Oversight of Assisted Living Puts Patients at Risk, Says Audit

As more Connecticut residents have waited until later in life to move into assisted living, these facilities have become more similar to nursing homes. But, a recent report from state auditors found that oversight of assisted living facilities has been far less stringent than nursing homes, raising concerns about patient care and safety. 

Today, an estimated 8,000 Connecticut residents living in these communities average between 84 and 86 years old, and suffer from a higher percentage of chronic illnesses or more severe medical conditions, according to the auditors.

Assisted living facilities serve people 55 and older and provide nursing services and assistance with daily activities like bathing and eating to residents who need the assistance. Compared to 20 years ago, when people moving into assisted living were younger and healthier, residents today move during their late-70s to mid-80s, the auditors said. 

The auditors said there was some disagreement about the level of care needed in assisted living facilities compared to nursing homes. “Assisted living facilities” is a term that is not defined in state law, but which the auditors use to refer to “managed residential communities.”

“One key stakeholder” told the auditors that residents in assisted living memory care units were higher functioning than those in nursing home memory care, but other stakeholders said there is no difference between the patients in the two systems. 

That has been a concern to the Department of Public Health and some local fire marshalls, who referred to some assisted living facilities with memory care units – rooms for residents with dementia –  as “miniature nursing homes” because of the high level of care the residents require, according to the auditors.

Though assisted living facilities commonly charge higher rates for residents living in memory care units, there aren’t any requirements for the number of aides a facility needs for every memory care patient. 

In one case, a patient in a memory care unit fell out of their bed at 9 p.m. and remained on the floor in pain for 12 hours because there was no one periodically checking on the residents throughout the night, according to the auditors.

That case highlights a concern Department of Public Health officials expressed to the auditors, that there is inadequate staffing in the units, particularly on-site nursing staff outside of regular hours. The department said some units are run only by aides in the evening, while at nursing homes, memory care patients have around-the-clock nursing care, according to auditors.

The auditors’ concerns extended to how effective the department’s oversight was in getting assisted living providers to correct any issues found in an inspection. Unlike in nursing home inspections where the department is required to mail the provider a copy of the report showing its deficiencies within 10 days of the inspection, there is no such requirement for assisted living facilities. 

The providers told auditors that there were instances where they received a letter of violation as much as six months to a year after the inspection, making it impossible to quickly address any deficiencies. 

The department told auditors that it agreed that it needs a policy that includes timeframes for the reviews, and said work is “prioritized and triaged” so findings can be issued at different times depending on the workload of the staff.

A difference in oversight

The auditors also found that the state Long-Term Care Ombudsman – which responds to about 3,000 complaints a year regarding nursing homes, residential care homes and assisted living facilities – provides more oversight of nursing homes than assisted living facilities. 

In 2018, ombudsman personnel visited 90 percent of nursing homes, and 37 percent of assisted living facilities at least once – a situation the ombudsman said was because the program never received funding for more staff to provide more oversight of assisted living facilities.

“Regardless of their setting, frail and vulnerable older adults should have similar protection, including facility inspections, background checks, and minimum staffing requirements,” the audit said. “The level of oversight for a similar population currently depends on if they reside in assisted living facilities or nursing homes.”

In addition to having less oversight than nursing homes, there is also confusion about the regulations governing assisted living facilities. That was particularly evident in the uneven application of fire codes that the auditors found in interviewing local fire marshals.

Some fire marshalls told the auditors that they believed they could only inspect the facilities under the residential fire code, but they are able to use a more stringent “institutional” code for facilities with more than 17 residents who are not capable of self-preservation, according to the auditors.

The confusion stems from the complexity of fire inspection criteria, which leaves local fire marshals with different interpretations of how to apply the code to assisted living facilities. There is no guarantee that the facilities are having the annual fire inspections required by law since they are not required to show proof of those inspections, the auditors found. Local fire marshals also reported that they didn’t have enough resources to conduct all of the statutorily-required building inspections every year.

Local fire marshals expressed concern to the auditors that, because of the state of residents in memory care units — one facility said none of its residents were capable of self-preservation, and another said only 5 of 89 could exit without help — there could be significant deaths if a facility were to catch fire.

In addition, the care providers that run assisted living facilities have separate oversight from the facilities themselves, the report found. Often these facilities have both residents who do receive care from the care providers — which can include daily activities like bathing, dressing and eating — in addition to more self-sufficient residents who live in the same facility but do not receive that care.

The care providers are licensed and can receive citations from the Department of Public Health for violating regulations. But the facilities are simply registered, not licensed, and the department cannot cite the facilities or require them to make corrective action plans for issues found during inspections.

Since 2019, when Minnesota required all assisted living facilities to be licensed, Connecticut has been the only state that does not license assisted living facilities, according to the auditors. 

Facility administrators told the auditors that the bifurcated system gives flexibility in managing residents, such as allowing them to remain in the same apartment while transitioning from independent living to assisted living, since not all residents require assisted living services. 

A downside of the bifurcated system is that even though the assisted living facilities are required to conduct criminal background checks on employees for a history of issues like elder abuse – just as nursing homes do – the facilities are not required to conduct the same background checks on recreation directors or transportation providers, according to the auditors. 

Changing the law

The auditors found that there was a procedural barrier for the department to address issues with the facility. 

A law passed in a 2009 special session of the Connecticut General Assembly eliminated a requirement that the department review every facility’s operations every two years and investigate complaints about potential violations of law — a change the auditors said they struggled to identify the reason for, though there were indications it was either because the department lacked the necessary resources or the law was considered redundant.

The department is still required to review the care providers that run the facilities, and if inspectors see something wrong with the facility they will try to link it to a deficiency of the provider so they can address it.

The auditors said that the department could resume reviews of the facilities, and simply conduct the reviews of the assisted living facilities and care providers at the same time. The department told the auditors that it would require lawmakers to change the statute and provide additional resources to conduct those inspections.

While the department agreed with many of the audit findings, and said it would look into changing some of its regulations – like broadening some of the requirements for nurses to work for assisted living agencies that have made it difficult to fill positions. But most of the recommendations would require changes to statute and more funding, including having the department inspect facilities and requiring facilities to submit an annual fire safety inspection report to maintain their registrations.

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