ElderWeb

The National Investment Center for Senior Housing Industries (NIC) reports in their February Newsletter that average resident turnover is 50%+ for assisted living and 30% for independent living. They also report that median occupancy rates for senior housing is now averaging:

90% - Independent Living
87% - Assisted Living
91% - CCRCs
87% - Nursing Homes

What does this mean to the consumer? Several things. First, the relatively high occupancies mean the over-supply of a couple years ago is working itself out and owners will probably be able to charge somewhat higher rates than they did when they had more occupancy problems.

Second, the high turnover levels indicate that people who move in are not staying long. This could be because they didn't like the facility, but could also mean they chose a place that couldn't handle their needs as they changed, and the resident subsequently had to move on to a place where they could get more care. Whichever it is, a short stay in an assisted or independent living facility is probably not good for anyone. The move is too traumatic if it isn't going to last.

I think the take-home message is that anyone investigating independent or assisted living facilities should be sure to ask lots of questions to help determine how long that solution can be expected to work, especially if the resident's condition deteriorates somewhat in the future.

Whether you're exploring options for yourself or for your aging parents, you know that navigating the world of health care services and long-term-care facilities can be a daunting task. Consumer Reports, well known as an objective and unbiased source of information, has created a guidebook to selecting long term care. The handbook is designed to help readers find the right services and secure them at the lowest cost. Some of the questions they try to answer include:

- How can you take advantage of pharmaceutical company drug-assistance programs? - What essential services should a home health aide provide? - How can you calculate annual health care expenses? - How do you decipher a state survey report for a nursing home? - Where can you find adult day care? - What should you look for in an assisted-living contract?

They also discuss the ins and outs of paying for health care services, including Medicare coverage and insurance options; and include city-by-city ratings for Medicare HMOs and Medicare supplement insurance policies, as well as a guide to how well each state is monitoring nursing homes, worksheets and tables to help people figure out their assets, judge an assisted-living facility, compare home care costs, evaluate an HMO drug plan, and comprehensive appendixes to guide readers to state-by-state information on insurance counseling, advocacy groups for the elderly, other helpful organizations.

Housing for Older People in Europe (HOPE), a network of seniors housing organizations, has issued a conference findings report on the state of seniors housing in Europe. Some of the things they noted include the fact that the population is extremely diverse, and that no one service option fits everyone's needs and expectations. Some people want to be surrounded by people in an active location, others want more solitude. Some want to be around people their own age, others do not want to be ghetto-ized. Some want ownership, others prefer to rent. They found that people wanted a place to "retire and live" rather than an "old people's home to go and die."

DaneAge survey results from 1987 and 1997 were compared, reflecting a trend away from living as cheaply as possible toward a preference for a central location along with access to "nature" and green areas. The DaneAge survey also found a desire by many people for shared accommodations, as a way to provide for needs they might have in the future if they were incapacitated.

Another theme that emerged from various questionnaires was the importance of autonomy -- having control over the little things in life. They found that older people do not want to give up their right to take risks, and do not want to be over-protected. They want to be able to control their own destinies.

Interestingly, one observation was that many people are far more concerned about getting help with practical needs like getting a roof fixed than finding care assistance, and they put a high value on features like an on-site handyman to help out. Many older people saw freedom from home maintenance as a compelling reason to move to a retirement home.

A HOPE questionnaire found that most older people expected that the government would provide financing for their care needs, and don't mind paying more taxes if they are used this way.

The report also notes that more and more large provider chains are emerging in Europe, which is changing the face of the industry. Some people who resonded to the questionnaire express concern about that trend, and a fear that these "super providers" will dominate the future, and damage the ability of non-profit providers to survive.

The AARP has published 118-page book by Patricia Baron Pollak of Cornell University on "Liveable Communities." It provides residents, organizations, and local governments with a tool to assess a community's "liveability." Numerous studies confirm that as people age, they want to remain in their home communities. However, these same studies also show that people often find "aging in place" difficult because the available services and physical environment of the community are not able to accommodate their particular needs. Using information derived from surveys of older people's concerns about their communities, the Guide focuses on eight areas: public transportation; driving; walking; housing; shopping; and municipal features, services, and leisure facilities. The guide is designed for individuals, organizations, and public officials to use as they look at the need to develop local community services that will support the ability of older people to continue to live independently.

When can an assisted living facility accept your loved one? When can they refuse to accept them? When can they kick them out? Unfortunately, deciding on an assisted living facility is not a simple decision. In addition to finding a facility that provides good care, you'll need to be sure you understand how long it is likely to provide a solution. For instance, in many places someone who needs a wheelchair can be involuntarily discharged, so families who know that a wheelchair may be needed in the near future should look for a facility that has more liberal policies about keeping someone if they develop that need.

"Critical Issues in Assisted Living: Who's In, Who's Out, and Who's Providing the Care", a new report from the National Senior Citizens Law Center, analyzes how consumers are protected, or harmed, by states' assisted living policies. It's a great summary of assisted living regulations across the country. Professionals will find it helpful to see how regulations vary across the country, and consumers may benefit by seeing what assisted living facilities can, and cannot, provide in their state.

I have seem some clips from what appears to be a very interesting look at life in an assisted living facility. The movie was filmed on location in an assisted living facility and actors were directed to blend in seamlessly with the normal environment. Many of the actors and all of the extras in the film are residents of the assisted living facility going about their normal lives or reacting to the action in a scene. As John Case of the Summerkamp Group put it:

"ASSISTED LIVING" was filmed on location in a working assisted living facility and paints a uniquely genuine and thought-provoking portrait of aging in America. Elliot Greenebaum'™s award-winning feature seamlessly blends the fictional story of one woman'™s poignant surrender to Alzheimer'™s with the day-to-day lives of actual patients and staff. The result is a startlingly clear-eyed allegory filled with compassion and wit.

Indiewire, the on-line authority on independent films, says 'œGreenebaum is an alchemist, combining real moments and real people with an exceptional story. What ensues is a magical film.' SYNOPSIS Assisted Living follows 21-year-old Todd through his final day of work as a janitor at a nursing home. Todd smokes pot frequently on the job, which allows him to enjoy the surreal environment of the assisted living facility. He also breaks the monotony of his days with entertaining'”and extremely unprofessional'”diversions involving the residents: he rides through the halls in borrowed wheelchairs; he plays pool and Scrabble with them; he even 'œplays God' on the telephone, giving residents the illusion of speaking to their departed loved ones in heaven. But however much these activities cheer the seniors, Todd'™s behavior angers the staff and undermines the policies of the home. It is ultimately Todd'™s interactions with Mrs. Pearlman'”a beautiful resident who longs for a visit from her son'”that jeopardize his job. Mrs. Pearlman, who is in the early stages of Alzheimer'™s, has difficulty distinguishing the real world from her memories of it. As her odd friendship with Todd develops, she begins to mistake the janitor for her son. When Todd in turn begins to assume the role, he rediscovers his own humanity and instigates a transformation for them both. FILM FESTIVALS 2003 Slamdance Film Festival GRAND JURY PRIZE 2003 GenArt Film Festival GRAND JURY PRIZE AUDIENCE AWARD 2003 Woodstock Film Festival GRAND JURY PRIZE 2003 Savannah Film Festival GRAND JURY PRIZE 2003 SXSW (South by Southwest) Festival OFFICIAL SELECTION 2003 Mill Valley Film Festival OFFICIAL SELECTION

ALFA Press Release Notes Trends and Advances in Consumer Choice

(WASHINGTON, DC, August 14, 2002) The Assisted Living Federation of America (ALFA), the leading trade association for assisted living providers, recently published its mid-year legislative wrap-up report. More than 180 bills with references to assisted living have been introduced in state legislatures around the country. The report highlights a significant push in 2002 for advances in consumer choice and rights for the states.

According to ALFA's President and CEO Paul R. Willging, Ph.D., a number of the enacted bills this year are indicative of trends shaping the regulatory environment in which assisted living providers will operate in the near future. 'When viewed in the context of legislation that has passed in other states in recent years, ALFA clearly sees a shift in trends towards consumer choice,' stated Willging. At the same time, many states have revised their assisted living regulations. The volume of state legislative and regulatory reform in assisted living is far greater than what most people think it is,' added Willging. 'What appears at first glance to a causal observer to be a patchwork of state rules is actually a growing body of consistently regulated areas of operation.' Bills enacted so far this year covered the following areas:

* consumer disclosure;
* consumer choice;
* consumer safeguards; and
* rules revision.

For a detailed description of the laws that were passed in a particular state, visit www.alfa.org and click on ALFA's Mid-Year State Legislative Wrap-Up Report under 'What's New at ALFA.' These bills demonstrate that states are continuing to take steps to protect the rights of residents. 'However, all states and providers struggle to find just the right balance of the consumer's desire for enhanced choice and control in assisted living with the responsibility of state agencies to ensure regulatory compliance and protect the welfare of residents. A new paradigm is needed that focuses on resident outcomes and customer satisfaction while preserving customer choice,' said Willging.

'There is a growing and discernible movement toward greater consistency in the way assisted living is regulated at the state level. Fortunately, state leaders and policymakers see the wisdom and benefit in allowing assisted living to be adaptive and responsive to the needs of each state's culture and its residents.'

For additional information on ALFA's Mid-Year State Legislative Wrap-Up Report, contact Francine Moore at (703) 691-8100 ext. 208 or email fmoore@alfa.org

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The Assisted Living Federation of America (ALFA), www.alfa.org, is the largest association dedicated to the assisted living industry and the population it serves. ALFA represents over 6,000 for-profit and not-for-profit providers of assisted living as well as a diverse range of organizations involved in the assisted living industry. With more than 40 state affiliates nationwide, ALFA promotes the philosophy of consumer choice and quality of life for seniors.

Many people are interested in knowing whether assisted living facilities will reduce the utilization of nursing homes. Since assisted living is less expensive than nursing home care, many states are exploring ways to move people who qualify for Medicaid and who need nursing home care into assisted living facilities instead. In addition, people who would "rather die than move into a nursing home" are hoping to find that assisted living will reduce the chance that nursing home care is in their future.

A recent study done by researchers from Texas A&M University System Health Science Center and Myers Research Institute addressed some of these issues. These researchers studied what happened to people who were discharged from assisted living facilities, including those who died in them, to help identify ways to keep people in the facilities longer. They looked at the reason for the discharge, and and found that most (80%) occurred because the resident needed more care. Those who were transferred often had cognitive problems, and many had been in the facility only a short time, which may indicate that the original placement was inappropriate or that the facilities need to be able to provide more cognitive care services. Researchers noted that the single most important factor in preventing discharges was the presence of a full-time registered nurse (RN), since facilities with RNs on staff were able to provide a broader spectrum of care.

An interesting finding in the study was how the expectations of family members involved in placement decisions changed over time. When they first looked for a facility, most family members thought that the availability of a private bedroom and bath was the most important aspect of a facility. By the time a family member was discharged, many family members said that the most important criteria was the ability of a facility to adapt to changing care needs, possibly because that might have avoided the need for a transfer.

Many people are concerned about the cost of assisted living, which is overwhelmingly paid for out-of-pocket and is not covered by Medicare and generally not covered by Medicaid. However, only 8% of the transfers in the study were made because the resident ran out of money.

Researchers found that about 24% of assisted living facility residents were discharged each year, including about 8% who died in the facility or immediately after discharge. Of those who were discharged and did not die, about 1% were able to return home and another 7% ended up moving into the home of a relative. 28% moved into another assisted living facility and 64% moved into a place that provided more care, like a nursing home, hospital, or sub-acute unit.

The U.S. Department of Housing and Urban Development has posted an application online for their Section 202 Assisted Living Conversion Program. The application is due June 21, 2001. If approved, the program would provide funds to nonprofit project owners of HUD 202, 236, and Section 8 low-income housing who want to convert the housing to assisted living units for low-income frail elderly. The program is intended to provide housing for people age 62 or older who are unable to perform 3 or more activities of daily living. This program was just started last year, when $50 million was appropriated and $19 million was awarded to 13 projects providing 508 units. For 2001, $75 million is available. The applications will be ranked based on criteria like the need for low income assisted living in the geographic area and the lack of financial resources available to the project owner to pay for the conversion without assistance.

HUD has posted a WebCast online which discusses the application process and the characteristics of projects which received funding last year, and the application and other program information is also available online.

The U.S. Senate Special Committee on Aging is holding a hearing today about assisted living. To be discussed are issues like whether or not the federal government should provide more oversight and regulation of assisted living, which today is regulated almost entirely by the states. One of the hearing witnesses is Hillary Rodham Clinton, a member of the Subcommittee on Aging of the Senate Health, Education, Labor and Pensions Committee.

In a November 1st memorandum to Florida Lt. Governor Brogan's task force, Northeast Florida Area Agency on Aging Executive Director Annette Kjeer said that in Jacksonville, eight of the largest of 37 participating ALFs were withdrawing from the Assisted Living Waiver program, and the remaining ALFs in the program are too small to handle what is approximately one-third of the total client population.

The Assisted Living Waiver program helps lower-income elderly in need of daily assistance to live in an assisted living facility, a less expensive alternative to state-funded nursing home care, and for the elderly person, a much less restrictive residential setting. For a facility to participate in the waiver program it must hold extended congregate care (ECC) or limited nursing services (LNS) licenses. Insurers are telling ALFs they will no longer cover facilities holding these licenses because of the greater potential for lawsuits, so many are dropping their ECC and LNS licenses so they can continue to stay open. Unlike nursing homes, Florida law requires ALFs to carry liability insurance as a condition of licensure.

The Florida Health Care Association, an organization of facility operators, warned that the insurance crisis jeopardizes the assisted living program. They said that some elderly clients may have no other option than state-funded nursing home care, the very thing the Assisted Living Waiver program was intended to prevent. They also report that Florida long term care facilities are three times more likely to be sued than a non-Florida facility because of the unique Florida law that provides incentives to sue nursing homes and assisted living facilities. As a consequence, Florida has the highest liability insurance rates in the nation. A recent Department of Insurance report confirms liability insurers fleeing Florida.

Lt. Governor Frank Brogan heads up a task force created to investigate the availability and affordability of long-term care, including the liability insurance crisis faced by long term care providers in the state of Florida.

The Assisted Living Federation of America (ALFA) has launched "ALFAcares - The Affordable Housing Initiative of the Assisted Living Federation of America." ALFA members are concerned about individuals who may be forced into institutional settings because affordable models are not widely available. For these reasons, ALFA is proactively supporting state, federal, and industry partnerships that will expand affordable housing opportunities for low-and-moderate income seniors.

They say that the dramatic growth of the assisted living industry has demonstrated the benefits of a residential environment where seniors can receive personal care assistance while maximizing their functional abilities and independence. Although assisted living is a more cost- effective model than institutional long-term care, the cost of private care in assisted living facilities remains out of reach for many low-and-moderate income seniors:

Current assisted living facilities have mostly been developed for higher income individuals residing in targeted urban and suburban communities throughout the country. Few models can be found for lower income seniors (income less than $30,000 per year) even though they outnumber higher income seniors 2 to 1.

Lower income seniors are often frailer than those with higher incomes, so they have a greater need for assisted living care. The most vulnerable group is single people over age 75. This group, which numbers 6.5 million, is projected to increase by 100,000 individuals each of the next ten years.

Seniors with income below $15,000 often qualify for various housing and entitlement programs, such as HUD Section 8 rent-subsidy vouchers, SSI welfare benefits and Medicaid. However, developers of affordable assisted living have difficulty utilizing these resources because of multiple funding streams and conflicting regulations within the state and federal agencies whose oversight complicates the delivery of housing and services in these type of publicly-supported environments.

The initiative goals are to:

Support federal legislation that promotes affordability
Facilitate national replication of "best practice" models of affordable assisted living through the combination of tax credits, subsidies, state programs, grants, etc.
Promote affordable assisted living through state reimbursement policies, including Medicaid waivers, state plans, and other long-term care benefits
Work at the state level to eliminate regulatory barriers that affect affordability while preserving resident rights and safeguards.
Encourage partnerships between HUD and HHS to coordinate the benefits of housing and health programs for low-income frail seniors.
Central to the success of these efforts will be the willingness of states to explore new models of affordable care, which are responsive to consumer preferences. One proposed new model is a Medicaid Consumer Account Program for Assisted Living. ALFA's Medicaid Consumer Account Program builds upon successful state programs that provide Medicaid reimbursement for assisted living services in residential settings. Features of the model program include:

Budget neutrality
An emphasis on consumer-directed decision making and independence
Funding that is "portable" because it will reimburse the consumer rather than the provider
ALFA also has tried to address people concerned about the "woodwork effect" which says that providing more home and community based services will increase overall costs because it will draw in thousands of people who are not receiving government-funded services now.

They say that there are examples which show that this has not happened. For instance, Oregon's use of home and community-based services instead of nursing facility care saved an estimated $227 million between 1981 and 1991 out of a projected direct service expenditure of $1.35 billion for the period. Additionally, the shift to home and community-based care has enabled the state to serve more beneficiaries with the Medicaid and state dollars they have available.

Maine actually reduced total long term care spending from $228 million in 1995 to $185 million in 1998 and served 3,700 more people by developing a comprehensive array of alternative services and by reducing the supply of nursing home beds.

The Assisted Living Federation of America (ALFA) issued a report on the state of the assisted living industry in the United States. They found that the average occupancy of assisted living residences increased to 91.5% in 1999 from 90.4% in 1998 at and 90.8% in 1997.

The percentage of semi-private assisted living rooms increased to 13% in 1999, after decreasing for three years. However, the average percentage of semi-private rooms being occupied as a private room also increased significantly.

About 52% of assisted living residents were reported as having some level of Alzheimer's or dementia impairment.

The average basic daily fee for a private room has increased to $73.97, the highest rate noted in the survey's history. 41% of providers used a "tiered" pricing formula and 13% used a flat rate for each service provided. This compares to 70% who used "tiered" pricing and 7% who used a flat rate for service in 1998.

A lower percentage of residents who moved out of their assisted living residences, 36%, were compelled to relocate to a nursing home for health reasons than in previous study years, while the percentage of assisted living residents who lived out their lives in assisted living has gradually increased over the same period, accounting for 30% of all discharges.

Medication-related issues ranked highest on the list of most frequent problems reported to state agencies. But there was no apparent correlation between the frequency of medication-related errors and the type of employee allowed by the state to administer or assist with medications.

Access to medical care, abuse and billing/charges are among the least frequent complaints to state agencies.

The Overview is the most comprehensive report of its kind, combining original research results from the largest annual survey of senior housing providers with the most relevant information gleaned from other top studies in the field. More than 373 facilities responded to the 1999 survey, representing 27,011 units and 26,742 residents from 44 states. In recognition of the changing membership of ALFA, the 1999 survey also went to Independent Living providers. Over 80 Independent Living properties from 30 states responded to this year's questions.

The American Nurses Association (ANA) has identified ten nursing-sensitive indicators of quality of care in non-acute care settings like long term care and home care. They are hoping to explore the relationship of nurse staffing and quality of patient care as they further develop these indicators. They are looking at pain management, consistency of communication, staff mix, client satisfaction, prevention of tobacco use, cardiovascular prevention, caregiver activity, identification of primary caregiver, psychosocial interaction, and activities of daily living.

The National Investment Center for the Seniors Housing & Care Industries (NIC) announced the results of a new survey, "National Survey of Adult Children: How They Influence Their Parents' Housing & Care Decisions." The survey found that over 75% of the time, adult children were involved in the decision to place a parent in a nursing home or assisted living facility, but that they were generally unaware of the options available, and confused about terminology. The study also found that over 66% of assisted living residents have incomes under $25,000 per year, and more than half of their adult children have incomes below $75,000 a year, yet 26% of the adult children contribute financially to their parent's care. 77% of these adult children said they had not discussed the costs of seniors housing and care with their relative.

The Alabama Public Health Department held an unusual public forum with leaders of the Alabama long-term care industry, to discuss regulation of assisted living in the state. The Health Department argues it has neither the money nor the authority to regulate the assisted-living industry, nor the patience to listen to the nursing home industry say that it's unfair to regulate nursing homes while not regulating assisted living. After efforts to write new laws failed in the last days of this year's legislative session, the Health Department invited dozens of leaders and thinkers to this forum. They say that it was not a legal hearing, just a public negotiation.

After that forum, the state released its proposed new assisted living regulations. Officials estimate that as many as half of the patients in standard assisted-living homes wouldn't be eligible to remain there under the new rules. At least 20 new state inspectors would be hired to inspect hundreds of assisted living homes statewide. The estimated $750,000 cost of those inspections would be paid from an emergency appropriation approved by Siegelman.

The stumbling block centers on whether dementia-care assisted-living homes would be subject to broader state control. The nursing home industry wants such facilities under Certificate of Need (CON) restrictions because they often compete for the same patients. Assisted-living leaders agree some control of growth is needed, but contend the CON is too politicized and doesn't guarantee a higher quality of care.

Grand Court Lifestyles, the operator of about 54 assisted living facilities across the country, is now in bankruptcy. Early in March, the company failed to make payments on $13.6 million in debt. By the end of March, the company had filed for Chapter 11 reorganization. In April, the company was delisted from the NASDAQ stock exchange.

Alterra, the operator of about 350 assisted living residences across the country, reported a first quarter loss of $.24 a share for the year 2000, as compared to income of $.06 a share in the same period of the prior year. Income per share for Sunrise Assisted Living for the first quarter the year dropped from $.35 in 1999 to $.19 in 2000, and first quarter income per share at American Retirement Corp dropped from $.20 a share in 1999 to $.04 in 2000.

Stocks of most publicly-held assisted living companies have been hammered this year, partly because the public doesn't differentiate between the regulatory and reimbursement problems which face the nursing home industry from the very different environment of the assisted living industry, and partly because of the poor financial results many industry leaders had displayed. Industry operators contend their industry is still healthy, and that the poor financial results are primarily due to the upfront costs of investing in land and buildings in new locations, costs will be recouped as the new facilities come online. Some observers counter that the poor results are an indication that the industry has overbuilt and overextended itself.

HB 1930, The Assisted Living Licensing Act, was referred to the Appropriations Committee May 1, 2000. This is an Act requiring the Department of Public Welfare to develop and implement a State plan for regulating and licensing assisted living residences and for coordination with other State and local agencies having statutory duties relating to assisted living residences and providers of assisted living services; providing for the Intra- Governmental Council on Long-Term Care, for appeals and for relocation; and prescribing penalties.

The prelude to the Act states, "In Pennsylvania, assisted living is a private market phenomenon. There is no uniform assisted living definition; no required public oversight of entities which hold themselves out as providing assisted living, although many are licensed as personal care homes; no uniform way of assuring assisted living quality; and limited access to assisted living except for persons with higher incomes. It is in the best interest of all Pennsylvanians that a system of licensure and regulation be established for assisted living residences and providers of assisted living services in order to ensure accountability and a balance of availability between institutional and home and community-based long-term care for older persons and persons with disabilities."

The Assisted Living Federation of America (ALFA) has announced the creation of an accreditation program for assisted living industry professionals as part of its continuing effort to encourage professional training and development within the industry. The program is offered under the auspices of ALFA University, the training arm of ALFA. The national Assisted Living Administrators Certification Program is available for executive directors, assisted living administrators and industry professionals seeking to prepare for administrative positions.

The program is based on ALFA?s "Management Library for Assisted Living Administrators and Executive Directors". It is self-study and self-paced culminating with a final examination. The program has been approved for 47 CEU credit hours through the NAB (National Association of Board of Examiners).

Initial response to the program has been overwhelming, reflecting the commitment of industry professionals to on-going training and development. Within the first few weeks, over 250 administrators signed up for the certification program.

Significant improvements are needed in the State's licensing and inspection of adult care facilities in New York, according to an audit released today by State Comptroller H. Carl McCall. "State officials responsible for the safety of adult care facilities do not regularly verify information before granting a license to operate, they don't conduct inspections as required, and they don?t always respond to complaints on time," McCall said. "When people make a decision to place a loved one in a state licensed adult care facility they should have the peace of mind that the State has met its responsibility for licensing and inspections."

McCall's auditors found that, while the Department of Health (DOH) and the Office of Children and Family Services (OCFS) require applicants to provide letters of reference and information about their prior work experience and financial resources, neither agency verifies the information or routinely seeks independent information about the applicants. Although State officials admitted knowledge of as many as 50 unlicensed adult care facilities operating in the New York City area alone and 800 unlicensed family-type homes operating statewide, little is done to investigate. DOH dedicated about ten percent of one staff person?s time to investigate reports of unlicensed facilities. During a visit to one of the unlicensed facilities, McCall's auditors found that one of the residents had required skilled nursing care for at least two years, but had yet to be transferred to a facility that provided the needed care.

McCall also identified serious weaknesses in the inspection of licensed adult care facilities. Unannounced inspections are required every 18 months, and annually if there has been a pattern of problems at a facility. Auditors found that the DOH computer system designed to track inspections was so riddled with errors it could not be used as a reliable source of information to determine if inspections were done on time.

McCall also found problems with DOH's response to complaint calls. For example, the Department waited seven days to respond to a complaint about at an adult care facility that had no medication available.

McCall outlined twenty specific recommendations to improve DOH and OFCS operations, and agency officials agreed to implement most of them.

The "1999 ALFA National Satisfaction Study" has just been released by the Assisted Living Federation of America (ALFA) and ServiceTRAC, Inc. This study represents an attempt to delve more deeply into understanding nuances about customer satisfaction by using an "expectations" scale rather than the commonly used "satisfaction" scale, and by seeking to establish not only which services are performed well in the eyes of one?s customers, but also which services matter most to the customers.

The report results reflected a disparity between the way that family members and residents evaluate their satisfaction with assisted living facilities. For example:

- 88% of family members of assisted living residents living in freestanding communities said their overall expectations had been met or exceeded, compared to only 80% of the residents in those communities.

- 74% of family members and 80% of residents were satisfied overall with assisted living facilities which were units within a larger healthcare facility.

- 89% of family members and 82% of residents were satisfied overall with assisted living units which were a part of a Continuing Care Retirement Community (CCRC).

- The satisfaction of family members was most often influenced by personal care services -- but food, staff, administration, and activities most influenced the satisfaction of residents.

Residents most often mentioned staff friendliness, floor plans, and safety features as some of the areas which exceeded their expectations, but they overwhelmingly cited food services as the area most in need of improvement.

Results of the Canadian Home Care Study are available from the National Association for Home Care (NAHC). This study, "The Comparative Cost Analysis of Home Care and Residential Care Services," examined the utilization and cost of services provided to people who received care at home as compared to those who received care in a residential setting. The results were stratified by the level of care needed to try to make comparisons more meaningful.

Overall, costs for community-based care averaged $8,900 a year, while residential care averaged $30,000 a year. The difference in costs varied with the level of care needed, so that home care represented about 40% of residential care costs for those with lower care needs, but 75% of residential care costs for those with more acute needs. The cost of home care as compared to residential care is highest for clients whose needs are changing, and for clients who die while under care.

Partially in response to this study, Canadian Health Minister Allan Rock proposed an expanded national home care program in a letter to officials in the nation's 10 provinces.

Allowing residents to make their own day-to-day decisions is essential to the assisted living philosophy. But what happens when a resident wants to pursue an activity that may be detrimental to their best interests? Increasingly, assisted living providers seek to resolve such dilemmas through the use of "negotiated" or shared risk agreements. To help providers understand and develop effective risk agreements, the Assisted Living Federation of America (ALFA) released a manual for providers called, "Negotiated Risk Agreements in Assisted Living Communities."

"Negotiated risk agreements are, at their best, a negotiating and problem-solving tool designed to bring residents and the community to a mutually agreeable level of ?choice? and ?risk,?" said Ken Burgess, ALFA?s General Counsel and author of the risk manual. "Increasingly, assisted living providers are being asked to push the envelope by allowing clients to take risks in the spirit of promoting autonomy and independence. But negotiation of risk with a resident does not necessarily mean the elimination of risk for the provider. This manual should help them reach a middle ground."

The manual attempts to tackle some difficult issues surrounding negotiated risk agreements including the mental capacity needed by a resident to enter into a negotiated risk agreement, waivers of liability, and other issues where there is little or no binding legal precedent.

The National Investment Center for the Seniors Housing & Care Industries (NIC) "National Supply Estimate of Seniors Housing & Care Properties" estimated that the number of assisted living beds in the country has increased from 362,000 in 1991 to 778,000 in 1999, an increase of over 114%. They also estimated there are another 821,000 senior-oriented independent living units which don't provide supportive services.

National estimates of assisted living beds have been difficult to come by because of the lack of consistency in licensing and regulatory requirements from state to state, and the evolving nature of the industry. The industry is so new that in 1991 few states had a licensing category called "assisted living," and the NIC had to compile an estimate of the inventory of "assisted-living-like" facilities from a variety of sources.

One of the problems in selecting and evaluating assisted living facilities has been the lack of any consistent standards or regular survey process across the country. There are no standards for assisted living at the federal level, and many states have only recently set licensing standards for this level of care. Worse still, most do not have any process in place for the regular and recurring surveys of these facilities which would provide data which could be used to evaluate quality of care.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has stepped into this void by publishing its first-ever standards for assisted living. JCAHO has long operated as an accreditation program for hospitals and nursing homes, but the development of an accreditation program for assisted living is a new endeavor. The JCAHO accreditation process is a voluntary program, as opposed to the mandatory state survey processes. To qualify for a JCAHO accreditation, the facility must pay a fee and undergo an initial survey, with follow-up surveys every three years.

To be eligible for accreditation, an assisted living community would need to provide or coordinate personal services, 24-hour supervision and assistance, activities and health-related services. The assisted living community would need to operate under the philosophy that it is in the best interest of the resident to offer and design services to minimize the need to move; accommodate individual resident changing needs and preferences; maximize residents? dignity, autonomy, privacy, independence, choice, and safety; and encourage family and community involvement.

The standards include: Consumer Protection, Rights, and Assisted Living Community Ethics; Continuity of Services; Assessment and Reassessment; Resident Services; Resident Education; Health and Wellness Promotion; Improving Performance; Leadership; Managing the Environment of Care; Managing of Human Resources; Managing Information; and Prevention and Control of Infections. The standards will be effective in June of 2000, and the first surveys are expected to be conducted by January 2001.

The only other national accreditation program for assisted living was developed by the Commission on Accreditation of Rehabilitation Facilities (CARF). The CARF assisted living accreditation program is also new, and was just unveiled in February of this year. CARF is a private, not-for-profit organization that accredits programs and services in Adult Day Services, Assisted Living, Behavioral Health, Employment and Community Services, and Medical Rehabilitation.