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The Michigan Long Term Care Companion
Chapter 14 Assisted Living Facilities Rachel Simon has little trouble understanding the stress, fear and sorrow of watching over someone afflicted with dementia. Rachel’s grandmother, Wilma Jackovic, has been diagnosed in early stages of Alzheimer’s Disease. Far-flung jobs and a widely scattered family have left Rachel with the primary responsibility to look after Wilma. Rachel is considering bringing Wilma into her own home, but Rachel’s husband strongly opposes this, saying they have their own small children and jobs to contend with. And it is true. But Wilma’s panicked phone calls are coming more often. At least twice a week now, Rachel finds herself trying to calm her late-at-night, because Wilma cannot recognize her own home or find her long-deceased husband. Trying to stay awake at her office after a rough night with Wilma, Rachel asks herself,
Isn’t there some safe place to live other than a nursing home? Some place more like home, where residents’ dignity, privacy and choices are respected. Rachel Simon’s question is on the mind of many people looking for long term care outside of their own homes. Assisted living operators say they have the answer for people like Wilma Jackovic, and adults with other disabilities who cannot live safely or securely at home. Assisted living is a general marketing term that describes a broad combination of housing, support services and health care. The services, accommodations, quality and costs vary widely. For example, some places offer very modest services while others provide extensive care comparable to that found at better nursing homes. In Michigan, most assisted living facilities are licensed by the state as adult foster care homes or homes for the aged. Some assisted living facilities, however, operate without any kind of license or government oversight. Assisted living facilities are one of America’s fastest growing industries because many consumers are embracing their non-institutional accommodations, flexible services, increased autonomy and enhanced privacy. Their physical accommodations are very diverse, ranging from converted houses and apartment complexes to specially designed communal residences. Michigan has several thousand assisted living facilities. Responsible and caring assisted living facilities are certainly meeting a growing consumer demand for non-institutional care... But labeling a facility as “assisted living” does not guarantee the quality of life or individualized support operators advertise. Recognizing our fundamental mistrust of nursing homes, assisted living operators have promoted an image designed to capture our hearts: autonomy, privacy, personal choice, companionship, and individualized care in a pleasant setting at an affordable price. If this sounds too good to be true, consider that businesses don’t always let facts get in the way of their attempt to cultivate a favorable brand image. Responsible and caring assisted living facilities are certainly meeting a growing consumer demand for non-institutional care. Creative and capable operators are demonstrating that it is possible to deliver quality services to vulnerable people in homelike places. But labeling a facility as “assisted living” does not guarantee the quality of life or individualized support operators advertise. Some operators offer little more than unrealistic promises and untrained staff. There is a growing number of unlicensed facilities. Prices are sometimes as expensive as nursing homes. Little financial support is available from government or other sources. Look beyond the promotions and the promises and examine assisted living options as carefully as you would any other long term care service. The Customers According to industry sources, a typical assisted living resident is female, 84 years old, and needs help with three activities of daily living, such as bathing, continence and mobility. If this description sounds like an average nursing home resident, it is no coincidence. Despite assisted living provider efforts to shed a nursing home image, many operators market their services to people who would otherwise seek nursing home care. Keep this in mind as you evaluate facilities. A pleasant setting is important but it cannot compensate for inattentive care. Assisted living facilities are not necessarily more effective at delivering personal services or nursing care than nursing homes. In some cases, the opposite is true. The more private living accommodations in some assisted living facilities may limit routine observation by caregivers and hinder timely help. Make sure that offered services are available and match your needs. Licensed Facilities: Homes for the Aged and Adult Foster Care Homes Michigan has two types of licensed assisted living facilities: homes for the aged and adult foster care homes. These are specific legal names created by Michigan law. Some licensed facilities use these legal titles in their names while others do not, sometimes using assisted living or some other marketing term. Some homes for the aged and adult foster care homes do not view themselves as assisted living residences. The varying use of legal and marketing terms often makes it hard to distinguish whether a facility is licensed and what type of license it has. How licensed facilities market themselves is far less important than the type of housing and support services they offer. Homes for the aged (HFAs) and adult foster care homes (AFCs) are housing facilities licensed to give personal care and supervision to adults who do not require continuous nursing services. HFAs serve people age 60 or older while AFCs help adults of any age. Because of the broad age-range they serve, AFC residents have very diverse needs. Some AFCs cater to special populations, like people with developmental disabilities, mental illness, dementia, and other chronic illnesses or physical disabilities. Others serve a more general population. HFAs and AFCs have other distinctive characteristics. HFAs are larger facilities, with accommodations for at least 21 residents. Some HFAs house hundreds of residents. Many HFAs are affiliated with nursing homes, and sometimes are on the same campus or part of the same building. Many older HFAs are run by non-profit organizations, such as church groups, while more of the newer facilities are owned by private, for-profit companies. There are about 150 homes for the aged in Michigan. Rights of Home for the Aged and Adult Foster Care Home Residents As a resident of a Michigan home for the aged or adult foster care home, you have the right to:
In contrast, most AFCs are very small, often operating in houses converted for group living. Most AFCs are privately owned and operated. Michigan has over 4,700 licensed AFCs, each housing from 1-20 residents. There are four types of AFC homes:
Although private rooms are available in some AFCs and HFAs, shared rooms are more common. Services vary greatly. All AFCs and HFAs offer room and meals and some help with personal needs or supervision. Residents may be assisted with medications, bathing, toileting, eating, dressing, grooming and mobility. Some facilities offer little help, forcing residents to leave when their needs increase. Others offer a wide range of help, adjusting services as residents’ needs and abilities grow or decrease. Determine what services are available and to what degree they are offered. AFCs and HFAs are generally allowed to limit the services they offer, so if your needs surpass these limits, you may have to leave. Find out in advance exactly what types and amount of care the facility will deliver. Ask for this information in writing. If you sign an admission agreement or contract, make sure any details you have negotiated are included. Ask for a copy and keep it with your records. HFA and AFC residents on Medicare and Medicaid are eligible for home health services and durable medical equipment covered by these programs, just as if they lived in their own homes. Check with the facility to see if it will help facilitate the delivery of these services if or when needed. Both types of facilities are licensed by the Michigan Department of Consumer and Industry Services. Michigan standards govern their operations and give important rights to residents. AFC standards are more modern than the decades-old HFA rules, which primarily focus on building safety rather than on resident care. HFAs are supposed to be inspected annually, while AFCs must be inspected every other year. In practice, these schedules are not always met because of a shortage of state inspectors. State standards restricting the role of AFCs and HFAs to personal care and supervision are sometimes ignored. By law, people needing ongoing, daily nursing care are not supposed to live in these facilities. In practice, regulators tend to look the other way if residents’ needs are being met. Residents usually prefer this approach as it allows them to stay in their residence. In other instances, lax regulation is not so beneficial. For example, some residents are allowed to remain in facilities that do not meet their needs. Unlicensed Assisted Living Facilities – Buyer Beware A growing number of assisted living facilities are taking advantage of regulatory loopholes to operate without a license. If a facility lacks a license, it means that no government office monitors its care and services. While a license is no guarantee of quality, lack of a license suggests that the operator may be unwilling or unable to meet public standards. To circumvent licensure laws, some unlicensed assisted living facilities operate their housing and personal care services through separate businesses. These businesses may be owned by the same parent company. Operators claim that the facility is the home of the residents and that a license is not required for residents to receive services from an independent company in their own homes. This legal fiction seems to serve operators’ needs, but strips consumers of the protections provided by AFC or HFA licensing standards. Unlicensed assisted living facilities often rely on the appeal of their attractive buildings and accommodations. They are more likely to be run in apartment-style complexes or similar settings offering private accommodations. While privacy is indeed very important, it is the largely the need for services, not privacy, that leads people to examine assisted living options. Make sure that the services, as well as the accommodations, are first-rate. Don’t assume that a facility is licensed. A facility’s name and reputation offer little insight on its licensure status. Check with your local ombudsman office (see appendix 1) to verify whether an assisted living facility is licensed as a home for the aged or adult foster care home. Or you can check its licensing status by calling the Michigan Department of Consumer and Industry Services at: (517) 334-8408 for homes for the aged, and (517) 373-8580 for adult foster care homes. Ask operators of unlicensed facilities why they don’t have a license. Find out how facility management evaluates the quality of its services and ask to see copies of written performance reports. If you don’t receive good answers and information, shop elsewhere. Facilities caring for vulnerable adults should expect some public monitoring and accountability. Consider whether positive features of an unlicensed facility are offset by the absence of any public monitoring of its services. If you select an unlicensed facility, you are putting your trust in the operator, in market-place pressures, and the terms of your admission contract to address any concerns you may experience. Locating Assisted Living Facilities in Your Area Your long term care ombudsman (see appendix 1) and area agency on aging (see appendix 2) offices are good places to get lists of licensed assisted living facilities in your community. Adult service workers with the Family Independence Agency can provide lists of local adult foster care homes. Other places to check include hospital discharge planning departments, local aging-related offices such as councils on aging, and community organizations like Alzheimer Association chapters (see appendix 3). Or check the yellow pages of your local telephone directory. Many AFCs serve specialized populations. When you request AFC listings, ask the source to identify homes that serve people with your needs. This specific information can spare you from checking out inappropriate facilities. Ask agencies you contact for recommendations. No organization rates assisted living facilities, but knowledgeable staff at some organizations will offer an opinion if you ask. Evaluating Facilities Three very important issues to examine are the quality of the staff, the availability of needed services, and their adaptability to your future needs. Conduct your own evaluation by visiting facilities you are considering. Your observations and impressions are your best guide to selecting a quality facility. Use the checklist included in this chapter as you evaluate facilities. Visit several facilities if at all possible. Assisted living facilities are quite diverse, so you may see very different models of operation. You will learn about various features and costs, and improve your ability to ask informed questions. At adult foster care homes and homes for the aged, ask to see a copy of their most recent inspection report. You can also obtain copies of HFA inspection reports at your long term care ombudsman office. Information on getting AFC and HFA inspection reports directly from the state is given at the end of this chapter. During your visits, talk to residents and visitors to see if they are satisfied with the accommodations and services. Observe meals, activities, and socialization among residents. Is this a place you or your relative would feel comfortable living at? If you visit during a weekday, ask about routines and services at night and on the weekends. Some issues are easier to judge than others. Most people are comfortable assessing the quality of the physical accommodations. Do this, but don’t stop there. Three very important issues to examine are the quality of the staff, the availability of needed services, and their adaptability to your future needs. Quality of the Staff Services are only as good as the people who deliver them. As you examine facilities, you must decide whether care is being delivered by competent people you trust. If medications are ordered, do staff have the skills to administer them properly and monitor for possible side effects? Think back to Wilma Jackovic. Who will be there to comfort her during the middle of the night during a panic attack? What training has this person and others on staff received on dementia care? Does the facility provide programs and services that engage residents and help limit disruptive or disturbing behaviors? Are good health services available to diagnose Wilma’s medical symptoms and provide needed treatment? If medications are ordered, do staff have the skills to administer them properly and monitor for possible side effects? Does the staff have any professional credentials? Are there nurses, social workers, or therapists? If so, what are their roles and when are they available? Who directs the work of the unlicensed staff members? Assisted living facilities rely mostly on unlicensed staff to provide most of the care. This is true regardless of whether the facility itself is licensed. Unlicensed staff members can give good care, but it is very important that they have strong training, sufficient support and qualified supervision. Ask for details. Find out if the training is specific to the needs of its residents. When visiting assisted living facilities, ask or observe: Is the inspection report and license from the Michigan Department of Consumer and Industry Services available for review? Are there house rules? Read them carefully. Are residents encouraged to exercise their rights? How large is the staff? How many staff members are on duty during different shifts? Different days? How many residents per staff member? What are the staff qualifications? What training have they received? Do staff members seem to care about the residents? Who plans activities for residents? Ask to see an activity schedule. Do residents seem friendly? Do they share any common interests with you? Common needs? Is the common living area used for entertaining visitors, watching TV, etc.? Do you like it? Is help with personal care, such as bathing and dressing, available? Are there extra charges for these services? Who delivers them? If your needs increase, will you be able to stay? Is help available? If you need a special diet, is it available? Do the meals look appetizing? Do residents dine together? Do they socialize during meals? Are residents’ rooms clean and pleasant? Are personal furnishings allowed? Is there adequate room for clothing and other personal possessions? Where do residents keep their valuables? Will you have to share a room? Who will be your roommate? Is privacy adequate? Are heating, cooling and lighting adequate for your needs? Is the building barrier-free? Is transportation available to shopping and services? Is there an extra charge for transportation? Do residents have kitchen privileges? Is there a yard for your use? Are pets allowed? Do telephones, televisions and radios have attachments for the hearing impaired if you need them? Some assisted living facilities use separate home care agencies to deliver some or all of the needed care. If so, find out if an agency being used in this way is certified by Medicare and Medicaid. Michigan does not license home care companies, but Medicare and Medicaid set standards for approved home health agencies. Ask why the particular agency was selected and seek information about the qualifications and availability of its staff. What are the costs of its services? How are they billed? Staff Size The number of staff is also important. Is there a sufficient staff around-the-clock, seven days a week to deliver care? What is the ratio of staff to residents for each shift? Does this seem sufficient given the care needs of residents you have observed? Does the facility have an effective system for replacing absent staff with qualified replacements? Do Services Match Residents’ Needs? Consider this question broadly at first. You must be concerned not only with your own needs, but those of other residents. Even if your needs are slight and easily met for now, you won’t be content in a place where other residents’ needs are neglected. As to your own needs, identify them precisely and ask what services will be available to meet them. Determine if there is a specific process for evaluating your needs and your right to participate in it. Find out what services will be offered to you, when, how often, by whom, and at what cost. Most assisted living facilities are not comprehensive care settings. Facilities generally accept only limited responsibility to meet your needs. Mindful of this fact, many assisted living facilities use their admission contracts to shift some responsibility and liability to you, the customer. In theory, this practice is supposed to show respect for your autonomy and self-determination. The assumption being made is that, by selecting assisted living rather than a nursing home, you are trading some degree of safety for greater privacy and independence. While this may be true, consumers are at a distinct disadvantage when decisions about choice, responsibility and liability are made.
Two industry created concepts, negotiated risk and bounded choice, are often used to define your choices and limit facility responsibility and liability. Negotiated risk is a practice of contractually establishing the care duties and limits of the home. This practice places some liability on the resident for injuries or loss of quality of life suffered because, as the reasoning goes, the resident chose to live in an environment that did not guarantee full care and protection in all circumstances. Bounded choice refers to the industry practice of creating care options and daily resident activities within prescribed limits set by the operator. Residents are given some choices about their care and lifestyle, but only within the boundaries set by the operator. As facility-drafted contracts are used to establish these agreements, residents are at a bargaining disadvantage. Is Wilma Jackovic likely to negotiate favorable terms for herself in this process? Or her granddaughter, Rachel Simon, without able legal counsel? These practices point out the importance of the admission agreement or contract you will be asked to sign. Read it carefully, ask questions about provisions that are not clear, and have any clarifications put in writing. If you disagree with a particular provision, ask that it be changed. If the contract is inconsistent with promises the facility is making to you, request that the contract be changed to reflect those commitments. Both sides should initial any changes that are made in the contract. Seek legal help if you need it. Meeting Future Needs One of the few certainties in life is that things change. If you are an older adult looking for long term care outside of your own home, you know that your needs and abilities have already changed. Plan for them to change some more. As you evaluate assisted living as an option, consider whether a facility is willing and able to adapt to your changing needs. Some assisted living facilities subscribe to a philosophy called aging in place. These facilities allow residents to stay even as their needs increase with age. This humane practice offers security and peace of mind to older people and their families who dread the thought of moving during the midst of late-life illnesses. Some assisted living facilities subscribe to a philosophy called aging in place. These facilities allow residents to stay even as their needs increase with age. There are, however, certain precautions to be aware of regarding aging in place. First, it only works if the needed services are readily available and provided in a dignified manner. Second, not all assisted living residents are comfortable living with others who are seriously impaired. Third, some facilities only partially subscribe to this philosophy. There may be practical or policy limits that prevent some residents from staying in certain circumstances. Ask facilities about their philosophy on aging in place. Does it meet your own desires and expectations? Talk with residents and visitors to find out how this practice is working. Is the facility honoring its commitments? Are there any limitations to these commitments? The admission contract describes the facility’s commitments to you. Make sure that it contains any agreements you have reached regarding your right to stay at the facility and receive any services you may need. If the facility does not honor commitments made in this agreement, you may be able to seek court action to enforce your rights. If the facility is licensed as a home for the aged or adult foster care home, you can seek enforcement of these agreements by filing a complaint with the Michigan Department of Consumer and Industry Services. Complaint procedures are described at the end of this chapter. Paying for Assisted Living Assisted living costs vary widely, ranging from about $1,000 to several thousand dollars per month. Most people pay assisted living costs from their own income and savings, as government coverage is very limited and few people have private health insurance covering it. Try to find a facility that you can afford. If you are paying out-of-pocket, you will likely be able to stay only as long as your money holds out. Determine how long you can afford to stay at the facility, factoring in likely future price increases. Consider where you might go if you had to leave the assisted living facility due to lack of funds. Your other options, including nursing homes, may be limited if you are out of money and must rely on Medicaid to help pay for your care. Many assisted living facilities charge extra for certain services. Seek detailed information about prices and billing procedures. Ask the operator: What exactly is included in the monthly rate? What gets charged as an extra? Is a deposit required? Under what circumstances, if any, is it refunded? What is the policy on rate increases? Are there other occasions for refunds, such as moving out before the end of the month? How much notice is required before moving out? If you find the facility to be unsatisfactory after a few days, can your money be refunded? Does anyone else have to sign the admission agreement on your behalf? If so, does this person become responsible for paying for your stay out of his or her funds? Read the admission agreement carefully. Make sure the information in it agrees with the answers to your questions. If not, ask the operator to make changes in the agreement. You and the operator should initial the changes. Government Assistance with Payment Some government assistance is available for residents of AFCs and HFAs who meet strict eligibility standards. The Michigan Department of Community Health helps pay for AFC or HFA care needed by those who are developmentally disabled, mentally ill or mentally retarded. Information about this assistance can be obtained from your county community mental health agency or from Michigan Protection and Advocacy Services (800/288-5923). The Veterans Administration (VA) provides pension benefits to veterans, their spouses, widows or widowers with limited incomes. Pension benefits are higher for persons needing daily assistance with personal needs. AFC and HFA residents may qualify for these benefits. Information can be obtained from the nearest VA office or call the VA at (800) 827-1000. The Michigan Department of Military Affairs operates two veterans homes, offering what it calls domiciliary care, in Grand Rapids (800/642-4838) and Marquette (800/433-6760). The Michigan Family Independence Agency helps cover some of the costs of AFC or HFA care for very low-income people with temporary disabilities through the State Disability Assistance Program (SDA). Contact your local FIA office for information. Medicare does not help pay for assisted living care, and Medicaid payments are only available to certain low-income residents of AFCs and HFAs. However, while you are in an assisted living facility, Medicare and Medicaid continue to pay for covered medical expenses, such as hospital care and doctor visits. These programs also help pay for skilled home health services you may need during your stay. The Social Security Administration runs an income supplement program for low-income blind, aged and disabled people. This program, Supplemental Security Income (SSI), has special income limits for people living in an AFC or HFA, so you may qualify for help even if you did not while you were living at home. Supplemental Security Income (SSI) To qualify for SSI, you must have less than $2,000 in countable resources. A couple may have up to $3,000 in countable resources. Resources are things you own. They include real estate, personal property, savings and checking accounts, cash, stocks, bonds and other assets than can be used to meet your needs for food, clothing and shelter. Not all resources count toward the SSI limit. Your home, personal and household goods, a car, some life insurance, burial plots and limited burial funds are usually exempt. Your income must also be limited. For SSI, income means earnings, Social Security checks, pensions and other money you receive. SSI income limits depend on your living situation. In Michigan, the 1998 limits are:
If you are married and your spouse also lives in the AFC or HFA, these income limits are doubled. Personal care means help with daily activities such as grooming, medication, laundry, cooking, eating and shopping. If you qualify for SSI in an AFC or HFA, you are paid a monthly check to bring your total income up to the SSI limit. Other income you receive reduces the amount of the SSI payment. However, SSI does not count the first $20 per month you receive from other sources. If the AFC or HFA accepts SSI, your payment to the home is the SSI payment level minus $40 per month you are allowed to keep for your personal needs.
If the AFC or HFA accepts SSI, it cannot charge you more than this amount for its services. It is your responsibility to pay this amount to the AFC or HFA from your income. You have $40 remaining each month to help pay for your personal expenses. AFC and HFA residents with income other than SSI have an additional $20 per month they can keep. Your SSI checks are sent directly to you unless the Social Security Administration appoints someone to act as your representative payee. A representative payee is a person authorized to receive your Social Security and Examples of SSI Payments to AFC and HFA Residents An AFC resident whose only income is $420 monthly from Social Security would receive $251.50 monthly from SSI in 1998 to help pay for care. SSI computes the SSI payment as follows:
An HFA resident whose only income is $500 monthly from Social Security would receive $193.30 monthly from SSI in 1998 to help pay for care. SSI computes the SSI payment as follows:
SSI checks and to use them for your benefit. A relative, friend, the AFC or HFA operator or other person could be appoint
Return to Michigan Long Term Care Companion - Table of Contents Order your own copy of The Michigan Long Term Care Companion! Copyright © 1998 by Citizens for Better Care. All rights reserved. No portion of this book may be reproduced in any form or stored in a retrieval system without permission in writing from the publisher, except short passages for review in print or electronic media. ISBN 1-880697-05-X
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Long
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