[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
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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.
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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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