Assisted living: a risky business

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Nancy Augustine
Nancy Augustine
The freedom to "age in place" conveys hope for seniors-a chance to enjoy the final season of life without being institutionalized and without burdening family members. As evidenced by exponential growth in assisted living, independent living and community-based programs, consumers are driving the long-term care market and they demand options, autonomy and the freedom to make choices-including choices that entail risk. Balancing autonomy with safety, however, presents a serious challenge to assisted-living facilities striving to deliver on the hope of aging in place for their frail and elderly residents.

Risk abounds

In a community of residents with an average age of 84 who depend on assistance for many daily tasks, risk abounds. Just consider the obvious risks in a population where 86% require assistance with medications, 68% with bathing, 47% with dressing and 25% with eating. And do not minimize the fact that, on average, half the residents also suffer from some form of dementia.  Falls, elopements, abuse, medication issues and contagious infections are just a few of the more common problems that keep both administrators and family members up at night.

But there is another layer of less obvious risks. Some seniors, who thought they bought the complete lifetime package, will face the risk of eviction. Glossy marketing brochures that assured prospective residents of services to meet all needs of all residents all the time have faded away leaving only a trail of broken promises.

Jim Moore, a respected assisted living consultant, refers to it as the "million dollar wake-up call" for assisted-living facilities. He notes that by adding just 60 minutes of assistance per day for just 40% of residents, a facility's costs can increase by $123,000 per month. Unless the facility can cover those expenses with higher prices, promises are broken. Even in the wake of broken promises, many residents will resist the need to move along the continuum of care. Likewise, many administrators who find themselves under constant pressure to keep the facility full may not pursue a transfer.

The confluence of these factors leads into another equally undesirable set of risks. Although the phrase "aging in place" conjures up favorable images for the majority of seniors, the reality may be a disappointment for them and their family members. Because assisted-living facilities are not regulated by the federal government, and only loosely regulated by state government, the level of services provided from facility to facility varies significantly. In an effort to minimize operating expenses, many facilities depend heavily on unlicensed personnel (universal workers) for a majority of resident care, including the administration of medication. For seniors with deteriorating health conditions and multiple chronic diseases, lack of adequate nursing care and nursing supervision can spell disaster. In fact, most mistakes that result in injuries to residents are typically rooted in staffing issues.

Industry responds

Recognizing these problems, industry leaders have united and taken several steps to bring about some baseline of industry standardization. For example, many states now require assisted- living facilities to provide a detailed disclosure statement to every potential resident. The disclosure statement varies by state; however, it generally identifies the specific care and services available in a uniform manner which empowers consumers to make comparisons between facilities. Such comparisons hopefully lead to more informed decisions and appropriate placements.

 A typical disclosure provides details on services included in the base rate and a listing of additional services available for purchase. More importantly, the form "should" include critical information regarding staffing patterns, staff licensing and staff training. Equally important, the form should disclose what changes in health status will result in a discharge or transfer. While the resident, the family and the facility may all agree that aging in place is the optimal goal, full disclosure assists everyone in the decision-making process and eliminates future surprises regarding the facility's capacity for delivering increased services.

Another recent development to manage risk is the negotiated risk agreement (NRA). This tool was developed as a practical strategy that operationally allows resident autonomy in the litigious assisted-living environment. It's a process designed to assure that residents maintain privacy, independence, choice and control over their lives while acknowledging both provider and state responsibility to assure quality and safety. For example, if a resident has a minor allergy to eggs, but wants to eat eggs on Sunday morning and suffer the allergic consequences, the resident is free to make that choice. Of course, there will be instances where the NRA is used inappropriately in an attempt to shirk responsibility; however, overall the NRA is a useful tool in the early identification of risk. NRAs are allowed in every state although many states limit their use.

Assisted living at a crossroads

As the pendulum shifts toward increased standardization and state regulation, many assisted-living facilities find themselves at a crossroads. Some facilities remain committed to a philosophy of complete autonomy and adamantly oppose the growing body of consistently regulated areas of operation. These facilities view NRAs as wholly unnecessary because they already operate under the assumption that a resident's right to all decisions is inalienable. These same facilities may view disclosure requirements as burdensome and unnecessary paperwork. In any case, certain assisted-living facilities are purposefully breaking away and converting to independent- living models of care.

Independent living, a relative newcomer to the long-term care industry, flies below the radar screen of both state and federal regulations. It allows seniors an independent lifestyle whereby they contract directly with third-party providers for the services they desire. Buyer beware, however, as units are marketed by commissioned sales people with little to no knowledge of senior health issues, and the fulfillment of promises made during the sales pitch should never be taken for granted. 

The balancing act

As the population of seniors surpasses the population of children for the first time in our nation's history, issues related to long-term care will take center stage. Stakeholders in the debate (residents, family members, advocates and industry leaders) will wrestle over where to place the divide between regulation and autonomy. Noted expert on quality in long-term care Dr. Robert Applebaum summed up this balancing act quite well when he said, "What we want is autonomy for ourselves and safety for those we love." What the elderly want is clear - they want to "age in place" with both choices and safety. Let's respect their desires and never cease wrestling until both can be delivered, simultaneously, in every senior-living environment.
Nancy J. Augustine, MSN, RN, NHA, RAC-CT, is the director of quality improvement and risk services, and Paola M. DiNatale, MSN, RN, NHA, RAC-CT, is a national account manager, risk services, at PointRight Inc., formerly known as LTCQ Inc.
PointRight Inc, based in Lexington, Mass., is a company committed to improving the quality of care in long-term and post-acute settings by providing information-based clinical management tools and services to providers, payers, regulators, suppliers and consumers. For more information, please call (781)457-5900 or visit


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