Is Florida Setting the Stage for the Future of Assisted Living?

Assisted living leaders are praising a reform bill in Florida that now is headed to the governor’s desk, which could be a model for how to increase oversight and accountability without unduly burdening providers.

However, both supporters and critics of the bill say that it is far from perfect.

The bill, sponsored by Sen. Eleanor Sobel (D-Hollywood) and Rep. Larry Ahern (R-Seminole), sprang from a 2011 investigative series in the Miami Herald, “Neglected to Death,” which looked into events that occurred over a 10-year timespan. Due in part to lax oversight and enforcement from Florida’s Agency for Health Care Administration, some assisted living residents had been harmed and died due to negligence and abuse during that period, the newspaper reported.

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Over the succeeding four years, lawmakers worked with assisted living providers, consumer advocates and others to create the bill that passed the legislature last week.

Provider organizations applauded. The legislation is “innovative,” state and national leaders of the Assisted Living Federation of America tell SHN.

In particular, the reforms expand the types of services that can be provided by assisted living nursing staff. Currently, staff nurses employed by certain AL facilities are limited due to the way regulations developed in the Sunshine State. This can mean that even though they have the clinical training and skills to perform particular tasks, the resident must still call in a home health nurse or go to an outside provider for some care.

Under the new law, AL staff nurses would have more ability to administer medication and treat medical conditions, such as wounds.

“Hopefully, there will be less turnover of staff because they can do what they were trained for,” says Gail Matillo, president and CEO of the Florida chapter of ALFA. “The turnover rate in AL is huge because [workers] want to get to settings where they can keep up with their clinical skills.”

These assisted living locations now could become clinical sites for nursing education programs, Matillo added.

Florida is joining the ranks of “innovative and proactive” states such as California and North Carolina by expanding what assisted living nurses can do, Paul Williams, ALFA’s national vice president of Credentialing & Certification Programs, tells SHN.

In addition to loosening the restrictions on staff, the bill could lead to fewer inspections for some facilities. To this end, it “is an excellent step toward promoting ALF accountability without imposing unnecessary regulatory burdens,” said the Florida Health Care Association, a long-term care provider group, in a written statement.

For instance, the bill gives the Agency for Health Care Administration more flexibility in targeting facilities for inspections.

“For some kinds of assisted living facilities that care for particularly high-needs residents, the state agency no longer has to do inspections as often if the ALF has a history of providing high-quality care,” says Susan Anderson, Florida ALFA’s vice president of public policy. “And the agency also has expanded authority to quickly go into facilities that have serious complaints lodged against them.”

This will enable the state agency to more strategically allocate its resources and free up the best providers to focus more on resident care, says Matillo.

But critics of the bill say the reduction in oversight is unacceptable.

“My biggest issue is that it takes inspectors out of those AL facilities that need to be inspected the most often — the limited nursing service license facilities and the extended congregate care license facilities,” says Brian Lee, executive director of consumer advocacy group Families for Better Care and the former top nursing home ombudsman for Florida. “I’ve been to a number of those types of facilities as the ombudsman and they look, feel, smell and act just like a nursing home. But because they aren’t subject to the inspections and other federal regulations that nursing homes are, the opportunities for problems is greater.”

There have been instances of a facility with a good history on paper developing problems that only are caught when inspectors arrive, Lee tells SHN.

While Lee believes the “compromise bill” should not have been passed, he does see some value in it. For example, he praises the requirement that facilities must have mental health licensure if even one resident has a qualifying diagnosis of mental illness.

ALFA’s Matillo and Williams also say that the mental health requirement is a good step. They also agree with Lee in praising another aspect of the bill: a consumer website with comprehensive information about assisted living facilities. The information will be highly detailed, including survey and violation data, what recreational programs are available, languages spoken by staff, and the organization’s religious affiliation.

“It might be a model for the rest of the nation,” says Matillo.

Still, there remains plenty of work to do in Florida and nationally to ensure that AL residents have access to the best quality care, Matillo and Williams say. With this reform package through the legislature at last, Matillo and her colleagues are focused now on being able to develop more innovative business models and implement telemedicine and other technologies.

And Williams says other states, such as North Carolina, are pushing the envelope even further than Florida on some issues, such as what types of staff members can help administer medication. These more ambitious reforms are achieving increased efficiency, lowered costs and improved outcomes for residents.

“This is a good first step, but the work isn’t done,” Williams says.

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