You asked how assisted living facilities provide 24-hour attendant care for residents who need it. Specifically you wanted to know (1) who determines the necessity for such care, (2) who arranges for the care, (3) who provides the care, and (4) whether the facility or the care provider bills the resident for the care. We also provide background on the regulatory environment in which assisted living facilities operate, including changes that took effect October 1, 2007 pursuant to PA 07-2, June Special Session.

SUMMARY

Typically, the family of an assisted living facility resident determines that the resident needs a 24-hour personal care attendant. Most often this determination comes after consultation with the facility director and the nursing staff of the licensed assisted living services agency with which the facility contracts for services. The family or resident contracts directly with a separate agency (such as a companion-homemaker or home health aide agency) for the attendant's services. And this agency directly bills the family or resident for the attendant; the facility is not involved in the transaction.

Connecticut does not license assisted living facilities, instead it licenses and regulates the “assisted living services agencies” (ALSAs) that provide such services. Only a Department of Public Health (DPH)-licensed ALSA can provide assisted living services, and it can do so only at a “managed residential community” (MRC). An MRC must meet DPH regulatory requirements by providing certain “core services,” such as housekeeping and laundry services, to its residents before it can engage an ALSA to provide services.

ALSA staff assess clients, develop a client service program and instructions for assisted living aide services, coordinate services, and make referrals to appropriate professionals or agencies when the client's condition necessitates this. Assisted living aides working for the ALSA can help a client with personal care activities including bathing, feeding, dressing, and toileting; assist a client with exercises, ambulation, transfer activities, and supervision of self-administered medication; and perform routine household services. Aides are not around-the-clock personal attendants.

Beginning October 1, 2007, MRCs must meet additional requirements, including making a written agreement with each resident that contains (1) a list of assisted living and other services the MRC will provide and (2) full disclosure of all charges the resident is to pay. The act also requires MRCs to (1) tell each resident of his or her right to directly contract with licensed health care providers to obtain needed health care services in his or her apartment or other available space and (2) arrange, at a resident's request and in conjunction with the ALSA, for ancillary medical services, including those of a home health agency.

FACILITY PRACTICES

We surveyed six assisted living facilities in various parts of the state to learn about current practices. All respondents stated that:

1. few, if any, current residents require a 24-hour personal care attendant;

2. the determination that a resident needs a 24-hour attendant is made by the resident or family, usually in consultation with the facility director and the ALSA nursing staff and, sometimes a physician;

3. the resident or family is responsible for hiring the attendant;

4. attendants are employed by agencies with which the facility has no formal relationships, although some facilities provide families with information about local agencies;

5. the agency that employs the attendant directly bills the resident or family. The facility has no financial involvement in the relationship.

Vicki Carlson, the DPH staff person responsible for licensing ALSAs stated that these findings confirm her understanding of industry practice.

ASSISTED LIVING REGULATORY FRAMEWORK

Current Rules

Assisted living residences primarily serve people age 55 and older who need some health or nursing care or assistance with activities of daily living, such as dressing, eating, bathing, using the toilet, or transferring from a bed to a chair but not the skilled care a nursing home provides. Connecticut does not license these residences (commonly called assisted living facilities); instead, it licenses and regulates the agencies that provide the services, which it terms “assisted living services agencies” (ALSAs). Only a DPH-licensed ALSA can provide assisted living services, and it can do so only at a “managed residential community” (MRC). DPH regulations govern ALSA services and specify requirements for MRCs (Conn. Agencies. Regs. § 19-13-D105, especially (h)-(j).

MRC Requirements. An MRC must meet DPH regulatory requirements by providing certain “core services” to its residents before it can engage an ALSA to provide services.

The “core” MRC services include:

The MRC must employ an on-site service coordinator who reports directly to the MRC's administrator. Among other responsibilities, the service coordinator must (1) help tenants arrange to meet all their personal needs and (2) establish collaborative relations with provider agencies and support services.

An MRC can become a licensed ALSA or can contract with an existing ALSA to provide services at the MRC. It cannot provide health services such as rehabilitation therapy, medication administration or supervision, or nursing care to residents unless it is licensed as an ALSA. It can contract with ALSAs, home health care agencies, or other licensed health care providers for these services.

ALSA Requirements. An ALSA can use its own staff to provide nursing and aide services, or it can contract with other organizations or individuals to provide these services. If it contracts for services, the arrangements must be contained in a written contract or memorandum of understanding between the parties. The ALSA must retain a nursing and an assisted living supervisor.

An ALSA nurse or an agency nurse working under a contract with the ALSA is responsible for, among other things:

Aides working for the ALSA can provide the following services, among others:

1. assisting the client with personal care activities including bathing, oral hygiene, feeding, dressing, toileting, and grooming;

2. assisting the client with exercises, ambulation, transfer activities, and supervision of self-administered medication; and

3. performing routine household services essential to client care at home, including shopping, meal preparation, laundry, and housecleaning. These services can also be performed by someone who is not a trained aide.

Resident Rights. DPH regulations specify ALSA clients' rights and responsibilities and require the ALSA to give each client notice of them. These include the right to:

New Requirements for MRCs

Beginning October 1, 2007, MRCs must meet additional requirements (PA 07-2, JSS §§ 30 to 43). These include entering into a written residency agreement with each resident that contains, among other items, (1) an itemized list of assisted living and other services (e. g. , transportation, recreation) the MRC will provide and (2) a full disclosure of all charges, fees, expenses, and costs the resident is to pay.

The act also requires each MRC to (1) inform each resident of his or her right to directly engage or contract with licensed health care providers to obtain needed health care services in his or her apartment or other space the MRC makes available and (2) arrange, at a resident's request and in conjunction with the ALSA, for ancillary medical services, including those of a home health agency.

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