with a care giver.
It’s a thin, fuzzy line, and it barely distinguishes nursing homes from assisted living facilities.
But state officials are at work trying to craft legislation that they hope will clarify those distinctions.
One key proposal will try to redefine the term “resident.” Another measure would, for the first time, allow assisted-living residents to temporarily receive skilled nursing care at the facility.
The proposed changes – brought forth by a working group of the state’s Long Term Care Coordinating Council – are a response to the changing nature of the assisted-living industry, which has exploded in Rhode Island and nationally over the past decade.
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The state now has 69 assisted-living facilities with 3,296 licensed beds – up from 35 facilities with 716 beds in 1991.
Critics charge some of that growth has been fueled by the industry’s expansion into what traditionally has been the nursing home industry’s turf: providing medical care or high-level personal care. Under Rhode Island law, assisted-living facilities aren’t licensed to provide medical services.
“A lot of these assisted-living centers are getting to look an awful lot like nursing homes,” said Roberta Hawkins, executive director of the Alliance for Better Long Term Care, an advocacy group here in Rhode Island.
As residents age, often their medical needs or required level of supervision spill over into the realm of skilled nursing, which would require transition to a nursing home. But the process of determining when a resident has crossed that line is murky – and it’s a question plaguing regulators and lawmakers nationwide.
One problem is residents want to stay put, and families often resist moving their loved ones from assisted living centers to nursing homes.
“People don’t want to hear that Mom needs to go into a nursing home,” said Rep. Peter T. Ginaitt, a Warwick Democrat who said he will sponsor the legislation now being fashioned by the working group.
But often there is reluctance on the part of the facility too, which is faced with losing a customer who is paying good money to stay there. The assisted-living industry expounds the theory of “aging in place,” arguing that pulling someone out of his or her home and into a different facility is an unnecessary, traumatic upheaval.
“A lot of these facilities will try to hang on to that resident for as long as they can, even when they require higher levels of care,” said Wayne I. Farrington, chief of the Department of Health’s division of facilities regulation. He says some assisted-living centers have become “de-facto health-care facilities.”
Hawkins said some of those facilities don’t have the staff to provide the near-constant supervision that some residents – such as late-stage Alzheimer’s patients – need. And assisted-living staffers sometimes are forced to provide services they aren’t qualified to give, such as administering feeding tubes or IVs, she said.
But Farrington said the majority of facilities are able to safely provide higher levels of care.
“We’re not saying they’re all providing bad care,” he said. “But the care they’re providing is above that for which they’re licensed.”
The proposed legislation attempts to clarify that line between assisted-living residents and nursing home patients. One key provision would attempt to quantify how much help residents need with their six “activities of daily living,” or ADLs, which include dressing, eating, bathing, continence, going to the bathroom and “transferring,” or getting from a bed to a chair, for example.
The draft legislation says that assisted-living residents can have a maximum of three ADLs that they require “extensive assistance” with. Anything more would require them to go into a nursing home.
“A clear definition is very important, because some of these people in assisted living facilities are so disoriented and need more supervision and staff time than most assisted living centers provide,” Hawkins said.
Another key measure would allow residents to receive skilled nursing care at the facility for up to 30 days. If they required skilled care longer than that, they would have to be moved into a home. Currently state regulations prohibit assisted living facilities from offering any skilled care.
But the prospect of giving assisted-living centers the latitude to provide higher levels of care has drawn the ire of the nursing-home industry, a sector that already is staggering financially.
“We need to draw a line in the sand,” said Orlando Bisbano Jr., president of the Rhode Island Health Care Association, a trade group for the state’s nursing homes. “At some point the state has the responsibility to step in and say ‘even though you want to stay in that (assisted-living center), we’re telling you that you cannot.’”
Bisbano said he thinks someone who needs “extensive assistance” with three ADLs should be in a nursing home. The association also wants the legislation to limit the number of days to 14 that a resident can receive skilled nursing care at an assisted-living facility.
A few assisted-living facilities were granted special permission by the state in recent years to add nursing-home beds, bypassing a moratorium on new nursing-home beds. For those facilities, transitioning a resident into nursing care is relatively easy.
“When a resident gets beyond the level of service we’re allowed to provide under our assisted-living license, we move them out of their apartment and into a nursing bed,” said Peter Sangermano, who owns Village at Waterman Lake in Greenville, as well as other assisted living facilities in the state.
While that model seems to make sense, Farrington said state regulations – most notably the moratorium on nursing home beds – present a barrier to such arrangements.
“I think ultimately what we want is an unfettered market, where everyone can compete in the same game, rather than keeping these services in separate cubby holes,” Farrington said.
Whatever assisted-living legislation emerges, there are doubts about whether the DOH will have the resources to enforce any new regulations.
When the original legislation regulating assisted-living facilities was passed more than 20 years ago, the legislature envisioned the DOH dedicating four full-time staffers to provide regulatory oversight, earmarking about $400,000 for regulation.
Twenty years later – after the industry’s exponential growth – the DOH has less than two full-time employees assigned to inspect 71 assisted living centers, at a annual cost of about $150,000. Meanwhile, about 20 DOH staffers regulate the state’s 101 nursing homes.
Farrington said the facilities-regulation division would be hard-pressed to increase regulation of assisted-living centers, given its limited resources.
“You can only go back to the well so many times,” he said.
Maureen Maigret, director of policy for Lt. Gov. Charles J. Fogarty’s office and executive director of the Long Term Care Coordinating Council, said the group will advise the legislature to earmark funding for at least one additional full-time employee to regulate assisted living facilities.
Maigret said other proposals include:
• Establishment of three distinct levels of assisted living: basic care, for people who require minimal help with their personal care; “enhanced personal care,” for more-dependent residents; and a “dementia care” level, for residents with Alzheimer’s disease or other forms of dementia.
• Training requirements for assisted-living staff who work with dementia-care residents. Direct-care workers would need 12 hours of initial training and 12 hours of continuing training every year.
• Requiring all facilities to devise quality-assurance programs.
• Criminal-background checks on all staff members, including a check of all administrators by the DOH.
