[Senate Hearing 108-85]
[From the U.S. Government Printing Office]



                                                         S. Hrg. 108-85
 
                            ASSISTED LIVING:
          EXAMINING THE ASSISTED LIVING WORKGROUP FINAL REPORT

=======================================================================

                                HEARING

                               before the

                       SPECIAL COMMITTEE ON AGING
                          UNITED STATES SENATE

                      ONE HUNDRED EIGHTH CONGRESS

                             FIRST SESSION

                               __________

                             WASHINGTON, DC

                               __________

                             APRIL 29, 2003

                               __________

                            Serial No. 108-8

         Printed for the use of the Special Committee on Aging




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                            WASHINGTON : 2003
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                       SPECIAL COMMITTEE ON AGING

                      LARRY CRAIG, Idaho, Chairman
RICHARD SHELBY, Alabama              JOHN B. BREAUX, Louisiana, Ranking 
SUSAN COLLINS, Maine                     Member
MIKE ENZI, Wyoming                   HARRY REID, Nevada
GORDON SMITH, Oregon                 HERB KOHL, Wisconsin
JAMES M. TALENT, Missouri            JAMES M. JEFFORDS, Vermont
PETER G. FITZGERALD, Illinois        RUSSELL D. FEINGOLD, Wisconsin
ORRIN G. HATCH, Utah                 RON WYDEN, Oregon
ELIZABETH DOLE, North Carolina       BLANCHE L. LINCOLN, Arkansas
TED STEVENS, Alaska                  EVAN BAYH, Indiana
RICK SANTORUM, Pennsylvania          THOMAS R. CARPER, Delaware
                                     DEBBIE STABENOW, Michigan
                      Lupe Wissel, Staff Director
             Michelle Easton, Ranking Member Staff Director

                                  (ii)




                            C O N T E N T S

                              ----------                              
                                                                   Page
Opening Statement of Senator Larry E. Craig......................     1
Opening Statement of Senator John Breaux.........................     2
Statement of Senator Ron Wyden...................................    12

                           Panel of Witnesses

Stephen McConnell, Vice President for Advocacy and Public Policy, 
  Alzheimer's Association, Washington, DC........................     4
Dan B. Madsen, President and Chief Executive Officer, Leisure 
  Care, Inc., Bellevue, WA, on behalf of the American Seniors 
  Housing Association............................................    13
Robert L. Mollica, Senior Program Director, National Academy for 
  State Health Policy, Portland, ME..............................    26

                                APPENDIX

Statement submitted on behalf of the AARP........................    49
Statement from the American Association of Homes and Services for 
  the Aging......................................................    53
Letter and additional material submitted by the National Senior 
  Citizens Law Center............................................    58
Statement of Bill Southerland, President, Idaho Assisted Living 
  Association....................................................    74
Statement of Tom Grape, Chairman Assisted Living Federation of 
  America........................................................    77
Additional Material submitted on behalf of the Assisted Living 
  Workgroup......................................................   109

                                 (iii)





 ASSISTED LIVING: EXAMINING THE ASSISTED LIVING WORKGROUP FINAL REPORT

                              ----------                              


                        TUESDAY, APRIL 29, 2003

                                       U.S. Senate,
                                Special Committee on Aging,
                                                    Washington, DC.
    The committee convened, pursuant to notice, at 10:02 a.m., 
in room SD-628, Dirksen Senate Office Building, Hon. Larry 
Craig (chairman of the committee) presiding.
    Present: Senators Craig, Breaux, and Wyden.

       OPENING STATEMENT OF SENATOR LARRY CRAIG, CHAIRMAN

    The Chairman. Good morning, everyone. Let me convene the 
Senate Special Committee on Aging. Thank you for attending this 
hearing this morning.
    Two years ago, this committee held a hearing to gain a 
better understanding of the emerging industry of assisted 
living. We learned that there are over 30,000 assisted living 
facilities nationwide, housing nearly one million people, and 
that such facilities are not regulated at the Federal level. 
Instead, individual States are responsible for oversight and 
are free to govern without Federal mandates.
    However, we have seen a great disparity of care given by 
assisted living facilities around the country. These facilities 
in some States are exemplary in providing appropriate quality 
care for their residents, while in other States, such 
facilities are clearly handling more than they are probably 
capable of doing.
    Because of the need for uniform guidance in rendering 
appropriate and competent care, the Special Committee on Aging 
charged consumers and industry groups within the assisted 
living community to come together and develop recommendations 
designed to provide uniform models of best practices to ensure 
more consistent quality in assisted living facilities 
nationwide and to provide consumers with sufficient and useful 
information.
    In the fall of 2001, the Assisted Living Workgroup, known 
as ALW, was formed with nearly 50 member organizations 
representing providers, consumers, long-term care 
professionals, regulators, and accrediting bodies. Our primary 
directive for this group was to be inclusive and our 
expectation was that model rules for assisted living care would 
be achieved. We have discovered difficulty.
    The committee recognizes that a great deal of time and 
monumental effort went into the final product. We appreciate 
that each recommendation was clearly put through a thoughtful, 
thorough process with the welcoming of divergent views. We 
commend the ALW on its effort to provide a comprehensive list 
of recommendations for assisted living facilities. We also 
appreciate the effort to bring about consensus and hope this 
product will be helpful to consumers and the industry alike.
    Having said that, I feel much more needs to be done. This 
report does not present a uniform set of model rules and 
regulations for the rendering of health care services in the 
assisted living context. However, it demonstrates the diversity 
of opinion and what needs to be done. Accordingly, it is a most 
important and valuable step in the further study of this 
important quest for uniform guidance.
    Today, we plan to examine the Assisted Living Workgroup 
final report and focus on the process in which the report was 
developed, the benefits and the shortfalls of the report, and 
how the report can best be used in the future. We will be 
hearing from industry and consumer groups that were involved 
within the ALW.
    Our first witness is Stephen McConnell, a Vice President of 
Advocacy and Public Policy with the Alzheimer's Association.
    Our next witness is Dan Madsen, President and CEO of 
Leisure Care, Inc., a member of the American Seniors Housing 
Association. Both of these witnesses are members of ALW and 
were involved in developing the report.
    We will also hear from an outside expert observer who was 
not involved in the ALW. We hope he can provide us with an 
objective opinion of the report. Bob Mollica is a Senior 
Program Director for the National Academy for State Health 
Policy.
    Before I turn to our witnesses, let me turn to my 
colleague, the ranking member here on the committee, Senator 
John Breaux of Louisiana. John.

            OPENING STATEMENT OF SENATOR JOHN BREAUX

    Senator Breaux. Thank you very much, Mr. Chairman. Welcome 
back. We have a great deal to do and we are delighted to have 
this hearing today.
    It was back in August 1999, as you stated, that the Aging 
Committee asked the assisted living community to do something 
that had never been asked for before in the area of health 
care, and that is to come up with recommendations themselves as 
to how quality health care can be guaranteed in the assisted 
living area.
    What they have come up with, indeed, is a lot more than 
many of us actually expected. It is over 380 pages of really 
substantive recommendations and discussions about how the 
entire area of health care and our assisted living facilities 
are going to be managed and handled. Indeed, I think that the 
given length and the substance and the time that went into this 
report all of the people who have been involved in this process 
are to be commended. They did a terrific job.
    We were not necessarily, when we made the request, seeking 
some type of a unanimous recommendation, knowing that that was 
not going to be possible the way it was structured, but to try 
and come up with something that could pass at least a two-
thirds recommendation, and that is what we have today. There is 
a lot of substance in this report. Each one of the votes that 
were taken really were taken with a sense of trying to find out 
the best recommendation that could possibly be put together.
    I said this was a unique and a new way of doing business. 
Most times, the Federal Government just says, all right, here 
are the regulations, go follow them, and we dictate from 
Washington. As a result, in some programs like Medicare, we 
have 133,000 pages of rules and recommendations, three times 
more than the Internal Revenue Code.
    This was unique in the sense that we said, ``All right, we 
want the people who are involved in running the facilities to 
sit down with those people who utilize the facilities,'' and we 
involved different organizations and groups that represent the 
various interests of assisted living facilities. So for the 
first time, we actually have those who own and run the 
facilities talking with those who utilize the facilities. I 
think this process was very, very unique. It was different from 
what we had done in the past, and hopefully this could be sort 
of an imprimatur type of process for how we ought to consider 
doing things in the future when we bring various groups 
together to create health care policy.
    As the chairman has pointed out, the regulations dealing 
with assisted living facilities are almost entirely State 
regulations. There are huge differences in the type of rules 
and regulations. It is hard to know what the rules are until 
you get out a geography map and figure out what they are. That 
is obviously not the right way to set up rules and standards, 
by a geography book, but rather by what is best for the people 
who utilize the services.
    In my own State of Louisiana, I think the type of 
recommendations developed by the ALW could be helpful and 
important towards developing some type of basic rules and 
regulations on a State level.
    There are a few organizations, I think, that need to be 
mentioned. There were some 13 organizations who acted as the 
steering committee and they are to be thanked for their time 
and their effort and their commitment. This was not an easy 
task. If it had been easy, we would not have had to do it.
    The Consumer Consortium on Assisted Living and the American 
Association of Homes and Services, deserve a nod for their work 
as co-chairs of the working group and the latter group for 
hosting the meetings and coordinating the workgroup website 
which is now in place.
    Additionally, the National Center for Assisted Living 
provided the resources, which we thank them for, for the 
creation of this written product. Indeed, a thank you to 
everyone who served on the panels.
    This is not the end of the process. I think it is rather 
the beginning of the process. But now we have some documents 
that have substance behind them. They have clarity and they 
have support from both the users and the providers, which I 
think is what is so unique. This is not a dictate from 
Washington but rather a recommendation from the people who are 
truly to be affected by what happens. So we thank them very 
much for their performance. It was a job very well done. Thank 
you.
    The Chairman. John, thank you for that comprehensive 
statement. As both Senator Breaux and I know, the difference 
between a rural community in Louisiana and Idaho, where there 
may be a facility that houses four, or five, or six, versus a 
large urban setting are a world apart often. While we believe 
that consistent and high-quality care needs to be delivered in 
both settings, at the same time, we recognize clearly the 
difference.
    With the witnesses we have today and the work that our 
staff will do in reviewing this, I have already contemplated 
with my staff the possibility, Senator, of doing a white paper 
to put on top of this for the public and for the professional 
provider community as a whole to consume in an effort at the 
State levels, I would hope, to continue to work to build this 
kind of consistency, and I thank you for recognizing those who 
were largely responsible for keeping the group together and 
causing it to function.
    So now if we would ask our witnesses to come forward, I 
want to thank them again for their time this morning. Stephen 
McConnell, Vice President for Advocacy and Public Policy, 
Alzheimer's Association of Washington, DC. Stephen, we will let 
you start. Thank you, Stephen.

STATEMENT OF STEPHEN McCONNELL, VICE PRESIDENT FOR ADVOCACY AND 
     PUBLIC POLICY, ALZHEIMER'S ASSOCIATION, WASHINGTON, DC

    Mr. McConnell. Mr. Chairman, Senator Breaux, thank you for 
inviting the Alzheimer's Association to testify this morning. 
Thank you especially for shining a light on this very important 
issue.
    I am humbled by the invitation and hope I don't humiliate 
myself here today. There are many knowledgeable people, as both 
of you have pointed out, that have been involved in this 
process. Many of them are in the room behind me, and it is 
important that we acknowledge them, as you have.
    Perhaps we are testifying because the majority of people 
within assisted living facilities have some form of dementia. 
Perhaps we are testifying because we were among the more 
moderate views in the group. Perhaps we are testifying because 
our organization's name begins with the first letter of the 
alphabet. [Laughter.]
    But nonetheless, we are very pleased to be here.
    We are not any more right on this issue than any of the 
other stakeholders that were involved in the process and that 
is perhaps the essence of the success and the failures of this 
undertaking.
    I would like to make four points. First, to ask a question, 
did the process succeed? More specifically, did it create a 
single definition? No. Did it achieve consensus on all the 
recommendations? No. Did it develop an exact blueprint for the 
States and the Federal Government? No. Did it answer all the 
right questions? No. But was it an honest process? Was it a 
good faith effort by all the organizations involved? That is an 
unqualified yes. Does it produce useful recommendations that 
address many of the key issues? It does. Is it a good resource 
document to guide States and the Federal Government as they 
move forward? Yes. Will it inch us forward toward better care? 
We believe it will.
    In some ways, this document is a bit like Los Angeles. If 
you try to relate to it as a whole, it is impossible, full of 
contradictions. But if you connect to the individual 
communities, the individual recommendations, there is a lot 
there and it makes much more sense.
    Perhaps this document is the best that could be achieved 
given that there wasn't a specific legislative outcome tied to 
it. All the groups needed to put forward their best thinking, 
as they did. Many of the groups helped to improve 
recommendations to the very end, even though in the end, they 
might have voted against one or more of these recommendations. 
But in the end, legislators must make the tough decisions, make 
the call. Making the final call was very difficult for a group 
process like this.
    The second major point is that there are differences among 
the groups as a result of different experiences and data, not 
unlike what you just pointed out, Mr. Chairman, about the 
differences between facilities in Idaho and California. There 
are differences in philosophies about how to approach care and 
there are different views about solutions.
    Our philosophy in this process followed six basic 
principles: (1) that care is a partnership between the resident 
and the provider; (2) that assisted living residents are 
diverse and a single set of prescribed services won't work; (3) 
preferences of individuals are important and flexibility is 
essential; (4) dignity, independence, and choice are important 
and assisted living should ensure these; (5) essentials must be 
provided and States should mandate these, for example, basic 
safety. Finally, even small steps forward are better than 
holding out for the perfect.
    The third major point I would like to make is that the 
process and the final product would improve care for people 
with dementia, which by some estimates could be as many as 40 
to 60 percent of the people in assisted living.
    I would draw your attention to just a couple of the things 
that are included in this report related to dementia. First, is 
that all staff have to be trained to recognize the signs and 
symptoms of dementia. This is pretty basic, but that awareness 
is not the case in many assisted living facilities, many 
hospitals, or many other settings where people with dementia 
reside. Second, the care plans must be adapted for residents 
with dementia to account for their cognitive impairments. 
Third, the direct care staff should receive training about 
dementia. Fourth, individualized activities should match the 
residents' abilities and interests. Finally, the residents 
should be protected from danger, especially unsafe wandering.
    Did we get all we wanted? No. We wanted specific numbers of 
hours for training and a variety of other things. But the key 
is that the dementia provisions would apply to all facilities, 
not just those that say they provide special care for people 
with dementia. This is a very important step forward. According 
to a University of North Carolina study in 1997 and 1998, 68 to 
89 percent of people with dementia in assisted living are not 
in special care units. So it is important that we ensure good 
care for people with dementia even though the facility doesn't 
hold itself out as providing special care. That is perhaps one 
of the most important recommendations in this report.
    The fourth and final point is that the key focus of the 
debate is really at the State level. Most States are examining 
or reexamining this issue. The key stakeholders, including the 
Alzheimer's Association and all the groups involved, need to 
get involved in the State legislative and regulatory process. 
The Alzheimer's Association will distribute this report to our 
advocates at the State level and work with them to ensure that 
as many of these recommendations as possible are implemented.
    Finally, I would encourage the Federal Government to play 
an ongoing oversight role, to continue to fund research so we 
understand outcomes better and we don't have to have as many 
regulations that are based on process, but more on the outcomes 
we are seeking. Finally, to help ensure access to assisted 
living for people who can't now afford it.
    I don't want to trivialize this process, Mr. Chairman, but 
I think of it as a bit like Goldilocks and the Three Bears. The 
porridge was too hot or too cold, and even when it was just 
right, after all, it was only porridge, and in the end, 
Goldilocks was damn lucky to get out of there alive, but----
[Laughter.]
    I think that is the way I will hope for it today. 
[Laughter.]
    Thank you again for shining a light on this very important 
issue. We look forward to working with you in the future.
    The Chairman. Stephen, I find it ironic that there are 
three people sitting up here at the dais at this moment. I 
don't know whether we are black bears, brown bears, or 
grizzlies. [Laughter.]
    We are not Goldilocks, probably. [Laughter.]
    [The prepared statement of Mr. McConnell follows:]
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    The Chairman. Dan, before I turn to you, let me turn to my 
colleague from Oregon who has joined us, Senator Ron Wyden, who 
has spent both his private and his public career working on 
behalf of our elderly and who comes from a State with probably 
a very clear set of regulations as it relates to assisted 
living.

             OPENING STATEMENT OF SENATOR RON WYDEN

    Senator Wyden. Thank you, Mr. Chairman. I will be brief, 
and I am pro-Goldilocks. [Laughter.]
    The Chairman. Well, I am not anti-Goldilocks. She was a bit 
naive, that is all.
    Senator Wyden. We'll build a bipartisan consensus from 
there.
    I think that it is important to remember the origins of 
this whole exercise. Then-Chairman Grassley and Senator Breaux 
and I began this effort and commissioned the government 
auditors to look at these issues. A host of discussions began 
from that report. As we said, given the demographic tsunami 
that is coming, with millions of baby boomers retiring in 2010 
and 2011, we want to do this job right. The real challenge is 
to learn from the nursing home experience.
    I was Co-Director of the Gray Panthers for about 7 years 
before I was elected to the House and specialized in these 
issues then. When this committee began examining assisted 
living I think our sense was that there were a lot of things 
you would have done differently for nursing home patients if 
you could go back and look at the nursing home experience. So 
we wanted to hear from that experience we thought then that the 
challenge for assisted living issues was to see if we can find 
common ground between consumer groups and industry groups, and 
clearly, we have made progress in a number of areas. Clearly, 
we still have a fair amount of work to do, as well.
    I think the principal concern that I have today is we have 
got a number of States that are doing a good job and we want to 
ensure that that progress goes forward. Second, we have got to 
have a safety net to ensure that every vulnerable older person 
in this country in every assisted living facility has certain 
basic protections, because they continue to be some of the most 
vulnerable people in our society.
    Beyond that, I think the challenge is going to be to get 
consumer groups to say that they are willing to meet the 
industry halfway on some things that are important to them the 
industry, then has to reach out to consumer groups on some of 
the issues that are still in contention, too.
    But we are on our way to putting in place a Federal-State, 
public and private long-term care partnership in this country 
with assisted living playing a key role. So if you all and the 
others who are involved in this exercise continue to work with 
this committee under Chairman Craig and Senator Breaux, and I 
am sort of a junior partner on these initiatives, but if you 
continue to work with us as you have in the past, I think we 
can set in place that kind of framework that allows older 
people in this extraordinarily fast-growing sector of senior 
health care to get the protections and the services they need 
while at the same time ensuring that we have the kinds of 
facilities and the number of facilities that we are going to 
need giving this demographic explosion which awaits us.
    I thank you, Mr. Chairman, and appreciate the good work of 
both you and Senator Breaux in this.
    The Chairman. Ron, thank you very much.
    Now, let us turn to Dan Madsen, President and CEO of 
Leisure Care, Inc., from Bellevue, WA, who in another life 
spent time in Idaho.
    Mr. Madsen. Yes, a lot of my life.
    The Chairman. For those of you who are here who are 
wondering why you are here, as Stephen had mentioned, my staff 
said that the spectrum of, and I think Senator Breaux mentioned 
that and certainly Ron Wyden understand that, if you were to 
graph you all, it would be a bit of a bell-shaped curve. You 
fall somewhere in the center of the bell, and I mean that 
reflective of probably the collective interests, but maybe not 
the extremes of the curve, but we think the report because of 
its process is reflective of that broader spectrum.
    Dan, please proceed.

   STATEMENT OF DAN B. MADSEN, PRESIDENT AND CHIEF EXECUTIVE 
OFFICER, LEISURE CARE, INC., BELLEVUE, WASHINGTON, ON BEHALF OF 
            THE AMERICAN SENIORS HOUSING ASSOCIATION

    Mr. Madsen. Good morning, Chairman Craig, Senator Breaux, 
and Senator Wyden. As mentioned, my name is Dan Madsen. I am 
the President and Chief Executive Officer of Leisure Care. We 
are located in Bellevue, WA, near Seattle. We operate 33 
retirement communities in nine Western States. We serve 
approximately 5,000 residents and their families.
    I am here today on behalf of the American Seniors Housing 
Association and representing over 250 companies involving 
management, ownership, financing, and development of senior 
services in housing. ASHA's members currently serve over 
500,000 seniors nationwide.
    We are proud to have been asked by the committee to 
participate in the Assisted Living Workgroup, the topic we are 
here to discuss today. I am proud to have been selected by ASHA 
to represent them and am very honored to be here today.
    The most positive aspect of ALW has been the opportunity 
and the interaction, as mentioned by everyone, between the 
organizations, people from all ends of the spectrum. The spirit 
of consensus and coalition building that produced this report 
will help policymakers at the State level understand what 
issues are important when they examine their current regulatory 
systems in assisted living.
    ASHA and its members are very committed to improving 
quality in assisted living residences nationwide and believe 
that ALW's report will be helpful to consumers, operators, and 
State policymakers in promoting quality of assisted living. In 
the end, ASHA supports more than 100 of the 127 recommendations 
included in the report. As mentioned previously, did we agree 
with all the recommendations? Of course not. On rare occasions, 
ASHA felt that certain recommendations would not have had an 
impact on quality or would dramatically have altered the way 
assisted living services are provided.
    We also carefully took into account the effect that some 
recommendations would have on accessibility of assisted living 
to low- and moderate-income individuals. We also voted against 
some recommendations because we simply didn't feel that they 
were consistent with ASHA's members' belief in the vital issues 
related to quality.
    For example, ASHA opposed language requiring assisted 
living operators to offer only private single-occupancy 
apartments. Many of ASHA's members offer shared room 
environments for residents, and requiring operators to offer 
only private apartments would significantly limit the 
accessibility for assisted living in moderate- and lower-income 
individuals. It would undermine consumer choice, as well, and 
affordability, and it has very little impact on quality.
    The Assisted Living Workgroup didn't operate in a vacuum. 
Since 2001, as Senator Breaux mentioned, 47 of the 50 States 
and the District of Columbia have made significant changes, as 
our exhibit shows, in the regulation of assisted living. These 
updates allowed assisted living operators to adapt and innovate 
while providing meaningful oversight of an industry caring for 
a population whose average resident is over the age of 80.
    The presence of State regulators at the ALW was a 
significant benefit. We hope that as States continue to monitor 
laws and the regulations, they will continue to implement a 
process that involves a wide variety of stakeholders to offer 
input, like the committee has done with the ALW.
    Assisted living residents and their family members are best 
served by State and local-based regulations that can truly meet 
the unique needs of the residents and the culture of the State, 
and this is vitally important because the culture of each State 
is different.
    Leisure Care operates in nine States, and while the core of 
what is required is very similar in those States, it is the 
variation of assisted living between States that allows the 
assisted living to be able to best meet the needs of those 
residents. An example of such variation would be the staffing 
patterns in those States.
    We recently, through our resident opinion surveys, made 
some significant changes in the way we operate on weekends. 
That was well accepted in our area in Los Angeles, scheduling 
more activities on Saturdays and Sundays and beefing up, so to 
speak, how we operated on those days. At our communities in 
Idaho Falls, ID, the residents came out against some of those 
initiatives and said we would like to see less staff on Sundays 
and have them home with their families where they should be and 
we would like that day in peace, as well. There is a perfect 
example of how regional preferences may dictate how we operate.
    We urge this committee to examine one item that is not 
covered in the Assisted Living Workgroup report and that was 
the cost of financing needed in long-term care services. Most 
Americans are woefully unprepared financially when they require 
assistance with activities of everyday life. We encourage this 
committee to continue to efforts to educate the American people 
on this pressing need.
    We are also pleased that President Bush supports similar 
proposals. In fact, Leisure Care, as a company, offers long-
term care insurance free of charge to all 2,000-plus of its 
employees. We make that accessible to their families, their 
immediate families, and their in-laws, as well.
    ASHA does not view today as an end to the ALW process. We 
will make the ALW report available to every one of our members 
and encourage them to use it when evaluating their own 
operations. I would venture to say that a great deal of those 
providers are already using the recommendations and putting 
them in place in their operations. Where they can make changes 
to improve quality, ASHA members should do so with or without 
regulation because it is the right thing to do. Our best 
regulators, after all, are our residents and our families.
    An example would be the recommendation to require assisted 
living operators to allow their residents to form resident 
councils. This is a practice that we have done for over 27 
years in our company and we strongly encourage residents to be 
involved in how their community operates. The ability of 
residents to meet independently allows them greater flexibility 
in the community operations. It definitely improves quality and 
resident choice and autonomy at the same time. When I go to 
communities and I have to meet with resident councils and I 
have to meet with groups of hundreds of residents, believe me, 
I am held accountable for the quality of services that I 
provide.
    ASHA will continue to seek collaboration with consumer 
organizations, such as AARP, the Alzheimer's Association, and 
with the Consumer Consortium on Assisted Living to help ensure 
the views of consumers and family members are heard by our 
members and that the highest level of quality in assisted 
living can be achieved at every residence.
    The relationships that were built around the Assisted 
Living Workgroup table will not be abandoned or allowed to fade 
away. As I stated earlier, ASHA encourages State regulators to 
solicit the input of assisted living consumers, providers, 
families, and address changes in their current regulations, and 
use the ALW report as an important reference guide, which was 
originally intended, to issues that should be considered in 
oversight structure of assisted living. The ALW provided the 
blueprint for such collaboration.
    In conclusion, I would like to thank Senators Craig, 
Breaux, and the entire committee for the opportunity not only 
to speak to you today, but for the continued efforts on behalf 
of America's seniors. Rest assured, ASHA and its members and 
the committee's commitment to improving the lives of assisted 
living residents nationwide. Thank you.
    The Chairman. And thank you very much.
    [The prepared statement of Mr. Madsen follows:]
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    The Chairman. Next, let me introduce once again to the 
committee Robert Mollica, National Academy for State Health 
Policy, Portland, ME. Robert, welcome to the committee.

   STATEMENT OF ROBERT L. MOLLICA, SENIOR PROGRAM DIRECTOR, 
     NATIONAL ACADEMY FOR STATE HEALTH POLICY, PORTLAND, ME

    Mr. Mollica. Thank you, Mr. Chairman and members of the 
committee for the opportunity to speak here today. The Special 
Committee on Aging is playing an important role in the future 
of assisted living, raising questions about its definition, 
direction, quality of care, government regulation, and the 
extent to which the interests of consumers and family members 
are protected. The committee's interests created the vehicle 
for stakeholders to discuss and debate important issues.
    You extended a challenge to all stakeholders to reach a 
consensus on a set of standards for policymakers and regulators 
to consider as they develop State policy. The Workgroup has 
produced a valuable report after 18 months of hard work by 
numerous individuals. The issues are complex, as you have 
mentioned. Current policy is very diverse and there is not 
enough research to know what works best.
    There is consensus on many recommendations and strong 
reservations about several that did receive the required two-
thirds vote for adoption. Differences among stakeholders 
reflected competing priorities, protecting the health and 
safety of residents and supporting consumer preferences and 
decisionmaking.
    A number of groups felt the recommendations gave more 
prominence to consumer and decisionmaking over protection and 
safety. Consumers may not always have enough information about 
a specific facility to understand the risks to their health and 
safety and to make decisions about where and how care will be 
provided.
    On the other hand, control and independence are important 
to quality of life and self-esteem. Systems that are flexible, 
offer choice, and emphasize consumer decisionmaking are 
generally preferred by consumers. Both perspectives are 
important and it is difficult to find a balance, but balance is 
what I believe is needed.
    The report's value lies, in part, on the presentation of 
all the proposals, the rationale for them, and the supplemental 
positions that present alternate views. The array of issues and 
options presented will help States and stakeholders understand 
the issues and decide their own approach.
    The report offered differing opinions about the value of a 
philosophy and principles of care. The number of States 
including a philosophy in their regulations has almost doubled 
in 6 years, from 15 in 1996 to 28 in 2002. By itself, a 
philosophy does not specify the requirements for licensing, but 
it does set a framework and gives us a benchmark for designing 
rules governing the accommodations, admission and retention 
criteria, service to be provided, staffing patterns, and 
training. A philosophy is a very useful way to frame 
regulations. However, we do not have enough research about how 
it works in practice and whether one approach or the other has 
better outcomes.
    Recommendations addressing screening and assessment, care 
planning, resident contracts, move-out protocols, and others 
offer helpful guidelines to States. The recommendations dealing 
with medication administration reflect trends among States. 
Sixty-four percent of the States now allow aides who have 
completed and passed a training program to administer 
medications. Ninety-eight percent allow aides to assist with 
self-administration. Thirty-three percent require facilities to 
have a consulting pharmacist, and other States require that 
medications are reviewed by registered nurses.
    As facilities serve residents with greater needs, 
assistance with medications has been cited as a concern by 
regulators. About half the states reported in 2002 that 
problems with medications occurred frequently or very often. 
The frequency of problems was not associated with who may 
administer or assist with medications. In fact, focus groups 
conducted by the Rutgers Center for State Health Policy suggest 
that errors may be less frequent when trained aides are allowed 
to administer medications, a somewhat surprising finding.
    The report contains some excellent discussions of the 
barriers to expansion of affordable assisted living. Affordable 
housing programs, such as low-income housing tax credits, HUD 
202 programs, and Section 8 vouchers are now being asked to 
support a product that was not envisioned when these programs 
were established. Currently, less than 15 percent of assisted 
living residents are low-income, while the percentage of low-
income nursing home residents is far higher. If assisted living 
is to be a viable option for low-income tenants, Federal 
policymakers need to consider the changes outlined in the 
report.
    Whether you agree or disagree with the recommendations, the 
report is an excellent tool to frame policy options and 
encourage discussion at the State level. There are clearly two 
distinct approaches to regulation among the Workgroup members. 
It will be useful for the group to develop a side-by-side set 
of model standards to fully develop and compare each approach.
    The Workgroup also recognized the need to develop outcome 
measures, update the recommendations, develop practice 
protocols, and offer technical assistance to States upon their 
request. There is much that we do not know about assisted 
living. What is the impact of different regulatory approaches 
and requirements? How do they affect quality? Do levels of care 
or general licensing guidelines work best? Do regulations based 
on philosophy of care produce different outcomes than 
regulations that do not? Research on assisted living in 
relation to the regulatory requirements is limited and much 
more is needed.
    While stakeholders disagree about the direction and content 
of the recommendations, they agree on one thing. We are not 
where we need to be. We know that regulation alone does not 
guarantee quality. We know that some facilities offer high-
quality care, others are eager to improve that may be lagging, 
and still others seem unable or unwilling to address quality 
issues. We hear that facilities are keeping people with needs 
that they do not have the staff to meet. It is important to 
distinguish between practices that are not allowed under 
regulation and practices that may warrant changes in 
regulation. We always need to understand when enforcement needs 
to be improved or regulations need to be strengthened.
    The results of the Workgroup will advance the development 
of State standards that achieve what all stakeholders want, 
quality of care for people served in these residential 
settings, and I thank the committee for its work in this 
regard.
    The Chairman. Robert, thank you very much for that 
testimony.
    [The prepared statement of Mr. Mollica follows:]
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    The Chairman. We will now turn to questions of our members 
here and we will adhere to a 5-minute rule and move through the 
rounds as often as we need until all of our questions or your 
additional comments to them are dealt with.
    Stephen, let me first start with you. I noted that there 
was apparent difficulty in meeting a common definition of what 
constitutes assisted living. Will you articulate why they had, 
collectively, such difficulty?
    Mr. McConnell. Again, as I mentioned, there are people who 
felt that the definition should be more stringent and others 
that wanted to keep it looser. What we ended up with was a 
series of, in effect, principles around which many people could 
agree.
    There were a couple of things that were important 
differences for some of the groups. One was whether assisted 
living facilities should be required to have private rooms. 
That is an issue that we felt there isn't enough evidence to 
suggest that it is necessary. It could increase the cost. But 
some people felt very strongly about that.
    A second issue that got the group tied up was around levels 
of care. Levels of care exist in regulations in your State, Mr. 
Chairman, and in several other States. While we think that 
levels of care make sense, our particular concern about the 
definitions of levels of care that were being developed by the 
workgroup is that they weren't specific enough to protect 
people with dementia. So that was another issue around which 
the group couldn't agree.
    I think part of it, too, is that if we had come up with a 
very narrow, strict definition, it is entirely possible that 
this would have ended the conversation in many States because 
there is such variability out there in how it is defined, and 
so I think that was at least an argument for why it shouldn't 
be too tightly defined.
    The Chairman. Dan, there are numerous competing thoughts on 
the various aspects of care in assisted living, or in that 
context, even to the extent of licensing requirements of 
facilities, and yet no definition of what is an assisted living 
facility. I think of where my mother-in-law lives today, in a 
large facility in Tucson. She lives on the independent side, 
but there is also the assisted side. There seems to be a line 
at which that facility defines and cares for its residents. Can 
you explain why there is this universe of different viewpoints 
and are there ways to bring a consensus on such definitions of 
terms?
    Mr. Madsen. I believe there is more in Part A when we talk 
about the definition of assisted living and that there has been 
some controversy about what that is. I know what we do, and I 
am in that business, and I know that there are domiciliary 
services that we provide as part of our assisted living and it 
is very well defined by bullet point.
    I think when, using your example in Tucson, where we have 
two communities, we are seeing the past change a bit in that 
there were segregated areas for assisted living at one time and 
we are seeing that become more mainstream and more integrated, 
which we think is a good thing, because residents are now 
coming in and looking at services not only for assistance with 
daily living skills because they need them, but because they 
want them, and we are seeing resident choices. We are seeing 
that they want to have meals delivered at different times. They 
want certain types of assistance, certain types of services, 
and served to them in their apartments and where they live 
versus an area of the building or a place where that is more 
regulated.
    So we look at our programs and we try to ensure the quality 
of the program itself. We focus on the quality of services 
being rendered. Or the fine line becomes to what level of 
service and still respect their dignity and choice and that 
they are in a home of their own within their environments, that 
they have choice to bring in outside services, for example, to 
receive higher levels of care than what we are licensed to do 
or comfortable in providing.
    The Chairman. You made one other comment that I thought was 
fascinating because I actually watched it work in this 
particular community that I am most familiar with, and that is 
the residents' council. The empowerment of the residents was 
phenomenal and the changes they brought about within a 
reasonable spectrum were very satisfying to them and they 
really did feel they were full participants in a community of 
common interests and helping guide that particular provider and 
that facility. I think you are right. That is a phenomenal tool 
in a regulatory process, or at least in a process of balance 
and quality of care, when the residents are empowered to 
participate.
    Mr. Madsen. I believe as well that we pay great attention 
to family members. We answer to the consumer, and in a very 
competitive environment that it is today, where we have 
families that are more educated about retirement communities, 
assisted living communities, they are shopping, there are 
higher quality providers today, the highest quality providers 
today that I have seen ever in the industry that I have been in 
for 15 years. We are absolutely operating at a higher level 
because of the competitive environment, and it is the right 
thing to do. But we raise the bar on each other constantly.
    The dialog that we have with residents and their families 
is extraordinary. We work very closely with resident opinion 
surveys. We formally do them on an annual basis, but we have 
secret shops that we perform monthly from an outside company 
giving us a perspective on the quality of our services that we 
offer, from the taste of the food to the cleanliness of the 
building to how they are treated by staff, and we do our own.
    Absolutely, we do our own surveys, and when we are onsite 
or we call residents, we call families. I personally call 
families every month and ask how we are doing. When in the 
communities, we meet with families, we meet with residents, and 
we get their feedback and we make changes. They are telling us 
what they want and we want to meet our needs.
    The Chairman. Dan, thank you very much.
    Now, let me turn to my colleague, Senator Breaux. John?
    Senator Breaux. Once again, I thank not only the witnesses, 
but everybody who has participated in producing this very 
elaborate document, the question now is, what becomes of the 
document? Does it go to a library somewhere and gather dust and 
10 years from now, somebody will pick it up and say, you know, 
they did good work back there a decade ago, but really nothing 
was ever done to follow up on it.
    So the question is, what becomes of this document? Is it 
something that the various States should pick up and utilize in 
revising or, in some cases, establishing their rules dealing 
with assisted living facilities? Is it something that Congress 
picks up and says, this should be a national standard of what 
all assisted living facilities should look like in terms of how 
they are regulated? Give me some discussion as to what you 
think perhaps should happen to this document.
    Mr. McConnell. Senator, we think this is a conversation 
that needs to happen primarily at the State level, and we have 
already had conversations with our state advocates about the 
key recommendations that relate to dementia care. We are 
encouraging them to work on these issues in their own State. 
This, as has been noted by everybody, is a terrific reference 
document. You can see where all the various interests lie, and 
it helps elucidate the issues, not just what a group's 
perspective is, but what are the kind of both sides, three 
sides, four sides of an issue.
    At the Federal level, it is less clear. I think as Medicaid 
becomes more a part of financing for assisted living, should 
that happen, there is more of a stake in this by the Federal 
Government. But we would still argue that the variability at 
the State level is not a bad thing entirely, that trying to fit 
assisted living into one box will reduce some of the 
flexibility and individuality that is still important in this 
industry.
    Senator Breaux. Mr. Madsen, what do you think?
    Mr. Madsen. I totally agree. I believe that the one-size-
fits-all approach would be difficult to employ. We represent 
different States, as you do. We have different cultures. I 
think this is a great, great point of reference. This is a 
continuing improvement process. That is what it needs to be----
    Senator Breaux. Suppose the States just ignore it.
    Mr. Madsen. I think that the States have obviously--we are 
seeing many of the States make adjustments in their assisted 
living regulations most recently, that they are looking for 
tools. I know the States that were in there looking for some 
guidance that they can customize to their own States and meet 
the needs of those residents. They are very active. States are 
very active in our industry and they are doing a good job.
    Senator Breaux. Some are, not all of them.
    Mr. Madsen. Yes.
    Senator Breaux. Mr. Mollica.
    Mr. Mollica. I think the report will be used by States. 
They clearly know about it. They are looking forward to it. I 
had one State person suggest that having a recommendation 
supported by the Workgroup might help them adopt it in a State 
where there might be some opposition. So I think it will be a 
very useful document.
    In terms of the Federal process, I think the first role 
would be to fund more research. We clearly need to know what 
works and what doesn't, and whether it is the broad approach, 
the broad definition that was included in the Workgroup's 
recommendation or a more narrow definition that was preferred 
by some members of the Workgroup. We need to know if one set of 
outcomes is derived from a certain staffing approach or 
training approach or levels of care versus non-levels of care. 
We simply don't know enough about what works to say that it 
should be one standard or another.
    Senator Breaux. Thank you. I notice one of the 
recommendations is a Center for Excellence in Assisted Living. 
I have always felt that when you give consumer choices, that 
you also have to give them information about what the choices 
are. Otherwise, bad information produces bad choices. So I have 
always thought that you ought to be able to go to some type of 
a national site to look at, whether it is nursing homes or 
whether it is toaster ovens or whether it is assisted living 
facilities, a type of consumer report on how the various 
organizations are doing so that when you make the choice, you 
know that you make the choice based on a history of 
performance.
    Is this what we are talking about on the Center for 
Excellence in Assisted Living? Is this a research group, or is 
this something that would help provide information to consumers 
as they go out and pick the best assisted living facility for 
their folks or themselves?
    Mr. McConnell. As I understand it, Senator, it is all of 
the above. It is to conduct the research to help us get to the 
point where we are looking at outcomes. It is designed to 
provide feedback to the industry so that what we learn about 
good care can be fed back and care can improve. It can also 
provide information and guidance to consumers.
    This is a concept that has been around for a while. We were 
involved in a smaller group several years ago called the 
Assisted Living Quality Coalition. This concept arose then, as 
well. I think it is a good idea. There is some nervousness 
about it, which probably suggests that it really is a good 
idea---- [Laughter.]
    Perhaps because consumers would have a role in guiding 
this, as well as the industry. It is in some ways an embodiment 
of what you have tried to do by creating the Assisted Living 
Workgroup.
    Senator Breaux. There are a lot of issues out there. You 
mentioned the question about who gives out medications in 
assisted living facilities, whether you are going to have to 
have a registered nurse or someone with a nursing background or 
degree to help administer the medications or whether you can 
have an aide who has been trained to provide the meds. All of 
these things are very, very important issues of which there are 
various opinions.
    What about, the final thing, licensing according to a 
degree of care? Obviously, assisted living facilities can range 
from those who are treating very healthy older Americans who 
need very little help as opposed to those who need a great deal 
of help, on the verge of having to require a nursing home 
facility, and you would think that the degree from a licensing 
standpoint would be different depending on the degree of 
services they provide. Can you give me any thought on that, 
anybody?
    Mr. Mollica. I think you have to look at the total context 
of the regulations to know how either approach would work. If 
you allow a more flexible array of services to be provided and 
serve people with different needs within the same facility, 
then, as a regulator, you have to look at the admission 
agreement and the staffing pattern and your oversight 
activities might be done a little bit differently than if you 
were looking at a specific level of care.
    I personally think that the general approach is preferred 
among consumers who want to age in place. They don't want to 
have to move when their level of care is no longer appropriate 
for that facility. On the other hand, as their level of care 
changes, there is a need for the oversight agency to make sure 
that the staffing pattern and the training of the staff is 
consistent with the changing needs of those facilities.
    Again, I don't think there is research one way or the other 
that suggests which is better. The level of care approach might 
be easier to monitor because you know specifically what you are 
going to look for. If the staffing patterns for one level or 
another are different, you know what to count. If the training 
requirements are different, you know what to look for. On the 
other hand, it doesn't have the same amount of flexibility that 
the broader approach does.
    Senator Breaux. I don't want to take more than my allotted 
time, but I guess the question is who determines whether an 
assisted living facility can accept Mr. and Mrs. Smith into a 
facility? I mean, some of them are Ritz Carltons. They run 
beautiful facilities, but they lack in terms, I think, of the 
amount of medical care they can give to an individual. How do 
you regulate that? It is a very difficult question about 
whether this person qualifies for a given institution. I am not 
sure how we go about setting those standards. Some people 
obviously sicker than others. Some need very little medical 
attention. Others need a great deal. Should there be someone 
that says, no, you cannot take this couple because they require 
far too much care, or can a facility take anybody who shows up 
with the money to pay the bill?
    Mr. Mollica. Well, I think States are, as expected, feeling 
a lot of tension in that regard. Some states allow facilities 
to take care of whomever they have the qualified, trained staff 
to serve, and others will draw some boundaries barriers, some 
lines. It is either a list of conditions or the need for 24-
hour care or unstable medical conditions.
    I think whichever approach a State uses, they have to look 
clearly at what the facility's capacity is and who the staff 
are. If the facility isn't making the proper judgments, and 
that has been a concern among a lot of regulators, then the 
oversight agency has to be there frequently enough to step in 
and say, your staffing pattern either has to change or you have 
to ask this person to move and help them to do so.
    Senator Breaux. I think that this document has been well 
put together. Nothing we do is the final answer to anything, 
but I think this really moves the ball down the field in a 
major way as far as establishing in one comprehensive document 
a set of guidelines that has been thoroughly discussed, not 
just by the Federal Government or not just by the State 
Government, but by the actual utilizers of the services, as 
well as by the providers of the services.
    I would hope that this sets a standard or a pattern that we 
can utilize on other difficult issues where we bring people to 
the table and somehow almost force them to do what has been 
done here, and sometimes they do it voluntarily and sometimes 
they do it with a little encouragement and sometimes it takes 
more than a little encouragement. But this is a good product 
and put together by good people and I thank them for it.
    Mr. Madsen. Senator Breaux, if I may go back and elaborate 
a little bit on the Center for Excellence and some of the needs 
for information for consumers, because I think that is an 
important issue, is there a catch-all checklist that you are 
going to be able to go on and seek information regarding each 
facility or community out there that is going to be standard 
and allow you to make choices for a family member or yourself? 
No. I don't believe that is possible.
    Should there be an incredible amount of information 
provided and guidelines and tips and the best ways to analyze 
any of those situations? Yes. I think we need to do a great job 
and have done a much better job in that area because we are 
focusing on something that is very, very important, and as a 
provider and being out there, it is a life decision. This isn't 
buying a car. These are people's lives, and there is nothing, 
there is not a survey, there is not a document, there is 
nothing that will replace going and seeing the community and 
talking to staff and talking to residents and talking to 
families that have received services there.
    Nothing will replace going and visiting and getting the 
feeling and interviewing people and finding out the quality, 
attending resident council meetings and seeing, does it work in 
this community, because they are going to vary, and no 
checklist will replace that, ever. These are lifestyle 
decisions and I think they need to be taken seriously and I 
think that is the best way to make those decisions.
    Senator Breaux. I don't disagree with that, but, I mean, a 
lot of families don't have time to visit ten different 
facilities.
    Mr. Madsen. I agree.
    Senator Breaux. It would be nice if we could visit every 
facility within a city or a State and say, here is the best one 
for Mom and Dad.
    Mr. Madsen. I agree.
    Senator Breaux. That information could be a good starting 
point. I mean, I have always said that if a facility has had 
ten fire code violations last year, I would like to know that 
somewhere, because I would say, whoa, I may go visit and see if 
they have changed it because it looks pretty bad up front. So I 
think you need that continuum of information that kind of gives 
you a parameter so that then you can go out and pick the ones 
that are really good and exit those who are really bad.
    The Chairman. In other words, it isn't buying a car, but 
you darn well better kick the tires.
    Mr. Madsen. Exactly. Absolutely. You better drive it, test 
drive it.
    The Chairman. Senator Wyden.
    Senator Wyden. Thank you, Mr. Chairman. I think all of you 
have been excellent, and I think you heard me say at the outset 
that my goal is to make sure that every single person in an 
assisted living facility secures a basic level of protection, 
and at the same time, we look at a way to try to be innovative 
so as to give industry and providers enough flexibility to 
avoid some of the problems that we have in nursing homes.
    I think probably the best way that we can proceed now is to 
have you walk us through some of the specific challenges. Let 
me take the example of dementia as a way to get us into this 
debate because I think that this is an area where we are 
clearly talking about a lot of frail people, we are talking 
about people that certainly consumer groups have advocated for 
and many in the industry have tried innovative approaches to 
care for, as well.
    Steve, if you would, tell me what percentage of States, or 
a number of States, are not yet where we need them to be with 
respect to treating dementia. Give us a sense right now of how 
serious it is in the United States with respect to the dementia 
question.
    Mr. McConnell. Bob knows the specific numbers, but a number 
of States have regulations, disclosure requirements for special 
care units. In other words, those that hang out a shingle 
claiming to have a special care unit for people with dementia 
would face disclosure requirements and there are better 
restrictions for many of those facilities. But as I pointed out 
in my testimony, most people with dementia are not in special 
care units, so there is very little protection from them.
    Second, one of the challenges with dementia is that we are, 
with advances in science, able to diagnose people earlier. 
Someone in the very early stages of dementia needs a whole 
different set of services and care than someone in the later 
stages, this relates back to the issue of levels of care. If 
that is defined simply by a diagnosis, that is a problem. That 
is like saying you get a diagnosis of Alzheimer's, you can't 
drive. Well, we know that is not appropriate.
    So I think the key is as I said, ``That there are 
requirements that staff be trained to recognize the signs and 
symptoms of dementia, and that there be basic training and 
basic protections in place.''
    Bob, you can straighten out the record on this, but I think 
there are very few States that provide protections for people 
with dementia in all assisted living facilities. If they do it 
at all, it is really only for special care units.
    Senator Wyden. So would you say a third of the States are 
not where the country ought to expect them to be with respect 
to the dementia question? What I am trying to do is to give us 
a sense on a very key question with respect to striking the 
balance between caring for frail and vulnerable people and at 
the same time ensuring that we will have the providers we need 
and the flexibility for them, get a sense of the problem. Then 
I am going to walk you through what the report says with 
respect to the dementia issue.
    But first, give me a sense, if you would, of how serious 
the situation is with respect to where the States are on this 
particular key area of the frail elderly population.
    Mr. McConnell. Bob, do you have the specifics?
    Senator Wyden. Mr. Mollica----
    Mr. Mollica. Between half and 60 percent of the States do 
have provisions for facilities serving people with dementia and 
about 40 percent or so do not.
    Senator Wyden. So 40 percent of the States have nothing at 
all on this?
    Mr. Mollica. Right.
    Senator Wyden. Of the States that do have protections for 
those with dementia, do we have any sense of whether they are 
good, bad, medium? Is this something that the task force looked 
at?
    Mr. McConnell. I think most of them, as I said, relate to 
disclosure requirements so that it is really only a matter of 
telling people what is provided, and then only if you declare 
that you have a special care unit. So I think disclosure was a 
good first step, and is very important. But, it is not enough.
    Senator Wyden. All right. So we have got 40 percent of the 
States with nothing, then we have 50 or 60 percent of the 
States with nothing, and Steve and the Alzheimer's Association 
says that it is fairly modest with just disclosure.
    Dan, do you want to weigh in on this? Do you have a 
difference of opinion on anything?
    Mr. Madsen. I don't have a difference of opinion. I think, 
again, it is a challenge. It is that balance that you are 
trying to strike, and that is, I think, a great first step is 
disclosure and understanding what you are qualified to provide 
in services. I know in our company, we have chosen not to treat 
that level of care because that is not where our specialty lies 
and there are people that are very, very good in that area, in 
the specialty care and Alzheimer's area. I think the disclosure 
piece of making sure the consumer doesn't expect to receive 
care in those areas is a great start.
    The identification, to be able to see the signs, I think is 
good. We should all be trained to a degree of that in all areas 
of life. But I think we also have the personal physician that 
is working with the resident and identifying those issues 
better than we can, and they are making recommendations on 
levels of care and where they should receive those services.
    Senator Wyden. So using this report, how can we take this 
document and upgrade what is done in the dementia area? Senator 
Breaux made the point, for example, with respect to making sure 
that this just doesn't gather dust somewhere. I think we can 
get pretty significant agreement among consumer groups and 
patient advocates and the industry that we need to have a 
monitoring process, and I assume that you are thinking about 
that in the context of a national center in some way.
    But how do we take this report and use what you have just 
told us with respect to dementia, a serious area, to make sure 
that we are putting in place the kinds of policies that bring 
about the changes we need?
    Mr. McConnell. It is both to try to get requirements in 
place that, for example, staff are trained throughout these 
facilities, not just if you have a special care unit. Any 
assisted living facility should train staff to recognize the 
signs and symptoms of dementia. So that is partly a requirement 
and partly training. The Alzheimer's Association is trying to 
help in communities around the country by providing resources 
on how to recognize dementia. So it is both putting some 
requirements in place and then making sure that the tools are 
available to facilities.
    I listed out a number of other things that should be put 
into State requirements. Each state will vary on exactly how 
this plays out.
    For example, on the issue of training, we had some very 
specific requirements we wanted to see in terms of training on 
dementia care and those didn't survive. The recommendation was 
watered down to get a two-thirds vote. But those are things 
that we will push for at the State level.
    So some efforts will focus on specific legislative 
requirements. Some will focus on working with the industry to 
try to upgrade the level of training.
    Senator Wyden. I want to ask just one other question. 
However, I really encourage you, in some of these key kinds of 
questions with respect to services for the frail that we take 
additional time to sort of walk through how we make progress in 
those kinds of areas. I think, as much as anything, if we have 
learned in the past, is if you can get at these questions early 
on in the formative days of policymaking at the State and the 
Federal level, you are more likely to prevent the kind of blow-
ups down the road.
    My last question, as I looked at it, there were areas where 
it seemed to me we could have some better coordination. For 
example, when a resident is moving in, apparently, the group 
came to the conclusion that there ought to be a pre-move-in 
screening process and then an initial assessment. There is 
going to be some concern about how you coordinate this so you 
don't just chew up a lot of time and additional cost. What 
efforts are underway to try to better coordinate some of the 
ways to address those concerns? Is that something you brought 
up in the report, because, I mean, it is in the report.
    Mr. Madsen. Sure. Absolutely. I think that assessment 
processes is a very viable tool. It is something that--
important in a--when a resident moves in, again, it is a life 
decision and I think it is important to, one, have the 
disclosure, these are the services we can and cannot provide in 
the setting, and go through the assessment process, work with 
the physician, work with the family, work with the resident to 
identify the services that you can and will provide and are 
saying you will provide and then to what level of quality and 
care.
    You know, is that something that the States should work 
with? Absolutely, and they do. You know, several States are 
working with that very accurately. What is that assessment 
process? What is that entry process? Again, is that something 
that comes from the Federal standpoint? No. I think the States 
are doing a good job.
    Senator Wyden. I would just rather make sure, for example, 
those dollars that may now get chewed up in a duplicative 
process are put back into services for people. I think those 
are the kinds of choices we are going to have to ensure get 
made Mr. Chairman, you have been gracious with the time for 
questions and I look forward to working with you and Senator 
Breaux.
    The Chairman. Well, thank you both.
    A couple more questions. Robert, do you think there are any 
additional areas of concern that should have been included in 
this study or should be included in future examinations and 
future studies that this one missed?
    Mr. Mollica. Well, I can't think of one. They did a---- 
[Laughter.]
    The Chairman. Now, we have got----
    Mr. Mollica. It is a challenge----
    The Chairman. We have got 110 recommendations here that met 
the two-thirds requirement, but surely one slipped out that you 
thought had to be critical and should be there. [Laughter.]
    Mr. Mollica. I think the ones that didn't meet the two-
thirds requirement are still worth considering and I am very 
pleased that the report included them because it gives 
stakeholders and regulators an opportunity to look at what is 
there that they didn't reach consensus on for their own 
deliberations.
    The Chairman. Dan.
    Mr. Mollica. There isn't much they have left out.
    Mr. Madsen. I agree. I am glad that we have the 
supplemental positions in there so that the States can see what 
was left out or what wasn't approved by the two-thirds so that 
they can consider all recommendations, consider all opinions 
when formulating their regulations on a State level. I think it 
is great.
    The Chairman. Stephen.
    Mr. McConnell. It is hard to imagine anything that was left 
out. If you think about whether this is too prescriptive or not 
prescriptive enough, most of the groups on the tails of that 
Bell Curve you talked about argue that it is not prescriptive 
enough. So I think it is really more a matter of defining these 
things more clearly. It is too bad we couldn't have come up 
with a definition we could have gotten two-thirds vote on. But 
I think the issues are laid out clearly here and now it is a 
matter of playing them out at the State level.
    The Chairman. Senator Breaux mentioned--another question to 
all three of you. Senator Breaux mentioned in one of his 
comments that many studies that are done either at the auspices 
of the Congress or done by Congress end up on library shelves 
gathering dust and somebody simply cleans them off a decade or 
so from now, might look at them, and might just toss them.
    How can we help you, or how can we help the industry 
elevate this in a way that it actually get read, gets looked 
at, is viewed as a template from which to make decisions, and 
that we move this industry in the direction that it ought to be 
moved in, and that is at the State level with State regulation 
to assure those kinds of quality, some degree of uniformity, as 
we go through, so that this isn't one of those dust-collecting 
projects? Recommendations, gentlemen, that we, I say we the 
Congress, we this committee, might participate in to lift it 
up?
    Mr. McConnell. I suspect that if you threatened 
legislation---- [Laughter.]
    There would be a lot of activity on this, because I think 
there are many groups that are interested in preempting federal 
legislation. I think there is a genuine interest in addressing 
this at the State level, and if there was a fear that something 
might happen federally--I mean, the fact that you asked these 
groups to get together, my hunch is that many of us came 
together because we thought, either on one side, gee, maybe 
they are going to do something about this, or, oh, my God, they 
are going to do something about this.
    So I think keeping that stick there might not be a bad 
thing, as well as continued oversight by the committee. I think 
it is very important you do these kinds of things, where you 
are asking questions, you are looking into the issues, paying 
attention. I think that will help everybody keep working on 
this.
    The Chairman. Surely. Dan.
    Mr. Madsen. I believe it is a living document. It is 
something that needs to be made available. It should be sent to 
the States, all interested parties. We certainly will urge all 
the providers to utilize this when looking at their own 
policies and procedure manuals, working with the State 
regulators. I think knowing that it is a continual improvement 
process, that we need to keep it alive. It is going to change. 
It is going to evolve. Our market changes and evolves----
    The Chairman. Sure.
    Mr. Madsen. Our residents, and I have seen over the last 15 
years change and evolve, and what they are looking for in 
assisted living is completely different today than it was 15 
years ago, and it will be different 15 years from now and I 
think that we should always have a process in place like this.
    The Chairman. Robert.
    Mr. Mollica. I think that if you announced that you were 
going to have a hearing in 2 years or some period of time to 
look at what has happened to the Workgroup recommendations and 
what have the States done, that would initiate consideration by 
states that might feel complacent that their regs are OK the 
way they are. Even if they are, if they just look at it and 
compare their regulations with the complaint and survey results 
and compare what the Workgroup has recommended, it would be 
worthwhile to make sure the regulations are working well in a 
State that may not change their regulations.
    But I think in many other States, they will look at them 
seriously. At any given time, about half the States are 
tweaking their regs or refining them or totally revising them 
and they will look to the recommendations for suggestions about 
what they might consider.
    The Chairman. John, the last word, if you wish?
    Senator Breaux. Not necessarily the last word, but I think 
the observation is correct. I think that while most of the 
payments for the assisted living facilities are currently 
private, I think that more and more, you are going to be moving 
into tax credits to buy long-term health insurance, which would 
mean that the Federal tax dollar is dramatically involved in 
it. You will see more and more States with more Medicaid 
waivers to allow Medicaid to cover the costs of these type of 
alternative facilities.
    There certainly is a legitimate national interest to make 
sure that the facilities are performing as they are intended to 
perform, so what we did with this is to say, look, the Federal 
Government doesn't have all the answers but there is a 
legitimate Federal concern. So you folks that run the 
facilities and you folks that utilize the facilities, see if 
you can get together and come up with some recommendations that 
make sense. Rather than having us go out into it on our own, we 
wanted you all to do it as a first cut, and I think the first 
cut is a very, very good starting point.
    But I do think that we are going to be looking to see what 
happens with this document, and it won't be 2 years from now, 
it will be sooner than that. But I guarantee you that to the 
extent that Senator Craig and I can work together on this, we 
are going to be saying, we want to know what happens to this 
wonderful document and that it is not sitting in a library 
somewhere. Thank you.
    The Chairman. Gentlemen, thank you very much, and for all 
the groups that participated, we want to thank you for your 
work effort. We think it is a phenomenal first step and a 
substantial document.
    With that, the committee will stand adjourned.
    [Whereupon, at 11:17 a.m., the committee was adjourned.]
                            A P P E N D I X

                              ----------                              


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