Heightened Assisted Living Scrutiny Highlights Need For Airtight Operations

The assisted living industry is changing from a hospitality-based model to one incorporating more health care options to allow seniors to age in place. The shift in operational strategy comes as more seniors indicated they prefer assisted living to moving in with family members. The anticipated “silver wave” of baby boomers aging into assisted living will tax demand like few generations before it.

The shift is not without its stumbles. As governments and the public continue to scrutinize lapses in care quality and unfortunate incidents in senior living, assisted living providers face both the specter of more outside regulation and the need to define and follow-through on high operational standards.

The Long Term Care Community Coalition (LTCCC) released a report last month identifying key best practices and policies for assisted living facilities to regulate their own operations, and ensure the safety and dignity of residents. The report lays out guidelines and requirements for staff training including cross training across multiple subject areas, establishing licensing and certification requirements where appropriate, allowing for alternative training methods, and required training assessments, LTCCC Executive Director Richard Mollot told Senior Housing News.

LTCCC’s report is a response to a February report by the Government Accountability Office (GAO) of assisted living communities in 48 states receiving Medicaid assisted living services, which identified over 23,000 “critical incidents” ranging from abuse and neglect to exploitation and death. The report uncovered significant gaps in state agency reporting of critical incidents — 26 of the 48 states observed for the study failed to track and/or report critical incidents — and called for increased guidance to these agencies by the Centers for Medicare & Medicaid Services (CMS).

The numbers from the report may be staggering, but they encompass more than senior assisted living, American Seniors Housing Association Vice President, Government Affairs Jeanne McGlynn Delgado told SHN. The numbers reflect the total number of people receiving assisted living services, regardless of age.

Still, the report reveals breakdowns in tracking critical incidents that can impact the licensing and certifications of assisted living communities, whether or not they receive federal or state payments. And both operators and industry groups are working to keep communities updated on laws and maintaining compliance.

Communication breakdown

The gaps in reporting critical incidents, and the number of states not reporting them, highlighted the varying degrees in which critical incident information is collected. Thirty-four states made critical incident information available to the public by phone, website, or in person, while another 14 states did not have such information available at all. Nine states were cited for being unable to track incidents by provider type or had no system in place to collect critical incidents. Five states lacked a system that could identify Medicaid beneficiaries.

State Medicaid agencies also differed in the types of critical incidents monitored. While all the states in the report listed physical, emotional or sexual abuse as critical incidents, five states failed to report injuries resulting in hospitalization, seven failed to report medication errors, and three states do not monitor unexpected or unexplained deaths.

“Even one incident of abuse, negligence or financial exploitation is too many,” Delgado said. “However we must keep in mind when a senior falls and requires a hospital visit, this too is reported as a critical incident. Falls are the number one cause of injury to seniors and so it is important to differentiate these types of incidents from those as a result of abuse or negligence.”

The lack of guidance from CMS to state agencies was the most notable takeaway from the report, Argentum COO Maribeth Bersani told SHN.

“There should be standard definitions and that does happen on the state level,” she said. “[CMS] should start looking at how states define critical incidents and move from there.”

Tightening the operational reins

Although the GAO report focused on smaller communities receiving Medicaid assisted living services, all communities must adhere to state laws and regulations regarding critical incidents.

“State regulations and policies are not limited to providers receiving Medicaid assistance. It is a home- and community-based standard,” Mollot said. “As the industry moves to more dementia care and acute care, good providers have staffed and trained appropriately.”

The industry was constantly looking at improving quality control and self-oversight before the GAO report arrived, Bersani said. Argentum is working on developing its own standards for its member groups, as well as advocating for more uniform regulations and guidelines on the state level.

“We’ve been proactive in improving regulations, so as to raise the bar for residents,” Bersani said. “Some states have new laws introduced all the time.”

Implementing best practices is something larger operators are already enacting.

“As the industry becomes geared to more dementia and acute care, larger providers added staff and trained appropriately,” Mollot said.

Even some mid-sized providers are taking a comprehensive approach to quality as acuity rises. Heritage Senior Living, a 14-community provider based in West Allis, Wisconsin, has implemented several best practices to reduce critical incidents in their communities throughout Wisconsin, Jaime Schwingel, RN, MSN, WCC, vice president of quality and clinical operations, told SHN.

“We’ve implemented PointClickCare system-wide to track daily living activities and monitor residents in real time,” Schwingel said. “And our recent partnership with Medication Management Partners simplifies the medication administration process and will further help reduce medication-related errors.“

Using electronic medication administration records (EMAR) and electronic health records (EHR) — as Heritage is using PointClickCare — allow operators to structure workflows so that items that may be missed on paper records are accounted for. These can be used to document the reason for, and outcome of, prescribing a medication, reducing the risk of prescribing incorrect medications, and charting incidents where the wrong medication was prescribed and the outcome of these incidents.

Argentum is lobbying on behalf of its member operators to ensure thoughtful, uniform state laws are on the books. Additionally, Argentum believes its SOPs can be used as a model for smaller operators.

“We recognize state laws differ and smaller providers may not have the staffing abilities of our members, either because they can’t afford it or may not need it,” Bersani said.

Cost should not be an issue, Medication Management Partners Executive Director Labinot Avdiu told SHN.

“The cost to provide quality care is ultimately lower than the cost not to provide it,” Avdiu said.

Medication management is one critical incident where it is relatively easy to implement best practices. Groups like the National Center for Assisted Living (NCAL) and the American Society of Consulting Pharmacists have standard operating procedures that any operator can adopt, whether they have a nurse on staff or not, Avdiu said. The procedures cover documenting medications and the conditions for which they’re prescribed, proper storage, reducing the use of high-risk medications and periodic reviews for compliance.

“Operators can use these procedures to standardize their processes and then utilize either independent nurse consultants or ask for the pharmacy partners they’re partnered with to provide consultant services to evaluate their communities,” Avdiu said.

Questions about cross-training

LTCCC’s best practice recommendations included training staff across a range of subject areas to ensure resident safety and well-being, including residents’ rights, detecting abuse and neglect, communication skills, emergency preparedness, assisting residents with Alzheimer’s disease and other dementia, and (when appropriate) assisting with medication. This would address the labor shortage in the industry as well as give workers more skills for working their way up the employment ladder.

Industry groups like ASHA and Argentum are receptive to the idea, but operators exploring cross-training need to be mindful of state licensing laws that may limit what they can do, such as administering medications or require additional training in dementia care, Delgado said.

“Recruiting and retaining a competent and compassionate workforce is a critical need for senior living operators,” she said. “Our members continue to explore creative and thoughtful ways to engage current and future employees.”

Written by Chuck Sudo