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.
Return to Contents
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.
Return to Contents
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 (PDF File, 700 KB; PDF Help) 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 http://www.ahrq.gov/research/residentcare/.
Return to Contents
Proceed to Next Section
540 Gaither Road Rockville, MD 20850