[Congressional Record Volume 146, Number 107 (Wednesday, September 13, 2000)]
[Extensions of Remarks]
[Pages E1461-E1462]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




  INTRODUCTION OF HOUSE JOINT RESOLUTION REGARDING QUALITY OF CARE IN 
                       ASSISTED LIVING FACILITIES

                                 ______
                                 

                        HON. FORTNEY PETE STARK

                             of california

                    in the house of representatives

                      Tuesday, September 12, 2000

  Mr. STARK. Mr. Speaker, I join today with my colleague Representative 
Coyne to introduce a House Joint Resolution relating to the quality of 
care in assisted living facilities.
  As long-term care has emerged as a vital issue for the health and 
well-being of our nation's elderly, assisted living is emerging as a 
popular model. More and more consumers are drawn to the ideals of 
privacy and independence that are promoted by the assisted living 
industry. States have followed the trend by increasingly providing 
public funding via Medicaid's Home & Community-Based Services waiver 
for assisted living services.
  Despite assisted living's popularity; however, there remain many 
questions regarding the direction of this industry. Assisted living 
facilities are defined and arranged in a variety of ways. Some view 
assisted living as housing residences while others view them as medical 
service providers. Many facilities often do not allow ``aging in 
place'' despite pictures painted by their marketing brochures. States 
have responded with varying definitions, regulations, and oversight, 
resulting in unequal consumer protections throughout the country.
  Quality of care in assisted living facilities has been an issue of 
concern. A GAO study found that 25 percent of surveyed facilities were 
cited for five or more quality of care or consumer protection 
violations during 1996 and 1997, and 11 percent were cited for 10 or 
more problems. I understand that steps have been taken to address these 
concerns, but news reports of lawsuits filed on behalf of assisted 
living residents continue to illustrate the impact of poor quality on 
the health of elderly residents.
  Just a few weeks ago in my district, an elderly woman passed away in 
an assisted living facility due to hemorrhaging from her dialysis 
shunt. Two times, she pressed her call pendant for help, but both of 
these calls were cleared and reset 10 minutes later. The facility did 
not place a 911 call for assistance until 1 hour and 34 minutes later. 
There was no nurse on duty, and all four resident aides in the facility 
at the time have denied responding to the calls or clearing/resetting 
the call system. This situation is still under investigation, but it 
highlights the seriousness of inadequate quality of care in these 
facilities.
  A new Milbank Memorial Fund publication entitled, ``Long-Term Care 
for the Elderly with Disabilities: Current Policy, Emerging Trends, and 
Implications for the Twenty-First Century,'' by Robyn I. Stone is an 
excellent review of issues facing assisted living. As the article 
indicates there are many questions concerning the current and future 
state of the assisted living movement. Because of these questions, I am 
proposing a White House Conference to help advance our knowledge and 
awareness of these issues, and if appropriate, recommend public policy 
steps that are necessary to ensure the optimal development of this 
industry.
  Mr. Speaker, I urge my colleagues to join me in increasing our 
understanding of the assisted living industry. By focusing on consumer 
protections and quality of care, we will work to ensure the health and 
well-being for our country's elderly.
  I submit an excerpt from the Robyn Stone paper along with a May 8, 
1999 New York Times editorial calling attention to problems in this 
sector:

                            Assisted Living

       Another trend that is attracting attention from 
     policymakers, private developers, and consumers is assisted 
     living. One significant problem with this trend is the lack 
     of a consistent definition used by providers, regulators, and 
     policymakers. Some argue that ``assisted living'' is just a 
     '90s label for a long-term care setting that has been around 
     for centuries--another example of ``old wine in new 
     bottles.'' Homes for the aged, frequently associated with 
     nonprofit fraternal and religious organizations, proliferated 
     in the nineteenth and early twentieth centuries to supply 
     room and board for poor, infirm elderly people. Over the past 
     three decades, sporadic attention has focused on scandalous 
     mistreatment of residents in board and care homes, a version 
     of homes for the aged that also became a refuge for the 
     people with chronic mental illness in response to the 
     deinstitutionalization frenzy of the 1960s.
       In the 1980s the term ``residential care facility'' became 
     fashionable as a catch-all label for places providing room, 
     board, and some level of protective oversight. Hawes et al. 
     (1993) have estimated that about a half million people live 
     in residential care facilities or board and care homes in the 
     United States. Perhaps twice that number are living in 
     unlicensed facilities (November et al., 1997).
       It is somewhat ironic that homes for the aged, board and 
     care homes, and other types of residential care were replaced 
     in the late 1960s and 1970s by nursing homes modeled after 
     hospitals. ``Nursing homes'' have delivered far less nursing 
     care than the name suggests. Today residential care is again 
     in fashion. It is viewed as a desirable alternative to 
     nursing homes because of its ostensibly less institutional 
     character and its emphasis on a social, rather than a 
     medical, model. A number of states, including Oregon, 
     Washington, Florida, and Colorado, have aggressively tried to 
     use residential care as a less costly substitute for 
     institutions. One recent study estimates that anywhere 
     between 15 and 70 percent of the nursing home population, 
     nationwide, could live in residential care instead (Spector 
     et al., 1996). Kane (1997) has questioned the judgment of 
     hospital discharge planners who refer elders with 
     disabilities to nursing homes, rather than alternative 
     arrangements, because 24-hour care is supposedly available. 
     She notes that remarkably little nursing care is provided in 
     nursing homes. For example, a survey of nursing home 
     residents in six states found that 39 percent of the 
     residents received no care from a registered nurse in 24 
     hours; residents who did receive such care received an 
     average of only 7.9 minutes; care by a nursing assistant 
     averaged 76.9 minutes daily (Friedlob, 1993). Despite these 
     arguments, empirical research has been equivocal on the

[[Page E1462]]

     issue of the ``substitutability'' and cost savings of 
     residential care compared to nursing home placement (Kane et 
     al., 1991; Newcomer et al., 1995b; Sherwood and Morris, 
     1983). In fact, residential care is more likely to be a 
     substitute for living in one's own home than in a nursing 
     home.
       What appears to distinguish assisted living from 
     residential care in general and from the somewhat pejorative 
     ``board and care'' is a matter of philosophy and emphasis on 
     care, not just housing (Kane, 1997). Some have also suggested 
     that assisted living is the rich person's residential care 
     while board and care is for poor people who rely on federal 
     Supplemental Security Income (SSI) and state supplements 
     (SSP) to cover the costs. A recent survey of assisted living 
     regulations in 50 states indicates that four states--Alabama, 
     Rhode Island, South Dakota, and Wyoming--use the terms 
     ``assisted living'' and ``board and care'' interchangeably 
     (Mollica and Snow, 1996). For the other states, key 
     characteristics differentiating assisted living from other 
     types of residential care are: an explicit focus on privacy, 
     autonomy, and independence, including the ability to lock 
     doors and use a separate bathroom; an emphasis on apartment 
     settings in which residents may choose to share living space; 
     and the direct provision of, or arrangement for, personal 
     care and some nursing services, depending on degrees of 
     disability.
       As noted in an earlier section on care settings, Hawes et 
     al. (1999) recently completed the first national survey of 
     assisted living, using a national probability sample of 
     facilities that met several criteria. These include having 11 
     or more beds, primarily serving an elderly population; and 
     providing 24-hour staff oversight, housekeeping, at least two 
     meals a day, and personal assistance with two or more 
     activities of daily living (ADLs). According to preliminary 
     findings from a telephone survey, most facilities offer 
     consumers a range of privacy options. Single rooms were the 
     most common residential unit (52 percent); the rest of the 
     units were apartments. The most common type of single room 
     was a private room with a full bathroom; the most common 
     apartment was a one-bedroom for single occupancy.
       While most facilities reported a general willingness to 
     serve residents with moderate physical limitations, fewer 
     than half were willing to admit or retain residents who 
     needed assistance with transfers from a bed or chair. 
     Furthermore, fewer than half of participating facilities 
     would admit (47 percent) or retain (45 percent) residents 
     with moderate to severe cognitive impairment; only 28 percent 
     would admit or retain residents with behavioral symptoms such 
     as wandering.
       In assessing the extent to which these facilities' 
     characteristics match the philosophy of assisted living, 
     Hawes et al., (1999) concluded that only 11 percent offered 
     high privacy and high service. Another 18 percent provided 
     high privacy but low service. Twelve percent offered low 
     privacy but high service. The researchers noted that 
     residents of these assisted living facilities had 
     considerably more privacy and choice than residents in most 
     nursing homes and in the board and care homes they had 
     investigated in a previous study. Nevertheless, facilities 
     varied widely. A substantial segment of the industry provided 
     environments that did not reflect the philosophy of assisted 
     living. Furthermore, the many facilities whose admission or 
     retention policies excluded people with the cognitive 
     impairments or severe physical disabilities suggests that 
     assisted living is not an environment where those who 
     experience significant functional decline can ``age in 
     place.''
       While assisted living does warrant serious consideration by 
     policymakers, providers, and consumers, a number of 
     impediments to its development need attention. Today, the 
     assisted living market is primarily composed of the well-off 
     elderly, with little available to moderate- or low-income 
     consumers, as the recent study by Hawes et al. (1999) 
     confirms. This gap is due, in part, to the limited sources 
     and inadequate amounts of public financing (primarily SSI and 
     SSP), which could help subsidize room, board, and care for 
     financially strapped individuals and their families. The most 
     common monthly rate for facilities offering either high 
     service or high privacy was approximately $1,800 in 1998.
       Other impediments to assisted living include concerns, 
     expressed by state policy-makers and potential private 
     providers, about balancing consumer choice and privacy on one 
     hand with health, safety, and liability considerations on the 
     other. One major issue reflecting this concern is the degree 
     to which states are willing to moderate their nurse practice 
     acts to allow the delegation of certain tasks, such as 
     administering medication, caring for wounds, and changing 
     catheters (Kane, 1997). A number of states, such as Oregon, 
     Kansas, Texas, Minnesota, and New York, have included nurse 
     delegation provisions, but the latitude and interpretations 
     of the provisions vary tremendously. Not surprisingly, they 
     have met serious resistance by many nurses' organizations, 
     for whom professional turf is as significant as care issues.
       The motives of the assisted living industry have also been 
     questioned. The industry includes more real estate developers 
     and hotel managers than care providers. Furthermore, as 
     nursing homes look for new markets and reimbursement 
     strategies that circumvent government regulation, many 
     skilled nursing facilities may simply lay carpet, install 
     door locks, and hang out the ``assisted living'' shingle. 
     Finally, there are questions about the amount of assistance 
     that these facilities actually provide. According to the 
     study by Hawes et al., 65 percent of the participating 
     facilities supplied ``low service''; that is, they did not 
     have an RN on staff or did not provide nursing care, although 
     they did provide 24-hour staff oversight, housekeeping, two 
     meals, and personal assistance. Another 5 percent, 
     categorized as ``minimal service,'' supplied no personal 
     assistance with ADLs. Given that many facilities do not admit 
     or retain people with severe physical disabilities or 
     cognitive impairment, the level of care is additional cause 
     for concern.

                 [From the New York Times, May 8, 1999]

                  The Need for Care as Well as Profit

       Among other things, the 1990's will be remembered as the 
     decade when developers and older, affluent, anxious Americans 
     discovered each other with enthusiasm, with results both 
     encouraging and worrisome. The concept that both they and 
     Wall Street have embraced is called assisted living. There is 
     no common definition of it. Each of the 50 states regulates 
     it differently, and the Federal Government not at all. But to 
     older retirees who can pay to live in the new and 
     reconditioned spaces sprouting across the country, the 
     assisted living communities offer something irresistible. It 
     is the promise of Pleasantville, where they can live out 
     their lives gracefully, with hotel services, assistance when 
     they need it, and the chance to hold off or avoid what many 
     of the aged most fear--the nursing home.
       For developers, some with no experience in caring for the 
     aged, the attraction is clear. The number of old people of 
     financial means is growing. Some 6.5 million now need some 
     help with the chores of daily living. That figure is expected 
     to double by 2020. Ten years ago there was not even an 
     industry trade group. Today the Assisted Living Federation of 
     American estimates there is a kaleidoscopic collection of 
     about 30,000 such facilities in the United States, with a 
     million old people living in them, almost all of whom pay 
     their own way.
       Some facilities fall into state licensing categories and 
     some do not. Their average national monthly rate per person 
     is $1,500 but elegant two-bedroom units on Long Island may 
     rent for $5,000 or more. The National Investment Conference, 
     a group that specializes in the senior housing market, found 
     in a survey of 73 assisted living developments released this 
     year that the median profit margin was 29 percent. For a 
     quarter of the properties, it was more than 35 percent. Those 
     numbers warm Wall Street, but do not guarantee that the 
     communities deliver high-quality services.
       Because the phenomenon has grown up around existing rules, 
     many kinds of places can advertise ``assisted living.'' A 
     Government Accounting Office survey, performed at the request 
     of the U.S. Senate Special Committee on Aging, found that 
     about half the residents sign up without being sure what 
     services the facilities provide, how much they cost or what 
     medical care the residents can count on. A quarter of the 
     places surveyed were cited for five or more problems 
     involving quality of care or resident protection within two 
     years.
       When Albert Fleischmann, 85, a St. Petersburg Yacht Club 
     member and retired owner of a hardware chain, moved into an 
     assisted living facility in Pinellas County, Florida, in 
     1997, his daughter was reassured. Patricia Fleischmann 
     Johnson heads a charity that serves as guardian for 134 
     people in such places. But when Mr. Fleischmann suffered a 
     heart attack at his table in the dining room this year, he 
     was ignored. He called his daughter. She took him to the 
     hospital. She then called back to ask the facility how he 
     was, and was told--as if he were there--that he was ``fine.'' 
     Because Mr. Fleischmann likes the place, he is still there. 
     But his daughter, who testified before the Senate committee, 
     is more concerned now, and she is not alone.
       There are no pending bills in Congress, but 32 states are 
     expected to consider legislation this year to increase 
     regulation of the assisted living industry. They should do 
     so. With so many frail lives and so much money involved, this 
     issue is not going away.

     

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