Assisted Living: Quality-of-Care and Consumer Protection Issues
(Testimony, 04/26/99, GAO/T-HEHS-99-111).

Pursuant to a congressional request, GAO discussed quality-of-care and
consumer protection issues in assisted living facilities in California,
Florida, Ohio, and Oregon, focusing on: (1) residents' needs and the
services provided in assisted living facilities; (2) the extent to which
facilities provide consumers with sufficient information for them to
choose a facility that is appropriate for their needs; (3) the four
states' approaches to oversight of assisted living; and (4) the types of
quality-of-care and consumer protection problems they identify.

GAO noted that: (1) assisted living facilities vary widely in the types
of services they provide and the residents they serve; (2) they range
from small, freestanding, independently-owned homes with a few residents
to large, corporately owned communities that offer both assisted living
and other levels of care to several hundred residents; (3) some assisted
living facilities offer only meals, housekeeping, and limited personal
assistance, while others provide or arrange for a range of specialized
health and related services; (4) they also vary in the extent to which
they admit residents with certain needs and whether they retain
residents as their needs change; (5) given the variation in what is
labelled assisted living, prospective residents must rely on information
supplied to them by facilities to select one that best meets their needs
and preferences; (6) in many cases, assisted living facilities did not
routinely give consumers sufficient information to determine whether a
particular facility could meet their needs, for how long, and under what
circumstances; (7) moreover, GAO identified numerous examples of vague,
misleading, or even contradictory information contained in written
materials that facilities provide to consumers; (8) the states have the
primary responsibility for the oversight of care furnished to assisted
living facility residents; (9) all four states reviewed have licensing
requirements that must be met by most facilities providing assisted
living services, and state licensing agencies routinely inspect or
survey facilities to ensure compliance with state regulations; (10)
however, the licensing standards as well as the frequency and content of
the periodic inspections vary across the states; (11) given the absence
of any uniform standards for assisted 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; (12) however, using available inspection surveys and reports
from the other oversight agencies in the four states, GAO determined
that the states cited more than 25 percent of the 753 facilities in its
sample for five or more quality-of-care or consumer-protection related
deficiencies or violations during 1996 and 1997; and (13) state
officials attributed most of the common problems identified in assisted
living facilities to insufficient staffing and inadequate training,
exacerbated by high staff turnover and low pay for caregiver staff.

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

 REPORTNUM:  T-HEHS-99-111
     TITLE:  Assisted Living: Quality-of-Care and Consumer Protection
	     Issues
      DATE:  04/26/99
   SUBJECT:  Extended care facilities
	     Elder care
	     Quality assurance
	     Consumer protection
	     Health care services
	     State programs
	     Long-term care
	     Elderly persons
	     Information disclosure
	     Surveys
IDENTIFIER:  Medicare Program
	     Medicaid Program
	     Supplemental Security Income Program
	     Florida
	     California
	     Oregon
	     Ohio
	     SSI

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ASSISTED LIVING: Quality-of-Care and Consumer Protection Issues
GAO/T-HEHS-99-111 United States General Accounting Office

GAO Testimony Before the Special Committee on Aging, U. S. Senate

For Release on Delivery Expected at 1: 00 p. m. Monday, April 26,
1999 ASSISTED LIVING

Quality- of- Care and Consumer Protection Issues

Statement of Kathryn G. Allen, Associate Director Health Financing
and Public Health Issues Health, Education, and Human Services
Division

GAO/T-HEHS-99-111

  GAO/T-HEHS-99-111

Assisted Living: Quality- of- Care and Consumer Protection Issues

Mr. Chairman and Members of the Committee: We are pleased to be
here today to discuss quality- of- care and consumer protection
issues in assisted living. Assisted living facilities are becoming
an increasingly popular option for providing long- term care for
the elderly in what can be a less costly and more homelike setting
than nursing homes. Current estimates of the number of assisted
living beds in the United States range from 800,000 to 1.5
million, and consumer demand is expected to grow significantly as
the projected number of elderly Americans in need of long- term
care doubles over the next 20 years.

Assisted living facilities offer a combination of housing, meals,
personal support services, and, in some cases, health care for
their residents. Although most assisted living is paid for
privately by individuals and their families, many states are using
Medicaid to fund services and care for residents in assisted
living facilities, and others are considering whether assisted
living can be a cost- effective alternative to publicly funded
nursing home care for some persons. At the same time as interest
in assisted living has grown, concerns about quality of care and
consumer protection in assisted living have been raised in recent
media accounts and other reports.

The information I am presenting is based on a report we are
issuing to your Committee today that examined assisted living in
four states California, Florida, Ohio, and Oregon. 1 My statement
focuses on four main issues:

 residents' needs and the services provided in assisted living
facilities;  the extent to which facilities provide consumers with
sufficient

information for them to choose a facility that is appropriate for
their needs;  the four states' approaches to oversight of assisted
living; and  the types of quality- of- care and consumer
protection problems they

identify. Our findings are based on an analysis of responses to a
mail survey of facilities in these four states, an evaluation of
the facilities' marketing materials and contracts, interviews with
state officials, a review of relevant state statutes and
regulations, visits to 20 assisted living facilities, interviews
with more than 90 assisted living residents or family members,

1 Assisted Living: Quality- of- Care and Consumer Protection
Issues in Four States (GAO/HEHS-99-27, Apr. 26, 1999).

GAO/T-HEHS-99-111 Page 1

Assisted Living: Quality- of- Care and Consumer Protection Issues

and an analysis of state data on verified quality- of- care and
consumer protection problems in assisted living facilities. 2

In brief, we found that assisted living facilities vary widely in
the types of services they provide and the residents they serve.
They range from small, freestanding, independently owned homes
with a few residents to large, corporately owned communities that
offer both assisted living and other levels of care to several
hundred residents. Some assisted living facilities offer only
meals, housekeeping, and limited personal assistance, while others
provide or arrange for a range of specialized health and related
services. They also vary in the extent to which they admit
residents with certain needs and whether they retain residents as
their needs change.

Given the variation in what is labeled assisted living,
prospective residents must rely on information supplied to them by
facilities to select one that best meets their needs and
preferences. However, we found that, in many cases, assisted
living facilities did not routinely give consumers sufficient
information to determine whether a particular facility could meet
their needs, for how long, and under what circumstances. For
example, many facilities did not provide prospective residents
with written information on such key issues as the amount of
assistance they could expect to receive with medications, the
circumstances under which the cost of services might change, or
when they could be required to leave if their health changes.
Moreover, we identified numerous examples of vague, misleading, or
even contradictory information contained in written materials that
facilities provide to consumers.

The states have the primary responsibility for the oversight of
care furnished to assisted living facility residents. All four
states we reviewed have licensing requirements that must be met by
most facilities providing assisted living services, and state
licensing agencies routinely inspect or survey facilities to
ensure compliance with state regulations. However, the licensing
standards as well as the frequency and content of the periodic
inspections vary across the states. The licensing agencies also
respond to complaints they receive related to potential violations
of state regulations. In addition, the long- term care ombudsman
agency in all four states and the Adult Protective Services (APS)
agency in Florida and Oregon

2 We sent our mail survey to 955 randomly selected facilities of
2,652 identified 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. Our analysis of quality-
of- care and consumer protection issues was based on a review of
state licensing agency deficiencies, ombudsman complaints, and
adult protective service allegations that state officials verified
in a sample of 753 facilities in these states.

GAO/T-HEHS-99-111 Page 2

Assisted Living: Quality- of- Care and Consumer Protection Issues

investigate complaints or allegations of problems 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 inspection surveys and reports from the
other oversight agencies in the four states, we determined that
the states cited more than 25 percent of the 753 facilities in our
sample 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 for 10 or more problems
during this time period. Most of the problems identified by the
state agencies were related to quality- of- care rather than
consumer protection issues. 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 providing inadequate or insufficient
care to residents; their having insufficient, unqualified, and
untrained staff; and their not providing residents appropriate
medications or storing medications improperly. State officials
attributed most of the common problems identified in assisted
living facilities to insufficient staffing and inadequate
training, exacerbated by high staff turnover and low pay for
caregiver staff.

Background Assisted living is usually viewed as a residential care
setting for persons who can no longer live independently and who
require some supervision

or help with activities of daily living (ADL) but may not need the
level of skilled care provided in a nursing home. It is promoted
by assisted living advocates as a long- term care setting that
emphasizes residents' autonomy, independence, and individual
preferences and that can meet their scheduled and unscheduled
needs for assistance. Typically, assisted living facilities
provide housing, meals, supervision, and assistance with some ADLs
and other needs such as medication administration. However, there
is no uniform assisted living model, and considerable variation
exists in the types of facilities or settings that hold themselves
out to be an assisted living facility. In some cases, assisted
living facilities may serve residents who meet the level- of- care
criteria for admission to a nursing home.

GAO/T-HEHS-99-111 Page 3

Assisted Living: Quality- of- Care and Consumer Protection Issues

Unlike residents of nursing homes, the majority of whom receive
some support from Medicaid or Medicare, most residents of assisted
living facilities pay for care out of pocket or through other
private funding. 3 However, public sources of funding are
available to help pay for services for some residents. For
example, some states are attempting to control rising Medicaid
costs by encouraging the use of assisted living as an alternative
to more expensive nursing home care. Currently, 32 states use
Medicaid funds to reimburse for services provided to Medicaid
beneficiaries residing in assisted living facilities. 4 However,
Medicaid payments do not cover the cost of room and board in
assisted living facilities. A combination of individuals' personal
resources, residents' Supplemental Security Income (SSI) payments,
and optional state payments pay for these costs.

The states have the primary responsibility for overseeing the care
that assisted living facilities provide residents, and few federal
standards or guidelines govern assisted living. 5 The four states
we reviewed vary widely in what they require of these facilities.
Generally, state regulations 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. 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.

Assisted Living Facility Services and Resident Needs Vary Widely

A wide variety of services are available to residents in assisted
living, and most facilities provide oversight to monitor and
supervise their residents. These oversight responsibilities
generally include providing 24- hour supervision; monitoring
changes in residents' health and functioning; notifying a
resident's physician, family, or other responsible person when the
resident's condition changes; and providing regular health or
wellness checks. Assisted living facilities in our survey reported
that they usually

3 Medicaid is the federal- state health financing program for low-
income and aged, blind, and disabled people. Medicare finances
health care for most Americans over age 65 and the disabled. In
1999, the federal government is projected to pay $39 billion for
nursing home care, mostly through Medicaid.

4 See State Assisted Living Policy: 1998 (Portland, Me.: National
Academy for State Health Policy, June 1998). States often use the
authority available under section 1915( c) of the Social Security
Act, which enables them to fund nursing services in a home and
community- based setting rather than in an institutional setting.

5 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).

GAO/T-HEHS-99-111 Page 4

Assisted Living: Quality- of- Care and Consumer Protection Issues

provide housekeeping, laundry, meals, transportation to medical
appointments, special diets, and assistance with medications. Many
facilities also provide 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. Some services may be provided by
facility staff or by staff under contract to the facility. In
other cases, the facility may arrange with an outside provider to
deliver some services, with residents paying the provider
directly, or residents may arrange and pay for services on their
own.

We found considerable variation among facilities and among states
in the needs of the residents they serve. The facilities we
visited have some residents who are completely independent and
ambulatory, some who have severe cognitive impairments, and 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. Assistance with dressing and toileting or incontinence
care are the next most frequently cited needs, and assistance is
needed to a lesser extent with eating, transferring, and walking.
The highest level of resident need for staff assistance with ADLs
was reported among facilities in Oregon and those in Florida
licensed as extended congregate care facilities. In addition,
residents often have some degree of cognitive impairment, such as
significant short- term memory problems, disorientation much of
the time, or Alzheimer's disease or another form of dementia.

The ability of residents to remain in a facility as their health
declines or their needs change, commonly referred to as aging in
place, is determined largely by admission and discharge criteria.
There is considerable variation across the states in these
criteria, some of which comes from state regulations, some the
facilities' choice of whom to serve, and some the particular
services a facility chooses to provide or make available. For
example, facilities in Oregon are more likely to admit and retain
residents with a higher level of need than those in other states.
Facilities responding to our survey vary in terms of resident
needs they accept on admission and the circumstances under which
they retain or discharge residents who develop certain needs or
conditions after being admitted. Although some facilities may not
admit residents with a particular need or condition, they do not
necessarily discharge them if they develop that need. For example:

 More than 75 percent of the facilities reported that they admit
residents who have mild to moderate memory or judgment problems,
are

GAO/T-HEHS-99-111 Page 5

Assisted Living: Quality- of- Care and Consumer Protection Issues

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, and most facilities discharge
residents who develop these needs.  Most facilities in Oregon
indicated that they do not admit people who are

bedridden, but half typically retain anyone who becomes bedridden
while a resident.

Consumers May Lack Adequate Information to Select a Facility That
Best Meets Their Needs

Given the variation in what is labeled assisted living,
prospective residents must rely primarily on information supplied
to them by facilities to select one that best meets their needs
and preferences. They can obtain information in a variety of ways,
including written materials, facility tours, personal interviews,
and personal recommendations. However, in order to help
prospective residents compare facilities and select the most
appropriate setting for their needs, key information should be
provided in writing and in advance of their decision to apply for
admission. Yet we found that written material often does not
contain key information; facilities do not routinely provide
prospective residents with important documents, such as a copy of
the contract, to use as an aid in decisionmaking; and written
materials that are available are sometimes confusing or even
misleading.

According to consumer advocates and provider associations,
consumers need to be informed about the services that will be
provided, their costs, and the respective obligations of both the
resident and the provider. Such information should include

 the cost of the basic service package and what it includes;  the
availability of additional services, who will provide them, and
their

cost;  the circumstances under which costs may change;  how the
facility monitors resident health care;  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, and the procedures for notifying and relocating the
resident; and  grievance procedures.

GAO/T-HEHS-99-111 Page 6

Assisted Living: Quality- of- Care and Consumer Protection Issues

The majority of facilities responding to our survey said they
generally provide prospective residents with written information
about many of their services and costs in advance of their
choosing to apply for admission. However, as shown in figure 1,
only about half indicated that they provide information on the
circumstances under which the cost of services may change, their
policy on medication assistance, or their practice for monitoring
residents' needs, and less than half indicated that they provide
written information in advance about discharge criteria, staff
training and qualifications, or services not covered or available
from the facility.

GAO/T-HEHS-99-111 Page 7

Assisted Living: Quality- of- Care and Consumer Protection Issues

Figure 1: Percentage of Facilities Reporting That They Provide Key
Written Information to Prospective Residents

Information Description of Basic Services

Cost of the Basic Services Residents' Rights and Responsibilities
Other Services Available Complaint or Grievance Procedure Cost of
Additional Services Medication Assistance Monitoring Resident
Needs Circumstances When Costs May Change Discharge Criteria
Services Not Available Staff Training and Qualifications

Percentage 0 10 20 30 40 50 60 70 80 90 100

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

GAO/T-HEHS-99-111 Page 8

Assisted Living: Quality- of- Care and Consumer Protection Issues

residents. Contracts range from a one- page standard form lease to
a 55- page document with 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 the facilities also vary widely from a one-
page list of basic services and monthly rent to multiple documents
of more than 100 pages.

We examined written marketing materials and contracts from 60 of
the facilities that responded to our survey to determine whether
they were complete, clear, and consistent with state laws. While
most of the facility materials we reviewed were specific and
relatively clear, we found that materials from 20 of the 60
facilities contained language that was unclear or potentially
misleading, usually concerning the circumstances under which a
resident could be required to leave a facility. Contracts and
other written materials we reviewed were often unclear or
inconsistent with each other or with requirements of state
regulation regarding how long residents could remain as their
needs change, resident notification requirements, and other
procedural requirements for discharge. For example, the contract
from a California facility was vague regarding the circumstances
under which a resident could be required to move. It stated that
the facility can discharge a resident for good and sufficient
cause without elaborating on what the cause might be. The contract
also failed to refer to state regulations that provide specific
criteria for discharge or eviction.

As shown in figure 2, the marketing material one Florida facility
uses is potentially misleading in specifying that residents can be
assured that if their health changes, the facility can meet their
needs and they will not have to move again. However, the
facility's contract specifies a range of health- related criteria
for immediate discharge, including changes in a resident's
condition or need for services that the facility cannot provide.
The contract of an Oregon facility is inconsistent with
requirements of state regulation regarding notification of
residents before discharging them. Oregon regulations specify that
residents may not be asked to leave without 14 days' written
notice that a facility cannot provide the services they need.
However, the facility's contract specifies that residents can be
required to move immediately if they need more care than is
available at the facility.

GAO/T-HEHS-99-111 Page 9

Assisted Living: Quality- of- Care and Consumer Protection Issues

Figure 2: Examples of Unclear or Misleading Written Information

Facility 1 Marketing Brochure

Contract Facility 2

State Regulation Contract

Resident may not be asked to leave without 14 days' written notice
stating reasons for the request. So you 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.

"... It's reassuring to know that even if my needs change, I won't
have to move."

... may terminate this Residency Agreement immediately ...

Due to changes in your physical or mental condition, supplies,
services or procedures are required that ... by certification,
licensure, design or staffing cannot provide.

... may terminate this agreement immediately upon notice and the
resident shall be required to immediately vacate the Premises in
any one of the following circumstances:

The States Use a Range of Approaches to Oversee Assisted Living
Facilities

Each of the four states we studied has licensing requirements that
must be met by most facilities that provide assisted living
services. Florida and Oregon have created a specific licensing
category and requirements for assisted living facilities, while
California and Ohio license these facilities under existing
residential care facility regulations. All four states have

GAO/T-HEHS-99-111 Page 10

Assisted Living: Quality- of- Care and Consumer Protection Issues

similar requirements regarding the type and level of services that
assisted living facilities must provide residents. In addition to
basic accommodations such as room, board, and housekeeping, all
the states require facilities to provide residents with basic
services, including assistance with ADLs, ongoing health
monitoring, and either the provision of or arrangement for medical
services, including transportation to and from those services as
needed.

All four states require assisted living facilities to conduct an
initial assessment of a resident's health, functional ability, and
needs for assistance. They also require that facilities provide
residents with reasonable advance notice of discharge or eviction,
and they specify certain rights and procedures for residents to
appeal or contest a facility's decision to discharge them. State
regulations also generally contain other consumer protection
provisions such as those governing resident contracts, criminal
background checks for staff, and residents' rights. All four
states require that facilities enter into contracts with
residents, but they differ in the level of detail they require in
these agreements. In addition, all four states require criminal
background checks for direct care staff, and three states
California, Florida, and Oregon require them for facility
administrators as well.

State regulations often differ, however, with respect to the level
of skilled nursing or medical care that facilities can provide to
residents and in 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, such as
catheter care, colostomy care, and injections. In contrast, Oregon
has no explicit restrictions on the care that facility staff may
provide, except that certain nursing tasks must be either assigned
or delegated to a caregiver by a registered nurse. In addition,
while all four 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 California, facility
staff may not administer medications but may only assist residents
to take their own medications. Requirements for staff levels,
qualifications, and training also vary among the states. For
example, Florida requires facilities to maintain a minimum number
of full- time staff that is based on the total number of
residents, California and Ohio require only that the number of
staff be adequate to meet the needs of residents, and Oregon does
not have any minimum staffing requirement.

GAO/T-HEHS-99-111 Page 11

Assisted Living: Quality- of- Care and Consumer Protection Issues

To ensure that assisted living facilities comply with the various
licensing requirements, all four states conduct periodic
inspections or surveys of facilities, and they may also conduct
more frequent inspections in response to specific complaints. 6
However, the four states vary in the frequency and content of
assisted living facility inspections. The frequency of required
licensing inspections ranges from at least twice a year for
extended congregate care facilities in Florida to at least once
every 2 years for assisted living facilities in Oregon. 7 The
content of periodic state surveys is driven primarily by the
requirements in state regulations. To assist surveyors, Florida
and Ohio have developed detailed guidelines, similar to those used
for nursing home inspections. In contrast, surveyors in California
and Oregon use a checklist that covers a subset of the regulations
and focuses on a few selected elements.

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 in assisted living. 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. Ombudsmen in Florida are also required
to inspect each facility annually to evaluate the residents'
quality of care and quality of life. In two of the four states,
Florida and Oregon, APS agencies are responsible for investigating
reports of alleged abuse, neglect, or exploitation of assisted
living residents; determining their immediate risk and providing
necessary emergency services; evaluating the need for and
referrals for ongoing protective services; and providing ongoing
protective supervision.

6 In Florida, Ohio, and Oregon, the agency with responsibility for
inspecting assisted living facilities also has responsibility for
nursing homes. In contrast, responsibility for the regulation and
inspection of assisted living facilities in California rests with
the Department of Social Services, while nursing homes fall under
the jurisdiction of the Department of Health Services.

7 Florida has multiple categories of assisted living licensure,
including standard assisted living, limited nursing services, and
extended congregate care.

GAO/T-HEHS-99-111 Page 12

Assisted Living: Quality- of- Care and Consumer Protection Issues

The States Identify Quality- of- Care and Consumer Protection
Problems in Assisted Living Facilities

Given that the 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 the facilities actually provide. Facilities
in states with more licensing standards, more frequent
inspections, or more agencies involved in oversight may be more
likely to have more problems identified and verified. Using
available data and reports from state licensing, ombudsman, and
APS agencies in the four states, we determined that 27 percent of
the 753 facilities in our sample were cited for five or more
quality- of- care or consumer protection related problems during
1996 and 1997. Most of these verified problems pertained to
quality- of- care rather than consumer protection issues. As table
1 shows, 22 percent of the facilities we sampled had 5 or more
verified quality- of- care problems during the period, and 9
percent of the facilities had 10 or more.

Table 1: 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 Number of problems

Quality of care or consumer protection Quality of care Consumer

protection

5 or more 27% 22% 3% 10 or more 11 9 0 Note: Number of facilities
= 753.

The most commonly cited quality- of- care problems included
inadequate care, staffing, and medication issues. 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
residents suffered harm as a result of insufficient numbers of
staff in the facility, as well as cases in which facilities had no
documentation to substantiate that required caregiver training had
been provided.

Inadequate care, such as instances of residents not receiving
appropriate access to physicians and other needed medical care or
treatment, was the most frequently cited quality- of- care
problem. For example, as illustrated in table 2, in one California
facility, staff neglected to call 911 after a resident fell and
injured her head. Instead, they gave her aspirin, and several
hours later she was found in a comatose state. She died 3 days
later. The second most frequently cited problem concerned staff

GAO/T-HEHS-99-111 Page 13

Assisted Living: Quality- of- Care and Consumer Protection Issues

qualifications and training and facilities not having sufficient
staff to care for the residents. For example, in an Oregon
facility, family members routinely assisted residents by changing
soiled garments because the facility did not have enough staff.

Table 2: Examples of Quality- of- Care and Consumer Protection
Problems Issue Problem

Quality of care Inadequate care Staff neglected to call 911 after
a resident fell and

injured her head. Instead, they gave her aspirin, and several
hours later she was found in a comatose state. She died 3 days
later.

Staffing Because of insufficient staff, family members in one
facility routinely assisted residents by changing soiled garments.

Medication Facility staff inconsistently and inaccurately
transcribed physicians' medication orders, often allowed sharing
of medications between residents, signed out narcotics on one
shift but had staff from another shift administer them, and
allowed unlicensed caregivers to alter residents' prescription
labels.

Consumer protection Billing or discharge A resident was told on
admission that she could stay in

the facility until she died. After living at the facility for 2
years, she began to wander within the facility. The facility then
issued a 2- week eviction notice stating that it could no longer
care for her. The facility also increased her monthly fee from
approximately $1,600 to more than $6,400. She moved to another
facility.

Contracts A resident contract did not contain all state- required
elements, such as the basic daily, weekly, or monthly rate and a
list of available services and fees not included in the basic
rate.

The third most frequently cited problem concerned medication-
related issues, such as not providing residents their prescribed
medication, providing them the wrong medication, or storing
medication improperly. For example, an Oregon facility was found
to have numerous medication problems, including (1) staff
inconsistently and inaccurately transcribing physicians'
medication orders to the residents' 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.

GAO/T-HEHS-99-111 Page 14

Assisted Living: Quality- of- Care and Consumer Protection Issues

Commonly cited consumer protection problems included those related
to circumstances under which a resident could be required to leave
a facility for health or financial reasons and those related to
provisions in resident contracts. For example, a resident of an
Oregon facility was told on admission that she could stay until
she died. However, the facility issued her an eviction notice when
she began to wander within the facility, and it raised her monthly
charge from approximately $1,600 to more than $6,400. In Florida,
a facility was cited for not having all state- required elements
in the resident contract, such as the basic daily, weekly, or
monthly rates and a list of available services and fees not
included in the basic rate.

In Florida and Oregon, the two states in which APS agencies have
some responsibility for oversight of residents in assisted living
facilities, resident abuse was also often cited. In Oregon, the
APS agency verified 48 cases of abuse in 21 of the state's 83
assisted living facilities during 1996 and 1997. In one case, a
resident was left on the toilet for 2 hours because the caregiver
forgot to return to the resident's room, and there was no call
button within reach. In Florida, the APS agency verified 39 cases
of abuse in 25 facilities and 103 cases of neglect in 32
facilities during the 2- year period. Florida cases included an
instance in which a 90- year- old resident was admitted to a
hospital with a stage IV pressure ulcer and found to be dehydrated
and poorly nourished.

Conclusions 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.
While many residents may enter assisted living facilities with
relatively few or minimal needs for supportive or health services,
these needs generally increase with age or with declining health.
Some assisted living facilities may be able to accommodate these
changing and more intensive needs, while others may not. Fully
understanding the strengths and limitations of facilities is
important as consumers and their families attempt to make the best
choice for what is often a difficult decision.

Currently, the assisted living industry is predominantly funded by
private resources and is licensed and regulated by the states.
However, as the states increase their use of Medicaid to help pay
for assisted living, the contribution of federal financing will
grow as well. This trend will no doubt focus more attention from
consumers, providers, and the public sector on several issues,
including where assisted living fits on the continuum of long-
term care, on standards needed to ensure quality of

GAO/T-HEHS-99-111 Page 15

Assisted Living: Quality- of- Care and Consumer Protection Issues

care and protect consumers, on appropriate approaches to ensure
compliance with those standards, and on the adequacy of
information available to help inform consumers' choices and
decisions.

Mr. Chairman, this concludes my statement. I will be happy to
answer any questions that you or other members of the Committee
may have.

(101815) GAO/T-HEHS-99-111 Page 16

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