What Assisted Living Can't DoCarolyn L. Rosenblatt, R.N., Attorney at Law
Assisted living facilities can be wonderful...but don't expect nursing.
Posted September 18, 2009
When aging parents come to the point when assisted living seems like the best choice, it is usually their baby boomer children who see it first. Perhaps the adult children live in another state. Perhaps they are unable to visit Mom or Dad often enough to feel comfortable leaving them alone. The death of a spouse or a gradual loss of independence in self care, inability to provide one's own means—any of these reasons may lead to the adult child's decision to move the parent. As an assisted living facility representative is likely to tell you, it is often the adult children who first come to look the place over, later bringing their parents to see the place for themselves. As the hidden consumers of services, adult children, especially their attorney children, need to be wise consumers.
Assisted Living vs. Skilled Nursing
As the hidden consumers, what do the adult children of aging parents need to understand about these facilities? Very simply: what the facility can't do. Invariably, the sales pitch tells adult children what the facility can do, which is fine, and to be expected. But as a consumer, it's wise to understand the difference between assisted living and nursing care. First, an assisted living facility is not a nursing home with fancy furniture. Assisted living is not licensed to give nursing care. Typically, assisted living facilities are places where elders live in a supervised community, with some personal care services available. Meals, social activity, and help with the activities of daily living such as bathing and dressing are usually all offered at such facilities. The focus is on providing a healthy social environment and preventing social isolation. It is a worthy focus, as isolation is dangerous, and widespread among elders whose independence is declining. Elderly suicide is a continuing risk for despondent and isolated elders who may live alone, or without social enrichment.
If your parent, client, or someone you care about is in fragile health and seems to be steadily declining physically or mentally, be cautious about recommending or choosing an assisted living facility over a nursing home (also known as a skilled nursing facility, or SNF). No one chooses a nursing home first. Nursing homes are more like hospitals, which they must be to deliver skilled care to frail seniors. The atmosphere can never be like home. Some try their best to create a comfortable living environment for those who do not have a choice. However, they must accept the sickest “custodial care” elders, and those who need attending around the clock. If your aging parent, client or loved one needs nursing care, and must be watched day and night, or you believe that he or she is likely to need such supervision in the near future, a nursing home, (SNF) is the only reasonable choice in types of facility.
Assisted living facilities are not licensed by Medicare or Medicaid to give skilled care. Some have a separate skilled nursing facility on-site or nearby, but it will have its own license to deliver skilled nursing care. That license does not apply to the assisted living component, even the two facilities are located on the same campus or are operated by the same parent company. The decision to move an elderly resident from the assisted living portion of a larger facility to its skilled nursing unit is usually made by the facility administration, leaving the elder who doesn't want to go there, with no choice in the matter. Typically, liability concerns and the need for 24 hour care are the considerations driving the choice. The point though, is to consider that an assisted living facility without a skilled nursing home component is not a wise choice for an elder whose physical health is clearly declining rapidly. For those elders, the move out of assisted living is inevitable, and may come sooner than anyone wants to face.
Medical and Nursing Care Not Required
Many assisted living facilities do not have any licensed nurse on staff, and may have no nurse connected to them at all. Because they are considered nonmedical facilities, having a licensed nurse is not required by law. Even if a nurse is employed by the assisted living facility, the nurse cannot give hands-on care in the form of dressing a wound, administering around-the-clock insulin, administering oxygen, or other tasks that are defined by the federal and state governments as “skilled nursing care.” A nurse in an assisted living facility can supervise and train the direct caregivers, who may or may not be certified by the state as nursing assistants. A nurse in such a facility may supervise a “wellness program,” give advice, or check vital signs, but cannot administer the kind of care nurses typically administer in a licensed hospital, SNF, or other setting. If your elder has a cardiac arrest in an assisted living facility, the nurse on staff will have to call 911, just as you would at home.
Skilled nursing care may only be administered within a facility that is licensed to do so. A SNF may have a different business name by which a consumer finds it, such as “extended care” or “long-term care.” Medicare and Medicaid designate these homes as skilled nursing facilities. Because skilled nursing facilities which are licensed to do so bill Medicare and/or Medicaid for this type of patient care, they must comply with many complex legal regulations and requirements which do not affect assisted living facilities. Some of these regulations affecting Medicaid vary by state, but all SNF's are required to have both medical supervision by a licensed physician, and skilled nursing care delivered by licensed nurses.
By contrast, assisted living facilities are usually regulated by the state Departments of Social Services, not the federal and states' Departments of Health (Center For Medicare and Medicaid Services, or CMS), which regulate nursing homes. Assisted living facilities do not have the same safety or administrative mandates as SNF's, and they are prohibited from giving care they are not licensed to give.
Limitations to Specialized Care Waivers
There are exceptions to some of the federal and state government's licensing requirements. For example, a licensed assisted living facility may take care of residents with dementias, including Alzheimer's disease, if it has a waiver to accept this kind of resident. The facility must also have certain protections, such as special doors in place to prevent wandering and injury to its demented residents. However, it is still prohibited from restraining a demented resident who has a tendency to wander. A combative resident cannot be restrained with the same kinds of physical restraints permitted in a SNF. Clearly, this presents a safety risk. It is a judgment call to determine if the protections in place at an assisted living facility for demented residents are sufficient to meet the needs of an elder with dementia. There are many other limitations to what an assisted living facility can do, even with waivers. Taking care of residents with dementia can be very unpredictable, and skilled nursing can become necessary as the disease progresses.
When an aging parent has to move out of the family home, or out of a long-term residence of any kind, the move can be difficult, even traumatic. If you are considering assisted living as an option for someone you care about, be sure your focus is on the long run. Carefully consider what he or she will need a year down the road. Moving an elder twice within a short period can be extremely hard on both the elder and the family, so make your decisions, and advise any clients in this situation to make their decision based on the overall picture, not just on what the assisted living facility can do for him or her right now.
As hidden consumers, adult children must be fully aware of the legal limits of assisted living. Assisted living facilities can be wonderful and supportive environments for residents who don't need skilled care. If you are considering assisted living for an aging parent, loved one or client, be sure this kind of place is a match for the elder's needs.
For further information on this subject, see How to Understand the Pros and Cons of Assisted Living, and How to Choose a Nursing Home, available as separate volumes of The Boomer's Guide to Aging Parents, ©2009, by Carolyn L. Rosenblatt, R. N., B.S.N., Attorney at Law, AgingParents.com.
Ms. Rosenblatt is a registered nurse, who practiced nursing for 10 years, working mostly with elders, before becoming a lawyer. She has practiced law for 30 years, as an advocate for individual rights. In 2005, she and her psychologist husband, Dr. Mikol Davis, founded AgingParents.com, a consulting and mediation service for families with aging loved ones. Dr. Davis’s practice of 35 years has focused on anxiety and depression. Together, they form a team to assist with legal, health care and mental health aspects of aging. Ms. Rosenblatt is the author of The Boomer’s Guide to Aging Parents, available at AgingParents.com.