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