[Senate Hearing 118-306]
[From the U.S. Government Publishing Office]




                                                      
                                                         S. Hrg. 118-306

                      ASSISTED LIVING FACILITIES:
                      UNDERSTANDING LONG-TERM CARE
                        OPTIONS FOR OLDER ADULTS

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

                                HEARING

                               BEFORE THE

                       SPECIAL COMMITTEE ON AGING

                          UNITED STATES SENATE

                    ONE HUNDRED EIGHTEENTH CONGRESS


                             SECOND SESSION

                               ----------                              

                             WASHINGTON, DC

                               ----------                              

                            JANUARY 25, 2024

                               ----------                              

                           Serial No. 118-14

         Printed for the use of the Special Committee on Aging
         
         
         
         
         
         
         

               ASSISTED LIVING FACILITIES: UNDERSTANDING

                LONG-TERM CARE OPTIONS FOR OLDER ADULTS
                
                
                
                
                
                
                
                
                
                




                                


                                                        S. Hrg. 118-306
 
                      ASSISTED LIVING FACILITIES:
                      UNDERSTANDING LONG-TERM CARE
                        OPTIONS FOR OLDER ADULTS

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

                                HEARING

                               BEFORE THE

                       SPECIAL COMMITTEE ON AGING

                          UNITED STATES SENATE

                    ONE HUNDRED EIGHTEENTH CONGRESS


                             SECOND SESSION

                               __________

                             WASHINGTON, DC

                               __________

                            JANUARY 25, 2024

                               __________

                           Serial No. 118-14

         Printed for the use of the Special Committee on Aging
         
         
         
         [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] 

         


        Available via the World Wide Web: http://www.govinfo.gov
        
        
        
                        ______

             U.S. GOVERNMENT PUBLISHING OFFICE 
 55-769              WASHINGTON : 2024     
        
        
        
        
        
                       SPECIAL COMMITTEE ON AGING
                              
                              
                              

              ROBERT P. CASEY, JR., Pennsylvania, Chairman

KIRSTEN E. GILLIBRAND, New York      MIKE BRAUN, Indiana
RICHARD BLUMENTHAL, Connecticut      TIM SCOTT, South Carolina
ELIZABETH WARREN, Massachusetts      MARCO RUBIO, Florida
MARK KELLY, Arizona                  RICK SCOTT, Florida
RAPHAEL WARNOCK, Georgia             J.D. VANCE, Ohio
JOHN FETTERMAN, Pennsylvania         PETE RICKETTS, Nebraska
                              ----------                              
               Elizabeth Letter, Majority Staff Director
                Matthew Sommer, Minority Staff Director
                         C  O  N  T  E  N  T  S

                              ----------                              

                                                                   Page

Opening Statement of Senator Robert P. Casey, Jr., Chairman......     1
Opening Statement of Senator Mike Braun, Ranking Member..........     3

                           PANEL OF WITNESSES

Patricia Vessenmeyer, Advocate, Gainesville, Virginia............     5
Jennifer Craft Morgan, Ph.D, Director and Professor, the 
  Gerontology Institute, Georgia State University, Waleska, 
  Georgia........................................................     7
Julie Simpkins, Co-President, Gardant Management Solutions, 
  Indianapolis, Indiana..........................................     9
Richard Mollot, Executive Director, Long Term Care Community 
  Coalition, New York City, New York.............................    11

                                APPENDIX
                      Prepared Witness Statements

Patricia Vessenmeyer, Advocate, Gainesville, Virginia............    37
Jennifer Craft Morgan, Ph.D, Director and Professor, the 
  Gerontology Institute, Georgia State University, Waleska, 
  Georgia........................................................    39
Julie Simpkins, Co-President, Gardant Management Solutions, 
  Indianapolis, Indiana..........................................    45
Richard Mollot, Executive Director, Long Term Care Community 
  Coalition, New York City, New York.............................    47

                        Questions for the Record

Patricia Vessenmeyer, Advocate, Gainesville, Virginia............    53
Jennifer Craft Morgan, Ph.D, Director and Professor, the 
  Gerontology Institute, Georgia State University, Waleska, 
  Georgia........................................................    54
Julie Simpkins, Co-President, Gardant Management Solutions, 
  Indianapolis, Indiana..........................................    58
Richard Mollot, Executive Director, Long Term Care Community 
  Coalition, New York City, New York.............................    78

                       Statements for the Record

Alzheimer's Association and Alzheimer's Impact Movement Statement    85
Argentum Expanding Senior Living Statement.......................    93
Oregon Health Care Association Statement.........................   105
Health Care Association of Michigan Statement....................   109
Leading Age Statement............................................   110
Justice in Aging Special Report..................................   119
AARP of Arizona: The Arizona Reuplic Article.....................   142
National Center for Assisted Living Statement....................   167
Pennsylvania Health Care Association Statement...................   169
Country Meadows Retirement Communities Statement.................   173
Delaware Health Care Facilities Association......................   175
Nebraska Health Care Association Statement.......................   177
Florida Health Care Association Statement........................   179
American Seniors Housing Association Statement...................   180
Center for Excellence in Assisted Living Statement...............   186
Julie Simpkins additional Exhibits Submitted.....................   190


                      ASSISTED LIVING FACILITIES:



                      UNDERSTANDING LONG-TERM CARE



                        OPTIONS FOR OLDER ADULTS

                              ----------                              
Thursday, January 25, 2024




                                        U.S. Senate
                                 Special Committee on Aging
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:03 a.m., Room 
106, Dirksen Senate Office Building, Hon. Robert P. Casey, Jr., 
Chairman of the Committee, presiding.
    Present: Senator Casey, Blumenthal, Warren, Kelly, Warnock, 
Fetterman, Braun, Rick Scott, Vance, and Ricketts.

                 OPENING STATEMENT OF SENATOR 
                 ROBERT P. CASEY, JR., CHAIRMAN

    The Chairman. The Senate Special Committee on Aging will 
come to order. As Chairman of the Aging Committee, my top 
priority is keeping our promises to older Americans and to 
Americans with disabilities.
    We owe it to every older adult, every person with a 
disability, and their families to have the necessary 
information to decide when, where, and how to receive care as 
they age. That has motivated my advocacy, for example, for home 
and community-based services.
    Every American who wants to receive care at home should be 
able to do so, and the workers providing that care must be 
paid, in my judgment, a living wage.
    It has similarly motivated my work to ensure that nursing 
homes are providing safe, quality care for all of their 
residents. We need to address the chronic underfunding and 
understaffing for the state agencies that conduct nursing home 
oversight, so they can effectively protect the health and 
safety of residents. This core mission of the Aging Committee 
brings us to today's topic, the topic of assisted living and 
that landscape. It has been 20 years since this Committee held 
a hearing on assisted living.
    With the dramatic growth of the assisted living industry in 
recent decades, it is long past time for Congress to reexamine 
this model and ensure that it is meeting our Nation's needs. 
The best estimates reveal that nearly one million Americans 
live in more than 30,000 assisted living facilities across our 
Nation, and that is almost certainly an undercount of that 
number.
    Assisted living facilities are state regulated residences 
that support assisted living while offering help with the 
activities--with activities of daily living, like bathing and 
medication management.
    They also often provide meaningful engagement and 
activities for their residents. Assisted living was first 
envisioned as a social model for residents who needed lower 
levels of support, but today, people living in assisted living 
facilities are older, require more care, and have health care 
needs similar to that of those who reside in a nursing home, 
and the needs of the assisted living population change. As 
those needs change, we need to know that--if assisted living 
facilities are meeting the needs of those residents or the 
needs of their families. One major issue I hear a lot about is 
cost. Assisted living facilities are widely unaffordable to the 
average American and their family.
    A recent survey found that 80 percent of older adults would 
be unable to afford, unable to afford, four years in an 
assisted living facility. The average annual cost is $54,000 a 
year, but the costs can be substantially higher depending upon 
the location and the type of care that a resident requires.
    The more assistance and care a resident needs, the more 
they pay. In some cases, residents and their families don't 
know the total cost until they receive their monthly bill. 
These substantial costs and often hidden fees make it nearly 
impossible for older adults and their families to accurately 
budget for long-term care.
    Now, that is one of the reasons why I am starting today, I 
am asking Pennsylvanians and people across the country to share 
their stories and their bills with us. I want to hear from you 
about the true cost of assisted living and understand whether 
families have the information that they need to make difficult 
financial and health care decisions.
    I am just going to hold up the--website address for those 
who need it. You can go to aging.senate.gov/
assistedlivingbills, all one word, assistedlivingbills, to 
share your stories. I think it is very important that we hear 
from people, hear from people about their own experience as 
family members, as people who are paying the bill and also 
expecting the promises that are made when someone becomes a 
resident of an assisted living facility.
    It is only by hearing those stories, only by hearing 
those--hearing about those experiences, can we bring the needed 
change that I know we all agree has to come. The assisted 
living industry is also facing the same workforce crisis that 
we see across other long-term care settings, and even beyond 
long-term care.
    It is also true in the context of childcare and so many 
other parts of our healthcare and care landscape. Workers are 
often struggling to support their own families because direct 
care workers are paid an average of just $15 an hour 
nationwide.
    Workers provide a higher level of care to support 
residents' growing needs, especially residents with dementia, 
but training requirements and worker support look very 
different in each state.
    As we will hear from our witnesses, these challenges make 
it harder for families to find the information that they need 
about assisted living facilities, including how much it will 
cost, the quality of the services they receive, and how safe 
their family member will be.
    A recent Washington Post investigation found that since 
2018, more than 2,000 people have left assisted living 
facilities unsupervised and have been left unattended outside. 
Tragically, 98, 98 of these 2,000 incidents have resulted in 
the death of the resident, and those are just the cases that 
have been reported.
    The findings of the post investigation demonstrate how 
urgent it is that Congress better understand this industry. 
There has also been significant reporting by the New York Times 
and in KFF in a series written before the end of last year.
    To help in our understanding, I have sent letters to three 
of the largest corporate owners of America's assisted living 
facilities. These letters request information about costs, 
workforce, safety, and availability of information about 
quality and services in assisted living facilities.
    I hope these letters, or I should say the response to the 
letters, will improve transparency in the assisted living 
industry and help to inform policy solutions to address some of 
these concerns.
    As families are making difficult decisions about where to 
age, they deserve to know that their loved ones are safe. I 
think we can all agree on that, and assisted living providers 
making promises they cannot keep is a violation of trust.
    As we continue to increase the quality of the continuum of 
long-term care for older adults, it is time we prioritize 
efforts to improve the assisted living care option. If we say 
we are, as a Nation, the United States, the greatest country in 
the world, then we have to have the best, not second, not 
third, the best long-term care in the world, and we are not 
there yet.
    Older adults and people with disabilities who call assisted 
living facilities home, we have to remember this is their home, 
their residence, where they live, where their families come to 
see them--if those older adults and people with disabilities 
are calling those facilities home, they should have quality, 
affordable care.
    I look forward to hearing from our witnesses today, and I 
will turn to Ranking Member Braun for his opening statement.

                 OPENING STATEMENT OF SENATOR 
                   MIKE BRAUN, RANKING MEMBER

    Senator Braun. Thank you, Chairman Casey. You know, in 
2050, you think the problem is bad now, one in four Americans 
will be 65 years of age or older.
    With an aging population that we know is coming at us, 
thank goodness we have hearings like this to highlight what you 
are going to do about it. Sometimes the market doesn't do the 
job. I do want to say that ideally, these things are crafted 
through the market and probably with states leading the way, 
and I say that for one big reason.
    I am on the Budget Committee, and the biggest thing that 
challenges this place is how you would add something even 
further to the list of things you want to do when we are now 
borrowing $1 trillion every six months instead of annually, and 
that has just changed over the last five years, so we have to 
be careful, but it still has nothing to do with a problem or an 
issue that is out there, and this is about highlighting who can 
do it best and how you get there.
    Chronic workforce shortage. When I travel, visit all 92 
counties in Indiana--pre-COVID, that was the number one issue, 
and it is about double now the number of jobs in my own State. 
I think it is close to 130,000. It was 65,000. Caregivers, 
large percentage of whom are--that assistance is given by 
independent contractors, you know, small business owners.
    We need to figure out how to enable that, make it easier 
how you actually have your curriculums in various states and 
school systems that show the full spectrum of what jobs are out 
there and where the needs are.
    Senator Kaine and I introduced the Jobs Act here, which 
allows students to use Federal Pell Grants for high quality, 
short term, job training programs.
    That is a good Federal program. Does not add much to it. It 
is increasing the flexibility of how you can use it. Senators 
Rosen, Collins and I also introduced the Train More Nurses Act, 
which reviews all nursing grant programs to find ways of 
increasing nursing pathways.
    Happy to hear some things do work well here. That passed, I 
think, by unanimous consent last night in the U.S. Senate, so 
now we got to get it over to the House to do the same thing. 
The Federal Government should make it easier for people to 
enter the health care workforce and for families to take care 
of their loved ones by making sure that it is energizing the 
people that may be interested in it and in the places they are 
going to probably be doing the heavy lifting.
    Right now, for instance, the Biden Administration is saying 
one thing and actually doing another, I come from the world of 
small business, independent contractors, retailers, individuals 
that make their living out of maybe running a small business. 
The independent contractor rule that is out there, which would 
make that more difficult, could eliminate many of the existing 
caregiver jobs for that reason, so you got to make sure you are 
not wanting to do something, and then you are working at a 
cross purpose through another agency that will make it even 
more difficult. Unlike nursing homes that are regulated by both 
Federal and State agencies, assisted living facilities are 
primarily regulated by states.
    To increase safety and transparency, Indiana requires 
staffing ratios, dementia training, and maintains a website 
that discloses, reports and enforcement actions. States and 
assisted living facilities are also working to find creative 
ways to use existing resources to assist seniors. Indiana is 
using a combination of State and Federal tools to provide more 
affordable assisted living to Hoosiers.
    As a result, Indiana has seen affordability and quality 
improve. However, there is always more work to be done. Some of 
my colleagues may be tempted to call for a shift toward 
increased Federal involvement and regulation.
    I would say be careful. Help us get best practices out 
there. Help us have an environment to get it done where it is 
normally done more effectively and more affordably, at lower 
levels of Government. I believe that states are best positioned 
to meet that growing need.
    I am glad we here at the Federal level, this is the big 
microphone that has to highlight the issues, that is what we 
are doing here today. Thank you to all the panelists for being 
here, and I am interested to see what we can come up with. 
Thank you, Mr. Chairman.
    The Chairman. Thank you, Ranking Member Braun. We will next 
turn to our witness introductions. I am grateful for the time 
and the work that goes into an appearance from our witnesses.
    Our first witness this morning is Ms. Patty Vessenmeyer 
from Gainesville, Virginia. Her first husband, John Whitney, 
had dementia and lived in an assisted living facility at the 
end of his life. She will share some of her and her husband's 
experiences, where she supported him in an assisted living 
setting.
    Patty, we are grateful you are here today. Thank you. Our 
second witness is as Dr. Jennifer Kraft Morgan. Dr. Morgan is 
from Waleska, Georgia. Dr. Morgan is a Professor and Director 
of the Gerontology Institute at Georgia State University.
    She studies issues related to long-term care dementia and 
the health care workforce. Thanks for being with us today, 
doctor. Our third witness is Julie Simpkins, and I will turn to 
ranking member Braun for that introduction.
    Senator Braun. Julie Simpkins is the Co-President of 
Gardant Management Systems. She has been in the long-term care 
arena for nearly 30 years.
    Ms. Simpkins focuses on affordable assisted living, and she 
advocates for both providers and older Americans in Gardant's 
82 facilities across the country.
    She leads on several state and national associations, 
including the Indiana Health Care Association Board of 
Directors and the National Center for Assisted Living Board of 
directors. Thank you for testifying here today.
    The Chairman. Thank you, Ranking Member Braun. Our fourth 
and final witnesses is Richard Mollot. He is the Executive 
Director of the Long Term Care Community Coalition.
    This coalition works to provide families with unbiased 
information about nursing homes, assisted living facilities, 
and other long-term care settings. Thanks for being with us 
today, and we will turn to our first witness, Patty 
Vessenmeyer.

   STATEMENT OF PATRICIA VESSENMEYER, ADVOCATE, GAINESVILLE, 
                            VIRGINIA

    Ms. Vessenmeyer. Good morning, Chairman Casey, Ranking 
Member Braun, and members of the Senate Special Committee on 
Aging.
    My name is Patty Vessenmeyer and thank you for allowing me 
to share this testimony of my experience with assisted living 
for my husband, John Whitney, during his journey through the 
middle stage of dementia. I will focus on my experiences and 
observations that I believe are most relevant to your national 
focus.
    In 2013, my husband was diagnosed with dementia with Lewy 
Body. Although this dementia is similar to Alzheimer's, it 
manifests itself a bit differently and it is important that 
caregivers be informed and trained to ensure the comfort, 
safety, and security of their patients.
    Some key systems are loss of sense of smell, REM sleep 
behavior disorder, which causes individuals to violently act 
out dreams, often falling out of bed, visual hallucinations, 
marked fluctuations in attention and alertness, and 
gastrointestinal issues, including severe constipation, all of 
which my husband experienced.
    Loss of memory often occurs much later in this disease 
process. I took several free courses on caregiving for 
individuals with dementia, including a virtual reality dementia 
experience, which helped me to understand the challenges that 
people with this disorder face, and most importantly, why they 
become fearful and combative.
    I mentioned this to provide a basis for my ability to 
recognize problems with care as I saw it. These same courses 
are offered for professionals at reasonable costs. In June 
2017, when my husband's disease was progressing more rapidly, I 
moved to Virginia to be near family.
    I cared for him alone at home until January 26th, 2018, 
when he attempted to strangle me in my bed. The State 
determined that John should be placed in a long-term care 
facility. I found him a room in assisted living facility in 
Warrenton, Virginia that specialized in memory care. He moved 
in the first week of March in 2018.
    I provided the management team with John's history, his 
diagnosis, and disease progression. The following is a list of 
issues that I observed in the Memory Care Unit during my daily 
visits with John. Poor facility design. There were blocks of 
rooms built around a large central room for group activities 
and TV.
    The central room was extremely loud and high levels of 
noise can easily agitate dementia patients. Activity stations 
were set up for residents. One of these had various lengths of 
PVC pipe, not kidding, some longer than a baseball bat. These 
were weapons in waiting and you can guess what happened.
    There was no quiet area for the residents other than their 
rooms. The hallways in the room blocks were isolated, making it 
difficult for staff to monitor. There were many incidents that 
I witnessed when there were no staff around. I will share one 
that I feel was very important.
    A woman fell by tripping on a raised area on the floor 
where the rug abutted the hard flooring. Nobody saw her fall. I 
found her bloody and staggering down the hallway. A company 
knowledgeable about dementia care would not design a facility 
this way. They would certainly understand that people with 
dementia have problems with gait and balance, and do 
understand, there were video cameras in place, but they only 
used them for reviewing incidents after the fact. They were 
understaffed. Too many patients were assigned to each 
caregiver. In the morning, each caregiver needed to give their 
assigned residence--get them up and dressed and ready for 
breakfast.
    Everybody ate at the same time, putting additional pressure 
on the staff. They only gave residents a shower when necessary, 
as they were always pressed for time. Caregivers needed extra 
time to spend on residents in more advanced--sorry, stages of 
dementia, as they required help to move from their bed to a 
wheelchair and be hand fed.
    After lunch, the caregivers would place most of the 
resident in chairs in the main room while they worked getting 
the advanced stage patients back into their beds. Every day 
after lunch, my husband urgently needed to empty his bowels.
    Several times when I was there, I tried to help him, but it 
was difficult for me as I had had a broken arm at the time. I 
could not find anybody, so I did the best I could, and often 
when I was not there, he soiled himself while waiting for help.
    I once believe I saved a man's life. I was with my husband 
in a room off the main activity area. I heard someone crying 
for help. I ran into the hallway and found an old man on the 
floor, trying to protect himself from being beaten with his own 
cane by another resident.
    I called for help, quickly moving closer and redirecting 
the attacker's attention. I kept him busy while calmly calling 
for assistance, trying not to further agitate him. It took 
several minutes before a staff member finally heard me and came 
to help.
    Night was no better as staff levels were lower as allowed 
by state regulations. They placed residents who had trouble 
sleeping in front of a TV while they dealt with other 
residents. Inadequate staff training.
    Most of their caregivers staff were trained as nurse's 
aides, but nothing specific to memory care that I could see. I 
witnessed them providing new hires dementia training care in a 
conference room.
    This consisted of a member of the management team showing 
them parts of Glen Campbell Zombie movie and pointing out some 
behaviors that demonstrated his dementia problems. I saw that 
movie and it was not appropriate for training purposes.
    I observed several instances where caregivers and nurses 
displayed limited knowledge of working with dementia patients, 
particularly those in mid-stage of the disease, who became more 
fearful and combative.
    Some examples: Nurses running toward the patient, causing 
the resident to become combative. Quick, erratic hand movements 
frightening the individual, and another example, the TV was on 
at 9:30 p.m. with extremely high volume. Several residents were 
seated in chairs and wheelchairs in front of the TV.
    Anyone who understands dementia and sundowning would never 
do this. They were overstimulating these residents instead of 
allowing them to relax and quiet their minds for sleep, and 
finally, at one point, the director of this facility told me to 
spend less time there and let them do their jobs.
    Well, I could not abide because I felt they weren't doing 
their jobs. In closing, unless things change, I could never 
recommend using this type of facility for a loved one unless 
things improve. I am hoping that you found my testimony 
helpful, and the Committee will find a way to set some national 
standards for appropriate levels of staffing and training for 
that staff.
    This would be a huge step in improving assisted living. 
Thank you for your time.
    The Chairman. Thank you very much, Ms. Vessenmeyer. I 
appreciate your testimony.
    Dr. Morgan.

      STATEMENT OF JENNIFER CRAFT MORGAN, PH.D., DIRECTOR

           AND PROFESSOR, THE GERONTOLOGY INSTITUTE,

           GEORGIA STATE UNIVERSITY, WALESKA, GEORGIA

    Dr. Morgan. Good morning, Chairman Casey, Ranking Member 
Braun, and the members of the Committee. I am honored and 
delighted to be here. Thank you, Patty, for sharing that story.
    Assisted living is a large and growing long-term care 
residential option for individuals who need or want additional 
supports for activities of daily living.
    There are approximately 30,600 AL communities in the U.S., 
with approximately 820,000 residents employing about 500,000 
workers. AL, often seen by the public as interchangeable with 
skilled nursing homes, was built and is regulated as a social 
model of care. This community-based care is less restrictive 
and strives to be home like.
    AL residents vary greatly in the amount of care they need 
from person to person. Rising acuity levels do mean that as 
residents age in place, they likely require more health 
services. While these services could overlay AL services, much 
like they would if the person was needing--needing care was at 
home, these are not provided directly by the AL communities.
    The haphazard growth of this model and the tensions between 
social care and health care inherent have spurred calls by 
scholars for assisted living to be reimagined. Most AL 
residents need help with medications, and more than half need 
help with three or more activities of daily living.
    AL residents depend on their care networks. The 
constellation of kin and non-kin involved in residents' lives 
to arrange medical care, to provide social support, to 
coordinate care, to engage residents, and activities, and bring 
needed supplies.
    These care works also play an important role in advocating 
for residents and negotiating care with AL staff. About 42 
percent of AL residents have a dementia diagnosis, but we can 
assume this is underreported as many older adults are not 
screened, tested, or diagnosed with dementia, despite showing 
symptoms and memory thinking or making decisions that impact 
everyday life.
    Like all people with chronic disease, people living with 
dementia have good days and bad days. Person centered dementia 
care is needed to tailor care and support to individuals in 
ways that account for preferences, life experiences, 
communication styles, and support needs that change over time.
    According to MCAL, the average monthly cost of AL is 
$4,500. As such, AL is inaccessible to most Americans. Yet on 
the spectrum of long-term care, it is often needed. Seen as a 
step between unpaid care by loved ones and nursing home care, 
AL provides an a very important long-term care option.
    When the care of NE care needs of a loved one exceeds the 
capacity of their care network, the person and their care 
network is forced to navigate with little support or education, 
a variety of options, none of which are usually covered by 
health insurance.
    If they have significant financial resources, AL is a 
useful and attractive option. If not, managing the care 
situation means they care partners reduce working hours, build 
precarious care or financial arrangements across families, hire 
piecemeal personal care support, or simply cross their fingers 
and hope that it all works out.
    Sixty-six percent of the AL workforce are aides or direct 
care workers. Direct care workers in AL and across long-term 
care are predominantly women, people of color, and 
disproportionately immigrants. The typical direct care worker, 
a Senator Casey said, makes about $15 an hour, works 36 hours a 
week in assisted living, and works for a for profit company.
    AL workers, like most direct care workers, tend to go into 
this line of work to give back, to make a difference because 
they value elders or because it is a calling for them. 
Unfortunately, the system we have set up works against them.
    Direct care workers in long-term care settings experience 
low wages, few benefits, heavy workloads, dangerous jobs, and 
little to no career mobility. In her book, Disrupting the 
Status Quo of Senior Living. A Mindshift, Jill Vitale-Aussem 
lays out what I think is the crux of the problems facing senior 
living.
    AL is marketed to those who can afford it with a 
hospitality mindset. They advertise and compete on the basis of 
beautiful campuses, luxury food and furnishings, and concierge 
services. This model encourages residents and families to think 
about this next step as though they are going to a hotel or a 
resort.
    This framing, where residents are guests and staff are 
encouraged to cater to their whims, increases what Dr. Bill 
Thomas of the Eden Alternative calls the three plagues of long-
term care, helplessness, boredom, and loneliness. By 
encouraging passivity, we leave residents with few 
opportunities for giving back or creative pursuits.
    Instead, long-term care that is person centered, community 
minded, and empowering for residents, staff, and care partners 
has a much better chance of success.
    My recommendations include improve and standardize initial 
continuing education training--initial and continuing education 
training for direct care workers and all staff in assisted 
living. Professionalize the direct care workforce.
    Incentivize and reward good employers who deliver high 
quality care. Increase access to assisted living. Improve care 
coordination and resources for people living with dementia and 
their care partners, and support standardization of monitoring 
and resources to increase state-based oversight and 
transparency. Thank you.
    The Chairman. Thank you, doctor, very much for your 
testimony. Ms. Simpkins, you may begin.

       STATEMENT OF JULIE SIMPKINS, CO-PRESIDENT, GARDANT

          MANAGEMENT SOLUTIONS, INDIANAPOLIS, INDIANA

    Ms. Simpkins. Thank you. Chairman Casey, Ranking
    Member Braun, and members of the U.S. Senate Special 
Committee on Aging, thank you for inviting me here today to be 
part of this important discussion on assisted living, a topic 
that is very near to my heart.
    My name is Julie Simpkins, and I am the Co-President of 
Gardant Management Solutions. We are a provider that develops 
and operates senior living, assisted living, and memory care 
communities.
    We are the fifth largest assisted living provider in the 
country and have communities in five states, Illinois, Indiana, 
Ohio, Maryland, and West Virginia. I have dedicated most of my 
life to senior living, with over 30 years to the assisted 
living sector.
    This is my calling, and I would like to speak with you 
today about Gardant's unique model, as we share thoughts and 
how we can work together on important issues facing those who 
need and work in assisted living.
    Gardant is uniquely focused on offering affordable assisted 
living to low-income seniors. Our company was founded in 1999 
after the creation of the Illinois Supportive Living Program, 
which is a home and community-based waiver program.
    Now, as we expanded into four other states, our commitment 
to serving this population remains. Many residents living in 
Gardant communities rely on Medicaid for their assisted living 
care through these waiver programs.
    Gardant has been limited in where we can offer our services 
due to the variability with state Medicaid waiver programs. It 
depends on the availability of state programs, of state 
reimbursement levels, and the number of available waiver spots.
    Offering affordable assisted living exclusively or even for 
a majority of residents like Gardant requires an entirely 
different business model altogether. We have had to 
persistently seek out HUD loans and income tax credits to stay 
viable.
    Therefore, we support efforts to make long-term care, 
including assisted living, more affordable to low and middle 
income individuals. With a rapidly growing elderly population, 
we need a public and private partnership to incentivize more 
providers to develop these models.
    When we talk about assisted living, it is important to note 
that every state, every community, and every resident is 
different. Efforts to standardize all assisted living 
communities would be both unworkable and irresponsible for 
resident care.
    State regulations recognize the diversity within assisted 
living by holding our profession accountable, and they are 
consistently updated to reflect the evolving nature of our 
sector and our residents.
    Meanwhile, Gardant is committed to exceeding the state 
requirements when we believe it is in the best interest of our 
residents. We will take memory care as an example and something 
that is top of mind for this Committee, as well as our 
residents and family. Every staff member at Gardant's memory 
care communities receive education and training in dementia 
related diseases, as well as training as a certified dementia 
practitioner.
    While elopements are rare, we all report to the state 
immediately, even something as technical as a resident walking 
out the door instantly returning with a staff member. We know 
they didn't leave our community and our staff immediately 
addressed the situation, but we still reported.
    The recent reports of resident elopements that were 
ultimately fatal are heartbreaking, and my thoughts and prayers 
go out to the loved ones of those residents. I serve in 
leadership positions on numerous national organizations 
dedicated to long-term care, and I know these tragic incidents 
are extremely rare and not indicative of the assisted living 
experience.
    The overwhelming majority of families and residents have a 
life affirming, safe experience. Assisted living providers are 
committed to upholding our policies and procedures, as well as 
continuing to learn all that we can about dementia care to 
prevent these incidents. It is critical that policies and 
regulations help protect residents while still supporting their 
freedom of movement and independence.
    Assisted living is a critical aspect of the long-term care 
continuum and dedicated to delivering person centered care to 
our Nation's seniors. We need collaborative, comprehensive 
solutions that ensure our ability as assisted living 
communities to continue doing what we do best, providing safe, 
quality care to our residents.
    From expanding more affordable long-term care options, to 
workforce programs, to addressing the growing caregiver 
shortages, these efforts could make a real difference.
    We must all work together to ensure current and future 
assisting living resident is seen, safe, and served to enjoy 
the highest quality of life possible.
    Thank you for your time and I look forward to answering 
your questions today.
    The Chairman. Thank you, Ms. Simpkins, for your testimony, 
and we will turn to our fourth and final witness, Mr. Mollot.

        STATEMENT OF RICHARD MOLLOT, EXECUTIVE DIRECTOR,

              LONG TERM CARE COMMUNITY COALITION,

                    NEW YORK CITY, NEW YORK

    Mr. Mollot. Good morning, Chairman Casey, Ranking Member 
Braun, and members of the Committee. Thank you for inviting me 
to testify today on this important issue.
    My name is Richard Mollot, and I am the Executive Director 
of the Long Term Care Community Coalition. LTCCC is a national, 
nonprofit, nonpartisan organization dedicated to improving care 
and quality of life for residents in nursing homes and assisted 
living.
    We conduct research on long-term care policies and the 
extent to which essential standards of care are realized in the 
lives of residents who are typically elderly and frail. In 
addition to conducting analysis and advocacy, we educate and 
engage residents, families, and those who work with them so 
that they are aware of their rights and are equipped to 
overcome the challenges that so many of our seniors face when 
they need residential care.
    Our interest in assisted living is long standing, and we 
appreciate your commitments to ensuring that the promise of 
assisted living is realized in the lives of our growing senior 
population.
    Assisted living emerged in the 1980's as an alternate to 
nursing homes for seniors who want or need to live in a 
congregate setting where they can get help with tasks like 
housekeeping, meal preparation, and access to activities and 
transportation.
    Over the last 40 years, three developments have drastically 
changed the nature and character of the assisted living sector, 
with both positive and negative implications. They are one, the 
needs and frailty of assisted living residents have 
dramatically increased.
    Two, assisted living operators have adopted increasingly 
sophisticated and large scale corporate models, including 
ownership by real estate investment trusts, private equity, and 
other sophisticated private investment structures, and three, 
public payment for and Government interest in assisted living 
has increased significantly. Assisted living facilities now 
care for people who in many ways have the same needs and 
vulnerabilities as nursing home residents.
    Assisted living residents are actually older on average and 
those in nursing homes. Approximately 40 to 70 percent of 
assisted living residents have Alzheimer's disease or some 
other cognitive impairment. Over half have hypertension.
    One third or more have heart disease or depression. About 
half need help with dressing and, or walking, and two thirds 
need help with bathing. Over 10 percent of residents with 
dementia receive antipsychotic drugs.
    Unfortunately, we as a country have failed to keep up with 
these trends. While some assisted living can be wonderful 
places to live and to work, too many take in or retain 
residents for whom they are unable to provide safe care and 
dignified living conditions. Too many residents and families 
are at risk for financial exploitation and even fraud.
    Too many seniors and families get taken in by promises of 
``memory care'' and aging in place, when in fact these are more 
often marketing terms than accurate representations of 
specialized care.
    The absence of any Federal quality of safety standards, 
coupled with the virtual absence of reliable public information 
on the quality, safety, and cost of assisted living, have made 
assisted living a sector ripe for investment by sophisticated 
private enterprises who can shuffle around resources and take 
profits, with little regard for the promises made to seniors 
and their family.
    These problems occur at every economic level, from $50,000 
a month or more paid to luxury assisted living, to the 20 
percent of seniors who access assisted living through public 
funds like Medicaid waivers. It doesn't have to be this way.
    Forty years ago, when nursing homes were in crisis, 
Congress took action. From numerous GAO reports to the growing 
chorus of local and national news reports of neglect, 
disastrous ``elopement,'' and financial shenanigans, it is 
clear that we have reached that point now with assisted living.
    We recommend three things. One, establish and implement 
national standards to promote quality, safety, and integrity in 
assisted living. Two, establish a national assisted living data 
base with information and metrics that the public needs to 
evaluate both costs and quality, and three, promote resident 
and family engagement to ensure that assisted living is truly a 
home and community-based service.
    As I mentioned earlier, assisted living experiences can 
range from positive to alarming, posing potential risks and 
exploitation. I think that we can all agree that the lives of 
seniors should not be left to chance, ambiguity, and 
insecurity. Thank you again for inviting me to testify today.
    The Chairman. Thanks very much for your testimony, and I 
will begin the first-round of questions, but I want to note for 
the record, we have Senators that are in and out because 
Thursday is a pretty busy hearing morning, and so, we will have 
Senators come here. Some will be here and then ask questions, 
and folks will be appearing intermittently throughout the 
hearing, but so far, I know that Senator Rick Scott was here, 
and Senator Blumenthal was here, and we will be awaiting others 
after my questions and those of the ranking member.
    I wanted to start with you, Patty Vessenmeyer, about your 
own experience, and I want to start by saying how much I 
appreciate--I know the Committee appreciates your willingness 
to share a personal story.
    That happens in hearings like this on a pretty regular 
basis, where an individual comes forward and talks about their 
own experience or that of their family, and from a distance it 
might seem easy, but I can't imagine how difficult it is to 
recount difficult, painful moments and doing it in the 
interest, of course, of helping others, so we are grateful for 
your willingness to do that, and telling your story is a very 
important part of the work we are trying to do together. I know 
that your husband was in an assisted living facility, and you 
were, as you indicated, paying privately for those services to 
make sure that he would get the care that he needed for 
dementia.
    I know I have heard from my own constituents back home 
similar stories. For example, Angela, who is a constituent of 
mine from Johnstown, Pennsylvania, Cambria County, out in the 
Southwestern region of our State. She wrote to me and said that 
her father was in one facility that charged $7,200 a month.
    I know that is not the average. It is very high. That works 
out to about $90,000 bucks a year, and Angela shared, and I am 
quoting her here, ``there was always a sense that no one cared 
for the residents beyond their monthly payments.'' That is one 
experience and that is one person's personal experience.
    Ms. Vessenmeyer, I wanted to ask, based upon your 
experience with your husband, did the facilities he lived in 
deliver on the care that they promised to provide?
    Ms. Vessenmeyer. Thank you, Senator. Thank you for 
appreciating me coming and doing this, and I think the good 
news is it has been six years, and I am able to do it without 
getting overly emotional.
    No, they did not deliver. They definitely over promised, 
and understand that they were absolutely a memory care 
facility, specialized in it, and knew what they were doing. His 
basic needs were not often met.
    You could hear from some of the examples that I gave, and I 
observed other people the same way. They would actually 
recommend that you pay an additional private caregiver to come 
in to give them the care they really should have gotten, but 
their staff was just--there just wasn't enough staff for them 
to get it done, and do understand that their staff was friendly 
and caring and they were wonderful people who were not trained, 
and they were just overwhelmed, but they definitely did not 
deliver, and by the way, it did come out of my pocket because 
my husband had chosen not to do long care insurance, and that 
number that the woman gave you was low. That was my starting 
figure, was $7,900. It cost me closer to $13,000 a month.
    The Chairman. We are grateful for you sharing your own 
story, your own experience.
    I wanted to, next turn to Richard Mollot, you mentioned the 
need for more substantive and meaningful ways for residents who 
might choose a particular facility or their families to know 
which services they receive, how much those services cost, the 
outcomes for residents living in a specific assisted living 
facility. For a family searching for care--and we hear about 
this all the time.
    I am not sure there is--doubt there is anyone in this room 
who doesn't know someone who has had the experience of having 
to search for care and to try to navigate it. It is obviously 
difficult to find the information that folks need about 
assisted living facilities, and sometimes they only have the 
word of an assisted living provider, or maybe someone else who 
has had their own experience they can rely upon.
    Can you elaborate more on the challenges that families have 
in finding both accurate information and unbiased information 
about services, about costs, about care outcomes for residents 
in assisted living facilities?
    Mr. Mollot. Thank you. Essentially, there is no 
independent, validated information on assisted living for the 
consumers, for policymakers, or for the general public, so 
families, as you noted, have to rely on facilities and facility 
marketing materials. They also quite often rely on companies 
like A Place for Mom and the other so-called consumer 
resources, excuse me, that are not independent of the industry.
    Companies like caring.com, A Place for Mom, that actually 
get money for--from facilities to be listed, so that is not 
independent either. That is not something that people can rely 
on as being necessarily an accurate information of what has 
happened, what they are going to pay for, and what they are 
going to get, and the state websites really are the last 
resource, and they tend to be very flimsy. I haven't looked at 
every single one, but the ones----
    The Chairman. They tend to be, you said?
    Mr. Mollot. Very flimsy, I am sorry.
    The Chairman. Flimsy. Okay.
    Mr. Mollot. Yes. Most often what we will see is they just 
list the facility. They may list the facility's administrator, 
their phone number, and the address. Sometimes there is a 
little bit of information, but you cannot, in my experience, 
ever get into finding out really what has--what the staffing 
is, what the costs are going to be, or what the quality has 
been and any issues.
    The Chairman. I know that in your--going back to your 
testimony, you mentioned the three recommendations. The first 
one was, establish and implement national standards to promote 
quality, safety, and integrity in assisted living. The second 
was establish a national assisted living data base. Is that 
what you are referring to?
    Mr. Mollot. Yes. Yes. Similar to care compare--you know, 
there is nursing home care compare, home health care compare, 
hospital care compare on the Medicaid website. There should be 
an assisted living compare.
    The Chairman. Well, I think--and look, I think it is pretty 
fundamental that people should have the opportunity to place 
reliance upon a source that is objective, and to use your word, 
independent.
    That is, I think that is true in any walk of life. Why 
would someone only--why should we settle for just relying upon 
assertions by those who are operating facilities?
    I think that is pretty elementary, but we haven't reached 
that point yet in terms of a change in policy. I know I am over 
time, but I will turn to our Ranking Member, Ranking Member 
Braun.
    Senator Braun. Thank you, Mr. Chairman. I want to start, 
first I want to ask Ms. Simpkins a question, but that idea of 
transparency and information, to me, I don't know how you could 
say that wouldn't be good.
    I have been a proponent since I have been here that this 
place out of focus as much on that as anything, because we are 
a portal of information that if you collate it properly, that 
would seem to make sense.
    I think that goes across the spectrum of health care as 
well. I have been the most vocal Senator that our health care 
system is broken. We do not have transparency. We do not have 
competition. It is kind of almost like an unregulated utility, 
and you get your bill at the--after you had a significant 
health care scrape or a bad accident. You got to hold your 
breath to see how much it is going to cost, or you can afford 
it. I like that idea.
    Ms. Vessenmeyer, you mentioned that it was $7,200 a month 
and it could have been more, and that is in Virginia, correct? 
Is that where the----
    Ms. Vessenmeyer. Yes, but that isn't the number that I gave 
you. That his room charge was $7,800 to--actually $7,900 to 
start, and it cost me close to $13,000 a month.
    Senator Braun. $13,000 a month, okay.
    Ms. Vessenmeyer. That is correct.
    Senator Braun. That sounds unaffordable, so.
    Ms. Vessenmeyer. If he hadn't passed away rather quickly by 
the time--the length of time he was in there, it would have 
used up all of my nest egg.
    Senator Braun. That is the kind of stuff I have been 
appalled by from the time I took on health care reform in my 
own business 15, 16 years ago.
    How lucky the industry would tell you it is only going up 
five to ten percent each year, you know, in your health care 
premiums. Sooner or later, people can't afford it and that has 
got--something has got to give.
    I was noticing in your background, Ms. Simpkins, you focus 
on low-income because some people are going to be able to 
afford it despite the quality of care and the level, but most 
people will not.
    In Indiana and the four other states where you operate, 
what would that range be per month as you would compare it to 
$7,000 to $13,000 bucks a month, and it seems like when it was 
all in, it was closer to that higher figure. Just curious.
    Ms. Simpkins. Yes. Thank you, Ranking Member Braun, and the 
range that a resident or resident family would pay under the 
home and community-based services is really nothing. In 
Illinois, there is a small personal portion.
    It is based on resident income and allowing them to do 
things and still have money in their pocket. In Indiana, there 
is no personal portion, so the State of Indiana will pay for 
those services through the State.
    Senator Braun. In your facilities, for low-income 
individuals, there is basically very little out of pocket?
    Ms. Simpkins. There is very little out of pocket. There 
might be some personal portion based on what they actually 
receive in income, but it doesn't go over what anything a 
Social Security amount is.
    Senator Braun. How much would you be able to generalize 
that across the rest of the country?
    Ms. Simpkins. To model that program? Oh, you can model the 
program.
    Senator Braun. Are other states doing that?
    Ms. Simpkins. There are other states that are doing it. 
Now, I will say that Illinois supportive living program and 
Indiana are probably--and Ohio are doing it really well, 
recognizing that there is a need within their State, there is 
an underserved population. There are people that cannot afford 
it, and so, that is what we were founded for. That is our 
business model is to say there is an unmet need and how are we 
going to do it, and we work with states that have the programs, 
Medicaid waiver programs in place along with rate reimbursement 
that makes sense.
    Senator Braun. Mrs. Vessenmeyer, you would not have 
qualified for any low-income opportunities then. Is that what 
kept you in that, what seems to be outrageous in terms of the 
cost per month?
    Ms. Vessenmeyer. That is correct, because even though we 
were both retired, they look at all of your savings, and if you 
have a decent IRA out there, that counts.
    Senator Braun. It begs the question then, is the low-income 
stratum across the country being served adequately?
    That almost would seem to be surprising to me if that were 
the case, but what we are seeing on the other side, and then it 
is a question, there just wouldn't be many families that could 
afford it, and you know, I don't know what the criteria or the 
cutoff is. Can you fill me in a little bit? It sounds like in 
Indiana, especially if there were other options to choose from 
other than just your organization, that the low to maybe middle 
income strata are being served well. Is that a fair statement 
or not?
    Ms. Simpkins. That is a fair statement, Ranking Member 
Braun.
    Senator Braun. Do you think that is the case across the 
country as well as you know, because you serve on some boards 
that--where I think you would have that information.
    Ms. Simpkins. It is not across the country. Nationally, 
there needs to be programs in each state to--to provide access 
to affordable assisted living, and they are not all there yet.
    Senator Braun. Generally--and that is at least a little bit 
surprising, and generally, it is a folks at the other end of 
the spectrum, the low and middle, especially low, that don't 
get adequate services.
    I think that is something that you need to get those 
practices spread out to where we at least can get that in most 
other states, and then you got to tackle something like this, 
that I don't know how wealthy you would have to be to be able 
to afford that easily and for a long time.
    Something has got to give there. I will rest with that 
right now, and I will have another round of questions if we do 
it.
    The Chairman. Thank you, Ranking member Braun. We turn next 
to Senator Kelly.
    Senator Kelly. Thank you, Mr. Chairman, and thanks to all 
our witnesses for being here today. Mr. Mollot, the Arizona 
Republic, the paper of record in my State, published a series 
of investigative reports last year about the State of long-term 
care facilities in Arizona, and these journalists spent more 
than a year on this investigation. They reviewed police 
reports. They reviewed footage in some facilities. They 
analyzed regulatory reports from the State, and they 
interviewed families and experts, and what they found was, I 
think it is fair to say, horrifying. They reported graphic 
stories of a resident dying after being attacked by a roommate 
who hadn't received her medication in time.
    Another report of an assisted living resident being 
sexually assaulted by another resident, and incidents of 
violence among residents that often aren't reported because 
they aren't required to be reported under state law, and they 
highlighted the failure of state agencies to investigate these 
cases in a coherent, transparent way that would allow families 
looking for a safe place for their loved one to know what 
really goes on in these facilities, and I think a lot of us 
knew there were issues in the system. We knew that.
    I don't think we knew how bad it was. Since these articles 
were published, Arizona's Governor has put together a strong 
legislative package to standardize inspections, promote 
transparency for residents and their families, and empower our 
adult protective services to investigate, and the State 
legislature is looking at proposals. Mr. Mollot, are these the 
type of steps that can help tackle these issues?
    Mr. Mollot. I believe so. I mean, of course it all--the 
details matter. This is a very nuanced issues about caring for 
people with dementia and ensuring that that things are reported 
appropriately and that there is good oversight.
    As much as possible, we would hope that the State would be 
looking to implement policies and practices that prevent bad 
things from happening, as well as, of course, ensuring that 
when they do happen that they are rectified and that they are 
reported appropriately.
    Senator Kelly. Arizona can't be the only State that is 
facing these challenges.
    Mr. Mollot. Not at all.
    Senator Kelly. Should the Federal Government maybe consider 
having a role here and providing oversight for assisted living 
facilities?
    Mr. Mollot. I think it is time for the Federal Government 
to step in. As I mentioned in my testimony, 40 years ago when 
nursing homes were in crisis, Congress stepped in. Congress 
took that, you know, initiated action, and we are here now with 
assisted living as well. The same population in terms of 
numbers of people are in assisted living as they are in nursing 
homes, but we don't know what is happening to them.
    We don't know the care they are receiving. A lot of it is 
private pay, not all of it, but there is unfortunately a lot of 
fraud.
    Senator Kelly. Apparently, more than 20 years ago, this 
Committee helped to facilitate the creation of an assisted 
living work group, which was made up of 50 organizations, and 
this work group was tasked with coming up with recommendations 
for best practices in assisted living facilities to ensure a 
more consistent quality landscape across states.
    The result was a 380 page report with a lot of 
recommendations, and these were hard to agree upon. Mr. Mollot, 
what has happened with these recommendations since this report 
was finished, if you are familiar with it?
    Mr. Mollot. I haven't read it in a long time, but I am 
familiar with it. Frankly, on the Federal level, nothing has 
happened.
    As Ms. Simpkins said, we do see some things going on in the 
states, but it is--generally speaking, the states are just not 
inclined, frankly, to take action on a lot of the work that 
they do.
    Hopefully they will be different in Arizona, but it really 
is time, I believe, for the Federal Government to step in to 
ensure that wherever someone accesses dementia care, that means 
something. It is not just a term of art, and wherever they go 
for safety, they know that they can live safely, and wherever 
they are going into, they know what the expenses are going to 
be, that they are cognizable.
    Senator Kelly. Well, thank you. I do want to note for my 
constituents a resource created by AARP Arizona and by the 
Arizona Republic following this investigative series that I 
mentioned. It is a backgrounder on long-term care, the 
definition--definitions of different terms, what family should 
look for, and what questions to ask, and folks can find this on 
the AARP Arizona website, and my office will be posting this on 
our social media accounts, and I am going to submit this for 
the record as well, Mr. Chairman, and I urge Arizonans or 
anybody else interested to check it out, and thank you.
    The Chairman. Thank you, Senator Kelly. That will be 
submitted--accepted for the record, not just submitted.
    Thanks very much. We will turn next to Senator Vance.
    Senator Vance. Thank you, Mr. Chairman. Thanks to you and 
the ranking member for hosting the Committee hearing today, and 
welcome to our witnesses. Thank you for being here, and welcome 
to all of our guests.
    I want to direct my questions to you, Ms. Simpkins, and I 
appreciate you being here. I am particularly concerned by some 
of the estimates that I have seen about labor shortages at our 
long-term care facilities.
    Not just now. I know there is sort of an immediate problem 
of not enough people at some of our elderly care facilities, 
but I saw an estimate that by 2030, we will need given--you 
know, obviously, people will retire, will drop out of the 
workforce, but then we also have changing demographics in this 
country.
    We are becoming older as a country. I read that we will 
need an additional seven million long-term caregivers at these 
elder care facilities. That seems like a shocking estimate to 
me. It is hard to imagine how we could possibly hire 
effectively one million additional people per year at these 
facilities, given the already existing labor shortages.
    I am curious if you think that estimate is within the 
reasonable range, and if it is not, how many more workers do we 
need over the next five to ten years?
    Ms. Simpkins. Thank you for the question, Senator Vance. I 
have not heard seven million. I have heard five million, but I 
can certainly I would be interested in your information, and I 
will follow-up and send you the information I have.
    In my response to that, we got hit by the pandemic really 
hard. Health care workers left, and they are never coming back. 
They said this was hard and we are not going to do it, and we 
have had to recover, and assisted living has recovered pretty 
well. What we also need to do is we need to build for this 
aging--our workforce is aging out and our seniors are aging, 
and we are doubling and tripling numbers when we get to 2040 
and 2050, and so, having a really intense effort and what that 
means to both recruit and retain, and if you don't mind, I 
would like to share just quickly what we are doing.
    Senator Vance. Sure.
    Ms. Simpkins. From a recruitment standpoint--so that is how 
we recovered. We were able to get really creative. We looked at 
people and said, what do you need? What is it going to help 
your household?
    We knew we needed to increase wages, so even in an HCBS 
environment, you can have rate methodology that allows you to 
pay a living wage and higher than what a minimum wage is, and 
then we looked at retaining because, you know, as people--
people come into the assisted living, and they stay because 
they are so passionate about it, and in honor of their passion, 
we need to create something for them. What we do is from the 
first interview, we asked them what they envision six months 
from today, one year from today, three years from today.
    We want them to envision a future with us and at least a 
future with the assisted living industry, and then we have to 
meet that need by career pathing, career net mapping, and what 
we have--so we have done a lot of that and what we have 
realized through those interviews and people saying, this is my 
career path, is we also need to skill path.
    We need to provide them with the resources, whether it is 
through a nursing grant, is through additional education that 
we are reimbursing them for, additional training that they 
need, so if you are going to commit to working within this 
space in a workforce, you also need to create and having a 
workforce that has continued to be passionate, make a living 
wage, and have the tools they need, and they will want to stay.
    Senator Vance. Got it. Appreciate that. You know, one just 
additional thought here is, you know, you hear about these 
cases of elopement at some of our eldercare facilities and they 
are mercifully rare.
    You know, we have close to a million Americans in elder 
care facilities right now. You know, maybe 2,000 or so 
elopements happen per year. That is a small number, but that 
is--I worry, with increasing labor shortages, whether that 
number goes up.
    I have heard some suggestions that you could fill the labor 
shortage gap by expanding certain immigration programs, certain 
visa programs, and the one worry that I have there, of course, 
is that, you know, if you take a person caring for an elderly 
citizen, you want to make sure there is not a language barrier 
there, especially with people who are going through dementia 
and might be, you know, losing some of their cognitive 
capacity.
    We really have to wrap our minds around this. I appreciate 
the work that you are doing on this, and I appreciate your 
answer to the question, but are you worried that we might see 
an increase in elopements over the next few years, or do you 
think not?
    Ms. Simpkins. We need to plan for how our seniors are aging 
and the additional care needs, and we do that through person 
centered planning.
    I believe Dr. Kraft Morgan mentioned that our person 
centered care plans revolve around what a resident needs, 
because and to Patricia's point too, somebody can have the same 
diagnosis and their needs are completely different, and if you 
are not having person centered plan for that individual, which 
is collaborative with their family, with the resident when--as 
much as they can participate in it, with their caregivers, you 
are not going to have the best plan to keep them as safe and 
secure as you possibly can.
    On the immigration side, I would--you know, there is an 
opportunity here with unused visas to at least start bringing 
in--if you think about the workforce, start bringing in some 
health care workers.
    Senator Vance, to your point, there are some markets 
within--that we are within, that have the residents who also 
have language barriers. Having staff who speak Spanish, we have 
staff that speaks Polish based on where the neighborhoods are.
    Senator Vance. Yes. Thank you. Thank you, Mr. Chair.
    The Chairman. Thank you, Senator Vance. Senator Ricketts.
    Senator Ricketts. Thank you, Mr. Chairman. Again, thank you 
to all of our folks here that are testifying. Appreciate you 
taking the time to help us out here today. I represent the 
great State of Nebraska.
    In Nebraska, we have nursing--skilled nursing facilities 
and assisted living facilities that are scattered throughout 
our State, and it is incredibly important to take care of the 
20,000 people who require care in the 500 different facilities 
that we have, and they can get that care for about $3,875 a 
month.
    Anybody who is providing assisted living services in the 
State of Nebraska that has four or more residents is designated 
as an assisted living facility that is regulated by the State 
and is licensed.
    While I was Governor, I signed into law an Assisted Living 
Facility Act to update the standards and the requirements that 
we have for our assisted living facilities. They are just 
absolutely critical, especially in rural parts of Nebraska, and 
to be able to help take care of people, and we want to make 
sure that we continue to have that service for our folks.
    Ms. Simpkins, as you know, assisted living facilities, as I 
mentioned, are a regulated at the state level, which allows 
states, you know, flexibility to be able to be responsive to 
local consumer demands.
    Are there any states in particular doing an exceptionally 
good job that we can draw lessons from? States you say, hey, 
they have got some good programs or things that we should be 
adopting across the country?
    Ms. Simpkins. Well, I can speak for the states in which we 
operate. Illinois, Indiana, and Ohio have exceptional programs, 
and with that, Senator Ricketts, one of the things we noted in 
reporting--all of those states will require reporting of any of 
the incidences that were talked about previously.
    Senator Ricketts. Are there other characteristics though 
that you think has led, or some of the approaches that you say 
that these states are doing a good job. What are they doing 
right?
    What are the things that--so you mentioned the reporting. 
That is obviously an important factor. Are there other things 
that they are doing that you say, hey, this is why they have 
such good systems.
    Ms. Simpkins. This is why there is a good system, because 
we have access within a state, in a state that is--where 
assisted living is regulated under the state.
    I am going to talk particularly about home and community-
based service, access to the regulators, access to families, 
access to everybody who--you know, you have this local model 
that can create and innovate and come up with best practices.
    I am a big proponent, let's share our best practices 
because there is nothing proprietary when it comes to caring 
for a senior and caring for somebody, and that is what those 
states are doing well.
    My fear is, if you move those conversations further away, 
we will no longer have those things. The states in which we 
serve, and I will talk about Indiana specifically, the state 
program, Medicaid waiver program and regulations are really 
dynamic.
    They promote and encourage having a local model where there 
is collaboration and there is innovation, and that is where we 
come up with best practices, so that--I would say that that is 
also a model.
    Senator Ricketts. Great. Well, hey, thank you because that 
actually leads into another question I had then. Last May, this 
Committee held a hearing that highlighted the strained nursing 
home inspection system.
    As you know, nursing homes are regulated at the Federal 
level and--are heavily regulated by the Federal level. Anyway, 
so if assisted living facilities are subjected to the same sort 
of one size fits all Federal type regulation, what can we do as 
lawmakers to ensure that assisted living facilities don't have 
the same sort of problems we are seeing in skilled nursing 
facilities? How do we protect that, what you talked about, that 
local model and best practices?
    Ms. Simpkins. Well, from the state level, we encourage all 
of the states, so the things that we were talking about, if we 
even just talk about reporting in the--reporting of those 
critical events, reporting those up through the Federal 
Government.
    Under the HCBS services, each State has really an 
obligation to report up in order to continue to have their 
federal funding. They also are well aware of the transparency 
that comes from and the opportunity--once those things the 
states report up, we have a transparency and the opportunity to 
see what home and community-based services are doing across the 
Nation, and we will have a window and more models that we can 
see, because I am sure there is more states that are doing it 
well. I just can't speak to those today.
    Senator Ricketts. Getting back to the idea of like if you 
have the Federal Government that is regulating those things, 
how do we preserve that ability of local folks to be able to 
really tailor how they are doing the regulation to make sure 
that we are not pushing a one size fits all answer?
    Ms. Simpkins. You know, there has been--we need to--from 
our perspective, we need to tell our story much better. There 
are really good stories to tell from a state perspective on our 
home and community-based services, and we need to do a better 
job of talking about those stories and the things that are 
going on within the states.
    The innovation that has happened. The times providers have 
been asked to sit at a table before there is a rule change and 
not just ask for comment, but sit face to face with somebody 
and say, if this rule changes, how does it impact the resident 
that you are caring for and your workforce who is caring for 
that resident.
    Senator Ricketts. Right. That interaction with--direct with 
the people who are doing the job----
    Ms. Simpkins. Yes.
    Senator Ricketts. Before rule changes are made with the 
regulators so that we don't have unintended consequences with 
regard to the rules that are made that will harm the care that 
is being delivered in assisted living facilities. Is that fair?
    Ms. Simpkins. That is fair, Senator. I like the way you put 
that. Thank you.
    Senator Ricketts. Great. Thank you very much. Appreciate 
it. Thank you, Mr. Chairman.
    The Chairman. Senator Ricketts, thank you, and we will turn 
next to Senator Warnock.
    Senator Warnock. Thank you so very much, Chair Casey. I 
would be remiss in this moment if I didn't just take a moment 
to remember the legacy of the late first lady, Rosalynn Carter, 
whom I was privileged to know and whose mission was to center 
and uplift our caregivers.
    Her extraordinary work demonstrates how a health care 
system that leaves so many drowning in caregiving costs, costs 
most of us will one day face, is a health care system that 
falls short of its basic obligations.
    Dr. Morgan, in your experience as a gerontologist, how does 
the cost, the cost of assisted living burden seniors, their 
caregivers, and their families?
    Dr. Morgan. Well, the cost of assisted living is both 
financial and emotional and real for many, many Americans.
    We have a system where there is not access to assisted 
living. In some states, there are Medicaid waivers that cover a 
larger portion of those who need it at the lower income, but 
there are also states that have virtually no waiver programs so 
that the only people that can afford assisted living are those 
who have those significant financial resources.
    The middle tier of America tends to do things that I talked 
about in my testimony. They reduce their working hours. They 
set up these arrangements across families to pay for assisted 
living, if that is what they can do.
    They bring in people who may not be trained to support 
their person living at home. They make these precarious work 
and family arrangements to be able to make it through whatever 
long-term care they have for their loved one.
    If they are lucky enough to get into assisted living, then 
they are still coming after work and they are still bringing 
the incontinence supplies, and they are still bringing the 
snacks and engaging the residents.
    It is another job on top of the job that they are trying to 
do if they are still working, if they are still able to work, 
and that is really important in young onset dementia as well, 
because in young onset dementia, these people are still 
earning, right, and they have young onset dementia and then the 
families have, very few options for thinking about their 
forward retirement, right.
    Retirement isn't what we end up doing. We end up mortgaging 
everything to do the care and to, you know, clean out our 
savings in order to support this person living with dementia 
who may not be able to be at home. A lot of the young onset 
dementias have the sorts of things that Patty was talking about 
with Lewy Body dementia and front temporal dementia.
    We have a different course of the disease, and it is really 
difficult for people to care for those folks at home, and so, 
even if they are able to afford assisted living for a time, 
they run out of resources, and then what do they do?
    Sometimes they can get into nursing home placement, and 
sometimes there is good nursing homes to go to, but not always. 
It is awfully precarious for many folks.
    Senator Warnock. Well, thank you. Your experience with this 
underscores the ways in which this cost not only to families, 
but all of us.
    It has implications for our workforce and our economy, and 
so we have to have long range, comprehensive thinking about 
this. The chair has been a leader in this, and I am happy to 
join him, I was happy in joining him, to ask that the GAO look 
into how Federal health care affordability programs like 
Medicaid and Medicare, which you mentioned, interact with 
assisted living facilities, how we can do better there, and 
whether families choose an assisted living facility or in-home 
care, they need help meeting caregiving cost. The average cost 
of $4,500 a month, that is an average cost, but you rightly 
point out the ways in which, for example, with early onset 
dementia, people's retirement funds actually drain just taking 
care of the individual, and that is why I support efforts to 
lower caregiving costs for aging adults. It is a critical issue 
for our country, and I will continue to work with my colleagues 
on this Committee, informed by the expertise of people like all 
the folks on our panel, to improve access to long-term care for 
families across Georgia and across the country.
    Thank you so much for your work in this area.
    Dr. Morgan. Thank you.
    The Chairman. Senator Warnock, thanks very much for your 
questions, and we will now move--a little bit out of order, we 
will move to a second round as we are waiting for Senators to 
ask their first-round questions, some of whom are on their way.
    I will start. I know Ranking Member Braun had some 
questions as well. Dr. Morgan, I will turn back to you. Your 
testimony provided a helpful overview of the importance of 
well-trained staff in assisted living facilities.
    We heard that direct care staff can have as few as six or 
eight hours of training only before beginning their care 
duties. They might be responsible, in some cases, for 20 or 
more residents.
    My--the constituent of mine that I mentioned earlier, 
Angela, said in part when she wrote to us, ``when I mentioned 
my concerns about my father falling repeatedly, a facility her 
head nurse said, ``falls are just part of aging.''"
    I would ask you, Dr. Morgan, are falls and other accidents 
in assisted living just part of aging, or are there procedures, 
strategies, rules that can be put in place to address the risks 
that older adults face?
    Dr. Morgan. Falls is a really important topic in aging. 
There are a lot of great tools that people can use. The 
National Institutes of Health has a great flier on this topic, 
six tips to help prevent falls. Falls is about--it is about 
prevention.
    Educating AL staff on fall prevention is vital. There are 
plenty of environmental audits that can be made, and some of 
these--some ALs have this training in place, but certainly it 
is an important aspect of initial and ongoing training that the 
AL workforce should do.
    The other thing that is tricky about falls is that there is 
a fear of falling that has a real impact in whether you are 
going to fall, and a fear from families who are scared that 
their mom or dad are going to fall, and one of the things that 
my father would say to his patients is if you don't use it, you 
will lose it, and in aging, it is important to keep up with 
balance, and balance exercises, and keep with strength training 
and doing those sorts of activities, and certainly, assisted 
living in other places could do that to really help with 
improving balance, because we know that balance is really 
important in terms of predicting mortality, and so, if we think 
about it and we support false prevention, that is what we--can 
really make a difference, and that is also educating families, 
that, you know, if you use your assisted devices, if you get up 
slowly, if you manage your medications, it make sense to really 
think about falls prevention, because a fall can really have an 
impact on the trajectory of aging for sure, and it is really 
important that long-term care take that seriously.
    The Chairman. Doctor, thank you so much. I am going to cut 
myself short here. I have a little bit of a jump ball between 
Ranking Member Braun's second round question and Senator 
Warren's first-round question. I think I will start with 
someone who is arriving.
    Senator Warren. I will yield to the Ranking Member.
    The Chairman. Thank you, Senator Warren.
    Senator Braun. That is very gracious. I will actually yield 
back to you since you haven't done it, so. I will be here at 
the tail end.
    Senator Warren. All right. Well, thank you both, and thank 
you for holding this hearing. I appreciate that we are having 
this hearing. I appreciate your leadership on ensuring quality 
care for seniors in assisted living facilities.
    This issue is not a new one for me. In July 2020, my office 
released the findings from the first national survey of COVID-
19 in assisted living facilities, revealing that about 7,000 
residents had died from COVID in just the first half of 2020.
    In many ways, the threat of COVID in assisted living 
facilities was just as serious as it was in nursing homes, but 
these facilities received little help and little attention. 
Now, before that, in 2018, I released the first ever National 
Assessment of Quality Care Issues in Assisted Living 
Facilities, which was completed by the Government 
Accountability Office at my request.
    That report revealed that over 20,000 serious health and 
safety problems occurring at assisted living facilities in just 
22 states, from physical assaults to medication errors, to 
unexplained deaths. In the years since my office did that work, 
new studies have revealed additional problems in assisted 
living facilities.
    Mr. Mollot, you lead the Long Term Care Community 
Coalition, which is dedicated to improving the quality and 
accountability of senior living facilities. Can you say a word 
about what kinds of threats seniors at assisted living 
facilities face, and how serious the risk is?
    Mr. Mollot. Thank you. I think there are two major risks 
and both of them are serious. First, due to the increasing 
needs and vulnerability of people who go to assisted living, 
the risk of harm has gone way up.
    People are vulnerable. People are depending upon assisted 
living for significant dementia care, etcetera, and we just 
don't know if they are getting it, and we often don't know when 
terrible things happen, as you noted from that GAO report, 
which was so important.
    Second, due to the increased sophistication of operators, 
we have private equity, we have real estate investment trusts 
that are circling around this industry. The risk of financial 
exploitation has gone up tremendously in recent years.
    Senator Warren. You know, and your keyword, we just don't 
know. These are serious problems that have been going on for 
years, but we hear so much less about what is going on in 
assisted living facilities than we do in other facilities like 
nursing homes.
    Mr. Mollot, why do you think assisted living facilities 
receive so much less attention than, say, nursing homes?
    Mr. Mollot. It is a really interesting question. If I may, 
I think that, you know, in the 70's and the 80's, we had some 
tremendous scandals in the nursing home world, and that led 
Congress to pay attention and finally to take action.
    I think that is where we are with the assisted living now, 
is that we are hearing more and more of these stories. The GAO 
reports of 1999 and the more recent report that you mentioned. 
Washington Post and Times reports that Senator Casey mentioned. 
Local news reporting from around the country.
    Over and over, we are seeing that these issues are coming 
up, and now is really the time to take action.
    Senator Warren. With nursing homes, we put in Federal 
standards on this, got more Federal oversight, but assisted 
living facilities are governed by a patchwork of state laws 
without any meaningful Federal oversight, and that means no 
national standards that assisted living facilities are expected 
to meet. That is particularly worrisome because private equity 
firms and real estate investment firms rates have gone on a 
buying spree of senior and assisted living facilities. We know 
how their model works.
    Private equity comes in, strips the assets, cuts the staff, 
and sends the quality of care down the tubes. Mr. Mollot, your 
organization has looked carefully at the data, and you have 
heard from the residents of these facilities. When private 
equity comes into an assisted living facility and slashes jobs, 
what impact does that have on the residents?
    Mr. Mollot. Well, workers are the most important component 
of care in any setting, especially in nursing homes and 
assisted living, so that could be devastating for residents, 
but we know, I mean, unfortunately, we don't have a lot of data 
directly on assisted living, we have some on senior care in 
general and of course on nursing homes and other care settings. 
We know that when private equity comes in to a sector, they 
often pillage it.
    Senator Warren. Yes. In other words, more people will 
suffer when private equity comes in. We need to do more here. 
At a minimum, the Biden Administration should require 
additional reporting on problems at living--assisted living 
facilities. In fact, that is a priority recommendation from the 
2008 team GAO report.
    While CMS is making progress on implementing this 
recommendation, they should finalize it quickly. This has gone 
on long enough without oversight, and Congress must look at 
ways to improve accountability, transparency, and quality of 
care in assisted living facilities.
    Again, I want to say to the chair and to the ranking 
member, thank you for holding this hearing, and to the ranking 
member, thank you for graciously letting me do this. I am 
trying to cover two hearings simultaneously, and I appreciate 
you letting me ask these questions. Thank you all for being 
here.
    The Chairman. Thank you, Senator Warren and Senator Braun 
is again seeing to a colleague, Senator Fetterman.
    Senator Fetterman. Thank you, Mr. Chairman. Again, a credit 
to--Senator Warren. That is--outstanding questioning as well 
too. All right, anyway, thank you. Ms. Simpkins, your website 
states that your company's operating margins are consistently 
among the top in the country.
    I understand that your company manages upwards $700 million 
from the low-income housing tax credit program, and a majority 
of your residents rely on Medicaid through Medicaid waiver. Ms. 
Simpkins, is it fair to say that, you know, your company is 
viable because of Government subsidies?
    Ms. Simpkins. Thank you for that question, Senator 
Fetterman. It is available for a few reasons, and what is--
because we do have investors, and we are grateful to those who 
want to invest in affordable assisted living across the 
country, otherwise we would not be providing to almost 6,000 
seniors today who are in Medicaid waiver.
    We also need a viable business plan, and it needs to be a 
business plan. When you talk about on the website, when it 
talks about our margins, our margins as compared when you look 
at affordable housing across the continuum, and it is because 
of our investors that we are able to have margins that we 
continue to do, like certified dementia practitioner training 
and give education reimbursements and get--you know, look into 
different workforce opportunities, and the third thing that 
happens in a viable business is you have to have a service 
plan. You have to have a service plan that is going to--it is 
focused on quality outcomes, and it is focused on high resident 
satisfaction, and it is focused on high employee satisfaction, 
and what you will see in our website, and thank you for 
noticing that, because what we are we doing our website, and I 
will be glad to send you a link as soon as it is done, because 
we are going to start posting our quality outcomes and our 
residents and employee satisfaction results, and that should 
probably be in March, so I will send you a link.
    Senator Fetterman. No, yes, of course I would be grateful, 
and also, true, I am glad that there are investors, and they 
are a critical part of it, but I think we are able to--it is 
safe to say that the subsidies from the Government is also very 
part--it is important too, right?
    Ms. Simpkins. It is definitely important. We need both to 
have a viable business.
    Senator Fetterman. Yes, and that is not a criticism or an 
attack. I am just wanting to establish that, so but you know, 
given the Government's undeniable role in this, in your 
operations, why do you believe that a company should not be 
able to use Federal dollars to make a profit?
    I don't judge anyone, of course, you know, or earning a 
profit, but if you are making that kind of a profit, you know, 
but at--maintaining at the same time the Federal care standard.
    Ms. Simpkins. Thank you for the question, Senator. You 
know, the Federal funds go into the state, and the state then 
decides and what that program is going to look like and what it 
is going to be.
    The opportunity at the state level is that we can have 
conversations with our state regulators and improve upon 
practices, share best practices across the continuum. I know 
Senator Warren mentioned the 2020 report that she had on COVID, 
and we were part of that report, and our outcomes were really--
you don't want anything to happen, but outcomes are really good 
in comparison to others, and we relied heavily on the state 
regulators and the resources within the state to help coach and 
educate and resource and everything we needed to do. I don't 
believe it could have happened at the Federal level, the amount 
of attention we were able to get from the state.
    Senator Fetterman. Sure. I want to be very clear that if--
earlier, of course, that we count on other investors to allow 
you to operate.
    I don't have an issue with you, you know, generating a 
profit. I mean, that is one of the reason why people are in 
this, and of course, it is--in fact, that is why it works, and 
I am grateful that it is, and really this line of questioning 
wasn't an attack or isn't anything other than just to just 
establish that because we are partnering through the kind of 
subsidies that we really--I think we should maintain those 
kinds of Federal standards as well, too, and because all of 
them are--they combine together to allow this to work and to 
provide that kind of--very important kind of a service, and 
that is really--do you--would you agree with that?
    Ms. Simpkins. They are providing a very important service, 
and Senator, I actually appreciate your line of questioning, 
because if we didn't have these kinds of discussions and even 
differencing in opinion--opposing views and different views, 
that is where great ideas come from and that is where 
improvement and evolution comes from, so I do appreciate your 
questioning today.
    Senator Fetterman. Okay and thank you.
    The Chairman. Thank you, Senator Fetterman. We will now 
turn to Ranking Member Braun.
    Senator Braun. What we have just been hearing here is just 
what I like about a committee like this. You are hearing a 
broad array of viewpoints. I have--health care has been 
something I wrestled with long ago, and the whole spectrum from 
early childhood through when you are needing to look at how you 
are going to spend your last years, it has been cloaked behind 
closed doors. Large insurance companies and hospitals where we 
spend most of our money on the way to maybe a nursing home, 
assisted living, or if you are lucky enough to live out in your 
own abode, it has got to be swamped with transparency and where 
we can see.
    Ms. Vessenmeyer's story, how can something like that 
happen, and that was in Virginia, when we are hearing $3,800 a 
month in Nebraska. Every state is going to have a different 
cost of living, a different cost structure, but that idea, Mr. 
Mollot, of a transparency portal and at least some things that 
are going to make it easier to shine the light on issues that 
are out there. To me, when you are against that, you are just 
trying to hide something.
    For instance, on the bigger picture, and this is an 
interesting combination of individuals, myself, Senator 
Sanders, Senator Grassley, Senator Smith, Senator Hickenlooper, 
it is two Republicans, three Democrats. I have been working on 
this since I have been in the Senate. Competition and 
transparency.
    If you want to be in the biggest part of our economy, 
health care, and especially at the tail end of our lives, be 
out there, be open. Ms. Simpkins, I was wondering, because you 
have done a good job, and like Senator Fetterman said, your 
payor is coming through either State or Federal Governments, 
and you are aimed at low-income.
    What is your cost, roughly, to do what you are doing, 
across those five states? Because we heard $3,800 here. I just 
asked my staff, so maybe closer to $4,500 in Indiana per month. 
What are you finding? You are servicing low-income residents, 
so what does that cost structure look like?
    Ms. Simpkins. Thank you for the question, Ranking Member 
Braun. I am trying to----
    Senator Braun. That would just mean in terms of your--you 
have a business----
    Ms. Simpkins. Yes.
    Senator Braun. Without giving any trade secrets away, what 
does it roughly cost in those states to provide a service? Your 
payor is mostly from Government. In the case over here, didn't 
have that advantage, and you saw what happened, and that was in 
a state like Virginia, which I would have thought would have 
been maybe moderate on costs.
    Ms. Simpkins. Yes. The thing I am struggling with is--and I 
certainly agree with the transparency. Those are things that we 
are going to be showing all the conversations here today of, 
you know, the cost of care and making sure there is no hidden 
fees. The expense side, what I am struggling with is the 
expense really depends on the state in which you are in. I 
would certainly be willing to----
    Senator Braun. Let's just pick Indiana then. Keep it 
simple, and then, what do you charge the Governments that end 
up paying you mostly?
    I am going to get an idea of what the variation is in cost 
across this country, and then that whoever is in any component 
of health care should be always willing to make it easy for us 
to understand, and on health care that leads up to assisted 
living or nursing homes, it is terrible. In in my own business, 
I tried to create health care consumers so you can actually 
manage your own well-being, and even when I attempted it, it 
wasn't easy, but we did it.
    Ms. Simpkins. Okay. Thank you for the clarity. The cost of 
care, if we were looking at Indiana specifically, and I think 
the best gauge is probably, you know, our operating margin 
because the cost of care of insurance and workforce--and 
insurance cost have going up 15, 20 percent, and sometimes it 
is, you know--a little bit higher in a, you know----
    Senator Braun. You can give me a range too.
    Ms. Simpkins. I can give you a range, yes, so the operating 
margins are going to be, you know, roughly between like 20 and 
28 percent. When everything is considered, that is also a debt 
load----
    Senator Braun. That is operating margins.
    Ms. Simpkins. Yes.
    Senator Braun. I am talking about what the Government ends 
up paying per month.
    Ms. Simpkins. I would be glad to send that to you, Senator 
Braun----
    Senator Braun. Well, you can get that to me, and I don't 
want to----
    Ms. Simpkins. Yes, I don't have that--I don't have the 
exact--yes----
    Senator Braun. belabor the point, but just the difficulty 
of this, and you guys are doing a good job by all standards. We 
have got to have transparency across the spectrum of health 
care, and when you get to the tail end of life, I think as 
important as it is, along the way, and until the industry and 
everyone in health care embraces transparency and competition, 
don't be surprised if there is going to be more of an interest 
to show how to do it from the Federal level. I am a believer 
that that generally isn't necessarily a solution. It can end up 
even costing more.
    Unless you at least embrace what is done in all other 
industries, which is make it easy for people that want to buy 
your services know what it is going to cost, embrace 
competition, don't try to keep people out of the business, you 
are never going to find solutions in health care. It is now up 
to 20 percent of our GDP.
    You know, as recently as three or four decades ago, it was 
only five percent of our GDP. It is breaking the bank even 
through the programs we offer here that elderly depend on, 
Medicare and Social Security on their retirement. Something has 
got to give.
    Ms. Simpkins. Okay. I understand, Senator. I will send you 
that information. It is not that I am not willing to share it. 
I am willing to share it wherever you want to share it. I just 
don't want to misspeak on what those numbers are.
    Senator Braun. I respect that. Thank you, and thank the 
other panelists for enlightening us on this subject.
    The Chairman. Thank you, Ranking Member Braun. We could 
spend a lot more hours, obviously, on these issues, so we are 
grateful for all of you helping us. I will have a closing 
statement and I will turn to Ranking Member Braun, and then we 
will wrap up. I know a vote is--if it hasn't started, it is 
about to start, but as we heard today, assisted living 
facilities are at a--or right now are growing piece of the, 
excuse me, the long-term care continuum, but more work is 
needed to ensure these facilities are quality facilities, that 
they are safe, and that costs are transparent and clear to 
families.
    As Ms. Vessenmeyer stated in her testimony today, assisted 
living facilities must provide what older Americans need to be 
safe and to be healthy as they age. This hearing has 
demonstrated that assisted living facilities face similar 
challenges to other long-term care options, including 
maintaining a well-trained workforce, providing safety, high 
quality services, and being affordable.
    Throughout my career, I have been working to improve care, 
to improve transparency and quality throughout the long-term 
care sector. We have a responsibility to make sure every 
American can age with dignity in a safe place of their 
choosing. That is why I have worked with my colleagues to 
expand access to home and community-based services, improve 
nursing home oversight, and strengthen the long-term care 
workforce, and now, we are going to continue our work on 
assisted living. As this sector grows, we must work to provide 
similar protections and safeguards that are in place for 
residents and their families as we have all strive to in the 
nursing home context.
    We also want to ensure that any facilities and corporate 
owners that violate the trust of American families are held 
accountable. I look forward to working with my colleagues to 
ensure everyone who needs long-term care has safe and 
accessible options.
    One way we will do that is to determine what the costs of 
assisted living are to families and how Federal dollars are 
being used. To ensure these funds are being used responsibly to 
pay for quality care, along with all of my Democratic Aging 
Committee colleagues, we have sent a letter to the Government 
Accountability Office asking them to conduct a study of 
assisted living costs and how available and transparent that 
information is to families, and as I said in my opening 
statement, I want to know more about what people are paying for 
assisted living and to have people tell their stories, as we 
heard some of the stories today.
    Again, we will be asking people from across my home State, 
as well as the country, to share stories and to share your 
bills with us, if you would want to do that. We want to hear 
from you about the true cost of assisted living and understand 
whether families have the information, the information that 
they need to make this difficult financial and health care 
decision for a family member and for the family.
    I will turn to Ranking Member Braun now for his closing 
remarks.
    Senator Braun. Thank you, Mr. Chairman, and thank you again 
to all the witnesses. This Committee is unique in that you 
really can't craft legislation out of it. A lot of it, though, 
from this discussion happens through other committees, so 
always keep that in mind.
    We heard how critical it is that Federal policies support 
the caregiving workforce. Senator Vance pointing that out. Back 
in Indiana, I mentioned how workforce in general has a lot to 
do with our school systems, making sure that they emphasize 
career and technical education along with four-year pathways, 
because not like in--across the country, maybe a third of jobs 
need the four-year degree, and we need a better high school 
education for many of these issues so we can hit the ground 
running. It should be policies from here, I think should focus 
on boosting workforce. I think we all kind of agree on that.
    Many bills are out there to do that, and to make careers in 
health care easier to attain. Got to make sure you don't work 
at cross-purposes. Like, some of the policies that are going 
through the labor agencies and that side of it that are wanting 
to get--make it harder for independent contractors, for 
individuals where a lot of this assisted living help comes 
from, so, we want to make sure we don't work at cross-purposes. 
We also heard how states and the providers themselves are doing 
things. Sadly, though, not all states seem to be doing it well 
because you cannot have many instances of that and say that you 
got an industry that is working. That should be the rare 
exception, never the rule, and then, when we are talking about 
how this place actually helps. When you are promoting 
transparency, it can bring on partners together. I have seen 
that. Two ends of the spectrum because no one should ever be 
against being able to have more information to make a good 
decision.
    When it comes to standards, I think that is important, data 
bases. That is all something we can do, share it with all the 
states. I think those are good ideas. I am encouraged by the 
conversation we have had here today.
    That is how you get better ideas, really good practices. 
This should be something--whoever is doing it the best, you 
need to shout it out so that the rest of the country can 
participate in it. Thank you again. Thank you, Mr. Chairman.
    The Chairman. Thank you, Ranking Member Braun. I wanted to 
thank again our witnesses for contributing both their time and 
their expertise, and of course bringing your own personal 
stories, your own personal experience to this issue.
    If any Senators have additional questions for the witnesses 
or statements to be added to the hearing record, the record 
will be open--kept open for seven days until next Thursday, 
February the 1st.
    Thank you all for participating today. This concludes our 
hearing.
    [Whereupon, at 11:42 a.m., the hearing was adjourned.]



      
      
      
      
      
      
      
      
      
      
      
      
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                                APPENDIX

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                      Prepared Witness Statements

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                 U.S. Senate Special Committee on Aging

 "Assisted Living Facilities: Understanding Long-Term Care Options for 
                             Older Adults"

                            January 25, 2024

                       Prepared Witness Testimony

                          Patricia Vessenmeyer

Good morning, Chairman Casey, Ranking Member Braun, and members 
of the Senate Special Committee on Aging. My name is Patricia 
(Patty) Vessenmeyer. Thank you for allowing me to share this 
testimony of my experience with assisted living for my husband, 
John Whitney, during his journey through middle-stage dementia. 
I will focus on my experiences and observations that I believe 
are most relevant to your national focus.

In 2013, my husband was diagnosed with Dementia with Lewy Body. 
Although this dementia is like Alzheimer's, it manifests itself 
a bit differently and it is important that caregivers be 
informed and trained to ensure the comfort, safety, and 
security of their patients. Some key symptoms are loss of sense 
of smell; REM sleep behavior disorder (RBD) which causes 
individuals to violently act out dreams, often falling out of 
bed, visual hallucinations, marked fluctuations in attention 
and alertness; and gastrointestinal issues including severe 
constipation, all of which my husband experienced. Loss of 
memory occurs much later in the disease process.

I took several free courses on caregiving for individuals with 
dementia, including a "virtual reality dementia experience" 
which helped me to understand the challenges that people with 
this disorder face, and most importantly, why they become so 
fearful and combative. I mention this to provide a basis for my 
ability to recognize problems with care. These same courses are 
offered for professionals at a reasonable cost.

In June of 2017, when John's disease was progressing more 
rapidly, I moved to Virginia to be near family. I cared for him 
at home until January 26, 2018, when he attempted to strangle 
me in my bed. The State determined that John should be placed 
in a long-term care facility. I found him a room in an assisted 
living facility in Warrenton, VA that specialized in memory 
care. He moved in the first week of March 2018. I provided the 
management team with John's history, his diagnosis, and disease 
progression.

The following is a list of issues I observed in the memory care 
unit during my daily visits with John.

Poor facility design

There were blocks of rooms built around a large central room 
for group activities and TV. The central room was extremely 
loud and high levels of noise can easily agitate dementia 
patients. Activity stations were set up for residents. One of 
these had various lengths of PVC pipe (not kidding), some 
longer than a baseball bat. These are weapons in waiting and 
you can guess what happened. There was no quiet area for the 
residents other than their rooms. The hallways in the room 
blocks were isolated, making it difficult for staff to monitor. 
There were many incidents that I witnessed when there was no 
staff around. I will share the one I feel is the most 
significant. A woman fell by tripping on a raised area where 
the rug abutted hard flooring and nobody saw her fall. I found 
her bloody and staggering down the hall. A company 
knowledgeable about dementia would not design a facility this 
way. They would certainly understand that people with dementia 
have problems with gait and balance. There were video cameras 
in place, but these were used to review incidents after-the-
fact.

Understaffed

Too many patients were assigned to each caregiver. In the 
mornings, each caregiver needed to get their assigned residents 
up and dressed for breakfast. Everyone ate at the same time, 
putting more pressure on the staff. They only gave residents a 
shower when necessary, as they were always pressed for time. 
Caregivers needed extra time to spend on residents in more 
advanced stages of dementia, as they required help to move from 
their bed to a wheelchair, be hand fed, etc.

After lunch, the caregivers would place most of the residents 
in chairs in the main room while they worked getting the 
advanced-stage patients back into their beds. Every day after 
lunch, my husband urgently needed to empty his bowels. Several 
times while I was there, I tried to find help as it was 
difficult for me to help him alone, since I had a fractured arm 
at the time. I could not find anyone, so I did the best I 
could. When I was not there, he often soiled himself while 
waiting for help.

I once saved a man's life. I was with my husband in a room off 
the main activity area. I heard someone crying for help. I ran 
into the hallway and found the old man on the floor, trying to 
prevent himself from being beaten with his own cane by another 
resident. I called for help and quickly moved closer and 
redirected the attacker's attention. I kept him busy while 
calmly calling for assistance, trying not to further agitate 
him. It took several minutes before a staff member finally 
heard me and came to help.

Night was no better, as staff levels were even lower, as 
allowed by state regulations. They placed residents who had 
trouble sleeping in front of the TV while they dealt with other 
residents.

Inadequate staff training

Most of their caregiver staff were trained as nurse aides, but 
nothing specific to memory care that I could see. I witnessed 
them providing some new hires dementia care training in a 
conference room. This consisted of a member of the management 
team showing them parts of Glenn Cambell's "I'll be Me" movie 
and pointing out behaviors that demonstrated his dementia 
problems. I saw the movie and it was not appropriate for 
training purposes. I observed several instances where 
caregivers and nurses displayed limited knowledge of working 
with dementia patients, particularly those in mid-stage of the 
disease who become more fearful and combative. Examples:

    * Nurse running toward resident, causing resident to become 
combative

    * Quick, erratic hand movements, frightening individual

    * TV on at 9:30 PM, with extremely high volume. Several 
residents were seated in chairs and wheelchairs in front of the 
TV. Anyone who understands dementia and "sundowning" would 
never do this. They were over-stimulating their residents 
instead of allowing them to relax and quiet their minds for 
sleep.

At one point, the Director of the facility told me to spend 
less time there and let them do their jobs. I could not abide, 
because they weren't doing their jobs.

In closing, unless things change, I would never recommend using 
this type of facility for a loved one. I am hopeful that you 
found my testimony helpful and that the Committee will find a 
way to set national standards for appropriate levels of 
staffing and training for that staff. This would be a huge step 
in improving assisted living.

Thank you for your time.

                 U.S. Senate Special Committee on Aging

 "Assisted Living Facilities: Understanding Long-Term Care Options for 
                             Older Adults"

                            January 25, 2024

                       Prepared Witness Testimony

                       Dr. Jennifer Craft Morgan

Assisted Living in the U.S.

Assisted living (AL) is a large and growing long-term care 
residential option for individuals who need or want additional 
supports for activities of daily living. There are 
approximately 30,600 AL communities in the U.S. with almost 1.2 
million licensed beds and 818,800 residents. This industry 
employs a total of 478,500 workers, 66% of which are direct 
care workers (DCWs) (NCAL 2023). These DCWs are the first line 
of care. AL, though often seen by the public as interchangeable 
with skilled nursing homes, was built and is regulated as a 
social model of care. This community-based care is less 
restrictive and strives to be home-like.

AL typically offers 1) 24/7 availability of supervision, 2) 
exercise, health, and wellness programming, 3) housekeeping and 
maintenance, 4) meals and dining services, 5) medication 
management or assistance, 6) personal care, and 7) arranging 
for transportation (NCAL 2023). This differs from nursing home 
care in that there is no promise of 24/7 access to medical 
services or constant supervision.

AL residents vary greatly in the amount of care they need from 
person-to-person (Kistler et al. 2017). Some AL residents are 
spouses who live with their partners whose care needs have 
become too great but are themselves much more independent. Some 
move into AL communes to support medication management, 
housekeeping and cooking and need little other support.

Rising acuity levels, meaning the average AL resident has 
increasingly more health conditions and functional limitations, 
do mean that as residents age in place, they likely require 
more health services. While these services could overlay AL 
services, much like they would if the person needing care was 
living at home, these are not provided by AL communities. These 
health care services include primary care, home health, 
physical and occupational therapies, and hospice and often are 
performed by contracted providers, sometimes associated with 
the AL and sometimes contracted or arranged by the resident's 
family. The haphazard growth of this model and the tensions 
inherent have spurred calls for Assisted Living to be 
reimagined (Zimmerman et al. 2022).

Assisted Living Residents

About half of AL residents are over the age of 85, most are 
women (70%), about three quarters are not married and about 90% 
are White. Most AL residents need help with medications, and 
more than half need help with three or more activities of daily 
living such as bathing, dressing, or toileting (NCAL 2023; 
Kemp, Ball & Perkins 2019). AL residents depend on their care 
networks, a constellation of kin and non-kin involved in 
resident lives such as friends, neighbors and church or other 
community members, to arrange medical care, provide social 
support, coordinate care, engage residents in activities and 
bring needed supplies such as medications, favorite snacks, 
health and beauty items, and incontinence pads. These care 
networks also play an important role in advocating for 
residents and negotiating care with AL staff (Kemp, Ball & 
Perkins 2013; Kemp et al. 2018; Kemp 2021).

Many residents living in AL have dementia. While the average 
older person living with dementia lives between four and eight 
years, they can live 20 years or more (Alzheimer's Association 
2023). About 42% of AL residents have a dementia diagnosis 
(NCAL 2023) but we can assume this is underreported as many 
older adults are not screened, tested, or diagnosed with 
dementia despite showing symptoms in memory, thinking, or 
making decisions that impact everyday activities.

The variability in symptoms and experiences is part of what 
makes people living with dementia so difficult to care for. 
Like all people with chronic disease, people living with 
dementia have good days and bad days. Person centered dementia 
care is needed to tailor care and support to individuals in 
ways that account for preferences, life experiences, 
communication styles and support needs that change over time 
(Fazio 2018). People living with dementia experience stigma and 
often become isolated. Residential care is an important option 
for combatting social isolation and exclusion often experienced 
by people with dementia and their care partners (Nguyen & Li 
2020).

Assisted Living is an Important Long-Term Care Option

AL, unlike nursing home care, is almost entirely private pay. 
Only 18% of residents rely on Medicaid to pay for daily 
services (NCAL 2023). Most of these residents are very low-
income and qualify for state Medicaid waiver programs that 
exist in 41 states and that often have waiting lists. According 
to NCAL (2023) the average monthly cost of AL is $4500. As 
such, AL is inaccessible to most Americans. Yet, on the 
spectrum of long-term care, it is often needed. Seen as a step 
of care between unpaid care by loved ones and nursing home 
care, AL provides an important long-term care option. When the 
care needs of a loved one exceeds the capacity of their care 
network, the person needing care and their unpaid care partners 
are forced to manage. This is often after an event. This event 
could be a hospitalization, a fall, a report of self-neglect, 
an unsafe situation, loss of driving ability or maybe 
mismanaged finances or medications.

Sometimes, after a hospitalization or after insurance-supported 
inpatient rehabilitation care, discharge planners help 
individuals with very high care needs and nursing home 
placement. If that doesn't happen, the care network is forced 
to navigate, with little support or education, a variety of 
options, none of which are usually covered by health insurance. 
If they have significant financial resources, AL is a useful 
and attractive option. If not, managing the care situation 
means that care partners reduce working hours, build precarious 
care or financial arrangements across families, hire piecemeal 
personal care support or simply cross their fingers and hope 
things turn out okay. Given the geographic dispersion of 
today's families, the lack of affordable residential care 
options often leaves American families in tough situations.

Assisted Living and Persistent Workforce Challenges

Sixty-six percent of the AL workforce are "aides" or direct 
care workers (DCWs) (NCAL 2023). DCWs in AL and across long-
term care are predominately women, people of color and 
disproportionally immigrants (PHI 2022). The typical direct 
care worker in AL makes about $15 an hour, works 36 hours week 
in AL, and works for a non-profit company. About half have 
health insurance through their employer and about 22% get 
health insurance through Medicaid or another means tested 
program. About half live under 200% of the poverty line with 
household income at about $46,000 (Kelly et al. 2020).

DCWs also face dangerous working conditions, persistent 
occupational segregation, have limited access to paid leave, 
and experience very little career advancement (Dill & Duffy 
2022; Dill et al. 2022). As stated by Scales & Lepore (2020) 
"[direct care work] requires a mix of technical caregiving 
skills; health-related knowledge; infection prevention and 
control expertise; emotional intelligence and relational 
skills; and problem-solving and decision-making abilities, 
among other competencies (p. 173). " Despite highly meaningful 
jobs with high intrinsic rewards, the lack of extrinsic rewards 
including compensation, drive turnover (Dill, Morgan & Marshall 
2013; Morgan, Dill & Kalleberg 2013). Turnover rates in long-
term care have been persistently slow to recover since the 
start of the COVID 19 pandemic and the recovery has been most 
difficult for women and people of color (Frogner & Dill 2022). 
In this context, the use of agency staff, or those that are 
temporarily hired from staffing agencies to all staffng 
shortages, has remained persistently high. Use of agency staff 
makes relationship-based, person-centered care difficult. Many 
organizations have reduced the number of new residents because 
they do not have the staffng to accommodate them despite having 
available licensed beds. More than sixty percent of AL 
facilities have moderate to high staffng shortages (NCAL 2022).

Assisted Living Context and Pressures

While the scope of abuse and neglect in AL facilities is 
unknown, several media reports have called attention to severe 
cases of neglect and mistreatment and the significant and 
surprising out-of-pocket costs that face older adults as they 
age in AL (Teegardin 2019; Rowland et al. 2023; Rau 2023). 
Abuse and neglect of our Elders and people with disabilities is 
unacceptable and is far too prevalent. I will say, though, in 
our hundreds of interviews with DCWs and other staff across the 
sector, I have met no "bad actors." While there are "bad 
actors" in all industries who are actively seeking to harm 
others, it is my experience that DCWs and AL staff go to work 
wanting to do the best they can, engage in meaningful 
relationships with their residents and promote their health and 
wellbeing. AL workers, like most direct care workers, tend to 
go into this line of work to give back, to make a diffierence, 
because they value Elders or because it is a calling for them 
(Kemp et al. 2010).

Unfortunately, the system we've set up works against them. DCWs 
working in all long- term care settings experience low wages, 
few benefits, heavy workloads, dangerous jobs, and little to no 
career mobility. These DCWs are managing heavy workloads with 
unrealistic expectations of what they can get done in one 
shift, put themselves and their families at risk of infectious 
disease, are called on to do heavy emotional labor, often 
managing multiple jobs to make ends meet and many are 
experiencing burnout after the multiple personal and collective 
traumas experienced during and after the pandemic. For a group 
that was already vulnerable, these workers faced grief, 
uncertainty, risk, high unpaid care demands and high work 
demands, and mental health needs that go largely unaddressed.

For AL management and owners, there is pressure to take or keep 
residents with high levels of acuity. Filling beds is an 
imperative to cover staffng costs and now rising agency staffng 
costs. Well-resourced families would rather have mom in a home-
like or hotel-like AL rather than an institutional nursing home 
if given the choice.

We gerontologists advocate for aging in place so that older 
adults can create home and have familiar settings in which to 
age well. This supports autonomy, meaning-making, relationship-
building and also supports people living with dementia to be in 
familiar settings to support their cognition. As a social model 
of care, the walls of the AL building are permeable. People go 
for walks, sign in and out, go visit families and go on 
outings. This engagement with the community is vital to the 
well-being of AL residents (Ciof, Kemp & Bender 2021). 
Overworked staff, lack of documentation, lack of meaningful 
oversight, higher acuity levels, lack of communication, and 
haphazard care coordination mean that residents are vulnerable 
without these wrap-around supports.

The tiered fee structure for additional services many Assisted 
Living communities offer, corresponds to the needs of residents 
and the need for providing additional staff to support those 
residents. Transparency in how those fees are determined and 
what impact they have on support for the residents who pay 
those premiums is certainly lacking. We know that 24/7 nursing 
home care and home health care are both, on average, more 
expensive than AL. The vast majority of AL services are private 
pay making it very difficult for residents and their care 
networks to plan for and understand how charges change over 
time.

Inconsistent Staffing and Training Requirements in AL

The AL direct care workforce is comprised of DCWs who are 
certified or registered (e.g., certified nursing assistants 
(CNAs)) and those who are not (e.g., personal care aides). AL 
communities make a choice between hiring CNAs, whose training 
and competency has been assessed by the State, or personal care 
aides with little to no formal training (Kemp at al. 2010). The 
CNA training is monitored by the state agencies responsible for 
facility licensure. Each state agency reviews CNA training 
programs for quality and state registries allow employers to 
verify credentials of DCWs who have completed this training and 
provide employers data on whether there are any outstanding 
complaints on file for a particular worker (Kelly et al. 2020). 
While many AL communities choose to hire CNAs, they lack this 
minimal oversight for initial training provided staff. In terms 
of initial and continuing education, states have sizable 
variability in the topics required (e.g. role of the PCA, 
consumer rights, ethics, and confidentiality, health care 
support, infection control) (Kelly et al. 2020). Several states 
have recently added training requirements for DCWs in AL, 
particularly in terms of dementia education, but these are 
generally loosely written and enforced with minimal oversight 
by state regulatory bodies.

Monitoring and Enforcement of Quality of AL

Monitoring and enforcement of quality of AL by states is 
inconsistent and not transparent. Kaskie et al. 2022, from 
their survey responses of state administrative agents, show 
that in half the states, monitoring and enforcement oversight 
of AL was dispersed across three or more agencies, staffing 
levels and budgets varied greatly. Fewer than 10 of the states 
shared information about their monitoring and enforcement 
procedures in a way that would be publicly accessible. Forty-
five states conduct inspections at the time of licensure, 39 
conduct annual or biannual inspections and only seven require 
AL facilities to submit an annual report (Kaskie et al. 2022).

A Mindset Shift is Needed

In her book, Disrupting the Status Quo of Senior Living: A 
Mindshift, Jill Vitale-Aussem (2019) lays out what I think is 
the crux of the problem facing senior living. AL is marketed to 
those who can afford it with a hospitality mindset. They 
advertise and compete on the basis of amenities, beautiful 
campuses, luxury food and furnishings, and concierge services. 
This model encourages residents and families to think about 
living in AL buildings as though they are going to a hotel or 
resort.

In reality, this framing, where residents are the guests and 
staff are encouraged to cater to their whims, increases what 
Dr. Bill Thomas of the Eden Alternative calls the three plagues 
of long-term care - helplessness, boredom and loneliness. By 
encouraging passivity, we leave residents with few 
opportunities for giving back, participating in the community 
or creative pursuits (Basting 2020). Instead, long-term care 
that is person-centered, community-minded and empowering has a 
much better chance of meeting the needs of residents, staff and 
care partners.

Person-centered care means that the person receiving care is in 
the driver's seat, to the extent they are able and for as long 
as they can. Ideally, the resident sets the goals of care 
collaboratively with both unpaid and paid care partners. 
Person-centered care practices have been associated with 
improved quality of life and quality of care for residents 
(Fazio et al., 2018; Poey et al., 2017). Shifting from a 
hospitality to a community mindset means that residents and the 
entire care network are valued members of the AL community. 
This shift encourages relationship building, transparent 
communication, interdependence and the promotion of citizenship 
where all members of the community have a role in improving 
quality of life. An open community mindset would also improve 
the safety culture of an AL by promoting communication, 
relationships and empowering all members to look out for one 
another.

Empowerment of residents and their care network is also vital 
to moving this sector forward. For residents, it's truly 
engaging them in their own care, using a strengths-based 
approach where individuals are supported to do as much for 
themselves for as long as possible no mater how slow the 
process (Yan et al. 2023). For workers, particularly DCWs, it 
is more complicated. Empowerment for workers means that we 
listen to, respect, pay, include, collaborate with, provide for 
the safety of, educate, and ultimately professionalize the 
workforce (Morgan and Ahmad 2023). The persons (e.g. resident, 
staff, care partner), not the task, is what we attend to first. 
This means that workers have the job quality they need to be 
whole and happy individuals who can then have the space in 
their work to be creative and engaged problem-solvers in the 
community. Empowerment for unpaid care partners includes 
education on dementia, support to continue to engage and 
support their loved one and an open invitation to be part of 
the communities in which their loved one resides (Kemp 2021).

Recommendations

    Support standardization of monitoring and resources to 
increase state-based oversight and transparency. Standardizing 
state transparency and oversight supports public awareness of 
the industry and promotes the ability of potential residents 
and their care networks to make informed decisions.

    Improve and standardize initial and continuing education 
training for DCWs in AL. This should include realistic job 
preview, interactive and engaging onboarding with peer 
mentorship and check-ins over the first three months, a 
training registry that supports both initial and ongoing 
training and promotes portability, stackability, and career 
progression. Training requirements should emphasize person-
centered dementia care, meaningful engagement, living well with 
dementia, strength-based approaches, trauma- informed and self-
care, communication skills, and non-pharmacological approaches 
to dementia care. See https://aging.georgia.gov/sites/
aging.georgia.gov/files/GARD%20Competency%20Guide--PDF.pdf

    Professionalize the direct care workforce. This strategy 
needs to be engaged in collaboration across long-term care 
sectors. This is one workforce that moves between and across 
sector lines constantly. Professionalization includes: 
occupational credentialing that acknowledges competencies of 
incumbent workers, ties competency accrual to significant and 
meaningful career lattices that have transparent wage 
increases, credentialing that is stackable and leads to higher 
order credentials that support key areas of need including 
meaningful engagement of residents, person- centered dementia 
care, strength-based creative expression outlets (e.g. music, 
drama, arts, expression), health and wellbeing, trauma-informed 
approaches, and documentation and quality improvement 
practices.

    Incentivize and reward good employers who deliver high 
quality care. Employers can make incredible differences in the 
lives of their workers and residents and curb turnover and 
improve recruitment by enhancing hiring practices, increasing 
compensation, enhancing benefits, improving orientation and 
onboarding, increasing access to education and training and 
expanding career opportunities (See short micro-learning videos 
on these topics: https://www.youtube.com/
playlist?list=PLXNnxuyRl8NQHl5kx6ukHxVHac--VjOCyn)

    Increase access to AL. Efforts should be made to increase 
affordable long-term care residential care options for middle 
class and working-class American families. This should include 
education about long-term care options, investment of resources 
in creating tools for navigating and making informed decisions 
about long-term care options, and incentives to develop and 
test inclusive models for rebalancing long-term care in ways 
that provides high quality care and system savings.

    Improve care coordination and resources for people living 
with dementia and their care partners. People living with 
dementia occupy many long-term care spaces. Regardless of 
space, they deserve high quality and coordinated care. People 
are not simply a diagnosis and holistic and integrated care 
approaches are possible and needed to support the growing 
number of people with dementia and their care networks. Models 
such as the GUIDE model (https://www.cms.gov/priorities/
innovation/innovation-models/guide) have great potential to 
provide holistic care to people with dementia and their care 
partners in ways that reduce stigma, coordinate care, improve 
outcomes and provide needed supports for all involved.

References


Basting, A. (2020). Creative Care A Revolutionary Approach to 
Dementia and Elder Care[Book]. HarperOne.

Cartwright, J., Roberts, K., Oliver, E., Bennet, M., & 
Whitworth, A. (2022). Montessori mealtimes for dementia: A 
pathway to person-centred care. Dementia, 21(4), 1098-
1119.Ciofi, J. M., Kemp, C. L., & Bender, A. A. (2022). 
Assisted living residents with dementia: Being out in the world 
and negotiating connections. The Gerontologist, 62(2), 200-211.

Dill, J., & Duffy, M. (2022). Structural Racism And Black 
Women's Employment In The US Health Care Sector: Study examines 
structural racism and black women's employment in the US health 
care sector. Health Affairs, 41(2), 265-272.

Dill, J. S., Morgan, J. C., & Marshall, V. W. (2013). 
Contingency, employment intentions, and retention of vulnerable 
low-wage workers: An examination of nursing assistants in 
nursing homes. The Gerontologist, 53(2), 222- 234.

Dill, J., Morgan, J. C., Van Heuvelen, J., & Gingold, M. 
(2022). Professional certification and earnings of health care 
workers in low social closure occupations. Social Science & 
Medicine, 303, 115000.

Fazio, S., Pace, D., Flinner, J., & Kallmyer, B. (2018). The 
fundamentals of person-centered care for individuals with 
dementia. The Gerontologist, 58(suppl--1), S10-S19.

Frogner, B. K., & Dill, J. S. (2022, April). Tracking turnover 
among health care workers during the COVID-19 pandemic: a 
cross-sectional study. In JAMA Health Forum (Vol. 3, No. 4, pp. 
e220371-e220371). American Medical Association.

Kaskie, B., Xu, L., Taylor, S., Smith, L., Cornell, P., Zhang, 
W., ... & Thomas, K. (2022). Promoting quality of life and 
safety in AL: A survey of state monitoring and enforcement 
agents. Medical Care Research and Review, 79(5), 731-737.

Kelly, C., Morgan, J.C., Kemp, C. L., & Deichert, J. (2020). A 
profile of the assisted living direct care workforce in the 
United States. Journal of Applied Gerontology, 39(1), 16-27.

Kemp, C. L. (2021). # MoreThanAVisitor: Families as 
"essential" care partners during COVID-19. The Gerontologist, 
61(2), 145-151.

Kemp, C. L., Ball, M. M., Hollingsworth, C., & Lepore, M. J. 
(2010). Connections with residents: "It's all about the 
residents for me." In Mary M. Ball, Molly M. Perkins, Carole 
Hollingsworth, & Candace L. Kemp (Eds.), Frontline Workers in 
Assisted Living (pp. 147-170). Baltimore, MD: Johns Hopkins 
University Press.

Kemp, C. L., Ball, M. M., Morgan, J. C., Doyle, P. J., 
Burgess, E. O., & Perkins, M. M. (2018). Maneuvering Together, 
Apart, and at Odds: Residents' Care Convoys in Assisted Living. 
The Journals of Gerontology: Series B, 73(4), e13-e23. https://
doi.org/10.1093/geronb/gbx184

Kemp, C. L., Ball, M. M., & Perkins, M. M. (2013). Convoys of 
care: Theorizing intersections of formal and informal care. 
Journal of Aging Studies, 27: 15-29. doi: 10.1016/
j.jaging2012.10.002

Kemp, C. L., Ball, M. M., & Perkins, M. M. (2019). 
Individualization and the health care mosaic in AL. The 
Gerontologist, 59(4), 644-654.

Kistler C. E., Zimmerman S., Ward K. T., Reed D., Golin C., 
Lewis C. L. (2017). Health of older adults in AL and 
implications for preventive care. The Gerontologist, 57, 949-
954.

NCAL (2022) htps://www.ahcancal.org/News-and-Communications/
Fact-Sheets/FactSheets/AL-Survey- June2022.pdf

Morgan J.C. & Ahmad W. (2022) Lifting them up: Building 
Person-Centered Organizations. CSA Journal, Vol 87 (4).

Morgan, J.C., Dill, J., & Kalleberg, A. L. (2013). The quality 
of healthcare jobs: can intrinsic rewards compensate for low 
extrinsic rewards?. Work, employment and society, 27(5), 802-
822.

National Center for Assisted Living (NCAL) (2023) Facts & 
Figures. (n.d.). https://www.ahcancal.org/Assisted- Living/
Facts-and-Figures/Pages/default.aspx

Nguyen, T., & Li, X. (2020). Understanding public-stigma and 
self-stigma in the context of dementia: A systematic review of 
the global literature. Dementia, 19(2), 148-181.

PHI (2023) Direct Care workers in the United States: Key Facts 
2023 - PHI. (2023, September 11). PHI. https://
www.phinational.org/resource/direct-care-workers-in-the-united-
states-key-facts-2023/

Poey, J. L., Hermer, L., Cornelison, L., Kaup, M. L., Drake, 
P., Stone, R. I., & Doll, G. (2017). Does person-centered care 
improve residents' satisfaction with nursing home quality?. 
Journal of the American Medical Directors Association, 18(11), 
974-979.

Rowland, C., Frankel, T.C., Torbati, Y., Weil, J.Z., 
Whoriskey, P. & Rich, S. (2023, December 17). An alarming 
number of assisted-living residents die after wandering away 
unnoticed. Washington Post. htps://www.washingtonpost.com/
business/interactive/2023/assisted-living-wander-patient-
deaths/

Rau, J. (2023, December 1). What to know about Long-Term Care 
Insurance. The New York Times. https://www.nytimes.com/2023/11/
22/health/long-term-care-insurance-explained.html

Scales, K., & Lepore, M. J. (2020). Always essential: Valuing 
direct care workers in long-term care. Public Policy & Aging 
Report, 30(4), 173-177.

Teegardin, B. S. C. (2019, September 29). Suffering behind the 
facade. AJC. https://www.ajc.com/news/state--regional/
suffering-behind-the-facade/gEMTySxJUMEQ6GhD1OQiFO/

Vitale-Aussem, (2019) J. Disrupting the Status Quo of Senior 
Living: A Mindshift. Health Professions Press, ISBN 978- 
1938870828, 216 pages.

Yan, Z., Traynor, V., Alananzeh, I., Drury, P., & Chang, H. C. 
(2023). The impact of montessori-based programmes on 
individuals with dementia living in residential aged care: A 
systematic review. Dementia, 14713012231173817.

Zimmerman, S., Carder, P., Schwartz, L., Silbersack, J., 
Temkin-Greener, H., Thomas, K. S., ... & Williams, K. B. 
(2022). The imperative to reimagine assisted living. Journal of 
the American Medical Directors Association, 23(2), 225-234.

                 U.S. Senate Special Committee on Aging

 "Assisted Living Facilities: Understanding Long-Term Care Options for 
                             Older Adults"

                            January 25, 2024

                       Prepared Witness Testimony

                             Julie Simpkins


Chairman Casey, Ranking Member Braun, and members of the U.S. 
Senate Special Committee on Aging, thank you for inviting me 
here today to be a part of this important discussion on 
assisted living, a topic that is near and dear to my heart. My 
name is Julie Simpkins, and I am the co-president and chief 
operating officer of Gardant Management Solutions, a provider 
that develops and operates senior living, assisted living, and 
memory care communities. We are the fifth largest assisted 
living provider in the country and have communities in five 
states - Illinois, Indiana, Ohio, Maryland, and West Virginia.

I have dedicated most of my life to senior living, spending 30 
years working primarily in assisted living. This is my calling, 
and I'd like to speak with you today about Gardant's unique 
model and share thoughts on how we can work together on 
important issues facing those who need and work in assisted 
living.

Gardant is uniquely focused on offering affordable assisted 
living to low-income seniors. Our company was founded in 1999 
after the creation of the Illinois Supportive Living Program, a 
home- and community-based Medicaid waiver program. Now, as we 
have expanded into four other states, our commitment to serving 
this population remains. The majority of residents living in 
Gardant communities rely on Medicaid for their assisted living 
care through these waiver programs.

Gardant has been limited in where we can offer our services due 
to the variability with state Medicaid waiver programs. It 
depends on the availability of state programs, state 
reimbursement levels, and the number of available waiver spots. 
Offering affordable assisted living exclusively - or even for a 
majority of residents like Gardant - requires an entirely 
different business model altogether. We have had to 
persistently seek out HUD loans and income tax credits to stay 
viable. Therefore, we fully support efforts to make long-term 
care, including assisted living, more affordable to low- and 
middle-income seniors. With a rapidly growing elderly 
population, we need a public and private partnership to 
incentivize more providers to develop these models.

When we talk about assisted living, it's important to note that 
every state, every facility, and every resident is different. 
Efforts to standardize all assisted living communities would be 
both unworkable and irresponsible for resident care. State 
regulations recognize the diversity within assisted living 
while holding our profession accountable, and they are 
consistently updated to reflect the evolving nature of our 
sector and our residents.

Meanwhile, Gardant is committed to exceeding state requirements 
when we believe it is in the best interest of our residents. 
Take memory care as an example, and something that is top of 
mind for this Committee as well as our residents and families. 
Every staff member at Gardant managed memory care communities 
receive education and training in dementia and related diseases 
as well as training as a Certified Dementia Practitioner 
training. While elopements are rare, we overreport any to the 
state immediately - even something as technical as a resident 
walking out the door and instantly returning after a staff 
member sees them. We know they didn't leave our facility and 
our staff immediately addressed the situation, but we still 
report it.

The recent reports of resident elopements that were ultimately 
fatal are heartbreaking, and my thoughts and prayers go out to 
the loved ones of those residents. I serve in leadership 
positions on numerous national organizations dedicated to long-
term care, and I know these tragic incidents are extremely rare 
and not indicative of the assisted living experience. The 
overwhelming majority of families and residents have a life-
affirming, safe experience. Assisted living providers are 
committed to upholding our policies and procedures, as well as 
continuing to learn all that we can about dementia care to 
prevent these incidents. It is critical that policies and 
regulations help protect residents while still supporting 
freedom of movement and independence for residents living with 
dementia.

Assisted living is a critical aspect of the long-term care 
continuum, dedicated to delivering person-centered care to our 
nation's seniors. We need collaborative, comprehensive 
solutions that help ensure our ability, as assisted living 
communities, to continue doing what we do best - providing 
safe, quality care to our residents. From expanding more 
affordable long-term care options, to workforce programs to 
address the growing caregiver shortage, these efforts could 
make a real difference. We must all work together to ensure 
every current and future assisted living resident is seen, 
safe, and served to enjoy the highest quality of life possible.

Thank you for your time and I look forward to answering your 
questions today.

                 U.S. Senate Special Committee on Aging

 "Assisted Living Facilities: Understanding Long-Term Care Options for 
                             Older Adults"

                            January 25, 2024

                       Prepared Witness Testimony

                             Richard Mollot


Introduction

Good morning, Chairman Casey, Ranking Member Braun, and Members 
of the Committee. Thank you for inviting me to testify today on 
this important issue.

My name is Richard Mollot. I am the executive director of the 
Long Term Care Community Coalition (LTCCC). LTCCC is a national 
non-profit, non-partisan organization dedicated to improving 
care and quality of life for residents in nursing homes and 
assisted living. We conduct substantive research on long-term 
care policies and the extent to which essential standards of 
care are realized in the lives of residents, who are typically 
elderly and frail. In addition to conducting systemic analysis 
and advocacy, we educate and engage residents, families, and 
those who work with them, so that they are aware of their 
rights and are equipped to overcome the challenges that so many 
of our seniors face when they need residential care.

While timelines vary, essentially, assisted living emerged in 
the 1980s as an alternate to nursing homes for seniors who want 
or need to live in a congregate setting where they an get help 
with tasks like housekeeping, meal preparation, and access to 
activities and transportation.\1\ Over the last 40 years, three 
developments have drastically changes the nature and character 
of the assisted living sector, with both positive and negative 
implications.
---------------------------------------------------------------------------
    \1\ Wilson, K.B., "Historical Evolution of Assisted Living in the 
United States, 1979 to the Present," The Gerontologist, Volume 47, 
Issue suppl--1, Pages 8-22 (December 2007). https://doi.org/10.1093/
geront/47.Supplement--1.8.

  1. The needs and frailty of assisted living residents have 
---------------------------------------------------------------------------
dramatically increased;

  2. Assisted living operators have adopted increasingly 
sophisticated and large-scale corporate models, including 
ownership by Real Estate Investment Trusts, Private Equity, and 
other sophisticated private investment structures;\2\ and
---------------------------------------------------------------------------
    \2\ See, for example, Fenne, M., "Private equity's growing presence 
in senior living," The Private Equity Stakeholder Project (blog post). 
(December 2023). https://pestakeholder.org/news/private-equitys-
growing-presence-in-senior-living/.

  3. Public payment and support for assisted living services 
---------------------------------------------------------------------------
has increased dramatically.

The subsequent discussion delves into some of the ramifications 
of these trends, followed by recommendations aimed at fostering 
a sustainable business model for assisted living that 
effectively meets the evolving needs of our expanding senior 
population.

The Growing Needs and Expectations of Our Expanding Senior 
Population to Live Safety and with Dignity

Assisted living facilities (ALFs) are increasingly viewed by 
seniors and their families as a desirable option for 
residential care, particularly for those who wish to avoid the 
institutional environment that typically defines life in a 
nursing home. In fact, assisted living is the fastest growing 
form of senior housing in the United States.\3\ While too often 
overlooked by policymakers and oversight agencies, assisted 
living facilities house a comparable number of individuals to 
nursing homes in the United States.
---------------------------------------------------------------------------
    \3\ Castillo, L., "Assisted Living Industry Statistics," GITNUX 
Marketdata Report 2024
    (December 2023). https://gitnux.org/assisted-living-industry-
statistics/#::text=
    Assisted%20care%experiences%20the%20highest%20growth%in%20
    terms,fastest%20growing%20segment%20of%20the%20senior%20
    housing%20market.

Importantly, ALFs do much more than just providing 
accommodations and assistance with housekeeping and prepared 
meals, as they largely did in the past. They now provide a 
range of health and support services to residents with 
---------------------------------------------------------------------------
increasing needs (and vulnerabilities):

  1. Approximately 40 - 70% of assisted living residents have 
Alzheimer's Disease or some other cognitive impairment.\4\
---------------------------------------------------------------------------
    \4\ Estimates vary, and the lack of firm data on this important 
point is a result of the lack of transparency in the assisted living 
industry (including the needs of those they serve and the capacity of 
those providing care and services).

  2. More than half of ALF residents are 85 or older (compared 
to 42% in nursing homes).\5\
---------------------------------------------------------------------------
    \5\ Zimmerman S, Sloane PD, Wretman CJ, et al., "Recommendations 
for Medical and Mental Health Care in Assisted Living Based on an 
Expert Delphi Consensus Panel: A Consensus Statement," JAMA Network 
Open (2022). https://jamanetwork.com/journals/jamanetworkopen/
fullarticle/2796840.

  3. Over 50% have hypertension.\6\
---------------------------------------------------------------------------
    \6\ Zimmerman, S., Wenhan, G., et al., "Health Care Needs in 
Assisted Living: Survey Data May Underestimate Chronic Conditions," 
Journal of the American Medical Directors Association, Volume 22, Issue 
2, 471 - 473 (December 2020). https://www.jamda.com/article/S1525-
8610(20)31022-7/fulltext.

  4. One-third or more have heart disease or depression.\7\
---------------------------------------------------------------------------
    \7\ Id.

  5. About half need help with dressing and/or walking and 64% 
need help with bathing.\8\
---------------------------------------------------------------------------
    \8\ National Center for Assisted Living, Assisted Living Facts & 
Figures.
    https://www.ahcancal.org/Assisted-Living/Facts-and-Figures/Pages/
default.aspx.

  6. Over 10% of ALF residents with dementia are administered 
antipsychotic drugs, which carry a FDA "black box" warning 
against use on elderly people, due to significant risks of 
heart attack, stroke, Parkinsonism, falls, and death.\9\
---------------------------------------------------------------------------
    \9\ Zhang, T., Thomas, K., et al., "State Variation in 
Antipsychotic Use Among Assisted Living Residents With Dementia," 
JAMDA, Volume 24, Issue 4 (February 2023).https://www.jamda.com/
article/S1525-8610(23)00088-9/fulltext.

In summary, the evolving care requirements of assisted living 
residents have grown increasingly intricate over the years. As 
seniors experience longer lifespans with chronic conditions, 
notably dementia, the susceptibility of this demographic has 
heightened. Despite the escalating needs and vulnerabilities, 
the federal government has consistently adopted a "hands-off" 
stance, and state regulations are generally characterized by 
weakness and lax enforcement. Consequently, the assisted living 
sector operates under a caveat emptor - let the buyer beware - 
principle. We can and must do better for American seniors and 
---------------------------------------------------------------------------
their families.

We can and must do better for American seniors and their 
families.

The Imperative to Improve Transparency About Quality and Safety

While the notion of "buyer beware" is already disconcerting for 
seniors and their families, the situation is exacerbated by the 
pervasive lack of transparency that extends to virtually every 
facet of assisted living. In any typical consumer scenario, one 
would rightfully anticipate clear information about the 
services to be provided, costs, quality, and safety. However, 
in the realm of assisted living, obtaining crucial indicators 
is challenging, if not impossible. Who's providing care? How 
much will living and services cost? What happens when/if I need 
more care and services? What happens if I run out of money? 
What is the quality record of this facility? If a facility has 
had issues, how do I find out what they were and, most 
importantly, what was done to address them?

In the world of assisted living, the answers to these vital 
questions are not only hard to find, they are often 
purposefully obfuscated by both operators and the state 
agencies that are supposed to be protecting residents. Unlike 
nursing homes, for which vigorous, professional assessments are 
required upon entrance and periodically, to a large extent ALFs 
are free to accept - and retain - whomever they want. Licensed 
nurses may or may not be on hand to supervise care for 
residents with higher needs, respond to a fall, or ensure that 
medications are given correctly. Care, monitoring, and dignity 
for individuals with dementia may be wonderful or slipshod, 
depending on the facility or, even, the operator's profit goals 
for the quarter. While approximately 75% of ALFs claim to have 
a "memory care unit,"\10\ this term is often more a marketing 
strategy than an accurate representation of specialized care. 
Seniors and their families may lean on this term when placing 
an individual with dementia, despite potentially disastrous 
disparities in actual care quality.
---------------------------------------------------------------------------
    \10\ Bretschneider, A., "Understanding the Cost of Memory Care" 
(December 2023). https://www.seniorly.com/resource-center/senior-
living-guides/how-much-does-memory-care-cost#.

The Case for Federal Interest and Engagement in Safeguarding 
---------------------------------------------------------------------------
Quality and Integrity in the Assisted Living Industry

Although assisted living is commonly seen as a private 
enterprise functioning with a non-governmental payment model, 
it is essential to recognize the growing importance of public 
funding and the escalating demand for federal involvement. The 
government's interests have expanded over the years, 
emphasizing the need to ensure robust consumer protections and 
foster a healthy assisted living industry.

  1. Close to 20% of assisted living residents currently rely 
on Medicaid to pay for services.\11\
---------------------------------------------------------------------------
    \11\ National Center for Assisted Living, Assisted Living: A 
Growing Aspect of Long Term Care.https://www.ahcancal.org/Advocacy/
IssueBriefs/NCAL--Factsheet--2023.pdf.

  2. Forty-seven states plus the District of Columbia provide 
---------------------------------------------------------------------------
access to Medicaid assisted living.

  3. The U.S. Supreme Court's landmark 1999 Olmstead decision 
established that the unjustified institutional isolation of 
people with disabilities is a form of discrimination under the 
Americans with Disabilities Act (ADA). The court declared that 
states are required to make reasonable modifications to 
publicly funded programs to accommodate qualified individuals 
who desire to live in the most integrated setting.\12\ To meet 
this requirement, states have been "rebalancing" access to 
publicly-funded long-term care services over the last 25 years, 
favoring home and community-based services, which can encompass 
assisted living, over nursing home placement.
---------------------------------------------------------------------------
    \12\ Long Term Care Community Coalition, Single Point of Entry for 
Long Term Care and Olmstead: An Introduction and National Perspective 
for Policy Makers, Consumers and Advocacy Organizations (2005).https://
nursinghome411.org/single-point-of-entry-for-long-term-care-and-
olmstead-an-introduction-and-national-perspective-for-policy-makers-
consumers-and-advocacy-organizations/.

  4. The U.S. Department of Housing and Urban Development (HUD) 
provides advantageous loans to finance the purchase, refinance, 
new construction, or substantial rehabilitation of assisted 
---------------------------------------------------------------------------
living.

  5. The Government Accountability Office (GAO) has focused on 
the need to improve safety and accountability in assisted 
living numerous times over the last 25 plus years. 
Unfortunately, the persistent failure to take substantive 
action to implement most of the GAO's recommendations over the 
years has resulted in untold numbers of residents suffering 
harm, including financial exploitation, sexual assault, and 
even death, due to substandard care and lack of promised 
supervision.

  6. The LTC Ombudsman Program, which monitors care and helps 
residents resolve complaints under the authority of the Older 
Americans Act, has been authorized to monitor assisted living 
and provide services to residents since 1981.

  7. Numerous news reports, in both local and national media, 
have uncovered the painful and heart-breaking problems that can 
occur as a result of the lack of federal standards and weak 
state oversight. A recent report from The Atlanta Journal-
Constitution is emblematic:

    "During a routine room check, an 88-year-old resident told 
workers that hours earlier she had been sexually assaulted by 
another resident." Three weeks later, an investigation by the 
Georgia Department of Community Health found that Savannah 
Court of Lake Oconee "failed to provide supervision consistent 
with the residents' needs."

    "While the incident would be distressing on its own, its 
timing adds a layer of alarm. The assault took place two months 
after the state sent Savannah Court of Lake Oconee a notice 
that it planned to revoke its license, and while such an action 
should imply serious safety concerns, the department's efforts 
to move the process along and ensure residents are free from 
harm have lacked urgency. ...Court documents and inspection 
reports reviewed by The Atlanta-Journal Constitution show that, 
since 2021, Savannah Court of Lake Oconee has accrued over 70 
state violations, including two incidents where residents 
died."\13\
---------------------------------------------------------------------------
    \13\ Gross, A., "Possible closure of Georgia senior home reveals 
flaws in state oversight," The Atlanta Journal-Constitution (January 
2024).https://www.ajc.com/news/possible-closure-of-georgia-senior-home-
reveals-flaws-in-state-oversight/RWJRB3GBABFUPJ7RFFBANW7FMI/#.

A senior or their family would have trouble finding out this 
history. Savannah Court's website provides no inkling about any 
of these problems (no matter what steps, if any, were taken to 
address them). It paints an entirely rosy picture of "an ideal 
place for your loved ones to age in place while also providing 
you with the peace of mind that comes with knowing they are 
well cared for."\14\ The state's "Find a Facility" page only 
provides a single row of information with the facility's 
address, phone number, bed capacity, and administrator.\15\ One 
has to do a separate search in a separate database of 
inspection reports to find any record of what has transpired in 
the facility.
---------------------------------------------------------------------------
    \14\ https://www.savannahcourtlakeoconee.com/. Accessed January 22, 
2024.
    \15\ https://forms.dch.georgia.gov/HFRD/GaMap2Care.html.

Beyond highlighting the imperative for substantive measures to 
enhance safety and quality, the substantial variances among 
assisted living facilities, encompassing staffing levels, 
services provided, and costs, underscore the need for decisive 
---------------------------------------------------------------------------
action to improve both quality assurance and transparency.

Recommendations

  1. Establish and Implement National Standards to Promote 
Quality, Safety, and Integrity in Assisted Living:

      For years, the states have functioned as an incubator 
for developing assisted living policies. While this has not 
resulted in a high-quality system, there are many lessons that 
can be learned, and existing state requirements provide a 
logical basis for promulgating federal rules.\16\
---------------------------------------------------------------------------
    \16\ See, LTCCC, Assisted Living: Promising Policies and Practices 
(2018). https://nursinghome411.org/ltccc-report-assisted-living-
promising-policies-and-practices/.

      A system of regular inspections and oversight at the 
facility and corporate levels should be developed to ensure 
---------------------------------------------------------------------------
compliance with these standards.

  2. Establish a National Assisted Living Database:

      Create a centralized and standardized database that 
includes key metrics on assisted living facilities' 
performance, include: staffing (levels and competencies), 
ownership, charges for residential and care services, and 
citation history (including how those citations were corrected 
and any penalties that were imposed).

      This database should be easily accessible to the public, 
empowering families with the information needed to make 
informed decisions.

  3. Promote Resident and Family Engagement:

      Develop rules for the rights of resident and family 
councils in assisted living.

      Strengthen the involvement of residents and their 
families in the internal policies and operation of their 
assisted living facility (such as by strengthening requirements 
under the Home and Community-Based Settings regulations 
promulgated in 2014).

Conclusion

Improving transparency, quality, and accountability in assisted 
living is not only a matter of public interest but a moral 
imperative. Now more than ever, federal action is needed to 
ensure that older Americans receive the care and support they 
deserve while fostering a system that promotes transparency and 
accountability within the industry.

I appreciate the Committee's commitment to addressing these 
critical issues, and I am available to provide any additional 
information or answer questions that may arise during or after 
the hearing.

Thank you for your consideration of my testimony and the issues 
raised herein.

?

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


                        Questions for the Record

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


?

      

                 U.S. Senate Special Committee on Aging

 "Assisted Living Facilities: Understanding Long-Term Care Options for 
                             Older Adults"

                            January 25, 2024

                        Questions for the Record

                          Patricia Vessenmeyer

                     Chairman Robert P. Casey, Jr.

Question:

What recommendations do you have to ensure that assisted living 
workers can provide residents with the type and quality of care 
that they need?

Response:

Caregiving for dementia patients is extremely difficult. There 
appears to be ample training options available, of which many 
of these facilities are not taking advantage. I would recommend 
that caregivers be required to take additional training classes 
to become certified as dementia-patient caregivers. They should 
also receive compensation commensurate with this higher level 
of training. Perhaps a program where the facility operators 
also reimburse the caregivers for their training costs would 
encourage more to enter the field.

Question:

What regulations or policies would you like to see in place to 
ensure that assisted living facilities are delivering on the 
services they promise?

Response:

Decreasing the maximum number of patients per caregiver would 
be very helpful. Right now, that number is controlled at the 
state level, and I understand that this would be a challenge to 
change on a national basis. However, as I mentioned in my 
testimony, many of these caregivers want to do a good job, but 
simply have too many residents in their care. Also, perhaps 
there could be a way to oversee performance and hold these 
organizations accountable.

                 U.S. Senate Special Committee on Aging

 "Assisted Living Facilities: Understanding Long-Term Care Options for 
                             Older Adults"

                            January 25, 2024

                        Questions for the Record

                       Dr. Jennifer Craft Morgan

                     Chairman Robert P. Casey, Jr.

Question:

Please share with us the profile of the assisted living direct 
care workforce, workplace supports, and opportunities for job 
growth, or lack thereof. Can you share any policy 
recommendations on increasing retention and creating 
opportunities for job advancement, including federal policies, 
or state policies that could be replicated?

Response:

A full profile of workforce demographics and training can be 
found in the linked article below (Kelly, Morgan & Kemp 2020). 
Like direct care workers across long-term care, AL DCWs are 
predominately women, about half are people of color and about 
20% are immigrants. The typical direct care worker in AL makes 
about $15 an hour, works 36 hours week in AL, and works for a 
for-profit company. About half have health insurance through 
their employer and about 22% get health insurance through 
Medicaid or another means tested program. About half live under 
200% of the poverty line with household income at about $46,000 
(Kelly et al. 2020).

DCWs also face dangerous working conditions, persistent 
occupational segregation, have limited access to paid leave, 
and experience very little career advancement (Dill & Duffy 
2022; Dill et al. 2022). As stated by Scales & Lepore (2020) 
"[direct care work] requires a mix of technical caregiving 
skills; health-related knowledge; infection prevention and 
control expertise; emotional intelligence and relational 
skills; and problem-solving and decision-making abilities, 
among other competencies (p. 173)." Despite highly meaningful 
jobs with high intrinsic rewards, the lack of extrinsic rewards 
including compensation, drive turnover (Dill, Morgan & Marshall 
2013; Morgan, Dill & Kalleberg 2013). Turnover rates in long-
term care have been persistently slow to recover since the 
start of the COVID 19 pandemic and the recovery has been most 
difficult for women and people of color (Frogner & Dill 2022). 
In this context, the use of agency staff, or those that are 
temporarily hired from staffing agencies to fill staffing 
shortages, has remained persistently high. Use of agency staff 
makes relationship-based, person-centered care difficult. Many 
organizations have reduced the number of new residents because 
they do not have the staffing to accommodate them despite 
having available licensed beds. More than sixty percent of AL 
facilities have moderate to high staffing shortages (NCAL 
2022).

Improve and standardize initial and continuing education 
training for DCWs in AL:

Policies to implement include increased requirements for 
initial training and continuing education of workers and 
implementing a coordinated way to share best practices and 
offer technical assistance. These practices and topics should 
include realistic job preview, interactive and engaging 
onboarding with peer mentorship and check-ins over the first 
three months, a training registry that supports both initial 
and ongoing training and promotes portability, stackability, 
and career progression. Training requirements should emphasize 
person-centered care, meaningful engagement, living well with 
dementia, strength-based approaches, traumainformed and self-
care, communication skills, and non-pharmacological approaches 
to dementia care. Several states including Florida (430.5025 
F.A.C.) have increased the required content for initial and 
continuing education for DCWs in Assisted Living. Also, while 
AL workers do not have to be CNAs, many of them are, so 
legislation that increased the continuing education 
requirements for the CNA workforce would raise requirements for 
initial and continuing education across much of long-term care.
Professionalize the direct care workforce:

This strategy needs to be engaged in collaboration across long-
term care sectors. States such as Wisconsin (https://
wiscaregivercna.com/) have created partnerships across provider 
associations and state government to establish education and 
career pathways for direct care workers. This is one workforce 
that moves between and across sector lines constantly. 
Professionalization includes: occupational credentialing that 
acknowledges competencies of incumbent workers, ties competency 
accrual to significant and meaningful career lattices that have 
transparent wage increases, credentialing that is stackable and 
leads to higher order credentials that support key areas of 
need including meaningful engagement of residents, person-
centered care, strength-based creative expression outlets (e.g. 
music, drama, arts, expression), health and wellbeing, trauma-
informed approaches, and documentation and quality improvement 
practices.

The Journal of Applied Gerontology has made this article 
publicly available upon my request: https://
journals.sagepub.com/doi/full/10.1177/0733464818757000.

Question:

Please share with us how assisted living facilities work to 
ensure that residents are supported in their activities of 
daily living, as well as being emotionally and intellectually 
supported?

Response:

Person-centered care means that the person receiving care is in 
the driver's seat, to the extent they are able and for as long 
as they can. Ideally, the resident sets the goals of care 
collaboratively with both unpaid and paid care partners. 
Person-centered care practices have been associated with 
improved quality of life and quality of care for residents 
(Fazio et al., 2018; Poey et al., 2017). Empowerment of 
residents and their care network is also vital to moving this 
sector forward. For residents, it's truly engaging them in 
their own care, using a strengths-based approach where 
individuals are supported to do as much for themselves for as 
long as possible no matter how slow the process (Yan et al. 
2023). Assisted Living organizations create dense activity 
calendars that offer things for Assisted Living residents to 
do, but to engage residents emotionally and intellectually, we 
have found that these approaches are the most successful 
(particularly for residents with dementia): 1) Knowing the 
person, 2) Connecting with and meeting them where they are, 3) 
Being in the moment and 4) Realizing that every interaction is 
an opportunity for engagement (Kemp et al. 2021).

Question:

Please share with us strategies that states use to hold 
assisted living facilities accountable and how they could do a 
better job?

Response:

Standardizing state transparency and oversight supports public 
awareness of the industry and promotes the ability of potential 
residents and their care networks to make informed decisions. 
This should include publishing of quality data similar to that 
of the nursing home sector (https://www.medicare.gov/care-
compare/). This will need to include regulation and oversight 
where states have to report survey results and individual AL 
communities will have to regularly report on quality 
indicators, incidents and deficiencies. Coordination of 
technical assistance and supportive resources for providers to 
meet standards and implement best practices will likely be 
necessary (Kaskie et al. 2022).

Question:

Would you support a set of federal regulations for assisted 
living facilities? If so, what issues would be most critical to 
have federal regulations address?

Response:

I would support federal regulations for assisted living 
facilities that support information sharing, transparency, 
public access to quality data and oversight data. These aspects 
are key to supporting high quality. Several states have made 
significant improvements to regulation(https://
www.ahcancal.org/Assisted-Living/Policy/Documents/2023--reg--
review.pdf). Technical assistance and support states to improve 
their regulation, quality data and documentation quality would 
be useful. The most critical issues to address are: worker 
initial and continuing training, career advancement, resident 
abuse, quality improvement efforts, efforts to combat social 
isolation, infection control, and strategies to support 
resident safety.

                       Senator Kirsten Gillibrand

Question:

Staffing shortages in assisted living facilities are reaching 
crisis levels and are exacerbated by insufficient pay and 
benefits, strenuous workloads, limited training and advancement 
opportunities, and stigma. MY National Domestic Workers Bill of 
Rights Act extends common workplace rights to assisted living 
facilities workers while at the same time creating new 
protections and stronger ways of enforcing them.

Is the current assisted living facilities workforce prepared to 
care adequately for residents with cognitive impairment and 
Alzheimer's Disease? Are programs or certifications available 
so that our ALF workforce may improve the quality of their care 
delivery?

Response:

No. Training is inconsistent across Assisted Living 
organizations and is not universally required (https://
www.ahcancal.org/Assisted-Living/Policy/Pages/state-
regulations.aspx). There are several training certifications 
that are useful but not widespread. These include but are not 
limited to the Eden Alternative's Certified Eden Associate 
Training and Dementia Beyond Drugs, Teepa Snow's Positive 
Approach to Care Training Certifications, and training offered 
by the National Council of Certified Dementia Practitioners.

Question:

How would direct care worker protections like adequate breaks 
during work hours and training programs also protect assisted 
living facility residents? Would addressing factors that 
contribute to assisted living facility direct care worker 
burnout also benefit organizations and residents?

Response:

These protections would help a great deal. Burnout is real and 
pervasive in these and most long-term care organizations. 
Resources and requirements that hold employers accountable and 
reward good employers are important. Employers can make 
incredible differences in the lives of their workers and 
residents and curb turnover and improve recruitment by 
enhancing hiring practices, increasing compensation, enhancing 
benefits, improving orientation and onboarding, increasing 
access to education and training and expanding career 
opportunities (See short micro-learning videos on these topics:

(https://www.youtube.com/
playlist?list=PLXNnxuyRl8NQHl5kx6ukHxVHac--VjOCyn). Greater 
access to mental health resources is sorely needed. This could 
be done through Employment Assistance programs or other 
collaboratives among organizations. High quality, low-cost 
mental health services are needed for all members of the care 
network, including residents. Destigmatizing and normalizing 
mental health and well-being promotion is vital for this 
industry. It is important to realize how interconnected 
residents, paid and unpaid care partners are in the AL context. 
The support of each impacts the other. Better supports for 
staff means they will be better positioned to provide care 
(Kemp 2021, Kemp et al. 2018).

Question:

What issues does marketing an assisted living facility as a 
"memory unit" create for consumers with cognitive impairment?

Response:

There should be standards attached to the ability to market 
dementia care services to potential residents and families. In 
my opinion, this would include environmental supports (e.g. 
lighting, built environment, privacy, community, safety), 
social supports (e.g. community engagement, meaningful 
engagement, avenues for contributing), and training supports 
(e.g. person-centered dementia care training, strengths-based & 
Montessori-based training, communication training, quality 
improvement and team training).

                               References

Dill, J., & Duffy, M. (2022). Structural Racism And Black 
Women's Employment In The US Health Care Sector: Study examines 
structural racism and black women's employment in the US health 
care sector. Health Affairs, 41(2), 265-272.

Dill, J. S., Morgan, J. C., & Marshall, V. W. (2013). 
Contingency, employment intentions, and retention of vulnerable 
low-wage workers: An examination of nursing assistants in 
nursing homes. The Gerontologist, 53(2), 222-234.

Dill, J., Morgan, J. C., Van Heuvelen, J., & Gingold, M. 
(2022). Professional certification and earnings of health care 
workers in low social closure occupations. Social Science & 
Medicine, 303, 115000.

Fazio, S., Pace, D., Flinner, J., & Kallmyer, B. (2018). The 
fundamentals of person-centered care for individuals with 
dementia. The Gerontologist, 58(suppl--1), S10-S19.

Frogner, B. K., & Dill, J. S. (2022, April). Tracking turnover 
among health care workers during the COVID19 pandemic: a cross-
sectional study. In JAMA Health Forum (Vol. 3, No. 4, pp. 
e220371e220371). American Medical Association.

Kaskie, B., Xu, L., Taylor, S., Smith, L., Cornell, P., Zhang, 
W., ... & Thomas, K. (2022). Promoting quality of life and 
safety in AL: A survey of state monitoring and enforcement 
agents. Medical Care Research and Review, 79(5), 731-737.

Kelly, C., Morgan, J.C., Kemp, C. L., & Deichert, J. (2020). A 
profile of the assisted living direct care workforce in the 
United States. Journal of Applied Gerontology, 39(1), 16-27.

Kemp, C. L., Ball, M. M., Morgan, J. C., Doyle, P. J., 
Burgess, E. O., & Perkins, M. M. (2018). Maneuvering Together, 
Apart, and at Odds: Residents' Care Convoys in Assisted Living. 
The Journals of Gerontology: Series B, 73(4), e13-e23. https://
doi.org/10.1093/geronb/gbx184.

Kemp, C. L. (2021). # MoreThanAVisitor: Families as 
"essential" care partners during COVID-19. The Gerontologist, 
61(2), 145-151. Kemp, C. L., Bender, A. A., Ciofi, J., Craft 
Morgan, J., Burgess, E. O., Duong, S., ... & Perkins, M. M. 
(2021). Meaningful engagement among assisted living residents 
with dementia: Successful approaches. Journal of Applied 
Gerontology, 40(12), 1751-1757.

Morgan, J.C., Dill, J., & Kalleberg, A. L. (2013). The quality 
of healthcare jobs: can intrinsic rewards compensate for low 
extrinsic rewards?. Work, employment and society, 27(5), 802-
822.

NCAL (2022) https://www.ahcancal.org/News-and-Communications/
Fact-Sheets/FactSheets/AL-SurveyJune2022.pdf.

Poey, J. L., Hermer, L., Cornelison, L., Kaup, M. L., Drake, 
P., Stone, R. I., & Doll, G. (2017). Does personcentered care 
improve residents' satisfaction with nursing home quality?. 
Journal of the American Medical Directors Association, 18(11), 
974-979.

Scales, K., & Lepore, M. J. (2020). Always essential: Valuing 
direct care workers in long-term care. Public Policy & Aging 
Report, 30(4), 173-177.

Yan, Z., Traynor, V., Alananzeh, I., Drury, P., & Chang, H. C. 
(2023). The impact of montessori-based programmes on 
individuals with dementia living in residential aged care: A 
systematic review. Dementia, 14713012231173817.

                 U.S. Senate Special Committee on Aging

 "Assisted Living Facilities: Understanding Long-Term Care Options for 
                              Older Adults

                            January 25, 2024

                        Questions for the Record

                             Julie Simpkins

    Please see pages 59 through 77 for Questions, Responses, 
and Exhibits
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For Exhibits 1 through 4, please see additional exhibits 
submitted by Julie Simpkins in the "Statements for the Record" 
section.
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                 U.S. Senate Special Committee on Aging

 "Assisted Living Facilities: Understanding Long-Term Care Options for 
                             Older Adults"

                            January 25, 2024

                        Questions for the Record

                             Richard Mollot

                     Chairman Robert P. Casey, Jr.

Question:

Can you tell us what standard information about assisted living 
facilities would be most useful to families and who should be 
collecting and disseminating that information?

Response:

Seniors and their families would strongly benefit from the 
following information about assisted living facilities:

  1. Staffing, including:
          a. the licensure, certification, and training levels 
of all staff providing resident care or services;

      b. whether there is a RN, MD, or other professional 
(i.e., individual with licensure to provide professional 
supervision, such as assess residents and manage medications) 
on staff with a regular presence in the nursing home (full time 
or part time indicated);

      c. the numbers of each type of care staff present in the 
building by shift and weekday vs. weekend based upon payroll or 
other auditable records; and

      d. Whether there are staff in the building 24/7 
(indicating whether or not staff are required to be awake 
during their shifts).

  2. Services offered, including:

      a. Care: Whether or not the facility provides specialized 
dementia care, aging in place, hospice, palliative, and/or 
Medicaid assisted living (or other reduced cost options), the 
extent to which these services are available (such as entire 
facility or one wing), the licensure/certification of 
individuals providing any special services;

      b. Community: Including whether there are resident and/or 
family councils (with contact information), a recent calendar 
of activities that the facility provides to residents, and how 
the facility provides connections to the broader community 
(i.e., bus to local shopping, religious services, etc.)

  3. Costs of residential, care, and other services in a clear 
and concise manner (including costs of residence, cost of 
meals, cost of assistance and other services; what is included 
in base rate vs what will cost extra now or in the future).

  4. Resident rights in the facility under state and federal 
law, including ADA and other non-discrimination rights, rights 
to access to LTC Ombudsman services, contacts for the LTC 
Ombudsman, Adult Protective Services, state oversight agency, 
law enforcement, emergency services and state "No Wrong Door" 
access point (see https://nwd.acl.gov/index.html).

  5. Quality & Safety of facility, including access to complete 
inspection and citation records that are unredacted (except for 
the name(s) of residents).

  6. Facility policies, including transfer/discharge policies, 
whether the facility imposes a pre-dispute arbitration clause 
in its residency agreements, whether residents have rights to 
have pets, smoking and drinking policies, etc.

  7. Ownership of facility, including any individual or entity 
with 5% or greater ownership interest and the administrator of 
the facility, in a searchable federal database that provides 
information on ownership within and across states, with access 
to inspection and citation records.

To the greatest extent possible, this information should be 
collected and published by the federal government in an online 
tool similar to Home Health Compare, Hospice Compare, etc. In 
addition, facilities should be required to have this 
information available for inspection by residents, families, 
and visitors in the facility and on its website (if it has 
one). The information provided by the facility should be in 
English and any other language of the residents that it has 
accepted into its facility.

Question:

The written testimony of Ms. Julie Simpkins stated that federal 
regulations would be irresponsible. Based on your research, do 
you think industry standardizations would be irresponsible for 
resident care?

Response:

The growing body of news media reports, Government 
Accountability Office reports, and peer-reviewed studies all 
indicate that, in fact, it is irresponsible not to have 
baseline federal assisted living standards to protect residents 
from physical, emotional, and financial harm. It is important 
to provide some background here. In order to fight growing 
calls for baseline federal standards, the industry has fallen 
back on the argument that such standards would inhibit its 
ability to provide individualized care and services. This is a 
false argument. Federal regulations are needed to ensure 
baseline safety, quality, transparency, and accountability. 
They would actually foster improvements in resident-centered 
care, by helping individuals and families understand what they 
have a right to expect and the extent to which a facility will 
be able to fulfill their needs, expectations, and goals now and 
in the future.

Question:

Can you speak to ways in which the industry standards could be 
improved, while still recognizing the diversity within assisted 
living?

Response:

Some ways in which industry standards could be improved 
include:

  1. Setting baseline requirements for the individuals 
providing care and services in assisted living (including the 
minimum numbers of care staff in a facility and the licensure/
certification of those staff;

  2. Establishing clear definitions of "memory care" and "aging 
in place" and other terminology used by the industry (so that 
they are more than just hollow marketing terms);

  3. Ensuring that facilities fulfill their promises to seniors 
and families by establishing standards for government oversight 
including annual inspections carried out by state inspection 
teams with relevant core competencies (i.e., nurse, dietician, 
social worker) and meaningful penalties for violations that 
impact resident safety and dignity.;

  4. Fire, emergency planning, safety requirements;

  5. Implement federal community characteristic standards - 
which were recently promulgated for Medicaid assisted living - 
for all assisted living.

None of these categories of standards would in any way impede 
an operator's ability to meet the diverse needs of the 
community it is serving. For more specific information on these 
and other policies that would improve quality of life and 
quality of care in assisted living, please see our report, 
"Assisted Living: Promising Policies and Practices for 
Improving Resident Health, Quality of Life, and Safety." 
https://nursinghome411.org/ltccc-report-assisted-living-
promising-policies-and-practices/

Question:

Ms. Simpkins also states in her testimony that state 
regulations are "consistently updated." Is it your experience 
that state regulations are consistently updated? If not, what 
are your recommendations for how and when they should be 
updated?

Response:

To my knowledge, state laws and regulations are not 
consistently updated. In fact, in my experience, state 
legislators tend to be disinclined to promulgate new assisted 
living laws and when changes or updates are implemented, they 
tend to be in response to pressure from industry lobbyists, 
resulting in a significant weakening of state rules and their 
enforcement.

                       Senator Kirsten Gillibrand


Question:

Assisted living facilities are not required to disclose 
inspection reports, financial reinvestment in patient care, or 
staffing requirements for services offered. Residents and 
families should be aware of safety violations found during 
inspections, but this information is not always made public. In 
New York, citations are available, but the full inspection 
report is not.

How would resident care improve by making information from 
current assisted living facilities inspections public?

Response:

Better information would enable prospective residents to make 
informed choices about where they are going. It would enable 
current residents and families to be aware of what is going on 
in their assisted living - their home - and hold their facility 
accountable for addressing the problems.

Question:

Does a lack of information exacerbate the health and financial 
burdens for residents and their families to house loved ones in 
assisted living facilities? What information should be 
available to the aging population to help them prepare for 
long-term care?

Response:

In short, yes. People tend to think that their base monthly 
payment will cover most if not all of their costs. However, 
additional costs often arise unexpectedly, particularly as an 
individual's needs increase. A resident may not realize when 
they ask for a helping hand it will come with a price tag.

Seniors and their families need accessible information on what 
services are available to them, where they can access those 
services (with meaningful information on the potential 
strengths and weaknesses of different options), who will be 
providing the services (nurse, certified nurse aide, or someone 
with less or no training), how much services will cost, and 
options for paying for those services. Furthermore, seniors and 
their families should be informed, in clear language, about the 
agencies or companies that are providing services and the 
quality record of those providers.

Question:

Would transparency in the assisted living facility industry 
help residents during the transition from assisted living to 
skilled nursing facilities?

Response:

Yes. Due to lax state rules and oversight, too many assisted 
living retain residents for whom they can no longer provide 
safe care. Transparency would empower residents and families to 
make choices appropriate for their needs.

Question:

Private equity firms have capitalized on assisted living 
facilities as a real estate opportunity to collect higher 
profit yields than other investments in offices and hotels. 
Assisted living facilities increasingly house older adults 
whose the health needs demand care and specialization, but 
private equity firms have minimal accountability for the 
services they provide.

When residents suffer harm while living in assisted living 
facilities, are they able to choose a course of action, such as 
a jury trial or arbitration, to hold assisted living facilities 
accountable. Does the current process adequately protect 
residents and the public from unnecessary harm? Does it 
facilitate transparency?

Response:

Too often, the answer to this question is no. Many assisted 
living companies insert pre-dispute arbitration clauses into 
their residency agreements, which effectively prevents someone 
from suing, even when their loved one has been severely harmed 
or dies as a result of neglect or grossly substandard care.

Question:

What consequences do private equity firms face when negligent 
behavior or harm occurs to residents or workers under their 
supervision?

Response:

Unfortunately, due to the lack of accountability and 
transparency, we have no way of knowing specifics about 
consequences for assisted living operators. However, we do know 
in the senior care industry generally that the use of complex 
investment vehicles in which the facility itself is depleted of 
assets is a common technique for avoiding accountability for 
negligence or, even, avoidable death.

Question:

How well is private equity delivering on the concept of an 
assisted living facilities as a social model? Are private 
equity-operate assisted living facilities performing comparably 
with the rest of the industry?

Response:

Based on what we have seen in nursing homes (and other areas of 
health care) quality and safety tend to degrade significantly 
when private equity investment enters the sector.



      
      
      
      
      
      
      
      
      
      
      
      
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                       Statements for the Record

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