A GAO study of ALFs in four states concluded that while most facilities provide information about the services available, they do not routinely provide information about discharge criteria, staff training and qualifications, services not available from the facility, grievance procedures, and medication policies. The GAO report concluded that the provision of adequate information to prospective and current residents is a major issue that requires additional oversight.14
With few exceptions, states that license residential care require facilities to include specific information in residency agreements. Connecticut and Minnesota do not use residency agreements per se because they only license the service provider and the housing provider executes a lease agreement with tenants. Table 1-4 lists the type of information that states may provide in resident agreements and the number of states that require the provision of this information.
TABLE 1-4. Residency Agreement Provisions
|Services included in basic rate||49||Grievance procedures||21|
|Cost of service package||44||Termination (admission/discharge)||20|
|Rate changes||30||Terms of occupancy||13|
|Refund policy||30||Advance payments||13|
|Cost of additional services||28||Temporary absences||12|
|Service beyond basic rate||27||Accommodations||10|
|Payment/billing||21||Services not available||7|
As can be seen, a majority of the states provide information about services, but only about half or less provide information about most of the other topics. Few states require information about medication policy and staffing.
Examples of “other” requirements follow:
Colorado requires facilities to disclose whether they have an automatic sprinkler system.
Kansas requires facilities to give prospective residents information on advance medical directives, resident rights, and the facility’s grievance procedure, before an agreement is signed.
Maine does not allow the resident agreement to contain any provision for discharge that is inconsistent with state rules or law or which implies a lesser standard of care than is required by rule or law. Agreements in Maine must also include information about grievance procedures, tenant obligations, resident rights, and the facility’s admissions policy.
Maryland requires disclosure in the agreement of the LOC that the facility is licensed to provide and the LOC needed by the resident at the time of admission. The state also requires facilities to disclose policies concerning shared occupancy and procedures that will be followed when a resident’s accommodations are changed due to relocation, change in roommate assignment, or an adjustment in the number of residents sharing a unit.
New Hampshire issued regulations in 2003 requiring disclosure of information to allow residents to compare ALRs, independent retirement communities, and elder housing, in order to make an informed choice about where to live. The state requires facilities to disclose whether they are licensed; the basic rate; the personal care and other services included in the rate; meals provided; transportation services; recreation and leisure activities; amenities in the living unit; policies regarding deposits/advance payment requirements and refundability; and services not included in the basic rate and their cost. Facilities must also provide information about their staffing, including whether staff are available 24-hours a day, and the availability of licensed nurses, personal care attendants, nursing assistants, and maintenance staff.
Wisconsin requires that the qualifications of staff who will provide services be included in the agreement as well as whether services are provided directly by the facility’s staff or under contract by an outside entity.
Some states require facilities to provide some of the information listed in Table 1-4 in a residents’ rights statement rather than a residency agreement, particularly information about grievance procedures.
The GAO study cited unmet consumer expectations for aging-in-place and forced moves as a major resident complaint. Twenty-eight states require agreements to include information about the facility’s criteria for admission, discharge, or transfer. Other states cover discharge criteria under provisions regarding termination.
Finally, several states have rules regarding the format of resident agreements. Kansas requires that agreements be written in clear and unambiguous language in 12-point type. Maryland requires agreements to use accurate, precise, easily understood, legible, readable, “plain” English. Wisconsin requires that agreement formats make it easy to readily identify the type, amount, frequency, and cost of services. Some states require information about provisions that allow staff to inspect living quarters, with the resident’s permission.
Most states do not have rules for revising or updating resident agreements. However, Alabama, Illinois, Mississippi, and Oregon require that agreements include the period covered by the agreement. Wisconsin requires that the agreement be reviewed and updated when there is a change in the resident’s condition or at the facility’s or resident’s request. Updates are otherwise made as mutually agreed to by the resident and the provider.
14. Assisted Living: Quality of Care and Consumer Protection Issues. GAO. T-HEHS-99-111. April 26, 1999.
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