Federal government needs to take closer look at assisted living facilities

November 01, 2006

Over the last 20 years, a housing industry has sprung up to handle elderly citizens who cannot live independently but do not require around-the-clock nursing.

Known as assisted living facilities or ALFs, the industry offers seniors a range of housing possibilities from two-bedroom suites with access to golf and tennis in ritzy vacation spas to small rooms in dilapidated motels and former hospitals.

ALFs have become the fastest growing segment of residential care for the elderly. And along with their rise have come a host of health and care issues that need to be addressed by the federal government, according to an article in the Elder Law Journal published by the Illinois College of Law.

By law, ALFs are not considered medical or mental health facilities and are viewed as residential only. In addition to a private or semi-private room, they typically offer meals for residents, housekeeping services, assistance for taking medications and provisions for social activities.

About half report having a registered nurse on staff either full- or part-time. But a number of differences exist between ALFs and nursing homes, Patrick A. Bruce, a former editor at the journal, noted in the article.

"In contrast to assisted living facilities, nursing homes are subject to federal guidelines because they rely on Medicaid and Medicare funds. A second major difference between assisted living facilities and nursing homes is their respective costs. Assisted living facilities typically cost less than nursing homes. However, this cost is misleading because assisted living residents use private funds to pay for their expenses while eligible persons can use Medicaid to cover nursing home costs."

Surveying the regulation of ALFs by state agencies, Bruce found lax rules and inconsistent inspections. Lack of staff training is a major shortcoming in many states. Maryland, for example, requires only three hours of training to work in an ALF, and inspections have found residents with untreated bedsores, hypothermia and other signs of neglect.

As a result of a budget crisis, California announced in 2003 that it would cut back its inspections of ALFs from yearly to once every five years. In Alabama, regulators spent $5.5 million to inspect 244 nursing homes in 2002, but only $500,000 to inspect 330 ALFs.

The federal 1987 Nursing Home Reform Act requires operators to provide a minimal level of service and established a resident's bill of rights.

Despite enforcement loopholes and shortcomings in inspections, the law has tangibly improved the quality of life for many nursing home residents. "Inappropriate use of physical and chemical restraints, rates of urinary incontinence and catheterization and, most importantly, hospitalization rates have all declined," Bruce wrote.

Similarly, federal standards that set norms for staff training, scope of care, and disclosure of coverage at ALFs would "provide a predictable setting for consumers, providers and payers," according to the article.

It is estimated that about 1 million people are housed in more than 36,000 ALFs nationwide. This compares with about 600,000 seniors housed in 11,500 ALFs in 1998.

The industry reported charging an average monthly fee of $2,627 for private units in 2006, although this figure varies widely depending on the size of the unit, services provided and location.

By 2020, the number of elderly Americans needing long-term residential care is expected to double from 7 million to 14 million.
The article is titled, "The Ascendancy of Assisted Living: The Case for Federal Regulation."

University of Illinois at Urbana-Champaign

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