“Assisted living and residential care” is an umbrella term that refers to many types of certified and licensed housing options that include services that are provided to the residents. These licensure categories and their definitions vary by state and include board and care homes, assisted living residences, residential care facilities, adult foster care homes, and many others. Different types of assisted living/residential care provide different levels of service. Board and care homes, for example, provide room and board and limited supportive services and protective oversight. Assisted living residences generally provide a higher level of services and emphasize a philosophy of individual autonomy, choice, privacy, and dignity.
The term supportive housing covers subsidized housing projects that provide or arrange for services and supports, including help with activities of daily livingADLs include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating. , in a residential setting. Residents can arrange for medical and nursing services if they need them. The availability of assisted living/residential care and supportive housing is growing in response to consumer demand and increased public funding for services in such settings (see Chapter 9, Livable Communities, for more information on the housing aspects of supportive housing).
Licensing and regulation of assisted living and residential care occurs at the state level. States use varying terms and definitions. There is no national standard or federal definition of such terms as “assisted living.” Given the enormous variability, consumers may be unsure what to expect in residences advertised as assisted living facilities.
The 2014 Medicaid home- and community-based services (HCBS) settings rule sets minimum requirements for integration, choice and control, privacy, and legal rights in order for the assisted living/residential care provider to be able to provide HCBS paid for by Medicaid, but the majority of assisted living/residential care residents are private pay.
Advocates have raised concerns about the potential consequences of the HCBS setting characteristics as established by Centers for Medicare & Medicaid Services (CMS) that are considered to be institutional in nature and which could affect:
- secured dementia units/neighborhoods within a larger assisted living community or as a freestanding community;
- continuing care retirement community arrangements where assisted living is located on the same campus as independent living and a nursing home;
- assisted living facilities that were built as a separate section of a nursing home or is a converted section of a nursing home; and
- assisted living facilities that are on the same campus or adjacent to a hospital or other health care provider.
While not prohibited by the HCBS rule, such settings could be presumed to have the qualities of an institution unless the state and CMS determine that they are home- and community-based through a process of “heightened scrutiny.”
Facilities vary widely in quality, with the most glaring deficiencies being found in some board and care homes serving mainly Supplemental Security Income (SSI) recipients. These homes sometimes operate without licenses, and efforts to identify and crack down on them are uniformly weak. Even with licensed homes, few states require operators to encourage resident autonomy or privacy. The reimbursement available through SSI, even with state supplementation, is frequently inadequate to meet minimum food, shelter, and service requirements of board and care residents. All in all, inadequate regulation and funding have contributed to chronic problems of poor care, financial exploitation, and abuse and neglect (see Chapter 12, Personal and Legal Rights: Elder Justice).
Assisted Living and Residential Care: Policy
Integration of community-based services
Federal and state governments should support and expand community-based service delivery programs, including programs targeted to residents in federally subsidized housing of certified and licensed assisted living and residential care facilities, provided that these meet standards for community settings.
Federal oversight and support
The federal government should assume a much stronger role in ensuring the quality of care in board and care homes, assisted living residences, and other types of residential care, regardless of payment source.
Federal oversight of Medicaid waivers used for assisted living and other residential care settings should be strengthened.
Federal Trade Commission oversight of advertising and contracting should be enhanced to ensure that sales claims are justified and backed up by contracts.
Federal agencies should develop a common database with information on assessment and outcomes across all care settings.
The federal government, in coordination with states, should conduct surveys of assisted living, board and care, and other residential care facilities to ensure that standards are adequately met. The surveys should include information on resident satisfaction, residents’ involvement in care plans, and outcomes.
The federal government should provide increased funding and authority for long-term services and supports ombudsmen to intervene on behalf of assisted living and residential care residents.
The Social Security Administration should be able to share Supplemental Security Income and Supplemental Security Disability Income information with states, while protecting beneficiaries’ privacy rights, to help identify unlicensed board and care homes.
Uniform definitions and standards of care
Federal agencies should monitor the progress of state efforts in developing common definitions of, and minimum standards for, services and facilities in board and care homes, assisted living residences, and other types of residential care.
Federal definitions and standards should be considered if states do not develop standards that adequately ensure quality and protect consumer rights.
Private right of action
Residents and ombudsmen should have a private right of action to sue operators that are abusive or fail to maintain state or federally established quality standards.
States should set and rigorously enforce mandatory minimum standards and make other efforts to promote quality and ensure quality outcomes for assisted living and residential care residents.
States should ensure that residents have the right to autonomy and privacy and the right to keep personal possessions. Residents or their representatives should have the right to manage personal funds, inspect records of any personal funds the facility manages for them, and meet with advocates and community organizations.
States should empower ombudsmen to have immediate access to all assisted living and residential care facilities, including board and care homes, without advance notice.
Consumer role in developing and assessing care plans
States should require resident assessments and the development of regularly updated individual care plans. Assessments should be valid and reliable, and core items should be uniform across populations.
Residents, their family members, and/or their representatives (as appropriate) should be fully involved in developing and updating care plans.
States should require adequate numbers of appropriately trained staff to ensure a high quality of care.
Required staff training should include:
- behavioral management;
- recognition and handling of dementia;
- handling of medications;
- cultural sensitivity;
- promotion of residents’ independence, dignity, autonomy, and privacy; and
- recognition and reporting of abuse and neglect.
States should require adequate training and careful supervision in statutes or regulations allowing registered nurses to delegate certain nursing tasks to paid direct-care workers. Allowing nurses to train and delegate certain nursing tasks to direct-care workers can ease the burden on family caregivers. The statutes must follow the state’s Nurse Practice Act guidelines for delegation by registered nurses and must provide adequate consumer protections and appropriate liability protections for nurses.
Contracts for assisted living and residential care
States should require that providers of assisted living and residential care have a contract with each resident and that the contract discloses such information as the services provided and their costs, residents’ ability to purchase additional services from outside providers, and the circumstances and conditions that would require the resident to move from the facility.
Coordination of state oversight
Each state should designate a lead agency to coordinate policy, including licensing, monitoring, quality improvement, and enforcement efforts.
Licensing standards and monitoring should reflect residents’ level of disability and the provider’s performance history.
States should require public agencies to ensure that the same social and medical services available to people residing in the community are also available to residents of assisted living and residential care.