.

Sometimes just mentioning the Fair Housing Act to the head of the assisted living residence or writing a letter requesting “reasonable accommodation” or “modification” is enough to stop an eviction. You can access a sample letter by clicking here: "Request for Reasonable Accommodation/ Modification Letter."

 

For additional help with transfers/discharges, contact the long term care ombudsman

 

 

Resources

Resident’s Guide for Assisted Living

A publication of The Long Term Care Community Coalition, New York.

Assisted Living Consumer Alliance

www.assistedlivingconsumers.org

Consumer Consortium on Assisted Living(CCAL)

www.ccal.org

Center for Excellence in Assisted Living

www.theceal.org/clearinghouse