Assisted Living: Quality-of-Care and Consumer Protection Issues in Four
States (Letter Report, 04/26/99, GAO/HEHS-99-27).

Pursuant to a congressional request, GAO provided information on whether
consumers are able to make informed choices about their care and about
the nature and extent of problems that may be occurring in assisted
living, focusing on: (1) residents' needs and the services provided in
assisted living facilities; (2) the extent to which facilities provide
consumers with information sufficient to help them choose a facility
that is appropriate for their needs; (3) state approaches to the
oversight of assisted living; and (4) the type and frequency of
quality-of-care and consumer protection problems identified by Congress.

GAO noted that: (1) assisted living facilities in California, Florida,
Ohio, and Oregon serve a wide range of resident needs in a variety of
residential settings; (2) the 622 facilities that responded to GAO's
survey include small homes providing meals, housekeeping, and limited
assistance for few residents, as well as large, multilevel communities
that provide or arrange a variety of care for as many as 600 residents;
(3) a majority of the facilities reported that more than half their
residents need staff assistance with bathing and medications, and 94
percent reported serving some residents who are cognitively impaired;
(4) providers do not always give consumers information sufficient to
determine whether a particular facility can meet their needs; (5)
marketing material, contracts, and other written material provided by
facilities are often incomplete and are sometimes vague or misleading;
(6) only about half of the facilities reported that they provide
prospective residents with such key written information as the amount of
assistance residents can expect to receive with medications, the
circumstances under which the cost of services might change, or when
residents might be required to leave if their health changes; (7) all
four states have licensing requirements that must be met by facilities
that provide assisted living services; (8) each of these states inspects
or surveys assisted living facilities to ensure that they comply with
regulations, yet they vary in the frequency and content of inspections
and the range of enforcement mechanisms available to ensure compliance;
(9) in all four states, the state long-term care ombudsman agency may
investigate and resolve complaints involving residents of long-term care
facilities, including those providing assisted living; (10) GAO
determined that more than one-fourth of the facilities reviewed were
cited by state licensing, ombudsman, or other agencies for five or more
quality-of-care or consumer-protection related deficiencies or
violations during 1996 and 1997; (11) most of the problems identified
were related to quality of care rather than consumer protection; (12)
while data were not available to assess the seriousness of each
identified problem, many problems seemed serious enough to warrant
concern; and (13) frequently identified problems included facilities:
(a) providing inadequate or insufficient care to residents; (b) having
insufficient, unqualified, and untrained staff; (c) not providing
residents the appropriate medications or storing medication improperly;
and (d) not following admission and discharge policies required by state
regulation.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-99-27
     TITLE:  Assisted Living: Quality-of-Care and Consumer Protection 
             Issues in Four States
      DATE:  04/26/99
   SUBJECT:  Extended care facilities
             Elder care
             Quality assurance
             Consumer protection
             Health care services
             State programs
             Information disclosure
             Elderly persons
             Long-term care
             Surveys
IDENTIFIER:  California
             Florida
             Ohio
             Oregon
             Medicaid Program
             Supplemental Security Income Program
             
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Cover
================================================================ COVER


Report to Congressional Requesters

April 1999

ASSISTED LIVING - QUALITY-OF-CARE
AND CONSUMER PROTECTION ISSUES IN
FOUR STATES

GAO/HEHS-99-27

Assisted Living

(108330)


Abbreviations
=============================================================== ABBREV

  ADL - activities of daily living
  AL - standard assisted living
  ALFA - Assisted Living Federation of America
  APS - adult protective service
  ECC - extended congregate care
  IV - intravenous
  LMH - limited mental health
  LNS - limited nursing services
  SSI - Supplemental Security Income

Letter
=============================================================== LETTER


B-278340

April 26, 1999

The Honorable Charles Grassley
Chairman, Special Committee on Aging
United States Senate

The Honorable John Breaux
Ranking Minority Member, Special Committee on Aging
United States Senate

The Honorable Ron Wyden
United States Senate

Assisted living facilities are becoming an increasingly popular
setting for providing long-term care through a combination of
housing, personal support services, and health care.  Consumer demand
is expected to grow significantly as the projected number of elderly
Americans needing long-term care doubles to nearly 14 million over
the next 20 years.  The provider and investment communities have
responded to this growing demand by increasing the supply of assisted
living facilities throughout the country in recent years, and Fortune
magazine identified assisted living as one of the top three potential
growth industries for 1997.\1 Unlike nursing homes, most assisted
living is paid for privately by individuals and their families. 
However, many states are exploring whether assisted living can be a
cost-effective alternative to nursing home care for some residents,
and they are expanding the use of Medicaid and other federal and
state sources of funds to help pay for care.\2 In addition, many
states are examining their role in regulating this industry, and,
according to the National Conference of State Legislatures, 32 states
plan to consider legislation related to assisted living during 1999. 

While interest in assisted living has grown among consumers, the
investment community, and state governments, concerns about quality
of care and consumer protection in assisted living have been raised
in recent media accounts and other reports.  As we discussed in an
earlier report, little is known about whether consumers are able to
make informed choices about their care or about the nature and extent
of problems that may be occurring in assisted living.\3 To help the
Congress better understand these issues, you asked us to (1) describe
the residents' needs and the services provided in assisted living
facilities, (2) determine the extent to which facilities provide
consumers with information sufficient to help them choose a facility
that is appropriate for their needs, (3) describe state approaches to
the oversight of assisted living, and (4) determine the type and
frequency of quality-of-care and consumer protection problems they
identify. 

To address these issues, we studied four states that have a range of
experiences with assisted living--California, Florida, Ohio, and
Oregon.  Specifically, we (1) analyzed responses to a mail survey
from 622 assisted living facilities concerning the services they
provide and the needs of the residents they serve; (2) evaluated
written marketing materials and contracts of 60 facilities for
completeness, clarity, and consistency with selected state statutes
and regulations; (3) interviewed state officials in the four states
and reviewed relevant state statutes, regulations, guidance, and
policy manuals; and (4) analyzed information on the quality-of-care
and consumer protection problems identified by the state licensing
and ombudsmen agencies in each state, for calendar years 1996 and
1997, for a random sample of 753 facilities and the adult protective
services agency in Florida and Oregon.\4 We also visited 20 assisted
living facilities in the four states and interviewed facility
administrators, staff, and more than 90 residents or family members. 
In this report, we do not evaluate the effectiveness of the state
agencies' oversight of assisted living facilities.  See appendix I
for a more detailed discussion of our methodology.  We conducted our
study from June 1997 through March 1999 in accordance with generally
accepted government auditing standards. 


--------------------
\1 Precise numbers of facilities and residents are difficult to
obtain because there is no generally accepted definition of assisted
living and no systematic means of counting these facilities. 
Estimates of the current number of assisted living beds range from
800,000 to 1.5 million. 

\2 Medicaid is the joint federal and state health financing program
for low-income families and aged, blind, and disabled people.  Those
who receive long-term care under Medicaid include the elderly,
persons with physical disabilities, and persons with developmental
disabilities. 

\3 See Long-Term Care:  Consumer Protection and Quality-of-Care
Issues in Assisted Living (GAO/HEHS-97-93, May 15, 1997). 

\4 We sent our mail survey to 955 randomly selected facilities of
2,652 potential providers of assisted living in the four states.  We
received responses from 721 facilities, or 75 percent of those we
surveyed, 622 of which identified themselves as providers of assisted
living services. 


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

Assisted living facilities provide a growing number of elderly
Americans with an alternative to other types of long-term care, such
as nursing homes, and many facilities serve a vulnerable population
with significant care needs.  To make informed choices among various
facility options, consumers need clear and complete information on
facility services, costs, and policies.  However, in many cases,
assisted living facilities in the four states we studied are not
routinely providing prospective residents with information sufficient
for them to select the setting most appropriate for their needs. 
Consumers also need assurance that facilities provide high-quality
care and protect consumers' interests.  All four states license
assisted living facilities and provide oversight through periodic
inspections and complaint investigations.  Licensing, ombudsmen, and
adult protective services (APS) agencies identified some assisted
living facilities with quality-of-care and consumer protection
problems during 1996 and 1997, such as inadequate care, insufficient
staffing, medication errors, abuse, and improper discharge. 

Within the parameters of state regulations, assisted living
facilities in the four states serve a wide range of resident needs in
a variety of residential settings.  The 622 facilities that responded
to our survey include small homes providing meals, housekeeping, and
limited assistance for as few as 2 residents as well as large,
multilevel communities that provide or arrange for a variety of
specialized health and related care for as many as 600 residents; the
average size is 63 beds.  The average monthly rate residents pay in
the facilities we surveyed ranges from less than $1,000 to more than
$4,000, and although the majority of facilities serve only a private
pay market, 40 percent reported receiving Medicaid or other public
funds to care for one or more residents, primarily in Florida and
Oregon.  As for the residents' needs, a majority of the facilities
reported that more than half their residents need staff assistance
with bathing and medications, and 94 percent reported serving some
residents who are cognitively impaired.  Facilities vary widely in
the level of care they choose to provide and in the extent to which
they allow residents to remain in a facility as their needs increase. 
For example, about half of the facilities would admit or retain a
resident who has an ongoing need for nursing care while half would
discharge a resident who developed that need. 

Given the wide variation in what is labeled assisted living,
consumers shopping for an appropriate facility must rely primarily on
providers for information.  However, we found that the providers do
not always give consumers information sufficient to determine whether
a particular assisted living facility can meet their needs, for how
long, and under what circumstances.  Marketing material, contracts,
and other written material provided by facilities are often
incomplete and are sometimes vague or misleading.  Only about half of
the facilities reported that they provide prospective residents with
such key written information as the amount of assistance residents
can expect to receive with medications, the circumstances under which
the cost of services might change, or when residents might be
required to leave if their health changes.  In addition, only about
one-third provide a description of the qualifications of facility
staff or information on the services that are not available. 
Moreover, while contracts are an important source of written
information about a facility and its services, only 25 percent of the
facilities routinely provide these documents to prospective residents
before they decide to apply for admission. 

All four states have licensing requirements that must be met by
facilities that provide assisted living services.  Each of these
states inspects or surveys assisted living facilities to ensure that
they comply with regulations, yet they vary in the frequency and
content of inspections.  For example, California requires inspections
annually, Ohio at least every 15 months, and Oregon every 2 years. 
Florida's requirements vary depending on the level of assisted living
provided--from every 2 years for facilities providing standard
assisted living services to twice a year for those providing more
extensive nursing care, referred to as extended congregate care (ECC)
facilities.  The state licensing agencies also respond to complaints
they receive related to potential violations of state regulations. 
In addition to the state licensing agency, other state agencies have
a role in the oversight of assisted living facilities.  In all four
states, the state long-term care ombudsman agency may investigate and
resolve complaints involving residents of long-term care facilities
including those providing assisted living.  In Florida and Oregon,
APS agencies also investigate complaints or allegations involving
residents of assisted living facilities. 

Given the absence of any uniform standards for assisted living
facilities across the states and the variation in their oversight
approaches, the results of state licensing and monitoring activities
on quality-of-care and consumer protection issues also vary,
including the frequency of identified problems.  However, using
available state licensing surveys and reports from other oversight
agencies in these four states, we determined that more than
one-fourth of the facilities we reviewed were cited by state
licensing, ombudsman, or other agencies for five or more
quality-of-care or consumer protection related deficiencies or
violations during 1996 and 1997.  Eleven percent of these facilities
were cited by the state agencies with 10 or more quality-of-care or
consumer protection related deficiencies or violations during this
same time period.  Most of the problems identified were related to
quality of care rather than consumer protection.  While data were not
available to assess the seriousness of each identified problem, many
problems seemed serious enough to warrant concern.  Frequently
identified problems included facilities (1) providing inadequate or
insufficient care to residents, such as inadequate medical attention
after an accident; (2) having insufficient, unqualified, and
untrained staff; (3) not providing residents the appropriate
medications or storing medication improperly; and (4) not following
admission and discharge policies required by state regulation. 
According to state officials, factors that contributed to these
problems included insufficient numbers of staff, inadequate staff
training, high caregiver staff turnover, and low caregiver staff pay
rates. 


   BACKGROUND
------------------------------------------------------------ Letter :2

Assisted living is usually viewed as a residential care setting for
persons who can no longer live independently.  It is designed to
respond to the needs of individuals who require help with activities
of daily living (ADL) but who may not need the level of skilled
nursing care provided in a nursing home.  However, there is no
uniform assisted living model, and considerable variation exists in
what is labeled an assisted living facility.  Assisted living
facilities are similar to board and care homes in that both may
monitor a resident's care needs and condition and may assist with
some ADLs and other needs such as medication administration. 
According to assisted living advocates, however, what may not be
evident in board and care is that assisted living emphasizes
residents' autonomy, their maximum independence, respect for
individual resident preferences, and the ability to meet residents'
scheduled and unscheduled needs for assistance.  Moreover, assisted
living facilities may sometimes admit or retain residents who meet
the level-of-care criteria for admission to a nursing home. 

Most residents pay for assisted living out of pocket or through other
private funding.  However, in some states, public funds are available
to pay for assisted living care for some low-income residents who may
be at risk of institutionalization.  For example, some states are
attempting to control rising Medicaid costs by using assisted living
as an alternative to more expensive nursing home care.  While all
states pay for nursing home care under Medicaid, according to the
National Academy for State Health Policy, 32 states use Medicaid to
reimburse for services in assisted living or board and care
facilities for more than 40,000 Medicaid beneficiaries.\5 This
represents an increase from 22 states that did so as recently as
1996, and several states are currently considering legislation to
allow the use of Medicaid funds for assisted living. 

To help pay for assisted living services for Medicaid-eligible
residents, states typically use Medicaid waivers, specifically the
Home and Community Based Services Waiver.\6

Medicaid waivers allow the states to reimburse assisted living
facilities for services such as personal care and homemaker services
that may not be covered by the states' regular Medicaid programs. 
However, these payments do not cover room and board.  In assisted
living, the room and board portion may be paid by a combination of
individual resident payments, residents' Supplemental Security Income
(SSI), and optional state payments.  Through these waivers, the
states may choose to provide specific services only to defined
groups, such as elderly persons at risk of institutionalization,
instead of to all beneficiaries who meet Medicaid's eligibility
criteria, which would be required under Medicaid without a waiver. 
In contrast, a few states pay for services in assisted living
facilities through the personal care option under the Medicaid state
plan.  State plan services are an entitlement, and all beneficiaries
who meet Medicaid's eligibility criteria can receive
government-funded medical assistance. 

The states have the primary responsibility for licensing and
overseeing care furnished to assisted living residents, and few
federal standards or guidelines govern assisted living.\7

Some states have set very general criteria for the type of resident
who can be served and the maximum level of care that can be provided,
while other states have set more specific limits in these areas, such
as not serving residents who require 24-hour skilled nursing care. 
In general, state regulations tend to focus on three main
areas--requirements for the living unit, admission and retention
criteria, and the types and levels of services that may be provided. 
However, the states vary widely on what they require. 


--------------------
\5 For further information, see State Assisted Living Policy:  1998
(Portland, Me.:  National Academy for State Health Policy, June
1998), prepared under contract to the Office of the Assistant
Secretary for Planning and Evaluation of the Department of Health and
Human Services. 

\6 Sec.  1915(c) of the Social Security Act. 

\7 For further information on federal programs' responsibility
related to assisted living, see Long-Term Care:  Consumer Protection
and Quality-of-Care Issues in Assisted Living (GAO/HEHS-97-93, May
15, 1997). 


   FACILITY SERVICES AND RESIDENT
   NEEDS VARY WIDELY
------------------------------------------------------------ Letter :3

There is no typical assisted living facility or resident, and within
the limits of state regulation, facilities have considerable
flexibility to decide what residents they will serve and the types of
services they will provide.  The assisted living facilities
responding to our survey range from small, free-standing,
independently owned homes with a few residents to large, multilevel,
corporately owned communities caring for several hundred residents. 
They also serve a wide range of resident needs, with some providing
only meals, housekeeping, and limited personal assistance while
others provide or arrange for a range of specialized health and
related services.  The facilities also vary in the extent to which
they will admit residents with certain needs and whether they will
retain residents as their needs change, referred to as aging in
place. 


      A WIDE RANGE OF FACILITIES
      PROVIDE ASSISTED LIVING
---------------------------------------------------------- Letter :3.1

The assisted living facilities in the four states include providers
of a variety of types, sizes, and costs.  The vast majority of the
622 facilities that responded to our survey, 93 percent, primarily
serve the frail elderly.\8 About two-thirds of the facilities in the
four states are run as for-profit organizations, ranging from a high
of 86 percent in Oregon to a low of 45 percent in Ohio.  In
California, Ohio, and Oregon, most assisted living facilities are
part of a corporation that owns or operates multiple facilities,
while in Florida most are independently owned and operated.  The
facilities vary widely in size and structure as well.  The facilities
in our survey range from as small as 2 beds to as large as 600 beds. 
On average, the facilities have 63 beds.  Although some facilities
are freestanding, about 57 percent are part of a multilevel facility
or community that offers other levels of care, such as nursing home
care or independent apartments without services.  Some providers also
offer different types of specialized care within assisted living. 
For example, about 20 percent of the assisted living facilities
reported that they have a special assisted living unit for residents
with dementia; the units' average size is 23 beds. 

The average monthly rate residents pay for basic and additional
services in these four states varies widely, ranging from less than
$1,000 per month for general assisted living in some facilities to
more than $4,000 per month for special dementia care in others. 
Among the facilities responding to our survey, about one-third have
an average rate for general assisted living of less than $1,500 per
month, about one-third between $1,500 and $2,000, and one-third more
than $2,000.  Although the market for assisted living is primarily
among seniors who can afford substantial private payments for their
care, many facilities serve some low-income residents who receive
government assistance.  About 40 percent of the facilities overall
reported that they receive Medicaid or other forms of public
assistance or subsidy to provide care to one or more residents.  The
use of public funds to subsidize assisted living care varies among
the states.  In Florida and Oregon, two states that pay for assisted
living care under a Medicaid waiver, 43 and 86 percent of facilities,
respectively, reported receiving public funds to pay for care for
some of their residents.  In contrast, 27 percent of the facilities
in Ohio and 28 percent in California receive some public subsidy. 


--------------------
\8 The remaining 7 percent of the survey respondents primarily serve
persons with developmental disabilities, mental illness, or other
special needs. 


      ASSISTED LIVING FACILITIES
      PROVIDE OR ARRANGE FOR A
      VARIETY OF SERVICES
---------------------------------------------------------- Letter :3.2

A wide variety of services are available to residents in assisted
living.  Some services may be provided by a facility with its own
staff or by staff under contract to the facility.  In other cases,
the facility may arrange with an outside provider to deliver
services, with the residents paying the provider directly, or
residents may arrange and pay for services without the facility being
involved at all.  As shown in table 1, the assisted living facilities
in our survey usually provide or arrange for housekeeping, laundry,
meals, transportation to medical appointments, special diets, and
assistance with medications.  Many facilities also provide or arrange
for skilled nursing services, skilled therapy services, and hospice
care for their residents.  More specialized services, such as
intravenous (IV) therapy and tube feeding, are least likely to be
available. 



                          Table 1
          
             Services Available to Residents in
                 Assisted Living Facilities

                    Provided
                          or
                    arranged     Resident must     Service
                      for by  make independent         not
Service             facility    arrangements\a   available
----------------  ----------  ----------------  ----------
Housekeeping              98                 0           0
Meals                     98                 0           0
Laundry                   97                 1           0
Special diets             93                 0           5
Supervision of            93                 1           4
 self-
 medication
Storage and               92                 1           5
 administration
 of oral
 medication
Transportation            87                 2           6
Storage and               78                 4          15
 administration
 of injectable
 medication
Skilled therapy           66                15          13
Hospice                   60                17          17
Skilled nursing           41                 9          44
IV therapy                20                 5          75
Tube feeding              15                 3          81
----------------------------------------------------------
Note:  Numbers are percentages of facilities in our survey.  They may
not add to 100 percent because some facilities did not respond to all
items on the survey. 

\a Some facilities allow residents to receive the service but require
that they make independent arrangements for the service with an
outside provider such as a home health agency. 


      FACILITIES SERVE A WIDE
      RANGE OF RESIDENT NEEDS
---------------------------------------------------------- Letter :3.3

Assisted living is generally considered to be a residential setting
designed to respond to the needs of persons who require some
oversight or help with activities of daily living but who may not
need the level of skilled care provided in a nursing home.  We found
considerable variation among facilities and among the four states in
the needs of residents they serve.  Facilities we visited serve some
residents who are completely independent, have some residents with
severe cognitive impairment, or have some who are bedridden and
require significant amounts of skilled nursing care. 

Residents of assisted living facilities typically need the most
assistance from facility staff with medications and bathing.  As
shown in table 2, more than half of all facilities reported that more
than 50 percent of their residents need assistance with these
activities.  Assistance with dressing and toileting or incontinence
care were the next most frequently cited ADLs.  Assistance was
reported to be needed least with feeding, transferring, and
ambulation.\9 The highest level of need for staff assistance with
ADLs was reported among facilities in Oregon and those in Florida
licensed as extended congregate care facilities.\10



                                     Table 2
                     
                      Percentage of Facilities in Which More
                        Than Half of Residents Need Staff
                       Assistance With Activities of Daily
                                      Living

                                                                Florida\a
                                                          ----------------------
                                  Califo
ADL need                   Total    rnia    Ohio  Oregon      AL     LNS     ECC
------------------------  ------  ------  ------  ------  ------  ------  ------
Medication dispensing         53      68      56      78      29      53      37
Bathing                       52      49      52      58      41      50      62
Dressing                      34      34      32      33      29      24      42
Toileting                     20      18      15      29      21      11      27
Ambulation                    11      11       8      15      13       9       8
Transferring                   6       3       4       6       9       0      10
Feeding                        2       2       1       1       3       3       4
--------------------------------------------------------------------------------
\a Florida assisted living licensing categories include standard
assisted living (AL), limited nursing services (LNS), and extended
congregate care (ECC). 

In addition to needing assistance with activities of daily living,
residents of assisted living facilities often have some degree of
cognitive impairment.\11 They may suffer from significant short-term
memory problems, be disoriented all or most of the time, have
difficulty making decisions, or be diagnosed with Alzheimer's disease
or some other form of dementia.  Their service needs may include
behavior monitoring and management, orientation, and reminders or
cueing to perform daily tasks.  Most facilities in the four states
have some residents who are cognitively impaired; however, they range
widely in terms of the percentage of their residents with cognitive
impairment.  More than half of the facilities reported that at least
25 percent of their residents have cognitive impairment, and
one-quarter of the facilities reported that more than 50 percent of
their residents are cognitively impaired.  This ranges from a low of
20 percent of facilities in Oregon to a high of 38 percent among
extended congregate care facilities in Florida. 


--------------------
\9 These findings are consistent with national studies of assisted
living resident needs.  The Assisted Living Federation of America's
(ALFA) 1996 survey found similar percentages of residents needing
assistance with bathing (64 percent), dressing (46 percent),
toileting (33 percent), transferring (15 percent), eating (10
percent), and medication dispensing (70 percent). 

\10 Florida has four assisted living licensing categories:  standard
assisted living (AL), limited nursing services (LNS), extended
congregate care (ECC), and limited mental health (LMH).  We did not
include LMH in our analysis. 

\11 ALFA's 1996 survey found 48 percent of residents in assisted
living with cognitive impairments. 


      MOST ASSISTED LIVING
      FACILITIES MONITOR
      RESIDENTS' CONDITION
---------------------------------------------------------- Letter :3.4

Almost all the assisted living facilities we surveyed reported that
they provide some form of oversight to monitor and supervise their
residents.  Their oversight responsibilities include monitoring
changes in residents' health and physical or cognitive functioning,
as well as notifying a resident's physician, family, or other
responsible person when the resident's condition changes.  About 90
percent of the facilities also reported that their oversight includes
regular health or wellness checks by a nurse or other licensed health
professional and supervision of residents by staff on a 24-hour
basis.\12 The only significant variation among the states in terms of
oversight is on the issue of 24-hour supervision.  While all
facilities in Oregon reported that they provide 24-hour supervision
by awake staff, only about two-thirds of facilities licensed as
standard assisted living in Florida do so.\13 (See table 3.)



                                     Table 3
                     
                        Percentage of Facilities Providing
                        Oversight to Residents of Assisted
                                Living Facilities

                                                                Florida\a
                                                          ----------------------
                                  Califo
Type of oversight            All    rnia    Ohio  Oregon      AL     LNS     ECC
------------------------  ------  ------  ------  ------  ------  ------  ------
24-hour supervision of        90      94      96     100      69     100      90
 residents by awake
 staff
Monitoring changes in        100     100      99     100     100     100     100
 residents' condition or
 functioning
Notification of              100     100      99     100     100     100     100
 physician or family
 when changes in
 condition are noted
Regular health or             91      91      91      90      89      97      91
 wellness checks
 provided by a health
 professional
--------------------------------------------------------------------------------
\a Florida assisted living licensing categories include standard
assisted living (AL), limited nursing services (LNS), and extended
congregate care (ECC). 


--------------------
\12 State regulations generally require the presence of staff on-site
24 hours a day in assisted living.  In some small facilities,
however, they do not require that staff be awake at all hours. 

\13 The Florida standard assisted living category includes a large
number of very small facilities.  Forty percent are licensed for 12
or fewer residents, 20 percent for 6 or fewer. 


      SUPPORT FOR AGING IN PLACE
---------------------------------------------------------- Letter :3.5

Assisted living is often promoted as supporting the concept of "aging
in place" that allows residents to remain in a facility as their
health condition declines or their needs change.  The ability of
residents to age in place is reflected in a facility's admission and
discharge criteria or its rules governing who it will permit to move
in and when they may be required to leave.  Facilities responding to
our survey vary in terms of resident needs they will accept on
admission, and they also vary in terms of the degree to which they
will retain residents who develop certain needs or conditions after
being admitted. 

As shown in table 4, more than 75 percent of the facilities reported
they admit residents who have mild to moderate memory or judgment
problems, are incontinent but can manage on their own or with some
assistance, have a short-term need for nursing care, or need oxygen
supplementation.  Less than 10 percent of the facilities admit
residents who are bedridden, require ongoing tube feeding, need a
ventilator to assist with breathing, or require IV therapy.  Although
some facilities might not admit residents with a particular need or
condition, they do not necessarily discharge them if they develop
that need.  In Oregon, for example, most facilities indicated that
they will not admit someone who is bedridden, but half would
typically retain that individual if he or she becomes bedridden while
a resident. 



                                Table 4
                
                 Percentage of Facilities That Support
                  Aging in Place as Reflected in Their
                    Admission and Discharge Criteria

                                                    Facility would
                                                      typically
                                                ----------------------
                                                           Not
                                                         admit
                                                           but  Discha
Resident condition                               Admit  retain     rge
----------------------------------------------  ------  ------  ------
Has mild to moderate memory or judgment             98       2       1
 problems
Lacks bladder control but can manage own            95       4       2
 incontinence supplies
Lacks bowel control but can manage own              82       8      10
 incontinence supplies
Requires oxygen supplementation                     80       7      14
Has a short-term need for nursing care or           76      12      12
 monitoring by a licensed nurse
Lacks bladder control but needs assistance to       75       9      15
 manage incontinence
Requires a wheelchair to get around                 73      18      10
Requires assistance to transfer from bed to         59      16      25
 chair or wheelchair
Lacks bowel control but needs assistance to         59      13      28
 manage incontinence
Requires colostomy or ileostomy care                49      12      40
Requires the use of an indwelling urinary           47      13      40
 catheter
Wanders                                             39       9      52
Has severe memory or judgment problems              37      15      48
Has an ongoing need for nursing care or             34      10      56
 monitoring by a licensed nurse
Requires intravenous medication or therapy           9       0      91
Requires a ventilator to assist with breathing       7       5      88
Requires tube feeding on an ongoing basis            6       7      88
Is confined to bed for 22 or more hours a day        4      19      77
----------------------------------------------------------------------
Note:  Percentages may not add to 100 because of rounding. 

There is also considerable variation across the states in admission
and discharge criteria, some of which results from regulatory limits
on allowable conditions or services in assisted living facilities,
the facilities' choice of whom to serve, and the particular services
they choose to provide or make available.  Facilities in Oregon are
more likely to admit or retain residents with a higher level of need
than facilities in the other states.  For example, 95 percent of the
Oregon facilities admit people requiring assistance to transfer from
bed to chair or wheelchair while only 35 percent of the California
facilities admit people with this need. 


   CONSUMERS MAY LACK ENOUGH
   INFORMATION TO SELECT A
   FACILITY THAT MEETS THEIR NEEDS
------------------------------------------------------------ Letter :4

Given the variation in what is labeled assisted living, consumers
must rely primarily on information supplied to them by the providers. 
In order to compare facilities and choose one that best meets their
needs, prospective residents should receive information about
facility services, costs, and policies in writing.  However, we found
that written material often does not contain key consumer information
or is not routinely provided to prospective residents to use as an
aid in decisionmaking.  Moreover, in some cases the written material
that is provided to consumers is unclear or inconsistent.  As a
result, consumers may not be receiving information sufficient to
determine whether a particular assisted living facility can meet
their needs, for how long, and under what circumstances. 


      CONSUMERS RELY ON
      INFORMATION PROVIDED BY
      FACILITIES
---------------------------------------------------------- Letter :4.1

Nursing homes are subject to extensive federal regulations that
prescribe detailed standards for their operations and services.  In
contrast, assisted living facilities are regulated by the states and
usually have considerable flexibility to determine what services they
will provide and what level of resident need they will serve.  As a
result, facilities vary widely, and consumers must rely primarily on
information providers supply to identify a facility that meets their
needs and preferences. 

Prospective residents may obtain information to aid in their
decisionmaking in a variety of ways, including facility tours,
personal interviews, personal recommendations, and written materials. 
Most residents we interviewed had had the assistance of a family
member, usually an adult child, in identifying possible facilities,
and they had often relied on the advice of family, friends, or health
professionals in making their decisions.  Residents often mentioned
the facility tour along with interviews with management, staff, and
other residents as important means of obtaining information to make
their decisions.  Providers indicated that written marketing material
and sample resident contracts are also useful sources of consumer
information. 


      MUCH INFORMATION CONSIDERED
      KEY BY CONSUMER AND INDUSTRY
      GROUPS IS NOT ROUTINELY
      PROVIDED IN WRITING
---------------------------------------------------------- Letter :4.2

To help consumers compare facilities and select the most appropriate
setting for their needs, key information should be provided in
writing and in advance of their application for admission.  However,
we found that written material often does not contain key
information, and facilities do not routinely provide prospective
residents with important documents such as a copy of the contract,
sometimes called a resident agreement, to use as an aid in
decisionmaking.  According to consumer advocates and provider
associations, consumers need to know about the services that will be
provided, their costs, and the respective obligations of both the
resident and the provider.\14 Specifically, this information should
include

  -- the cost of the basic service package and what is included such
     as room, board, supervision, amenities, and personal care;

  -- the availability of additional services such as skilled nursing
     care or therapy services, who will provide them, and their cost;

  -- the circumstances under which costs may change, such as when
     care needs increase;

  -- how the facility monitors resident health care needs, including
     requirements for regular health examinations, and how the
     facility coordinates with a resident's physician;

  -- the qualifications of staff who provide personal care,
     medications, and health services;

  -- discharge criteria, such as when a resident may be required to
     leave the facility because health or need for supervision
     changes, and what procedures will be followed for resident
     notification and relocation; and

  -- grievance procedures, including the resident's right to
     challenge decisions about care. 

The majority of the facilities responding to our survey said that
they generally provide prospective residents with written information
about many of their services and costs in advance of a resident's
choosing to apply for admission.  However, as shown in table 5, less
than half indicated that they provide written information in advance
on discharge criteria and staff training and qualifications or a
description of services not covered or available from the facility. 
Only about half indicated that they provide information on the
circumstances under which the cost of services might change, their
policy on medications, or their practice for assessing or monitoring
residents' needs. 



                                Table 5
                
                Percentage of Facilities Reporting That
                They Provide Key Written Information to
                         Prospective Residents

                                                                Facili
Information\a                                                   ties\b
--------------------------------------------------------------  ------
Description of services included in the basic rate                  78
Cost of the basic service package                                   73
Statement of residents' rights and responsibilities                 73
Description of services available beyond the basic rate             70
Description of complaint or grievance procedure                     65
Cost of additional services                                         63
Policy on medication assistance or administration                   56
Facility practice for assessing or monitoring resident needs        53
Circumstances under which costs may change                          49
Discharge criteria related to change in health status               47
Description of services not covered or not available                39
Description of staff training and qualifications                    31
----------------------------------------------------------------------
\a Key information includes that identified by consumer advocates and
provider associations as important for consumers to have in order to
choose a facility appropriate for their needs. 

\b Survey respondents indicating that they provide information in
writing and, in the case of the contract, in advance of a resident's
choosing to apply for admission. 

The contract or resident agreement is an important source of written
information and, in some cases, may be the only place where certain
key points such as discharge criteria or circumstances when costs may
change are addressed.  However, most providers indicated that they do
not routinely make a copy of the contract available to prospective
residents to aid in their decisionmaking.  Only one out of four of
the facilities we surveyed indicated that they routinely provide a
copy of the contract to consumers before they make their decision to
apply for admission.  About 65 percent of the respondents said they
would provide a copy if requested, and 10 percent said they do not
provide contracts to prospective residents. 

We also reviewed the contents of a sample of contracts, marketing
materials, and other written information from 60 of the facilities
that responded to the survey.\15 These written materials almost
always include information about the services available from a
facility and, in the contract, some discussion of discharge criteria. 
However, the written materials we reviewed rarely mention staffing,
medication policies, or grievance procedures.  Only one in three
contain information about services not covered or not available, the
facility practice for monitoring resident needs, or the circumstances
under which the cost of services might change. 


--------------------
\14 Advocacy and provider associations we consulted to help identify
key consumer information included AARP, the American Association of
Homes and Services for the Aging, the American Bar Association
Commission on Legal Problems of the Elderly, the American Health Care
Association, the Assisted Living Federation of America, the Consumer
Consortium on Assisted Living, the Consumers Union, and the United
Seniors Health Cooperative. 

\15 We reviewed written material provided by 60 of the facilities
that responded to the survey as providers of assisted living--10 each
from California, Ohio, and Oregon and 10 from each of the three
licensing categories in Florida. 


      WRITTEN INFORMATION MAY BE
      UNCLEAR OR MISLEADING
---------------------------------------------------------- Letter :4.3

In addition to lacking important content, the facility contracts,
marketing material, and other written information that we reviewed
are sometimes vague or misleading.  To the extent that contracts and
other written material contain information on key points, we examined
them to determine whether the information is clear and understandable
and whether marketing materials and contracts are consistent with
each other and with relevant requirements of state regulations. 
Contracts range from a one-page standard form lease to a detailed
55-page document that includes multiple attachments.  Some are
written in very fine print, while others are prepared in large
easy-to-read type.  Some contracts are complex documents written in
specialized legal language while others are not.  Marketing and other
written material provided by facilities also varies widely from a
one-page list of basic services and monthly rent to multiple
documents of more than 100 pages. 

While most facilities use written materials that are specific and
relatively clear in the points they cover, we found written materials
from 20 of the 60 facilities, or 33 percent, that contain language
that is unclear or potentially misleading, usually concerning the
circumstances under which a resident can be required to leave a
facility.  Contracts and other written materials are often unclear or
inconsistent with each other or with requirements of state regulation
regarding how long residents can remain as their needs change,
resident notification requirements, or other procedural requirements
for discharge.  Some examples follow. 

  -- The marketing material used by one Florida facility is
     potentially misleading in specifying that a resident "can be
     assured if health changes occur, we can meet your needs.  And
     you won't have to deal with the hassles of moving again."
     However, the contract specifies a range of health-related
     criteria for immediate discharge, including "changes in [the
     resident's] physical or mental condition, supplies, services or
     procedures
     .  .  .  that [the facility] by certification, licensure,
     design, or staffing cannot provide."

  -- In another Florida facility, the marketing material states that
     the facility is committed to helping individuals to live at the
     facility "for the rest of their lives by .  .  .  adapting
     services and care plans to meet the needs of each person." The
     facility contract, however, states that the facility may
     terminate the agreement immediately "if the Resident requires
     services which are outside the scope of those services which the
     facility is licensed to provide" or if the facility "determines
     that the discharge of the Resident is appropriate for the
     Resident's welfare or for the welfare of other Residents."
     Florida law states that "any resident who is determined by the
     medical review team to be inappropriately residing in a facility
     shall be given 30 days' written notice to relocate unless the
     resident's continued residence in the facility presents an
     imminent danger to the health, safety, or welfare of the
     resident."

  -- The contract of a California facility lacks specific information
     about discharge requirements, stating only that the facility
     "reserves the right by action of its Board of Directors to
     dismiss Resident for what is, in the judgement of the Board,
     good and sufficient cause." Moreover, the contract makes no
     mention of state regulations that specify criteria for discharge
     or eviction. 

  -- The contract of an Oregon facility is inconsistent with
     requirements of state regulation regarding notification of
     residents before their discharge.  Oregon regulations specify
     that residents may not be asked to leave without 14 days'
     written notice and may be asked to leave only in specified
     circumstances, such as when the facility cannot meet the
     residents' needs with available support services or required
     services are not available.  In contrast, the contract states
     that "the resident shall be required to immediately vacate the
     Premises .  .  .  [if] the Resident requires medical or nursing
     care of a higher level or degree than may be available at [the
     facility]."


   THE STATES USE A RANGE OF
   APPROACHES TO OVERSEE ASSISTED
   LIVING FACILITIES
------------------------------------------------------------ Letter :5

Each of the four states we studied has licensing requirements that
must be met by most facilities that provide assisted living
services.\16 Some states have created a specific licensing category
called "assisted living" while others license and regulate assisted
living under existing residential care standards.  All states inspect
or survey assisted living facilities to ensure that they comply with
regulations for quality of care and consumer protection, yet unlike
annual nursing home inspections, they vary in the frequency and
content of inspections and the range of enforcement mechanisms
available to ensure compliance.  The state licensing agencies also
respond to complaints they receive related to potential violations of
state regulations.  In addition to the state licensing agency, other
state agencies have a role in the oversight of assisted living
facilities.  In the four states we studied, the state ombudsman
agency may investigate and resolve complaints involving residents of
long-term care facilities, including those providing assisted
living.\17

In two of the four states we studied, Florida and Oregon, APS
agencies also investigate complaints or allegations related to abuse,
neglect, or exploitation involving residents. 


--------------------
\16 California and Ohio may have some facilities that advertise
themselves as "assisted living facilities" but do not provide a level
of care that is required by state law to be licensed.  For example, a
facility may call itself an assisted living facility but provide only
an apartment and one meal per day but no direct care or no
supervision of personal care or medical needs and, therefore, it does
not meet the criteria that require it to be licensed by the state. 
In Florida and Oregon, any facility that holds itself out as an
assisted living facility must be licensed by the state. 

\17 In California and Oregon, the ombudsman investigates and resolves
complaints only in licensed long-term care facilities.  In contrast,
ombudsmen in Florida and Ohio may respond to complaints in both
licensed and unlicensed facilities. 


      STATE REQUIREMENTS FOR
      ASSISTED LIVING FACILITY
      LICENSING VARY
---------------------------------------------------------- Letter :5.1

Most facilities that provide assisted living services must meet
licensing requirements in the four states we studied.  Regulations
that address quality of care and consumer protection generally cover
such areas as admission and discharge criteria, the type and level of
services that can be provided, staffing levels and training, as well
as resident rights and consumer access to information.\18 However,
the four states vary in how they define these requirements and the
level of detail with which they describe them. 

Florida and Oregon have created a specific licensing category and
requirements for assisted living facilities, while California and
Ohio generally license them under existing residential care facility
regulations.\19 In addition, Florida has four subcategories of
assisted living licensure, depending on the types and levels of care
that can be provided.  These include facilities that provide standard
assisted living services, limited nursing services, and extended
congregate care for residents needing more care than can be provided
in an LNS facility.\20

Three of the four states we studied have established specific
criteria that define who can be admitted to an assisted living
facility, and all four states have criteria that specify when a
resident must be discharged.  In addition, all four states have rules
governing the process for resident admission and discharge.  For
example, regulations in California and Florida generally require that
a person needing 24-hour skilled nursing care or supervision cannot
be admitted to a facility and must be discharged if he or she
develops such a need.  In contrast, Oregon regulations allow
facilities the most flexibility in deciding who they will serve.  For
example, Oregon regulations allow residents to remain in a facility
as their health condition declines or their needs change, provided
the facility can continue to meet their needs. 

With respect to resident admission, all states require facilities to
conduct an initial assessment of a resident's health, functional
ability, and needs for assistance.  Except for Florida, the states we
studied require all facilities to develop a plan of care to address
the identified needs.\21 In California, the initial assessment must
include a physical examination of the resident, tests for contagious
and infectious diseases, documentation of prior medical services and
history and current medical status, a record of current prescribed
medications, identification of the resident's physical limitations to
determine his or her capability to participate in the facility's
programs, and a determination of the person's ambulatory status. 

Concerning resident discharge, all states generally require that
facilities provide residents with sufficient advance notice of
discharge or eviction, ranging from 14 to 30 days, except in certain
emergency situations where continued residence would jeopardize the
health or safety of the resident or others in the facility.  In
addition, all state regulations specify certain rights and procedures
for residents to appeal or contest a facility's decision to discharge
them. 

State regulations have similar requirements for the types and the
levels of services that assisted living facilities must provide
residents.  In addition to basic accommodations that include room,
board, and housekeeping, all the states require assisted living
facilities to provide residents with certain basic services,
including (1) assistance with ADLs, (2) ongoing health monitoring,
and (3) either the provision or the arrangement of medical services,
including transportation to and from those services as needed. 

State regulations for assisted living differ with respect to the
level of skilled nursing or medical care that facilities can provide
to residents and the circumstances under which it can be provided. 
For example, California regulations contain a list of services that
facility staff are generally not allowed to provide, including
catheter care, colostomy care, and injections.  According to state
officials, the care for such conditions in California assisted living
facilities is normally provided through a contract between a resident
and a home health agency.  With a few exceptions, Ohio regulations
limit skilled nursing care to residents who need it only on a
part-time, intermittent basis and restrict it to no more than 120
days per year.\22 Oregon, in contrast, has no explicit restrictions
on the types or levels of care that facility staff can provide,
except that certain nursing tasks must be either assigned or
delegated to a caregiver by a registered nurse. 

Although all states require facilities to provide some degree of
supervision with medications, they differ in the degree to which
facility staff can be directly involved in administering medications
to residents.  For example, in Oregon, unlicensed, nonprofessional
staff can administer medications to residents if they have
appropriate authorization, training, and general supervision. 
However, in Florida and Ohio, only staff specifically licensed or
certified to administer medications may do so.  In California,
facility staff may not administer medications to residents but may
only assist residents to take medication themselves.  The rules
governing medications can limit a resident's ability to continue
residing in a facility if he or she is unable to manage his or her
own medications and licensed or certified staff are not available. 

Requirements for staff levels, qualifications, and training also vary
among the states.  Florida's regulations require facilities to
maintain a minimum number of full-time staff, based on the total
number of residents, while regulations in California and Ohio require
that the number of staff be sufficient to meet the needs of
residents.  In contrast, Oregon provides no specific guidance on how
many staff are needed to provide for the residents' needs.  The
regulations in all four states specify minimum qualifications for the
education and training of facility administrators, and they generally
require that caregivers receive training for the personal care
services they are to provide.  Only Florida's regulations specify the
amount and content of training that caregiver staff must receive. 

State regulations also generally contain consumer protection
provisions governing resident contracts, criminal background checks
for staff, and residents' rights, including resident participation in
decisionmaking.  All four states require that facilities enter into
contracts with residents.  Although the contracts typically include
provisions related to residents' rights, services to be provided,
charges, and refund policies, state requirements differ in the level
of detail they require in the agreements.  California, Florida, and
Oregon have explicit requirements in regulations for criminal
background checks of facility administrators, and all four states
require such checks for direct care staff. 


--------------------
\18 The regulations also cover minimum space for the resident's
living unit and building and safety standards that we have not
covered in this report. 

\19 According to state officials, the Oregon regulations that apply
to assisted living were recently revised effective April 1, 1999. 
Not all assisted living facilities in Ohio are licensed as
residential care.  Some are unlicensed, and some may be licensed as
adult care facilities or homes for the aged. 

\20 Florida has another assisted living licensing category called
limited mental health that we did not include in our study. 
Facilities with this licensing type serve three or more mental health
residents. 

\21 Florida requires the development of a plan of care for residents
in an ECC and residents under the Medicaid waiver. 

\22 Exceptions include (1) supervision of special diets, (2)
applications of dressings, and (3) medication administration, which
facilities can provide on an ongoing basis if they have the
appropriate skilled staff. 


      STATE INSPECTIONS OF
      ASSISTED LIVING FACILITIES
      VARY
---------------------------------------------------------- Letter :5.2

All four states are responsible for conducting periodic inspections
or surveys of facilities to ensure that they comply with licensing
requirements, yet they vary in the frequency and content of those
inspections and in the range of enforcement mechanisms that can be
used to correct problems.  In each of the four states, licensing
agencies conduct periodic inspections or surveys to ensure compliance
with regulations.  The licensing agency in California is required to
inspect facilities annually, and the licensing agency in Ohio is
required to inspect facilities every 15 months.  Florida and Oregon
survey facilities at least once every 2 years.\23 Facilities in
Florida licensed as limited nursing services are to be inspected at
least once a year for compliance with LNS regulations, and facilities
licensed to provide extended congregate care are to be inspected at
least twice a year for compliance with ECC regulations.  One of these
visits may be made in conjunction with the state's biennial standard
assisted living survey.  Licensing authorities in all four states
also conduct investigations in response to complaints they receive
regarding the services and care provided to facility residents. 

The content of periodic state surveys is driven primarily by the
requirements in state regulations.  To assist licensing staff in
interpreting the regulations, Florida and Ohio have developed
detailed guidelines, similar to those used for nursing home
inspections, that cover most aspects of regulated facility practice. 
In contrast, licensing staff in California and Oregon use a checklist
that covers a subset of the regulations and focuses on a few selected
elements.\24

The licensing survey process generally includes meeting with the
facility's administrator, touring the facility, reviewing facility
and resident records, and interviewing residents and staff.  A
complaint survey can include interviews with the resident, staff, and
other relevant persons and a review of facility records.  When
deficiencies are found, facilities are given the opportunity to
correct them.  The four states we visited use a variety of means to
ensure that facilities correct deficiencies.  These include requiring
a written plan of correction, reinspection of facilities to verify
compliance, civil monetary penalties, restrictions on admissions,
criminal sanctions, or license revocation, although not all states
use all these.  For example, in Florida, a facility with severe or
repeated deficiencies with respect to medications or dietary services
may be required to add a consultant pharmacist or dietitian to its
staff until problems are resolved. 


--------------------
\23 While Oregon has historically conducted biennial inspections to
coincide with the expiration of the 2-year license, the licensing
agency officials said they have increased the frequency of
inspections of all assisted living facilities to at least once a
year. 

\24 According to state officials, Oregon's checklist is intended to
focus on selected elements related to resident care. 


      OMBUDSMEN AND ADULT
      PROTECTIVE SERVICES ALSO
      PROVIDE OVERSIGHT OF
      ASSISTED LIVING FACILITIES
---------------------------------------------------------- Letter :5.3

In addition to the state licensing agency, other state agencies play
a role in the oversight of assisted living facilities.  In the four
states we examined, the state ombudsman agency has a role in
overseeing the quality of care and consumer protection of residents. 
The ombudsmen are intended to serve as advocates to protect the
health, safety, welfare, and rights of elderly residents of long-term
care facilities and to promote their quality of life.  One of their
primary responsibilities is to investigate and resolve complaints of
residents in long-term care facilities, such as nursing homes, board
and care homes, and assisted living facilities.\25

Typically, ombudsmen receive complaints from residents, family,
friends, and facility staff or they initiate a complaint based on
their own observation.  The complaints name the facility and describe
the problem and the resident involved.  The ombudsman assigned to
that facility generally interviews the resident within a certain
period of time to gather additional information about the complaint,
to assure the resident that his or her identity will remain
confidential unless he or she indicates otherwise, and to request
permission to investigate the complaint.\26 The ombudsmen may also
need to gather additional information by interviewing physicians and
other health practitioners, facility staff, other residents, or
family members and reviewing resident records.  If the resident gives
permission, then the ombudsmen can try to resolve the complaint with
the appropriate facility staff.  Depending on the state and the
nature of the complaint, ombudsmen may refer the complaint to another
agency, such as the state licensing agency or adult protective
services. 

Ombudsmen in Florida are also required to inspect each facility
annually to evaluate the residents' quality of care and quality of
life.  The inspections provide ombudsmen an opportunity to (1) talk
to residents, (2) inspect the facility and residents' rooms, (3)
identify the level of resident privacy, and (4) check certain safety
requirements.  Upon completion of the inspection, the ombudsmen
discuss any problems with the facility administrator and negotiate a
resolution.  Any unresolved problems are referred to the licensing
agency. 

In some states, APS has oversight responsibility for assisted living
residents.  In two of the four states we studied, Florida and Oregon,
APS agencies have authority to investigate complaints or allegations
related to abuse, neglect, or exploitation involving residents.\27

In general, the APS agencies are responsible for (1) investigating a
complaint or allegation, (2) determining the immediate risk to the
person and providing necessary emergency services, (3) evaluating the
need for and referrals for ongoing protective services, and (4)
providing ongoing protective supervision.  The investigations
typically include interviewing the victim, alleged perpetrator, and
witnesses separately to obtain their accounts of what occurred and
obtaining relevant documents and other physical evidence to determine
whether abuse, neglect, or exploitation has occurred. 

Florida's and Oregon's Medicaid-funded residents receive additional
oversight from case managers.  Both of these states' Medicaid
programs require case management for residents who receive assisted
living services under the Medicaid waiver.  Case managers meet
periodically with residents, their facility administrator, or
facility staff and discuss the residents' needs, changes in what
services they require, and any other additional issues related to the
care plan.  In Oregon, the Medicaid Fraud Control Unit within the
Office of the Attorney General has investigated cases involving
residents of assisted living facilities that receive Medicaid
funding.\28 The Oregon Attorney General's office has also been active
in educational and training sessions to ensure that residents of
assisted living facilities are provided good-quality care. 


--------------------
\25 Ombudsmen also (1) visit facilities to educate the administrator,
staff, and residents about the ombudsman program; (2) distribute
program materials; and (3) offer educational and training programs. 
For example, Oregon ombudsmen have participated in an assisted living
association's monthly training sessions of facility administrators
and staff. 

\26 If the resident is unable to provide written or verbal consent
because of functional or cognitive limitations, then the ombudsmen
follow certain guidelines on who can give consent, especially in
cases involving access to medical files. 

\27 In California and Ohio, the APS agencies' authority is limited to
investigating problems involving persons not residing in
"institutions" or "facilities." However, in these two states,
complaints related to abuse, neglect, and exploitation of residents
in assisted living facilities may be investigated by the licensing
agency or the ombudsman agency. 

\28 The Florida Medicaid Fraud Control Unit has the authority to
investigate cases involving assisted living facility residents in
Medicaid-funded facilities.  However, as of late February 1999, no
investigations of assisted living facilities had taken place. 


   STATES IDENTIFY QUALITY-OF-CARE
   AND CONSUMER PROTECTION
   PROBLEMS IN ASSISTED LIVING
   FACILITIES
------------------------------------------------------------ Letter :6

Given that states vary in their licensing requirements for assisted
living facilities and in their approaches to oversight, the type and
frequency of quality-of-care and consumer protection problems
identified by the states may not fully portray the care and services
actually provided.  However, using available state licensing surveys
and reports from ombudsmen and APS agencies, we determined that 27
percent of the facilities in the four states were cited for 5 or more
quality-of-care or consumer protection related problems, and 11
percent for 10 or more problems, during 1996 and 1997.\29 The most
commonly cited problems were related to quality of care and included
inadequate care and staffing and medication issues.  According to
state officials, factors that contributed to these problems included
insufficient numbers of staff, inadequate staff training, high
caregiver staff turnover, and low caregiver staff pay rates. 
Thirty-eight percent of the facilities in the four states were not
cited for any quality-of-care or consumer protection related problems
during this period. 


--------------------
\29 Our analysis includes quality-of-care or consumer protection
related problems (1) cited during each facility's most recent
licensing survey or (2) verified by state licensing, ombudsman, or
APS agencies for the period 1996 and 1997.  The quality-of-care
problems related to resident care, services, medications, staffing
and training, and outcomes of care.  The consumer protection problems
related to contracts, consumer disclosure and financial issues,
tenant-landlord issues, resident access to information, and resident
participation in decisionmaking. 


      SOME FACILITIES HAVE BEEN
      CITED FOR DEFICIENT CARE
      PRACTICES AND INADEQUATE
      CONSUMER PROTECTION
---------------------------------------------------------- Letter :6.1

Twenty-seven percent (200 of 753) of the assisted living facilities
for which we requested state agency data were cited for 5 or more
quality-of-care or consumer protection related problems by state
oversight officials during 1996 and 1997, while 11 percent (86 of
753) of these facilities had 10 or more problems during this same
time period.  As shown in table 6, most of the problems identified by
the oversight agencies were related to quality of care.  While data
were not available to assess the seriousness of each identified
problem, many problems seemed serious enough to warrant concern. 



                          Table 6
          
           Percentage of Facilities With Quality-
          of-Care and Consumer Protection Related
             Problems Identified by Licensing,
          Ombudsman, and APS Agencies in the Four
                           States

                 Facilities with verified problems
          ------------------------------------------------
              Quality of
Number           care or
of              consumer      Quality of          Consumer
problems      protection            care        protection
--------  --------------  --------------  ----------------
5 or                 27%             22%                3%
 more
10 or                 11               9                 0
 more
----------------------------------------------------------
Note:  Number of facilities = 753. 

The number and type of problems identified in assisted living
facilities often depend on a number of factors that may be unique to
each state.  For example, facilities in states with more licensing
standards, more frequent inspections, or more agencies involved in
oversight may be likely to have more problems identified.\30
(Appendix III contains frequencies of the four states' licensing
deficiencies and verified ombudsman complaints and Florida's and
Oregon's verified APS allegations.)

The most common problems, as shown in table 7, that licensing and
ombudsman agencies cited in the four states concerned inadequate
care, staffing, and medication.  Other frequently cited problems
involved resident care plans and assessments; admission, discharge,
and level-of-care issues; billing charges; and abuse.  These problems
included instances in which a facility was found to be providing
inadequate care to residents as well as instances in which a facility
did not demonstrate the capacity to provide sufficient care.  For
example, staffing problems included cases in which a resident
suffered harm as a result of an insufficient number of staff in the
facility, as well as cases in which facilities had no documentation
to substantiate that required caregiver training had been provided. 



                                     Table 7
                     
                      Types of Quality-of-Care and Consumer
                        Protection Issues Most Frequently
                      Identified by Licensing and Ombudsman
                       Agencies in the Four States, 1996-97

          California         Florida             Ohio              Oregon
       ----------------  ----------------  ----------------  -------------------
                  Ombud             Ombud             Ombud             Ombudsma
       Licensing  sman   Licensing  sman   Licensing  sman   Licensing  n
       deficienc  compl  deficienc  compl  deficienc  compl  deficienc  complain
Rank   ies        aints  ies        aints  ies        aints  ies        ts
-----  ---------  -----  ---------  -----  ---------  -----  ---------  --------
1      Inadequat  Inade  Staffing   Inade  Care       Admis  Care       Inadequa
       e care     quate  or         quate  plans or   sion,  plans or   te care
                  care   training   care   assessmen  disch  assessmen
                                           ts         arge,  ts
                                                      or
                                                      level
                                                      of
                                                      care\
                                                      a

2      Medicatio  Admis  Medicatio  Billi  Inadequat         Medicatio  Staffing
       n          sion,  n          ng     e care            n          or
                  disch             or                                  training
                  arge,             charg
                  or                es\b
                  level
                  of
                  care\
                  a

3      Admission  Abuse  Care       Abuse  Medicatio         Inadequat  Billing
       ,                 plans or          n                 e care     or
       discharge         assessmen                                      charges\
       , or              ts                                             b
       level of
       care\a

4      Staffing   Billi  Admission  Staff  Staffing          Staffing   Medicati
       or         ng     ,          ing    or                or         on
       training   or     discharge  or     training          training
                  charg  , or       train
                  es\b   level of   ing
                         care\a

5      Care       Staff  Contracts         Access to         Abuse      Care
       plans or   ing    \b                informati                    plans
       assessmen  or                       on\b                         or
       ts         train                                                 assessme
                  ing                                                   nts
--------------------------------------------------------------------------------
Note:  Includes only types of problems cited at least five times
across all facilities we sampled in each state during the 2-year
period.  Blank cells indicate that no additional type of deficiency
or complaint was cited more than four times.  All problems are
related to quality of care unless noted otherwise. 

\a Problem may be related to either quality of care or consumer
protection. 

\b Problem is related to consumer protection. 

Deficiencies and complaints related to inadequate care in the four
states most frequently dealt with such problems as residents not
receiving adequate access to physicians and other medical care or
treatment for symptoms, such as pressure sores.  For example, in one
California facility, staff neglected to call "911" after a resident
fell and injured her head.  Instead, they gave the resident aspirin,
and several hours later she was found in a comatose state, and she
died 3 days later.  In an Oregon facility, a resident's catheter was
to be irrigated daily; however, records indicated that the irrigation
had not been done for approximately 6 weeks.  Subsequently, the
resident was sent to the emergency room and diagnosed with a urinary
tract infection.  An Ohio facility failed to notify a resident's
physician that the resident had fallen at least 22 times and
sustained head injuries.  In that same facility, another resident
fell 32 times over a 6-month period and was not evaluated for
possible transfer to another facility for closer supervision. 

The second most frequently cited problem area included issues related
to staff qualifications and training and facilities having sufficient
staff to care for the residents.  For example, in a Florida facility,
staff had not received any training in personal hygiene care or
proper infection control procedures, which could result in exposure
to a wide range of viruses and bacterial infections, including
influenza and hepatitis.  In Oregon, family members routinely
assisted residents by changing soiled garments because the facility
had insufficient staff. 

The third most frequently cited problem area concerned medication-
related deficiencies and complaints, such as not providing residents
prescribed medication, providing them the wrong medication, or
storing medication improperly.  An Oregon facility was found to have
numerous medication problems, including (1) staff inconsistently and
inaccurately transcribing a physician's medication orders to the
resident's medication administration records, (2) medications often
being borrowed or shared between residents, (3) one staff member
signing out narcotics but another staff member on a different shift
administering them to residents, and (4) unlicensed caregivers
altering residents' prescription labels.  In a California facility,
staff failed to provide psychiatric medication to a resident for 20
days. 

Other commonly cited problems dealt with care plans and admission,
discharge, and level-of-care issues.  In one case, a Florida facility
was cited for having four residents who had more care needs than an
assisted living facility is allowed by state law.  One of these
residents required a special mechanical lift to transfer from bed to
wheelchair, and the resident's room was on the second floor, which
could prove extremely difficult to evacuate in an emergency.  The
three other residents were unable to respond to questions and had
heavy care needs; they were all located on the second floor, which
made them also incapable of evacuating in case of an emergency. 

Oregon APS verified 48 cases of abuse in 21 of the 83 assisted living
facilities over the 2-year time period.  Oregon APS also found
numerous cases of inadequate care, problems with care plans and
assessments, and medication issues.  For example,

  -- Investigators found a resident who had a serious stage III
     decubitus ulcer on her foot and three other open skin areas. 
     The decubitus was not being treated or documented, and no
     physician had been notified. 

  -- A resident was left on the toilet for 2 hours because the
     caregiver forgot to return to the resident's room and a call
     light was not within reach.  Only one caregiver was scheduled
     for the night shift to care for 30 residents, some of whom had
     need for a high level of care. 

  -- Staff ordered a resident's medications from a new pharmacy, but
     the medications received were the wrong ones.  Methyldopa, a
     heart medication, was sent instead of Levodopa, a medication for
     Parkinson's disease.  The error was not detected by the
     medication aides for 2 months.  The medication mix-up was
     finally discovered by the admitting physician when the resident
     was hospitalized with low blood pressure and fever. 

In Florida, the APS agency verified 39 cases of abuse in 25 assisted
living facilities and 103 cases of neglect in 32 facilities.  Florida
cases included the following. 

  -- A 90-year-old resident was admitted to a hospital with a stage
     IV pressure ulcer and found to be dehydrated and poorly
     nourished. 

  -- A resident did not receive his medications over several days,
     resulting in the resident's having a seizure and being
     hospitalized.  The facility had contacted the pharmacy several
     times for the medication, but the pharmacy did not deliver it
     because the pharmacy had run out of its supply.  The facility
     and the pharmacy were both found negligent. 

  -- A resident who was at the facility for respite care fell,
     bruising her face.  Later that day, the resident was found
     nonresponsive and was transported to the emergency room.  The
     physician diagnosed a hematoma that was inoperable because of
     her severe vein disease, and she subsequently died.  The
     administrator admitted that he should have sought medical
     treatment after the resident's fall. 

In addition to the other state agencies, the Oregon Attorney
General's Office investigated three cases involving residents of
assisted living facilities during 1996 and 1997.  For example, the
Office's Medicaid Fraud Control Unit investigated a case involving a
resident with end-stage renal disease who was receiving dialysis
treatments and was on a special diet.  However, the facility had no
certified or trained dietitian available, and the resident was not
receiving proper nutrition.  In another case, the Oregon Financial
Fraud Unit investigated the death of a resident in an Alzheimer's
secured unit.  The resident had exited the unit through a window,
subsequently dying of exposure and hypothermia.  The unit qualified
as "secure" under the applicable regulations, but the windows were
easily opened wide enough for a person to pass through. 

State officials attributed the most common problems identified in
assisted living facilities to insufficient staffing and inadequate
training.  Inadequate care and medication issues were most frequently
attributed to shortage of staff and inadequate staff training.  The
officials also cited high staff turnover rates and low pay rates for
caregiver staff.  When facilities do not have adequate numbers of
staff, then residents may be more likely to receive inadequate ADL
assistance or have their call lights left unanswered or have
inadequate assistance in case of an emergency.  Furthermore, if
facilities do not adequately train their staff, residents' medication
may be improperly administered, the facility may experience
widespread infections, or staff may injure or harm the residents
through improper lifting or bathing techniques. 


--------------------
\30 Appendix I discusses the methodology we used to analyze the state
data, and appendix III describes the limitations of the data. 


   CONCLUSIONS
------------------------------------------------------------ Letter :7

As a growing number of elderly Americans reach the point where they
can no longer live independently, many look to assisted living
facilities as a viable, homelike setting to meet their long-term care
needs.  Currently, the assisted living industry is regulated by
states and predominantly funded by private resources.  However, as
the states increase the use of Medicaid to help pay for assisted
living, the contribution of federal financing will grow as well. 
These trends will likely focus more attention from consumers,
providers, and the public sector on where assisted living fits on the
continuum of long-term care, on the standards the states use to
ensure quality of care and protect consumers, and on the approaches
the states use to ensure compliance with those standards. 

With attention on assisted living facilities growing, our work in
four states suggests that two issues are likely to be at the
forefront of discussions about potential oversight needs.  First,
many assisted living facilities are not routinely providing
prospective residents with key information they need in advance so
they can compare what several facilities offer and determine whether
a facility is appropriate for their needs.  Second, it is apparent
that residents of a number of assisted living facilities are
encountering problems with quality of care or consumer protection,
which in some cases can have a serious effect on their health.  State
regulators, providers, consumer advocates, and the federal government
will need to be attentive to these problems as they surface and will
need to consider what additional steps, if any, may be advised to
best ensure that adequate quality of care and consumer protections
are in place. 


   STATE AND OTHER COMMENTS
------------------------------------------------------------ Letter :8

We obtained comments on the draft report's section on state oversight
from officials representing licensing and ombudsman agencies in the
four states we studied and also from Florida's and Oregon's APS and
Medicaid agencies and Medicaid Fraud Control Unit.  We also obtained
comments on our draft report from expert reviewers and
representatives of provider associations.  All reviewers suggested
technical changes, which we included in the report where appropriate. 

The expert reviewers, who are nationally known researchers in the
assisted living field, were Catherine Hawes, Ph.D., Senior Research
Scientist at the Myers Research Institute, and Robert L.  Mollica,
Ed.D., Deputy Director of the National Academy for State Health
Policy.  Generally, they commented that the report is balanced,
should help consumers and policymakers think more carefully about the
potential of assisted living to meet the needs of the frail elderly,
and should be useful to states as they review their regulations and
monitoring activities for assisted living facilities. 

The provider associations that reviewed and provided comments on the
draft report included the American Association of Homes and Services
for the Aging, the American Health Care Association, and the Assisted
Living Federation of America.  In general, these reviewers reiterated
the importance of clear and complete information to help consumers
select an appropriate assisted living facility.  With regard to our
findings on quality-of-care and consumer protection issues, they
noted the importance of better understanding the seriousness of
verified problems and the states' approaches to addressing and
resolving them. 


---------------------------------------------------------- Letter :8.1

As agreed with your office, unless you publicly announce the report's
contents earlier, we plan no further distribution for 30 days.  We
will then send copies to interested congressional committees and
members and agency officials and will make copies available to others
on request.  If you or your staff have any questions about this
report, please call me at (202) 512-7118 or John Hansen, Assistant
Director, at (202) 512-7105.  Major contributors to this report are
listed in appendix IV. 

Kathryn G.  Allen
Associate Director, Health Financing
 and Public Health Issues


SCOPE AND METHODOLOGY
=========================================================== Appendix I

Our study focused on four states with a range of experiences with
assisted living facilities--California, Florida, Ohio, and Oregon. 
We chose these states because they have a large number of assisted
living facilities and represent four distinct regions of the country. 
We selected Florida and Oregon because they have an assisted living
licensing category and use Medicaid waivers to reimburse assisted
living facilities for covered services for Medicaid-eligible
residents.  We used two methods to identify potential facilities.  In
all four states, we included the facilities that are members of trade
associations that represent assisted living facilities.\31 In the two
states with an assisted living licensing category, Florida and
Oregon, we also included facilities that were licensed as of 1997. 

To identify the facilities' services and their residents' needs, we
conducted a mail survey of 955 randomly selected facilities of 2,652
identified facilities in the four states.  We received responses from
721 facilities, or 75 percent of those we surveyed; 622 of those
identified themselves on the survey as providers of assisted living
services.\\32 See table I.1 for details on the study sample by state. 
We also visited five facilities in each of the four states, met with
facility administrators and staff, and interviewed more than 90
residents or family members. 



                         Table I.1
          
              GAO Assisted Living Study Sample

                             Number of  Number of assisted
             Number of        assisted   living facilities
             potential          living    GAO analyzed for
              assisted      facilities     quality-of-care
                living       returning        and consumer
State       facilities          survey   protection issues
----------  ----------  --------------  ------------------
California         387             134                 150
Florida\a        1,939             276                 370
Ohio               243             140                 150
Oregon              83              72                  83
==========================================================
Total            2,652             622                 753
----------------------------------------------------------
\a Florida assisted living licensing categories include standard
assisted living, limited nursing services, and extended congregate
care. 

To determine whether prospective residents and their families receive
sufficient information to make an informed decision about which
facility to enter, we (1) asked several assisted living industry
experts, including experts at AARP, the American Association of Homes
and Services for the Aging, the American Health Care Association, and
the Assisted Living Federation of America, to identify the kinds of
information that would be useful to potential residents and their
families in selecting an assisted living facility; (2) obtained
information from our mail survey of assisted living facilities on
which of these items they usually provide and in what form; and (3)
evaluated written marketing materials and contracts of 60 facilities
for completeness, clarity, and consistency with pertinent state
statutes and regulations. 

To determine how the states oversee assisted living facilities, we
interviewed state officials in the four states and reviewed relevant
state statutes, regulations, guidance, and policy manuals.  We did
not evaluate the effectiveness of the state agencies' oversight of
assisted living facilities.  To determine the type and frequency of
quality-of-care and consumer protection problems the four states
identified in assisted living facilities, we analyzed information
obtained from the state licensing and ombudsmen agencies in each
state, and the adult protective services (APS) agency in Florida and
Oregon, for the period from January 1, 1996, through December 31,
1997, for a randomly selected sample of 753 of the 955 facilities
that received our survey.  See table I.1 for detail on the sample by
state.  We examined each facility's most recent licensing survey and
all complaint investigations for the facility that had resulted in
deficiencies or complaints the state had verified concerning quality
of care or consumer protection.  We assessed the reliability of the
state data by testing multiple data elements to confirm their
expected relationships to one another and by testing individual data
elements for specific attributes.  We consider the states' data to be
reliable for the purpose of this study.  However, the results of our
study cannot be projected to all assisted living facilities in these
states. 

We considered the deficiencies or complaints that concerned resident
care, services, medications, staffing--levels, training,
qualifications--and outcomes of care to be quality-of-care problems. 
We considered the deficiencies or complaints related to contracts,
consumer disclosure and financial issues, tenant-landlord issues, and
resident access to information and participation in decisionmaking to
be consumer protection problems.  We did not analyze deficiencies or
complaints that dealt with resident rights, quality of life,
administration, safety, or physical plant or environment issues. 
These data may include cases that were investigated and verified by
more than one state agency.  For example, a licensing agency may have
cited a deficiency in a facility and also referred the case to the
APS to investigate.  In this case, if the APS agency also verified
that allegation, then we would have counted two problems occurring as
opposed to one.  However, because of the agencies' data limitations,
we were unable to identify when this occurred or the extent to which
it occurred.  We also obtained information on factors that may have
contributed to the identified problems through interviews with
officials from the four states' licensing, ombudsman, and APS
agencies. 



(See figure in printed edition.)Appendix II

--------------------
\31 The associations were the American Association of Homes and
Services for the Aging, the American Health Care Association, and the
Assisted Living Federation of America. 

\32 We excluded from our analysis 32 respondents from Florida and
Oregon that were identified as assisted living facilities by their
association membership but were not licensed by the state as assisted
living facilities.  Of the remaining 689, we excluded from our
subsequent analysis 67 respondents that indicated on the survey that
they do not provide or arrange for any assisted living services. 


OUR SURVEY OF ASSISTED LIVING
FACILITIES
=========================================================== Appendix I



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)


ADDITIONAL INFORMATION ON
QUALITY-OF-CARE AND CONSUMER
PROTECTION PROBLEMS IN FOUR STATES
========================================================= Appendix III

Licensing agencies across the four states have different assisted
living regulations--that is, the content, level of detail, and coding
schemes for their assisted living licensing regulations all differ. 
Similarly, Florida's and Oregon's APS agencies have different
allegation categories that they assign problems to.  A problem or
deficiency in one state may have one regulation requirement or
allegation category, whereas another state may have four relevant
regulatory requirements or allegation categories for the same
problem.  Therefore, the frequencies of licensing deficiencies should
not be compared across states, and neither should frequencies of APS
allegations be compared between Florida and Oregon.  Only the
ombudsman agencies across the four states use the same categories for
complaints, which allows for the possibility of comparing the
findings across the states.  Furthermore, because of the
inconsistencies with how licensing and APS agencies categorize
deficiencies or allegations across the states, no comparisons should
be made across the ombudsman, licensing and APS data. 



                              Table III.1
                
                 California's Frequency of Quality-of-
                Care and Consumer Protection Problems by
                            Agency, 1996-97

                                          Licensing       Ombudsman
                                        --------------  --------------
                                        Number  Number  Number  Number
                                            of      of      of      of
                                        facili  proble  facili  proble
Problem                                   ties      ms    ties      ms
--------------------------------------  ------  ------  ------  ------
Quality of care
Abuse                                                       15      22
Admission, discharge, or level of care      25      39      12      29
Care plans or assessments                   18      27       7       8
Inadequate care                             28      53      23      40
Medication                                  25      43       8      10
Neglect                                      1       1       2       2
Nutrition or special diet needs                              2       2
Restraints
Staffing shortages, qualifications, or      26      33       8      11
 training
Other
Consumer protection
Access to information                        1       1       4       4
Billing or charges                                          10      15
Contracts                                    3       3       3       3
Criminal background checks                  11      12
Exploitation                                                 4       4
Other                                        5      11       5       6
----------------------------------------------------------------------
Note:  Number of facilities = 150.  Numbers cannot be compared or
aggregated across the licensing and ombudsman agency columns.  A
blank cell indicates that the agency database had no facilities with
deficiencies in this problem category.  These data may include cases
that were investigated and verified by more than one state agency. 
However, the agencies' data limitations left us unable to identify
when this occurred or the extent to which it occurred.  Also,
problems classified under the category of "admission, discharge, or
level of care" may be related to either consumer protection or
quality-of-care issues. 



                                       Table III.2
                         
                          Florida's Frequency of Quality-of-Care
                           and Consumer Protection Problems by
                                     Agency, 1996-97

                         Licensing               Ombudsman                  APS
                   ----------------------  ----------------------  ----------------------
                    Number of   Number of   Number of   Number of   Number of   Number of
Problem            facilities    problems  facilities    problems  facilities    problems
-----------------  ----------  ----------  ----------  ----------  ----------  ----------
Quality of care
Abuse                                               6           9          25          39
Admission,                 65         118           5           5
 discharge, or
 level of care
Care plans or             115         201           2           2
 assessments
Inadequate care            44          51          19          29
Medication                116         266           5           5
Neglect                                                                    32         103
Nutrition or               38          49           3           3
 special diet
 needs
Restraints                 38          38           4           4
Staffing                  151         393           5           7
 shortages,
 qualifications,
 or training
Other                      28          28
Consumer
 protection
Access to                  55          76           5           5
 information
Billing or                  4           5          13          13
 charges
Contracts                  72          82           1           1
Criminal
 background
 checks
Exploitation                                        3           3           1           1
Other                      55          73           1           1
-----------------------------------------------------------------------------------------
Note:  Number of facilities = 370.  Numbers cannot be compared or
aggregated across the licensing, ombudsman, and APS agency columns. 
A blank cell indicates that the agency database had no facilities
with deficiencies in this problem category.  These data may include
cases that were investigated and verified by more than one state
agency.  However, the agencies' data limitations left us unable to
identify when this occurred or the extent to which it occurred. 
Also, problems classified under the category of "admission,
discharge, or level of care" may be related to either consumer
protection or quality-of-care issues. 



                              Table III.3
                
                Ohio's Frequency of Quality-of-Care and
                Consumer Protection Problems by Agency,
                                1996-97

                                          Licensing       Ombudsman
                                        --------------  --------------
                                        Number  Number  Number  Number
                                            of      of      of      of
                                        facili  proble  facili  proble
Problem                                   ties      ms    ties      ms
--------------------------------------  ------  ------  ------  ------
Quality of care
Abuse                                                        3       3
Admission, discharge, or level of care       3       3       6       6
Care plans or assessments                   17      25       1       1
Inadequate care                              8      14       1       2
Medication                                   8      12
Neglect                                                      2       2
Nutrition or special diet needs              4       4
Restraints                                   2       2
Staffing shortages, qualifications, or       9      10       3       3
 training
Other                                        2       2
Consumer protection
Access to information                        6       6
Billing or charges                           2       2       2       3
Contracts
Criminal background checks
Exploitation
Other                                        2       2       2       2
----------------------------------------------------------------------
Note:  Number of facilities = 150.  Numbers cannot be compared or
aggregated across the licensing and ombudsman agency columns.  A
blank cell indicates that the agency database had no facilities with
deficiencies in this problem category.  These data may include cases
that were investigated and verified by more than one state agency. 
However, the agencies' data limitations left us unable to identify
when this occurred or the extent to which it occurred.  Also,
problems classified under the category of "admission, discharge, or
level of care" may be related to either consumer protection or
quality-of-care issues. 



                                       Table III.4
                         
                          Oregon's Frequency of Quality-of-Care
                           and Consumer Protection Problems by
                                     Agency, 1996-97

                         Licensing               Ombudsman                  APS
                   ----------------------  ----------------------  ----------------------
                    Number of   Number of   Number of   Number of   Number of   Number of
Problem            facilities    problems  facilities    problems  facilities    problems
-----------------  ----------  ----------  ----------  ----------  ----------  ----------
Quality of care
Abuse                       2           6           4           7          21          48
Admission,                                         10          14           2           2
 discharge, or
 level of care
Care plans or              34          86          11          18          13          18
 assessments
Inadequate care            15          26          26          74          26          50
Medication                 24          33          10          20           9          17
Neglect                                             4           4          14          16
Nutrition or                                        6           8           5           7
 special diet
 needs
Restraints                                          2           2
Staffing                   10          12          20          59           1           1
 shortages,
 qualifications,
 or training
Other
Consumer
 protection
Access to                                           5           6
 information
Billing or                                         15          27           1           1
 charges
Contracts                                           1           1           1           1
Criminal
 background
 checks
Exploitation                                        2           3           3           3
Other                                               4           5           5           5
-----------------------------------------------------------------------------------------
Note:  Number of facilities = 83.  Numbers cannot be compared or
aggregated across the licensing, ombudsman, and APS agency columns. 
A blank cell indicates that the agency database had no facilities
with deficiencies in this problem category.  These data may include
cases that were investigated and verified by more than one state
agency.  However, the agencies' data limitations left us unable to
identify when this occurred or the extent to which it occurred. 
Also, problems classified under the category of "admission,
discharge, or level of care" may be related to either consumer
protection or quality-of-care issues. 


MAJOR CONTRIBUTORS TO THIS REPORT
========================================================== Appendix IV

John C.  Hansen, Assistant Director, (202) 512-7105
Eric R.  Anderson, Senior Evaluator
Connie Peebles Barrow, Senior Evaluator
Ann V.  White, Senior Evaluator
David W.  Bieritz, Evaluator
George Bogart, Attorney-Adviser
Susan Lawes, Senior Social Science Analyst (Survey Specialist)
Elsie Picyk, Senior Evaluator (Computer Science)
Joan Vogel, Senior Evaluator (Computer Science)


*** End of document. ***