Rules let sicker clients into living centers

This story originally appeared in the U-T San Diego.
One factor contributing to medical errors at assisted living homes is that California regulators over the past decade have opened the doors of the facilities to ever sicker seniors by changing the rules.

Families have increasingly turned to assisted living, attracted both by the homelike atmosphere and by the lower cost compared to nursing facilities.

As the ranks of older, sicker residents swelled, critics say, regulators tried to accommodate demand and did not typically require homes to enlarge their staffs or increase training.

Some assisted living homes can now house residents with serious communicable infections, deep bedsores, staph infections, tracheotomies, catheters, colostomy bags and more, as long as those homes have filed requests showing they can meet residents’ needs and had the requests approved.

Paper records housed in state offices in Mission Valley show that many of the care homes licensed by the California Department of Social Services have permission to care for large numbers of bedridden and other frail seniors.

These homes, however, are not required to have the larger, medically trained staffs of nursing homes, which are overseen by a different state agency, the state Department of Public Health.

State Social Services Director Will Lightbourne, in response to written questions for this story, said his agency is reviewing its role in handling the changing population.

“As expectations evolve regarding the increased delivery of medical services in home care settings, the department is looking at what steps need to be taken to ensure facility administrators, caregivers and state licensing staff are adequately trained to assess and address those needs,” Lightbourne wrote.

The state has used waivers and rule changes to grant homes more leeway, according to its regulations, manual and responses to questions:

Bedridden: Before 2001, homes were not allowed to care for most bedridden residents. Today, they can house such seniors — even those who can’t turn on their own in bed — as long as they receive approval from local or state fire agencies. They must also document in a plan how they will care for bedridden seniors, according to state officials.

Dementia: Starting in 1995, homes had to get waivers or permits to care for residents with dementia. The state replaced the waiver rule in 2004 by issuing standards for dementia care. Today, a home can provide dementia care to all residents if it meets regulations and residents’ needs, officials said. Homes that advertise dementia care must submit a plan to the state and make sure staff members caring for dementia residents have six hours’ orientation in dementia care and eight hours in in-service training, regulations state.

Hospice: As of 1992, Social Services mandated that homes caring for hospice patients get waivers or permits, which are still required. Homes can also get permission to care for residents who need care “to perform all their activities of daily living.” The agency approves a waiver based on what it calls a home’s ability to provide appropriate care.

An array of consumer groups say that by giving homes such leeway without increasing training and staff, the state has seriously compromised basic safeguards meant to protect seniors from abuse, neglect and poor care.

“All they do is make it easier for the facilities to accept and retain people — in many cases, people that they shouldn’t be able to accept and retain,” said Patricia McGinnis, executive director of California Advocates for Nursing Home Reform, which issued a report last month calling for an overhaul of state regulations.

The state agency has not kept a central count of the number of dementia or hospice residents approved to live in the state’s 7,700 assisted living homes, also known as residential care facilities for the elderly or RCFEs.

Consumer Advocates for RCFE Reform, a A San Diego-based group that did its own count based on state files, found that 13 percent of beds in 632 San Diego and Imperial counties’ assisted living homes were approved for either bedridden or hospice patients.

The California Assisted Living Association, which represents hundreds of homes, is preparing a proposal to increase requirements for dementia care.

Sally Michael, president of the state industry group, said in written comments that the changes in state rules reflect an evolution in how aging seniors receive care.

“Much of the changes are part of an overall shift in the health care system away from institutional bias and in support of home and community-based options,” Michaels wrote.

“Fewer people are faced with living in a health facility,” Michaels added, “when their needs can be met by utilizing supportive services from licensed professionals in a residential environment, such as assisted living.”

When a senior is diagnosed with dementia, for instance, that person should not automatically be admitted to a health facility, Michael wrote.

Social Services spokesman Weston said assisted living offers families a flexible environment.

He gave the analogy of two homes on a single street, one a private home where a family is caring for an ailing or dying relative, and one an assisted living facility caring for residents with similar health problems.

“You can have medical professionals come into RCFEs just as anyone can come into someone’s home,” he said. “You can have people come in and administer shots.”

The rules allowing homes to care for hospice patients, for instance, “is meant to provide people with the same rights and the same freedoms that you would have in your own community,” Weston said.

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