Guiding Principles for Assisted Living
Almost one million Americans reside in assisted living facilities. Assisted living is a growing and dynamic form of residential care, serving primarily elderly people and individuals with disabilities. Assisted living is more than a physical setting – it embraces a philosophy of care. Created in response to customer preferences and demand for individual-centered care, assisted living residences provide assistance with physical activities and health-related needs. They also strive to meet the social, emotional, cultural, intellectual, and spiritual needs of residents.
The National Center for Assisted Living (NCAL) developed these Guiding Principles to describe what assisted living is and how the assisted living profession is striving to continue developing and improving services.
Defining Assisted Living
Assisted living has evolved in a variety of models based on consumer preferences and regional differences. As a result, states take a variety of approaches in overseeing the industry and establishing standards.
While assisted living is the most common term used in the nation both by the industry and state regulatory agencies, assisted living settings may be known by different names, including, but not limited to, residential care, personal care, adult congregate care, boarding homes, and domiciliary care. Regardless of what it is called, NCAL believes assisted living should be:
- A congregate residential setting that provides or coordinates personal services, 24-hour supervision and assistance (scheduled and unscheduled), activities and health-related services, and that includes at least one awake staff member at all times;
- Designed to minimize the need to move;
- Designed to accommodate individual residents’ changing needs and preferences;
- Designed to maximize residents’ dignity, autonomy, privacy, socialization, independence, choice, and safety;
- Designed to encourage family and community involvement; and
- A setting that provides assistance in maintaining and enhancing the physical, emotional, intellectual, social, and spiritual needs of residents based on their preferences.
Assisted living also encourages:
- The personal development of residents, on an individual basis;
- Physical activity that maintains and enhances fitness;
- Family and community involvement; and
- Development of positive relationships among residents, staff, families, and the community.
Size
An assisted living residence is not defined by its capacity for residents, but by the scope of the services it provides. The size and configuration of each assisted living residence should be determined by consumer demand and the types of services provided. Services to individuals with mental illnesses, developmental disabilities, Alzheimer’s disease, other forms of dementia, or disabilities requiring specialized services should be delivered in an appropriate and safe setting in compliance with state and federal regulations.
Physical Plant
An assisted living residence should be designed, operated, and maintained in a manner appropriate to the special needs of the population served. The residence should be located, constructed, and equipped in compliance with all applicable local codes and state and federal regulations.
A ssisted living facilities should have effective fire safety systems. Smoke detectors should be installed in all rooms and common areas in existing buildings that are not fully sprinklered. NCAL believes that new facilities should be fully sprinklered. Existing facilities without sprinklers should be retrofitted for sprinklering where economically and physically feasible.
An assisted living setting should be designed in a way that maximizes the quality of life, independence, autonomy, safety, dignity, socialization, choice, and privacy of residents. Settings should also be designed in a manner that encourages family and community involvement.
Move-In and Occupancy
New residents and/or their family members should receive an orientation about the services the assisted living residence offers. Individuals should not be allowed to move into an assisted living residence that is unable to meet the full scope of their needs.
Occupancy agreements should clearly specify what services can and will be provided, the facility’s rates for all services and payment structure, and the facility’s occupancy and relocation criteria. Agreements should be reviewed periodically to ensure accuracy. Copies of original and any amended agreements should be provided to the resident and/or responsible party.
Services
When moving into an assisted living setting, each resident should be evaluated or assessed to determine how his or her need for services can best be met. A service plan should be developed indicating services that will be delivered to meet particular needs based on the individual’s physical, psychosocial, and cognitive capabilities. The individual, family, or a responsible party should be encouraged to participatein the development of the service plan, which should be reviewed and updated regularly or as significant changes in the resident’s condition occur.
An assisted living service coordinator should be designated to be responsible
for developing, implementing, and evaluating the progress of the service
plan. A copy of the service plan should be given to the resident and/or responsible
party.
Advertising, Sales, and Marketing
NCAL is committed to professional and ethical conduct in all advertising,
sales, and marketing activities. Assisted living is a multi-faceted profession
that has developed over the past 20 years into a unique and diverse component
of the long term care spectrum. Because of this diversity, it is increasingly
critical for providers to present their customers with complete, concise,
and candid information about their residence and the services provided. Those
responsible for the advertising, sales, and marketing of assisted living
services should fully disclose all services offered and fees charged by the
assisted living community. Providers should also ensure that all communications
are consistent, accurate, and in accordance with applicable laws and regulations.
In addition, providers should not engage in any false or misleading advertising
and sales practices that are intentionally designed to deceive or manipulate
consumers.
Health Needs
The assisted living residence should provide daily supervision or assistance with activities of daily living (eating, bathing, dressing, toileting, and transferring) and instrumental activities of daily living (such as shopping, meal preparation, telephoning, medication assistance, etc.), as needed. It should coordinate services by outside agencies and monitor the activities of the resident to ensure his or her health, safety, and well being. Daily assistance with activities may include the administration, supervision and/or assistance with self-administration of medication by a qualified staff person, and other health care services as permitted by state laws, rules, and regulations. Daily monitoring of residents’ health status should be an available service.
An emphasis on wellness should be part of each setting’s approach toward health care delivery. In addition, staff should assure that prompt and appropriate medical and other health-related services are obtained when required. The health care of each resident should be under the supervision of a physician of his or her choice. NCAL believes that a nurse should be available, on an on-call basis, 24 hours a day. Providers should inform consumers about the policies and procedures followed in emergency medical situations.
Residents with temporary periods of incapacity due to major illness, injury, or recuperation from surgery should be allowed to remain in the facility or be readmitted from a hospital if appropriate services can be provided. If possible, the facility should help residents remain in the facility when death is imminent if appropriate hospice and/or palliative services can be provided in the setting.
Aging in Place
Once used to describe a commitment to minimize the need to move, the phrase “aging in place” has evolved to mean many different things to different people. To prevent any consumer confusion or misunderstanding, NCAL discourages the use of the phrase “aging in place” unless accompanied by an explanation that includes any health-related occupancy restrictions mandated by the residence and/or state regulation.
Staff Qualifications and Training
The assisted living residence administrator (or director) should be responsible for the overall operation of the facility. The administrator should ensure that all staff members are qualified to care for residents and are competent in performing their duties consistent with applicable state and federal regulations. The administrator should assure that residents receive all services indicated in their service plan.
An assisted living residence administrator should have:
- An adequate education, demonstrated experience, and/or ongoing training to meet the health and psychosocial needs of residents; and
- Demonstrated management or administrative ability to maintain the overall operations of the setting.
A competent acting administrator should be designated to act on the administrator’s behalf when the administrator is not readily available.
The personal care staff should:
- Be sufficient in numbers and qualifications to meet the 24-hour scheduled and unscheduled needs of residents and to deliver provided services; and
- Have adequate skills, education, experience, and ongoing training to serve residents and their families in a manner consistent with the philosophy of assisted living.
Personal care staff or medication assistants whose responsibilities include administration, assistance with self-administration, or supervision of medications should be qualified by certification and/or training.
Staffing Patterns
Assisted living residences should offer 24-hour supervision and oversight of residents. NCAL believes that at least one staff member should be awake at all times. Residences should embrace a philosophy that allows individuals to remain at the assisted living community as long as staff can properly provide for residents’ health, safety, and well being within the scope of the service program.
The number and type of staff employed by an assisted living facility should depend on a number of factors, including state regulations, the number of people living in the facility, each resident’s service requirements, and the range of services offered.
The assisted living residence should employ adequate staff to maintain the facility in a manner that promotes the safety, health, and well-being of residents and staff. As noted above, NCAL believes that a nurse should be available, on an on-call basis, 24 hours a day.
Resident Rights
The philosophy of assisted living emphasizes the right of the individual to choose the setting for care and services. Resident rights may include the following:
- Privacy;
- Being treated at all times with dignity and respect;
- Controlling the delivery of personal finances;
- Retaining and having use of personal possessions;
- Interacting freely with others both within the assisted living residence and in the community;
- Practicing religion or abstaining from religious practice;
- Controlling receipt of health-related services;
- Being free from abuse and neglect;
- Organizing and participating in resident councils and other resident activities;
- Being free from chemical and physical restraints;
- Complaining without the fear of reprisal; and
- Accepting or refusing services.
Upon move-in, all residents should be given a copy of their rights and responsibilities and should be encouraged to ask questions or discuss their rights with staff or the administrator at any time. A copy of those rights and responsibilities should be posted in a conspicuous place at all times.
Assisted living administrators should also:
- Permit access to the facility and to residents (with the individual resident’s permission) by approved advocates and community organizations at reasonable times;
- Ensure that an informal or formal communications process is in place between the residence administration, residents, and families;
- Establish residence rules governing visitors, usage of tobacco and alcohol, and the use of personal property; and
- Ensure each resident is free from discrimination as provided by local, state, and federal law.
Licensure and Certification
The health, safety, and well being of residents should be the primary consideration when states develop regulations for the licensure and operation of assisted living facilities. In most states assisted living residences are licensed or certified by an appropriate department or agency that should have a process for issuance of initial licenses and for renewing existing licenses. NCAL believes that assisted living facilities or services should be licensed or certified, as applicable under state law. However, a variance or waiver should be available to allow an individual facility to seek an exception to a requirement of the licensure or certification rules (if such a request is reasonable and does not compromise residents’ health, safety, or well being).
The state should maintain a program to identify facilities that fail to comply with applicable state standards. The health, safety, and well being of the residents should be the primary consideration when a state determines if a facility can be brought into compliance in a reasonable period of time or if closure is necessary. In addition, poor performing facilities that refuse to correct incidences of abuse and neglect should not be allowed to continue to operate.
Each state should also establish a program to reward -- through public recognition, financial incentives, or both -- assisted living residences that provide the highest quality care to residents.
Measuring and Improving Quality
NCAL is committed to quality and performance excellence in the assisted living profession and actively supports Quality First, a covenant for healthy, affordable, and ethical long term care, and adherence to its principles and goals.
NCAL strongly believes that placing assisted living on a parallel regulatory track with nursing homes would be a mistake. Such a regulatory model would stifle the very spirit that led to the creation of assisted living. Instead of following the nursing home regulatory model, quality assurance systems for assisted living that focus on customer satisfaction and actual outcome measures should be developed and implemented. Such systems can be utilized by providers, consumers, managed care entities, and government agencies to ensure that quality services and care are being maintained. More important, such systems would better serve the interests of assisted living customers by providing them with powerful input into the quality evaluation process and the delivery of services.
Survey processes used by state government agencies should address not only minimum standards but also areas where facilities excel and achieve high levels of customer satisfaction and outcomes.
Customer satisfaction measurement must be at the root of any system designed to measure quality in the assisted living setting. Beyond customer satisfaction, any quality measurement system should also include measurement of actual facility performance. To be able to measure performance, certain data about each resident must be obtained, tracked, and updated. From this data, performance measures can be identified and utilized to track the outcomes of the care and services being provided by a facility. The performance measures should produce tangible data and feedback that can be used to continuously improve assisted living quality. NCAL currently is conducting research and gathering data to develop performance measures for the assisted living setting.
Note: The assisted living profession continues to grow and evolve as does NCAL’s perspectives on our changing profession. The concepts and terms used in this document may vary from state to state and are provided as a framework to help promote a general understanding of assisted living. The guiding principles and content in this document are not “standards of care.”
As approved by the NCAL Board of Directors June 27, 2006.