Consumer Consortium on Assisted Living (CCAL)

On behalf of the Consumer Consortium on Assisted Living (CCAL), we are pleased to submit written testimony to the United States Senate’s Special Committee on Aging regarding the Assisted Living Workgroup’s (ALW) final report. Our written testimony details:

Our strong support of the ALW report and the inclusive process used by the ALW
Ground breaking ALW recommendations and agreements
The immediate and long-term usefulness of the recommendations in the report
The report’s important approach to blending strong minimum standards with consumer outcome and satisfaction measures
The critical next steps to fulfilling the Committee’s charge to improve quality in assisted living

We would like to thank Chairman Craig and Ranking Member Breaux for the opportunity to submit this written testimony on the day of the Committee’s hearing on the ALW’s final report, as well as your interest and leadership in assisted living quality improvement. At the outset, let us share with you some background information on CCAL and our work in and commitment to consistent, quality care for assisted living residents nationwide, including affordable options for individuals with low and moderate incomes.

CCAL was founded in 1995 as a national assisted living advocacy organization to provide support and educate assisted living consumers, professionals and the general public to ensure: consistent, quality resident care; resident rights and protections; affordable options for individuals with low and moderate incomes; and information and resources to assist consumers to make informed choices. A founding objective of CCAL is to serve as a national resource and facilitator to promote the exchange of information and ideas among the diverse stakeholders of assisted living. CCAL held the first national consumer-focused conference in 1996 entitled, "What Do Consumers Want?"

Mr. Chairman, we believe the recommendations contained in the ALW report, taken as a whole, represent a historic agreement among a majority of diverse assisted living stakeholders about what assisted living is, what minimum service capacity and standards are required to deliver assisted living’s promise, what consumer protections and disclosure should be in place given the high level of disability among the residents that assisted living serves, and how outcome standards and satisfaction measures should be integrated into regulations and internal quality improvement systems as they are designed and validated.

We believe that the dialog, debate, and collaboration that went into each recommendation resulted in recommendations that represent the best collective wisdom of the industry’s leading stakeholders. While there are some recommendations that each participating organization could not support in the end, we believe that each recommendation benefited from the input of all ALW participants, as well as the significant modifications made during the ALW process as a result of the diverse perspectives represented. The final report provides great insight into each recommendation, both through the recommendation’s text and rationale, as well as through the voting record and supplemental positions from various organizations.

It is important to recognize that the intent of the recommendations was not to provide regulatory language or definitions - regulatory or program language will need to be crafted by each state or agency using the report based on their own particular legal and structural requirements. Rather, the recommendations are meant to be descriptive of the goals, minimum standards, processes and outcomes recommended.

Given that the report has the broad support of consumer, provider, and professional groups, we believe that it provides highly credible and detailed guidance. It will be a very useful tool to states, providers, consumer advocates, and federal agencies as they design programs, reforms, and regulations to assure quality and extend the benefits of assisted living to low- and moderate-income individuals.

As requested by the Committee, the ALW process was designed to be all-inclusive and assure maximum access to all groups wishing to participate. Without an applicable precedent that a majority of stakeholders supported, we designed and continuously modified (over successive meetings) our own process to accommodate the unique needs of participants, where possible, while still meeting the Committee’s guidelines and schedule. We believe that the open, inclusive, iterative, and flexible process adopted by the ALW served to accomplish as much consensus and agreement as possible, allowing each recommendation to benefit from the diverse perspectives of stakeholders at multiple stages (through small group and full ALW discussions) and to undergo edits approved by a majority of stakeholders.

The process agreed to by majority consent of the stakeholders was to work in topic groups (open to all participants and co-chaired by a consumer advocate and someone from the provider/professional community) to develop recommendations in the following areas: quality assurance/regulatory systems (referred to as Accountability and Oversight), affordability issues, direct care services, medication management, operations, residents’ rights, and staffing. Topic groups controlled their own schedules but generally met twice a month for two or more hours by conference call and in person. Once topic groups set their agenda and priorities, specific recommendations were discussed and draft language was created. Draft language was approved in a topic group by consensus or a two-thirds majority.

Once the recommendation was approved by the topic group, it was presented to the full ALW. All ALW meetings could be attended in person or by conference call. Each recommendation went through a three-stage approval process at the full ALW meetings, allowing multiple opportunities for edits and review by the attending participants.

Due to its complexity, the definition of assisted living was the only recommendation that required a special process outside of the three-step approval system. Several special work sessions, open to all participants, were convened to reach majority agreement. A three-part definition was presented by the topic group to the full ALW for a final vote.

While each recommendation deals with an important aspect of assisted living, we believe that the majority agreement on the definition, combined with the recommendations that directly detail what quality outcomes and minimum capacities are required to qualify as assisted living, are the greatest accomplishment of the ALW.

Both the definition and the recommendations set minimum standards for assisted living by detailing what is required to meet assisted living’s ultimate goal – supporting physically and cognitively impaired residents’ dignity and maximum independence by delivering privacy (through private units), a high capacity for resident-directed services, and quality. These minimum standards are designed to allow consumers to know with certainty what core services and environmental standards they can expect when they choose and pay for assisted living. The diverse stakeholders’ majority agreement on the parts of the definition that outline the philosophy, service, and privacy standards required for assisted living is an enormous accomplishment.

Above the minimum requirements, the recommendations establish an important, flexible array of services that can be customized in assisted living to promote innovation and meet consumer preferences. The emphasis on flexibility in services is combined with strong consumer disclosure requirements so that residents can compare between providers and know with certainty what they are purchasing. Performance measures, where appropriate, are coupled with the flexible services recommendations to assure quality and consumer direction. Process requirements are provided where performance recommendations are considered ineffective in assuring quality or avoiding unacceptable risk.

Also significant in the recommendations is the agreement that an entity, the Center for Excellence in Assisted Living (CEAL), should be established and governed by a board of key stakeholders to: develop performance measures, including measures of clinical outcomes, functional outcomes, and resident satisfaction; continuously update recommended minimum standards to state-of-the-art practices, and disseminate measures, effective practices, and update standards as they are developed; provide technical assistance to states; and provide a regular report to Congress on the state of the assisted living industry (see AO.01).

CCAL strongly supports this recommendation for its role in keeping standards current and responsive to innovations as well as the critical development of outcome and satisfaction measures for use in regulation and internal quality improvement. We believe that the CEAL is an innovative and effective way to assure that assisted living is meeting its goals and obligations.

Each ALW recommendation states clearly how the ALW believes the recommendation should be used. The ALW has five implementation categories: guidelines for federal policy, guidelines for federal and state policy, guidelines for state regulation, guidelines for state policy, and guidelines for operations. We, like the majority of ALW members, hope that the recommendations and their supplemental positions will be used by federal and state agencies to review their programs, policies, rules, and regulations. Where state and federal agencies, as well as providers, determine that their assisted living practices vary substantially from the ALW recommendations, it is our hope that state and federal staff will engage in a vigorous debate regarding the benefits of modifying their laws, policies, or programs to align with the best practices and minimum standards outlined in the ALW recommendations.

We especially hope that federal, state, and provider stakeholders will utilize the ALW participants as resources in their discussions. CCAL is committed to providing technical assistance on any of the ALW recommendations where we may be helpful. We are pleased to note that we have already been made aware that state and federal agencies, as well as industry organizations, have made use of the recommendations in reviewing or establishing standards. We are confident that the recommendations will continue to serve as a catalyst for strong and healthy debate about ways to improve quality and consumer satisfaction in assisted living.

ALW’s Blend of Strong Minimum Standards with Consumer Outcome and Satisfaction Measures

The framework of the ALW’s response to addressing current and long-term quality assurance in assisted living is to:

We strongly support the incorporation of outcome and satisfaction measures into assisted living standards and quality monitoring systems as they become available and are validated. We especially hope that in regulatory areas where outcome and satisfaction measures are found to provide a better quality monitoring method than minimum standards, they will replace those minimum standards. We do not, however, believe that (in the foreseeable future) outcome and satisfaction measures will completely replace minimum standards. Rather, we anticipate and support a regulatory system that uses both, each being employed where it is most effective in delivering consistent, high quality results that meet consumers’ expectations and preferences.

CCAL was particularly pleased by the majority support for substituting reliable outcome and satisfaction measures for more process-oriented regulatory requirements and view this as significant new area of agreement for the stakeholders. Creating and validating reliable and practical outcome and satisfaction measures so they may be incorporated into regulations and quality programs will provide significant advances in quality in areas that are particularly important to consumers.

There are two critical next steps in the assisted living quality improvement efforts.

Chairman Craig, Senator Breaux, and members of the Committee, thank you for the opportunity to speak with you today about what I believe is one of our nation's most important long term care concerns. I am here today on behalf of the Consumer Consortium on Assisted Living (CCAL). We commend you for taking up this timely topic again following this Committee's important hearing on assisted living in 1999.

CCAL, established in 1995, is the only national, consumer-focused organization dedicated solely to the needs and rights of assisted living residents. I have been an administrator of several assisted living facilities ranging in size from 60-beds to a 220-bed campus. I co-founded CCAL and currently serve as Co-Chair of the Board of Directors. I am a consumer. My father has Alzheimer's disease and has resided in an assisted living facility for over two years. CCAL heartily supports assisted living as a vital option for long term care services. However, CCAL does not support caring for America's frail elderly in assisted living without defining and specifying what appropriate care is and without assuring its provision through national standards. Our country, perhaps inadvertently, is placing a very vulnerable population at an extraordinary risk. The tremendous growth of this industry runs the risk of overriding our commitment to the care and protection of this vulnerable population.

An estimated 1.0 million elderly currently reside in assisted living. Compare this to the estimated 1.5 million residents of nursing homes, an industry that has been around significantly longer than assisted living, and one understands the explosive growth occurring in this relatively new long term care option. The U.S. Bureau of the Census projects that the population of individuals 85 years and older will be the fastest growing part of the elderly population throughout the rest of this century, and will more than double by 2030. This enormous growth has significant implications for the assisted living industry as individuals 85 years and older are those most likely to become assisted living residents.

At times, the rapid growth of the industry has occurred at the cost of resident care as quality resident services have not kept pace with "bricks and mortar" construction. The average assisted living resident is an 84-year old frail female. Catherine Hawes, PhD, author of the U.S. DHHS funded National Assisted Living Study, found that one in four assisted living residents needs as much help as a typical nursing home resident. Yet despite the tremendous growth of the industry and the frailty of its residents, there are no uniform standards or federal regulations to protect residents.

In a sobering report to this Committee two years ago, the General Accounting Office (GAO) noted that the lack of uniform standards forces consumers to rely primarily on providers for information about assisted living. The GAO found that providers do not routinely provide consumers with the information necessary to select the setting most appropriate to meet their needs. CCAL has found that some marketing literature continues to be misleading (such as showing pictures of staff in lab coats with stethoscopes when, in fact, the facility does not provide healthcare), or incomplete, (such as not fully describing costs and eligibility, requirements for different levels of care, or what happens when a resident's finances are exhausted or when he or she becomes seriously ill or disabled).

Other frequently cited problems identified in the GAO report include: inadequate or insufficient resident care; insufficient, unqualified, and untrained staff; and inappropriate medication administration. One recent caller to our Helpline described a situation in which her father has lived in an assisted living facility for over three years. This caller described her father as needing assistance daily with basic care needs such as bathing and dressing. Her father often goes without assistance because there are not enough staff. As a long time resident, he has bonded with the staff and residents and is willing to accept poor care in lieu of moving somewhere else where he does not know the staff or residents. This creates serious conflicts for the daughter because she hates to see her father poorly care for, yet she understands his need to fit in as well as his ability to make his own decisions. Dr. Hawes recently found that 25% of the more than 300 assisted living facilities she studied had only one caregiver for every 20 residents in the 3-11 shift and one for every 34 at night. According to a statement Dr. Hawes made last year, the combination of sicker people and low caregiver-to-resident ratios is dangerous. "These two things are on a collision course - it's just a time bomb waiting to go off."

We fear that in the two years since the Committee's last hearing the time bomb may have already gone off. Recent front-page articles in The New York Times, The Washington Post, and Wall Street Journal abound with stories of problems in assisted living facilities. The Washington Post reported that an 83-year old frail female resident residing in a facility of one of the industry's largest providers was assaulted in a day room by a male resident with a psychiatric history. This vulnerable resident died two days later in a hospital from injuries sustained in the assault. Was this male resident an appropriate admission to a facility caring for vulnerable individuals?

Not only are catastrophic events for some residents and their families continuing, but in the last two years, a dearth of workers in the long term care industry and low occupancy rates pressuring the need for providers to fill beds have further heightened concerns about quality care for the vulnerable consumers of assisted living.

These significant problems are compounded by an uneven and patchwork approach to state regulation and oversight thus producing an increasingly alarming picture of the assisted living industry. The assisted living industry is regulated individually by states and predominantly funded by private resources. State standards are highly variable, and the variability begins with the very designation of the name 'assisted living'. Broadly defined, assisted living can be described as a residential care alternative to nursing homes that allows people to "age in place" while receiving services to help them retain their dignity and preserve and enhance their autonomy. States, however, use over two dozen designations even to refer to what is commonly known as assisted living, for example: California - residential care facilities; New Mexico - adult residential shelter care facility; New York - assisted living program, adult care facility, adult home, and enriched housing program; and Michigan - home for the aged and adult foster care.

This lack of any consistency or uniformity in definitions can create great confusion and poor outcomes. For example, both New York and Michigan have many facilities that fall into none of the categories in existing law, meaning they do not have to be licensed. These unlicensed facilities include some that are owned by some of the nation's biggest assisted living operators. Alterra Healthcare Corporation, the nation's largest operator of assisted living facilities, for example, has 19 homes in New York State. Half of these facilities are unlicensed despite a claim by their President and CEO, who is quoted in the November 26, 2000 edition of The New York Times as stating "I am proud of the fact that all of our residences are licensed and that we have done that voluntarily". That is simply not true.

The regulatory variances among states are vast. In California, for example, residents may be required to leave a residential care facility if they become incontinent. New Mexico statute has no provisions for a resident bill of rights, admission criteria, contracts, or grievance procedures. In New York there are no specific guidelines for care of individuals with dementia. In Kentucky, new regulations exempt all facilities that already existed when the new law took effect in July 2000. A Michigan task force on assisted living rejected the idea of stronger state oversight, recommending instead, that the state simply require facilities to sign a clear contract with each person who moves in. Even this poorly conceived proposal has languished.

The processes by which states develop their assisted living regulations also leave much to be desired. For example, the Tennessee Department of Health recently determined that the most expedient way to develop assisted living regulations for their state was to invite leaders from the nursing home and assisted living trade associations together to form consensus on new assisted living regulations. The groups were given the state's nursing home regulations to use as the basis for developing assisted living regulations. Consumers and other advocates were excluded from the process. The state's Commission on Aging was invited to participate, but declined. Unfortunately, this approach is not unique to this state.

The patchwork state regulatory approach is extremely confusing to those with expertise in the assisted living field. Imagine the difficulty faced by consumers who typically must make their placement decisions in the midst of personal crisis.

Is there any industry that would not love the opportunity to police itself? By default in some states, and by a patchwork of regulations in other states, this is in effect happening all too often in the assisted living industry. According to a founder of Kapson Senior Quarters, a chain of assisted living facilities that is now part of Atria Inc., "the industry is doing one hell of a good job of policing itself". Many consumers, long term care ombudsmen, state regulators, geriatric care managers, elderlaw attorneys and other advocates would beg to differ not to mention the abundance of front-page newspaper stories describing egregious incidents.

"If a consumer does not like a certain facility, they can let their feet vote", is a statement oft heard from leaders in the industry such as two past presidents of the Assisted Living Federation of America. This statement is demeaning to consumers, and does not reflect market or personal realities for consumers. Making a decision to leave a facility that is not providing appropriate care for a resident's needs is not the same as deciding not to return to a certain restaurant because service was poor, or to take your dry-cleaning elsewhere if prices are increased. The decision to move out of a facility is a last resort decision fraught with emotional, psychological, and financial complications.

Many myths immediately surface whenever there is any discussion about the need for federal regulation or oversight of assisted living facilities. One myth is that there are very few federal dollars spent on assisted living, and therefore the federal government should not be involved in regulating this industry. We all know what would have happened had the tire industry not been subject to any federal scrutiny over tire standards for SUVs. The federal government does not directly subsidize the tire or auto manufacturers, yet they oversee and protect consumer safety needs for both of these industries. Nor has the federal government delegated this important function to individual states. It can be argued that increasing amounts of federal dollars are in fact going to assisted living. More and more states are allowing the use of Medicaid waiver dollars for residents of assisted living. Medicaid is a shared federal-state responsibility with the federal government paying fifty percent of the cost.

Another myth is that federal regulations have not worked to provide quality care for nursing home residents, therefore, this same approach should not be replicated for the assisted living industry. Research has demonstrated that improved quality of care has occurred as a result of OBRA 1987 - the landmark Nursing Home Reform Law. For example, the use of physical and chemical restraints in nursing homes has dropped dramatically as a result of OBRA 1987. A closer look at nursing home regulations, however, finds that it is not federal regulations that have not supported quality resident care, but rather, too often, the quality of the management and operators of individual nursing homes, as well as uneven oversight by state regulators. Often, when nursing home providers speak of over burdensome regulations, closer inspection reveals that they are speaking of important standards relating to fire safety or sanitation, or outdated state-specific regulations, not standards or requirements in federal law or regulations. Furthermore, when nursing home providers malign the regulatory system, they are often referring to the enforcement process - not the regulations.

Good, caring providers and health care professionals working in nursing homes are generally in tune with the national standards for quality of life, quality of care, and resident's rights. In fact, the national nursing home trade associations came to consensus with consumers and advocates on the standards in current law, with the exception of the enforcement provisions and the need for stronger nurse staffing requirements.

Another frequently heard myth is that consumers in each state have their own specific needs and therefore the standards and regulations need to be uniquely tailored to individual states. Through the CCAL Help line, we hear from consumers and advocates from across the country. It is CCAL's belief, based upon our personal experience with consumers and their families, that consumers, regardless of where they live, have the same concerns about receiving good quality and appropriate care. We live in a highly mobile society where family members and special friends are often scattered throughout the country. It is natural and practical that we want consistency in how our loved ones are cared for. One last myth - that regulation stifles innovation. Many other industries have been successfully regulated without adversely affecting innovation such as the building industry, auto manufacturers, and pharmaceuticals to name a few. It is the individuals who design and create products and services that affect or limit innovation - not the standards themselves.

ALFA, the largest trade organization of assisted living providers, indicates that it is eager to improve quality, but prefers a new private system of voluntary accreditation that is beginning to inspect facilities and grant a seal of approval. In 2000, both the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Commission of Accreditation of Rehabilitation Facilities (CARF) began accrediting assisted living facilities. The accreditation criteria are very broad and nonspecific. Several examples of criteria include: "The assisted living facility provides safety and security measures to meet the needs of residents"; and "The assisted living community provides services for each resident according to accepted standards of practice and law and regulation." Both organizations refer to their accreditation criteria as 'standards'. Rather than setting definite requirements, these 'standards' set out general objectives that are meant to focus on continual quality improvement. These 'accreditation standards' would more accurately be defined as quality improvement tools. They cannot be equated with or considered to be specific, uniform and measurable standards. In effect, they can only be measured with a "yes" or "no" response. Can any of us imagine a facility answering "no" to the sample criteria noted above? Unfortunately, in the absence of any consistency in assisted living standards, these new accrediting programs can serve to further confuse assisted living consumers about what defines and connotes appropriate resident care.

As the aging of America continues to spiral upward, so will the number of individuals residing in assisted living. One of the problems with nursing home oversight and national standards is that advocates have spent decades trying to catch up to an industry that got off to a freewheeling and virtually unrestrained start. Our nation's nursing home residents and their loved ones have paid and continue to pay a high price for that. The assisted living industry has been given a virtually unrestrained start as well. CCAL believes no further time should pass before our nation begins to appropriately and responsibly address the serious conditions that have developed in assisted living. From urban to rural locale, from coast to coast, from provider to provider, our nation's frail elderly need uniform standards that define and provide guidance and protections to consumers.

We at CCAL feel so strongly about this that we have initiated an effort to develop model standards for assisted living. I am delighted to say that the American Bar Association's Commission on Legal Problems of the Elderly has agreed to join us in this effort. The National Citizen's Coalition on Nursing Home Reform also supports this initiative. While we believe there should be national standards -- and that in time there will be national standards -- we can help now by offering a set of model standards. Our hope is that at minimum, individual states will agree to adopt our model standards, and that progressive industry leaders would adopt them for their own facilities. We hope that the industry will join us along with many others who are stakeholders in assisted living in developing these standards.

Chairman Craig, Senator Breaux, and members of the Committee, my name is Lou Kilby. I am a resident of an assisted living facility. It is my pleasure to testify today, and provide a resident-centered perspective of what it is like to live in assisted living.

Assisted living provides comfortable living for thousands of seniors with physical and mental disabilities and a retirement home for independent persons not wishing to continue maintaining a separate dwelling. In my case, as a paraplegic, it was an ideal solution to my problems, as I had not expected to spend my golden years in a wheelchair without long term care insurance. Residing in assisted living has given me a chance to be fairly independent, to be up and around most of the day, to order and take my own medications (avoiding the $7 a day charge for administration), and to continue in a leadership capacity serving on committees. A worrisome thing for me is that costs go up yearly, and I fear I will outlive my money.

The setting where I have lived for six and one half years is a large, attractive home. There are currently 50 residents - 30 in assisted living and 20 in the Alzheimer's special care section. The grounds are equally attractive and well maintained. Most of the residents live in private apartments complete with their own bathroom, shower, and a small refrigerator. Despite the positive aspects of this lovely setting, the environment tends to be depressing with some residents unable to communicate, uninterested in taking part in activities, and sleeping in the common areas. It is sad when a resident dies or leaves for a nursing home for more care.

Meals are served in an airy, spacious dining room with lace tablecloths and flowers on the table. Flowers are arranged by residents in the floral club. There is a salad bar and a dessert table, and ever popular ice cream. Emphasis is on choice with 2 entrees for dinner and supper or sandwiches if preferred. I am happy to report that fresh fruit was available all winter long. The chef is responsive to residents' concerns and his menu committee meets twice a month to discuss likes, dislikes and special functions. The private dining room, seating 8 comfortably, is available for special parties like a birthday celebration. This space is also used for meetings with family members to discuss a resident's care plan.

The activity program is outstanding with varied programs for the active-minded resident. The program has consistently been an important part of my life and was of great help in my transition from independence to assisted living. More effort could be made by the staff to encourage attendance of the 30 assisted living residents. Barely a third regularly participate in any activity. Activities frequently fall through the cracks during the weekends. Videos are organized to be shown, but that does not always happen.

I actually wrote some of my testimony while sitting on the sun porch listening to a sing-a-long. Other musical programs include a swing band, a classical pianist, guitarists, and others too numerous to mention. There are regular opportunities to do some food preparation to make one feel at home. Residents mix ingredients to make cookie dough, for example, and spoon the dough onto trays to be baked later. Bingo is popular with 7 residents in our facility. I am pleased to say that a number of residents regularly report for morning stretch which I lead utilizing my background in health and physical education. My star pupils are a 99-year old woman and a 98-year old man. The woman has expressed her exercise philosophy by saying she participates not to live longer, but to make her days better. Seasonal activities such as the 4th of July barbecue and the Winter holiday party bring family and residents together for wonderful food and musical fun.

Pets are allowed and this is really a plus. Some residents keep a cat in their room. My facility has a dog, cat, and a bird. Our facility pets are not properly cared for though causing me and other residents to worry about them. They are often fed and hydrated irregularly and not regularly groomed.

The wellness nurse supervises the administration of medications and sees that an updated list for each resident is computerized. A copy of this list accompanies a resident to a doctor visit or to the hospital. The nurse also supervises the monthly check on weight and vital signs. We have a LPN during the weekends. Both the nurse and LPN only work daytime hours. During evening hours, the supervisors and medication technicians make decisions about 911 calls and consult with the resident's doctor. There is no doctor on the premises.

A medication technician delivers pills and other medications such as atomizers. A resident may receive as many as a dozen pills with a small glass of water despite the fact that most pills say to take with 8 ounces of water. Sometimes pills are given out before the resident has had breakfast. I wonder about the advisability of such practices. The medication technician does not wait to see if the resident actually downs the pills. Occasionally a resident refuses even to take the pills, and little is actually done about that.

I have concern about the protocol practiced when a resident falls. The resident should be carefully helped up once a determination has been made that it is safe to move them. The staff should check the resident's vital signs and range of motion. This is not always done. Also, an accident report is supposed to be written up.

A care plan is developed for each resident following a conference with the executive director, wellness nurse, a supervisor, a family member, and if possible, the resident. Per state regulation, the care plan is to be updated yearly. Mine has not been reviewed in over a year, so I guess I am all right.

The resident assistants (RAs) are the workhorses (for lack of a better word) of the house. . An effort is made to hire RAs with some experience. New staff participate in a rigorous training program conducted by a senior staff member. Fortunately our home currently has an excellent trainer, but this has not always been the case. The RAs provide the personal care for the residents such as giving showers and baths, changing diapers, dressing, seeing that residents get to meals, etc. They also do the laundry and make the beds on their assigned floor. In addition, they work in the dining room waiting on tables and doing the dishes. All this for $7.00 or $7.50 an hour depending on their experience. For many, English is a second language and misunderstandings do occur. Presently, since the house is not full, the RA's work hours are being cut by one full day a week. This represents a loss of wages of approximately $56 a week. When this happened once before, I asked - not too innocently - if the wellness nurse's hours were also being cut. There was no response to my query.

A continuing staff problem is absenteeism. Holidays are particularly difficult. This past Easter Sunday, there were only two staff members for the 3-11 shift. They delivered medications, served dinner, put residents to bed, and cleaned dishes. Fortunately for us, these two staff were old-timers and very capable. I doubt they received any extra pay for their hard efforts.

Of great concern is the unrecognized deterioration of some residents, particularly the more independent residents who do not receive daily assistance from staff. Problems such as depression, confusion, unsteadiness, and weight loss are not always brought to the attention of the nurse or the executive director. The dining room hostess does not appear to follow up if a resident does not come for meals. Alert residents are frequently more aware of these resident changes than the facility staff.

The turnover in staff at all levels is truly appalling. In my 6 l/2 years, for example, we have had 7 executive directors, 5 activity coordinators, and countless RAs. The turnover is disruptive. Just as you get used to the RA, she is gone. The work pressures, low pay, and amount of work are surely factors. To make ends meet, some of the staff take on second jobs. Cutting each RAs time by one day per week not only discourages loyalty, but also sends a message that they are not important to the home. Our chef told me he works 3 jobs.

The marketing person, called Director of Community Relations, is under pressure to fill the house and keep it filled. You get the impression that the home will take anybody. I doubt this is completely true, but this is how it feels. Admission mistakes are made. Sometimes a new resident arrives directly from the hospital, but does not seem well enough to handle assisted living. This puts a burden on the RA who must handle the difficult situation. Sometimes residents are admitted to assisted living, but it becomes apparent after a few days that the person is not appropriate for assisted living and they are moved to the Alzheimer's section.

There does seem to be an attempt to keep people here when they begin to need more care. This is more the case of individuals living in the Alzheimer's section as their families want them to stay. For those residents not residing in the Alzheimer's section, family members seem to recognize when assisted living is no longer appropriate for their loved ones, and they make arrangements for a change to a nursing home. Two of my friends left recently.

I appreciate this opportunity to express my views about assisted living. Assisted living has made my life, which is difficult at best, much more pleasant.

CCAL's Congressional Testimony