Assisted Living: What’s the Difference Between Assisted Living and Nursing Homes?

By D’Lisa Simmons and Skip Comsia

Mom is 72 years old, educated with a bachelor’s degree in Nursing, and worked most of her adult life. Looking forward to her golden years with her husband and traveling to various parts of the world to visit her children, grandchildren, and friends, Mom’s plans were curtailed immediately as her husband died at 67 years of age of a massive heart attack. Two years later she was diagnosed with dementia and Alzheimer’s disease. Sonny, her only living son, noticed Mom’s behavior becoming more erratic and her mental status more forgetful, but attributed it to “old age” initially. Determined to allow Mom to live independently as long as possible, Sonny visited Mom every week at her home 60 miles away.
Over a two year period, Sonny assumed more and more of Mom’s personal obligations, including utilizing Mom’s Durable Power of Attorney so that he could pay her bills and her Medical Power of Attorney to order her medications and communicate directly with her doctors. On several occasions, Sonny noticed garbage piling up in the garage, and on closer inspection, found dividend checks, uncashed, at the top of the trash heap. He also found unopened mail-order merchandise and mail-order boxes and envelopes with frivolous merchandise stashed in unused closets, under beds, and in the trash heaps in the garage. The crisis stage came when the local police department called to advise him that Mom had sent three wire transfers during the same week in amounts of $5,000, $7,500, and $9,000 to a dubious non-profit organization located in Canada. Although Mom was still in fairly good physical condition, her mental status had deteriorated so much that she was at risk to herself and others as she continued to insist on driving. What was Sonny to do, since he did not want to put Mom in a nursing home?

An Aging Population Bubble is a Growing Concern for All
As our population ages with the Baby Boomers entering their golden years, we are faced with the growing concern of how to care for our loved ones properly. According to the National Center for Health Statistics, the current life span expectancy for Americans is 77.6 years, the highest average age recorded.1 Senior citizens in the United States are 12.4 percent of the total population with the largest population group in the age range of 15- 64 at 67 percent of the population.2 Baby boomers have been targeted with increased marketing such as new business opportunities, increased health care and end stage of life issues, which now confront our aging population. A critical component in analyzing the latter is determining the type of care necessary or desired in order to give the aging family member a sense of dignity, while providing respite to supporting family and friends.

Assisted Living
For many families, assisted living facilities offer an alternative care and support network for an aging relative. In many instances, the aging relative may require additional care, but not the full nursing facilities provided at a nursing home. Facilities providing residential care for four or more residents must be licensed with the State of Texas.3
A facility that administers medications to its residents must have properly licensed or certified health care professionals authorized to administer health care on staff and available to the residents. Health care professionals include physicians, registered nurses, licensed vocational nurses, licensed dieticians, physical therapists, and occupational therapists.4 An assisted living facility provides assistance with activities of daily living, such as assistance with bathing and personal grooming, medication monitoring and dispensing, meal service, movement and transport as necessary; further, these facilities provide secure homes for residents with dementia.5 Many Alzheimer’s facilities have been built with special consideration for their residents, including color-coded rooms, spaces on the outside of the room for a family photo to help orientate the resident, locked facilities to prevent wandering, and staff specially trained to deal with “sun downers” who sleep most of the day and are active or agitated most of the night.
Enough emphasis cannot be placed on the need to visit an assisted living location personally prior to admission of the resident to check for appropriateness of the facility in terms of the care the resident needs. Some facilities segregate the resident population depending on the level of care required by the residents, which helps in organizing staffing where most needed. Further, the segregation of the residents provides family members with some assurance that their loved one will not be ignored or neglected as the staff tends to more needy residents. An additional benefit of segregating residents lies in the fact that those residents who are still able to engage in daily life activities are less likely to suffer from severe depression, which is often found when the resident population is mixed.
In many instances, assisted living care may be a good alternative, and a less expensive alternative, to full blown nursing home care. Unfortunately, unless the resident has a long term care insurance policy, most assisted living fees are paid out of pocket. If a long term care insurance policy is available, one should carefully review the policy restrictions, as some policies will cover assisted living expenses, but only in two year intervals, which requires a move out of the facility for a determined length of time while the new coverage period is confirmed and begins. There are instances in which Medicaid may be accessed through the State of Texas to pay for assisted living fees if the resident is enrolled in the STAR PLUS program in Harris County or in the Community Based Alternative (CBA) program if the resident lives in other Texas counties An additional source of funding through the State of Texas includes the state-sponsored Residential Care Program. In addition, another potential funding source is the Veteran’s Administration, assuming the resident qualifies under the VA program and for assistance under the Aide and Attendance program.
In the scenario outlined at the beginning of this article, Sonny must take a very critical look at Mom’s financial well-being, assets, and any long term care insurance coverage available. The Houston Forum Senior Guide Book, which is available at many Walgreen’s stores, provides information annually, free of charge, on assisted living facilities, day care programs, nursing homes, and governmental assistance.

Checklist for Interview by Family Member
For Assisted Living Facility

Use your eyes, nose, and ears first.
Look at the residents of the facility:

• Are they dressed appropriately, appear clean, and well nourished?
• Are staff interacting with the residents?

Look at the facility’s surroundings:

• Is the furniture sturdy and in good condition?
• Are there tears and snags in the carpets which may contribute to a fall?
• Are the floors highly polished, which may contribute to a fall?
• Are there dustballs in the corners and visible under furniture?
• Is paint chipped excessively?
• Are there excessive marks and holes in the walls?
• Is there an automatic door opener for residents using wheelchairs and walkers?
• Are there excessive visible water spots on the ceiling? Active leaks?
• Do the residents appear to be appropriately segregated?
• What markers/colors/photographs are on the doors to designate a resident’s room?
• Where are the laundry facilities and how is residents’ clothing separated?
• How is human waste handled (adult diapers and catheter care)?
• Look for fire extinguishers placed in convenient locations.

Use your nose:

• Does the facility have an odor of stale urine or feces?
• Do residents smell unclean and unbathed?
• Go at mealtime and note whether the food is aromatic, sufficient, and appetizing.
• Is there a moldy or musty odor?
• Do the rooms smell clean, or is there an overriding odor of cleaning products to mask unclean and unsanitary conditions?

Listen to what is happening around you:

• Note how long it takes for a staff member to answer the telephone.
• Note how long a resident’s call button rings.
• Note how the staff interacts and communicates with one another.
• Listen to how the staff communicates with the residents.

Clarify services provided, in writing.
Cleaning:

• Ask how the laundry services are provided and where the facilities are located.
• Ask how often the residents’ rooms are cleaned, and the extent of the housekeeping provided.

Personal Grooming:

• Ask how often bathing services are provided, and how this is documented with the staff.
• Ask if on-site beauty parlor services are provided, and if so, at what cost, and then visit the facility.
• Ask if diaper service is provided and if there is any additional charge, or whether the family members are responsible for providing this item.

Meals and Dietary Needs:

• Ask what assistance is provided with meals and whether staff is available to assist with feeding.
• Ask whether dietary supplements (i.e., nutritional drinks such as Ensure or electrolyte drinks such as Gatorade) are part of the meal plan offered.
• Ask how many residents prefer to eat meals in the rooms. Some facilities try to continue care of permanently bed-ridden residents when that resident should be in a nursing home.
• How are dietary restrictions enforced?
• Look at the menu and note whether fresh fruits and vegetables are provided, or whether it appears that mostly processed food is being served.
• Would you eat the meals being offered?

Activities:

• Ask about supervised activities and personally inspect the mode of transportation if a facility van is available.
• Ask whether assistance is provided getting in and out of wheelchairs and other movement aids.
• Is there an area where the residents can enjoy the outdoors?
• Is the smoking area outside and away from doors, where non-smoking residents might congregate, or otherwise in an inconvenient location?

Medications and Healthcare:

• Ask how medications are segregated, monitored, and dispensed to the residents.
• Ask whether arrangements have been made for periodic visits by outside healthcare providers and how these services are billed (i.e.: quarterly visits by a doctor, podiatrist, eye specialist, hearing aid specialist, physical therapists, massage therapists, and the like)
• How are residents segregated, if at all, based on the level of care needed? Be wary of the facilities which keep all residents together, as severely demented residents require extra care and may take the staff’s attention away from your family member’s needs. Also, a resident who is not severely demented is more likely to become depressed when living directly with severely demented residents.
• Is a monthly weigh-in of residents required, and will you be notified if there is a weight gain or loss of more than 3 pounds? Weight loss may signify a deteriorating condition of your loved one, poor diet, unappetizing food choices, or insufficient meal portions.

Staffing Issues:

• Ask about the experience and qualifications of the administrator of the facility.
• What is the frequency of staff meetings?
• How often is staff training provided?
• Who has access to resident files and confidentiality of the residents’ information?
• Are background checks required for employees? How are criminal checks conducted?
• What is the transportation policy? Are transportation and assistance provided for residents to go to nearby healthcare providers?

Emergency Preparedness:

• What is the emergency evacuation plan?
• Where is the nearest hospital?
• Does the facility have a back-up generator on site, in the event of power failure? Does it provide enough power for the needs of the facility, including air conditioning for several days?
• What are the plans for meal service in the event power is cut and access to fresh groceries is not available, such as in the aftermath of a hurricane?

Check other Sources:

• Chat with the family members of other residents and find out what they like best and least about the facility and how long their loved one has been there.
• Check the Better Business Bureau for a rating of the facility and whether any complaints have been filed.
• Check with the Department of Human Services about any complaints filed with the facility within the past three years.
• Ask to see the review of health department visits, and pay particular attention to repeated notices of the same violations and whether the agency has ever recommended fines or revocation of license.

At first blush these may not appear to be substantively legal issues. Current elder and health law practitioners are more often finding clients that need advice regarding assisted living options. We hope this article and the checklists help you provide a more complete picture of the options available to your clients and family.

D’Lisa Simmons works of counsel to The Shanks Law Firm. She is a trial attorney, focusing on probate and business litigation matters in state and federal courts. Simmons is a 1990 graduate of South Texas College of Law and was a Rotary Ambassadorial Scholar to the University of Singapore.

Skip Comsia is a licensed Texas real estate broker and a certified property manager. Additionally, he is a founding member and is the current chair of the Texas Assisted Living Association and the current treasurer of the Assisted Living Federation of America, both organizations representing the assisted living industry and its professionals.

Endnotes
1. See http://www.cdc.gov/nchs/fastats/lifexpec.htm. 2. See http://geography.about.com/library/cia/blcusa.htm. 3. TEX. HEALTH & SAFETY CODE ANN., §§ 247.002, 247.021 (West 2001 & Supp. 2004-05). 4. Tex. Health & Safety Code Ann., § 247.067 (West 2001). 5. Tex. Health & Safety Code Ann., §§247.0011, 247.002, 247.026, 247.029 (West 2001).

Text is punctuated without italics.

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