Chapter 4. Tools to Help Consumers Evaluate Assisted Living Facilities

Private accreditation organizations, State regulatory systems, consumer advocacy organizations, assisted living providers, and the Federal Government supply information to help consumers navigate the wide range of assisted living offerings. The array of information could help consumers develop a comprehensive system for supporting their decisionmaking. This chapter examines State and private initiatives directed at quality monitoring in assisted living, the availability of consumer-oriented information, and existing government resources designed to inform consumers.

Quality Monitoring

Although there is not a standardized method for assessing the quality of assisted living (Thayer, 2003), this section looks at three means available: State licensing and inspections, investigations and complaint monitoring by State ombudsman programs, and private voluntary accreditation surveys. Quality indicators for assisted living are currently in the development stage through the InterRAI initiative (InterRAI, 2005).

State Licensing

Although States license, certify, and inspect assisted living facilities (Kane and Wilson, 2001), these inspections differ significantly both within and among States, in part because of the lack of a uniform definition of assisted living. The standards reviewed are predominantly process versus outcome oriented (Mollica, 2002; Wilson, 1995). For example, the standard might relate to food preparation and nutrition (process), not how many residents are underweight (outcome). The GAO report (1999) found that State reviews occur every 1 to 2 years, and the results of monitoring activities varied. Twenty-seven percent of assisted living facilities surveyed (200 of 735) were cited for five or more consumer protection or quality of care deficiencies from State agency data (GAO, 1999). A National Academy for State Health Policy (NASHP) survey of State licensing officials noted that the most common areas of deficiencies included medication issues, quality of staff, quantity of staff, inadequate care and recordkeeping, admission/discharge issues, access to medical care, abuse, and billing issues (Mollica, 2002).

Several States have adopted a "level of service licensure model" designed to provide information for consumer choice. These models, established in Idaho, Maryland, and other States, distinguish the levels of health care provided and the type and needs of resident services that the facility can accommodate (Center for Medicare Advocacy, 2003).

State initiatives to systematically measure resident experience in long-term care facilities (including assisted living) are in an early developmental stage (Lowe, Lucas, Castle, et al., 2003). Some States have developed innovative assisted living programs for residents. For example, Florida's Department of Elder Affairs (2003) sponsors a "find a facility" Web site to allow public access to information (available at http://www.floridaaffordableassistedliving.org/). Texas enacted a law that requires assisted living facilities to provide a standardized report of information such as staffing, discharge criteria, charges, etc., which would allow consumers to compare facilities (GAO, 2004). The Texas Department of Aging and Disability Services (2005) sponsored Web site is http://facilityquality.dhs.state.tx.us.

The Virginia Department of Social Services has posted information from reports about care in assisted living facilities at http://www.dss.virginia.gov/facility/search/alf.cgi. This Web site provides access to information on licensing, inspections, and violations, as well as the actions taken to correct the violation and whether the violations were related to a complaint (Virginia Department of Social Services, 2005).

For additional State initiatives describing levels of care and offerings that help consumers compare assisted living facilities, refer to the Assisted Living Compendium, 2004 (Mollica and Johnson-Lamarche, 2005).

State Ombudsman Programs

The Federal Older Americans Act (2000) requires that all States have an Ombudsman Program to advocate for and address complaints from residents in long-term care, including assisted living. According to data from the 2003 National Ombudsman Reporting System, the most frequent complaints involving assisted living (board and care) involve medication administration, menu quality, discharge eviction planning/notice, dignity/respect of staff, and equipment/building problems (Administration on Aging, 2004).

Private Accreditation Programs

The main accrediting bodies for assisted living facilities are the Commission on Accreditation of Rehabilitation Facilities (CARF) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Both organizations implemented their assisted living programs in 2000 and provide information regarding the results of facility surveys through their Web sites. These organizations evaluate similar areas, e.g., resident rights, continuity and coordination of services, resident education, and health promotion. The JCAHO accreditation process uniquely includes infection control.⁵

These two organizations accredit a small proportion of the total number of assisted living facilities. According to a representative from JCAHO, the organization accredited 115 facilities in 2004 (J. Walsh, Personal Communication, July 26, 2005). Similarly, a CARF representative stated that they have accredited 46 facilities as of 2005, including international facilities (S. Matheson, Personal Communication, July 26, 2005). Based on the GAO estimate of 36,000 U.S. assisted living facilities, less than 1 percent of the total industry is accredited by one of these two private accreditation organizations.

The CARF accreditation standards are divided into three main sections. Several dimensions are covered under each of these sections, as listed below:

• Business practices. Information management, resident rights, leadership, and legal requirements.
• Process of assisted living. Philosophy and physical environment, continuity and coordination of services, policies and procedures, and resident needs assessments.
• Assisted living. Medication administration, smoking policies, transportation, and other aspects of resident life (CARF, 2005).

CARF offers a search function on its Web site that allows consumers to search for accredited providers by location (available at: http://www.carf.org/consumer.aspx?content=ConsumerSearch&id=7).

JCAHO organizes its accreditation standards into 12 sections. The following is a list of the major dimensions covered and a brief overview of the content of each of the standards.

• Consumer protection and rights and assisted living community ethics. Improve resident outcomes by recognizing and respecting resident rights; identify the need to recognize residents as individuals with different needs; emphasize dignity, quality of life, and ethical behavior.
• Continuity of services. Define, shape, and sequence processes and activities that maximize coordination of services and minimize the need to move; address issues that arise prior to arriving at the assisted living community, during move-in, during time spent in the community, and while transfers take place.
• Assessment and reassessment. Determine the services to be provided by the community to meet the needs of the resident; assess each resident's service needs upon move in or when those needs change; collect and analyze data to make these assessments and inform decisions regarding care plans.
• Resident services. Provide individualized, planned, appropriate services in settings appropriate to the resident's needs; maintain a resident-specific planning process; implement the planned services; monitor resident response to services; modify the service plan based on reassessment, changes in the type or level of services needed, and the resident's need for further services.
• Resident education. Improve resident outcomes by providing information that meets the resident's learning needs, promotes healthy behavior, and allows residents to make informed decisions about services.
• Health and wellness promotion. Address maintaining resident's health, maintaining and improving function, preventing injuries, and avoiding or delaying the deterioration of residents' health status associated with chronic and degenerative diseases.
• Performance improvement. Systematically monitor, analyze, and improve its performance; monitor performance through collecting data, analyzing current data, and improving and sustaining improvements.
• Leadership. Plan, direct, coordinate, provide, and improve services that respond to residents' changing needs and help them to remain in the community.
• Managing the environment. Provide a safe, functional, supportive, and effective home environment for residents, staff, and others in the community; conduct ongoing master planning, education, standards development, and implementation plans.
• Human resources management. Identify and provide the right number of competent staff to meet the needs of residents served by the community; plan, provide competent staff, assess and maintain staff competence, and provide an educational work environment.
• Information management. Obtain, manage, and use information to improve resident outcomes and individual and community performance; manage resident applications, resident assessments, service-planning documentation, actual services provided, financial information, organization improvement information, billing information, and statistical information.
• Prevention and control of infections. Identify and reduce the risks of acquiring and transmitting infections among residents, visitors, employees, and contract services staff (JCAHO, 2005b).

The Joint Commission also highlights safety goals for assisted living (JCAHO, 2006). The 2006 Assisted Living National Patient Safety Goals include the implementation of a standardized approach to "hand off" communications, improve accuracy of resident identification, reduce harm resulting from falls and infections, and facilitate resident and family involvement and reporting of their safety concerns (available at: http://www.jointcommission.org/AccreditationPrograms/LongTermCare/). The JCAHO also provides a Quality Report on specific facilities through its Quality Check® search engine, including assisted living facilities, and serves as "one source of accreditation and comparison information that a person can use to determine whether a health care organization will meet his or her needs" (available at: http://www.qualitycheck.org/consumer/searchQCR.aspx). The Quality Report site is searchable by ZIP code, and provides information about accreditation status, implementation of specific assisted living safety goals, and a history of accreditation decisions for individual assisted living facilities. In addition, the Quality Check site allows users to compare facilities within a specified geographic region based on their success in meeting their patient safety goals. Importantly, since only JCAHO accredited organizations are featured in the Quality Check database, it does not provide a comprehensive comparison of all assisted living facilities available.

Quality Indicators in Assisted Living

A first set of quality indicators for assisted living has been developed as an extension of the nursing home version of the Resident Assessment Instrument (RAI), which includes information from the Minimum Data Set (MDS) (Hawes, Morris, Phillips, et al., 1997). Process-oriented indicators include providing needed services, good care practices, poor care practices, percentage of residents with little or no activities, and percentage of residents with multiple psychotropic drugs. The only outcome-oriented quality indicator that has been developed is the percentage of residents with falls.

These efforts provide comprehensive objective evaluations of facilities and valuable content that could help consumers make choices. However, from a practical perspective, finding the results of these licensing, accrediting evaluations, and quality measures requires time, effort, and knowledge of their availability. The average consumer likely will not have the experience and skills to access these data. This fact, combined with the undisputed need for consumers to have accessible, comprehensive information for making decisions, supports the current effort to determine consumers' information needs to make decisions and to develop tools that support decisionmaking.

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Consumer-Oriented Information

The materials that are designed to help consumers make decisions—such as marketing brochures, checklists, and referral services—are more readily available, but they may not provide the objective, comparative data necessary for a truly informed choice. The following paragraphs discuss the types of consumer-oriented information that are available, including marketing materials from facilities, consumer checklists, referral services, the results of provider surveys, and government resources.⁶

Facility Marketing Materials

Marketing materials, which include promotional brochures, provide facility-reported information to consumers and their families. These materials typically focus on the real estate aspects of assisted living, have global terms about their operating principles, and often do not provide information useful for decisionmaking (Lieberman, 2000). For example, in Carder's (2002a) systematic examination of the content of assisted living marketing materials from 63 Oregon facilities, she found that the primary focus of the materials was to support residents' "independence" (that is, the amount of assistance they receive). The majority of the organizations' materials addressed issues of incontinence and cognitive impairment in their marketing information, but they did not include specific criteria for admission. The GAO assisted living study (GAO, 1999) noted that only half of facilities studied in four States (Oregon, Ohio, Florida, and California) provided information on the conditions under which the cost of services may increase, and less than one-half provided discharge criteria.

Consumer Checklists

Several checklists and guides are available to help consumers prospectively assess assisted living facilities. These tools typically are developed by provider facilities, advocacy groups, States, and industry organizations (e.g., AARP, Alzheimer's Association, Yale-New Haven Hospital, Consumer Consortium on Assisted Living, and the Assisted Living Federation of America). The tools recommend that the prospective consumer perform an initial self-assessment of their needs. Based on their needs, the checklists prompt the consumer to evaluate the facility's atmosphere, physical features, required contracts, admission and discharge criteria, costs (both monthly and fee-for-service costs), financing, health care services including medication management and emergency care, other amenity services, unit features, social and recreational activities offered, food services, staff training, management expertise, characteristics of current residents, and any State inspection reports on the facility.

Lieberman (2000), with the editors of Consumer Reports, published a guide to help consumers select long-term care services, including assisted living. This guide suggests that the prospective consumer review materials, compile questions, and make observations during site visits to assess the following:

• Staff rapport with residents.
• Signs of resident life and energy in the facility.
• How well the facility accommodates to the prospective resident's needs.
• Level of oversight.
• Contractual terms/rules.
• Admissions process, application.
• Package of services, including rates and rate increases.
• Staff training based on agency licensing specifications.
• Activities offered.
• Kinds of services offered, such as transportation, housekeeping, laundry, meals, privacy.
• Type of medical care, including ability to see their personal physician.
• Medication administration and care plan.
• Transfer criteria.
• How they accommodate increasing frailty.
• The physical environment.

Internet-Based Referral Services

Companies that advertise a service to help consumers locate assisted living facilities are available through the Internet. These services typically are lead-generation services for facilities that pay a marketing fee to be featured in their networks or for a corporate chain of long-term care providers. Other "find a facility" organizations may charge the consumer user fees to access facility quality reports and ratings and sometimes offer discounts for selecting a provider. The methods and criteria of these ratings often are not specified and, consequently, prompt concerns about the accuracy of the information. Some services supplement the self-reported data from participating providers with publicly available data sources such as licensure status, Medicare sanctions, and results from State inspections.

Comprehensive Provider Surveys

There are also assisted living surveys that examine the facility characteristics that are publicly available, usually through surveys of administrators or walk-through observation studies, and report aggregate information. As with the licensing and accreditation information, these may be difficult for consumers to obtain easily. However, they could provide valuable information for consumer choice by comparing the facility and services that they are considering with the aggregate data.

Hawes and colleagues (Hawes, Rose, and Phillips, 1999; Hawes, Phillips, and Rose, 2000b; Hawes, Phillips, Rose, et al., 2003) present results of the assisted living facility makeup in the United States from data collected from nearly 1,500 facilities during a government-funded study of the industry. The data were collected from surveys (with administrators, staff, and residents) and walk-through observation.

Surveys of facilities include information about the facility location (e.g., urban-rural); facility size (number of residents); ownership status (e.g., private-public); room characteristics (e.g., number, size, type); privacy level (e.g., private entrance rooms, limited access, private bathrooms); the types of services provided (e.g., with ADL/IADL assistance); the level of services provided (e.g., how much help is given); admittance policies (types of disabilities allowed into facility); retention policies (how much disability a resident can have and remain at the facility); cost; insurance coverage; staffing (number/hours of nurses, doctors, etc.); medication assistance; and food services (e.g., how much, when, choice, cost).

The American Senior Housing Association (ASHA) also sponsors an assisted living facility survey that is targeted to administrators of ASHA member facilities (available at: http://www.seniorshousing.org/). The survey collects similar data to the studies by Hawes and colleagues (Hawes, Rose, and Phillips, 1999; Hawes, Phillips, and Rose, 2000b; Hawes, Phillips, Rose, et al., 2003), with more emphasis on financial and operational information about the facility (e.g., labor-related expenses by staff function, revenues, net income, etc.).

The National Center for Assisted Living (2005) is a part of the American Health Care Association (AHCA), which represents the largest federation of long-term care providers. Based on information that they received from a periodic survey of providers, NCAL publishes Facts and Trends: the Assisted Living Sourcebook (Kraditor, Dollard, Hodlewsky, et al., 2001). This resource provides aggregate information on finances and physical plant, resident characteristics, services provided, and wages and staffing   (full report: http://www.ahca.org/research/alsourcebook2001.pdf).

Government Resources

The Eldercare Locator (http://www.eldercare.gov) was established in 1991 as a public service of the Administration on Aging, U.S. Department of Health and Human Services, to help users obtain trusted information about local resources and community programs for the elderly, including assisted living facilities. Administered by the National Association of Area Agencies on Aging and the National Association of State Units on Aging, the service is designed to help both the elderly and their caregivers (who may not live in the same area as the person who needs assistance) identify available resources.

The Eldercare Locator provides information by county, city, or ZIP code on programs such as home based meal delivery or transportation, housing options, elder abuse prevention, health insurance counseling, legal assistance, and specialized services for older adults with illnesses such as cancer or Alzheimer's disease. In addition to the online service, which is available 24 hours per day, the Eldercare Locator service provides a toll free number that is staffed Monday through Friday 9 a.m. to 8 p.m. EST (Administration on Aging, 2005).

Another effort sponsored by the Administration on Aging (AOA) and the Centers for Medicare & Medicaid Services (CMS) is a grant program to develop State Aging and Disability Resource Centers (ADRC). These resource centers are designed to provide a single point of access for consumers to help minimize confusion and support informed decisionmaking. By creating formal linkages among existing programs and agencies that provide long-term care, the ADRC's tasks are to integrate information and referral services, provide benefits counseling on options, facilitate access to the public, and provide long-term care services for individuals, their families and caregivers or those planning for future long-term support. The resource centers are also aimed at improving a State's ability to manage resources and monitor program quality and costs, including reducing unnecessary high cost options such as nursing facility services (AOA, 2005).

Other functions include the following: promoting awareness of public and private long-term support options, especially to underserved populations; providing information and counseling on long-term support; facilitating programmatic eligibility and level of care determinations for Medicaid nursing facility and waiver programs for home and community-based services; providing short-term case management services prior to long-term care support; and providing information about programs and benefits that allow people to remain in their community (AOA, 2005).

All of the current types of information—including consumer checklists, quality indicators, marketing materials, and other resources—can be used to inform additional efforts to provide more objective, comprehensive, and readily acceptable materials to consumers. This information, combined, with the literature-based evidence on what consumers consider important (go to Chapter 5 of this report), analysis of current survey instruments used in long-term care (go to Chapter 7 of this report), and Appendix A. Reviewed Surveys and Tools [ - 883.69 KB] can help bridge the gap between the information currently available to consumers and what they really need to make fully informed decisions about their long-term care.

⁵Note: JCAHO discontinued its accreditation program for ALFs as of January 1, 2006.
⁶Since the writing of this report, the Agency for Healthcare Research and Policy has released a report on residential care and assisted living. The report, Residential Care and Assisted Living: State Oversight Practices and State Information Available to Consumers, presents a review of information that is available to consumers and family members on State agency Web sites. The report was prepared by Robert Mollica of the National Academy for State Health Policy. The full report can be accessed at https://www.ahrq.gov/research/residentcare/.

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