# Chapter 6

## 

## Strategies for

## Handling the Situation

> *There are many services available to assist people with Alzheimer's,
> as well as services for their families and caregivers. It's important
> to identify resources available in your community, and to understand
> your role and responsibilities in the coordination of these services.*

### 

#### Dementia In Housing

#### Within the Housing industry, there are a number of housing professionals who will, at some point, come into direct contact with residents. These may include, but are not limited to, the following:

-   Property Managers

-   Site Managers

-   Maintenance Technicians

-   Housekeeping

When a member of the housing team encounters an individual that he or
she suspects may have dementia, a referral should be made to the
Resident Service Coordinator. If there is no Resident Service
Coordinator on staff, housing professionals should discuss concerns with
members of the resident's family or the emergency contact listed in the
resident's file. Concerns should be communicated in terms of specific
behaviors. When no family members are available, housing staff should
consult with an outside agency such as the Maine Alzheimer's
Association. For a complete list of agencies, please see Chapter 10.

### 

### The Role Of The Resident Service Coordinator

Service Coordination is a resident-driven program designed to assist
residents to live safely and independently. The RSC's primary role is to
link residents with services in the community, advocate when necessary,
and provide education about area services and benefit programs.

Alzheimer's and Memory Impaired residents are a special concern for the
RSC in housing as the signs and symptoms are sometimes overlooked or
misinterpreted. Recognizing warning signs is crucial in identifying that
there may be a problem and beginning the process of assisting residents
in getting the help they need. Therefore, a crucial part of being an
effective Resident Service Coordinator is to seek educational
opportunities around Alzheimer's disease as well as other diseases that
may affect the lives of residents.

### 

### Confidentiality. Resident Service Coordinators are bound by codes of confidentiality. That is, they are not permitted to reveal any information received on a confidential basis to anyone not authorized in writing by the resident. The only permissible exceptions to this rule are:

-   If a resident is a danger to himself or herself or others

-   If a RSC is subpoenaed in a court of law

-   If the resident is engaging in lease violating behavior (most, but
    not all, projects require the RSC to report lease violations).

#### Release of information. Resident Service Coordinators do attempt to obtain a release form from each resident when the resident first moves in to the site and then again at annual re-certification. If, over the course of a RSC's work with a resident, the situation warrants, the RSC may again request that the resident sign a release of information. Residents are not required to sign a release form. A resident may revoke a release at any time, or opt to sign a release at any time should it become evident that he/she may require assistance in obtaining services, information or assistance from an outside person/agency.

### 

### Providing education. Whenever possible, RSCs meet with residents, residents' family members, members of the community and housing staff to provide materials and information about Alzheimer's disease and other related dementias. Often times efforts to educate residents demands creativity and sensitivity.

### 

### Support. Whenever possible, make an attempt to involve a resident's family, friends, and caregivers in the educational process. These people provide the resident with a crucial support system, as well as a mouthpiece to communicate important information to helping professionals.

### Tips for approaching the resident

-   Follow up any written communication with a face-to-face visit.

-   Follow up any face-to-face visit with a written communication
    summarizing the discussion. (Always keep a copy of any written
    correspondence and notes in the resident file.)

-   However, recognize that the resident may no longer be able to
    comprehend written notices and warnings and therefore may fail to
    comply with the instructions they contain.

-   Choose the resident's best time of day for an important meeting.

-   Consider holding the meeting in the resident's apartment where he is
    most likely to be relaxed and oriented.

-   Remember: Your approach is critical because the resident will likely
    mirror your tone. Be calm, reassuring and supportive. \[See Chapter
    3 for more tips.\]

-   Remember that the resident is not being deliberately stubborn,
    defiant or non-compliant, nor being manipulative -- she has a
    disease.

-   Avoid long explanations, legalese and jargon.

-   If the resident seems frustrated or upset, back off. Reassure him
    that you are there to help. Change the subject to a pleasant topic
    and try again later.

### 

### Handling Specific Situations: Factors to Consider

How to handle a specific situation depends on whether or not it is an
emergency and whether or not there is a current release of information
on file authorizing you to obtain or share information on the resident's
behalf. The following flowcharts and scenarios are intended to assist
you in determining the best course of action.

***Emergency Scenario***

#### Example: Emergency With No Release of Information

> An 83-year-old female was living in senior housing. Neighbors reported
> to the site manager that the woman seemed very different. She was
> wandering the hallway late at night, looked disheveled, and was
> non-communicative. A referral was made to the RSC, who scheduled a
> visit to the woman's apartment. When the RSC entered, the kitchen and
> hallway floors were covered with bottles of cleaning products. The
> woman was unkempt and the apartment was cluttered. The RSC asked the
> woman what she was doing with the cleaning products spread out on the
> floor. The woman responded that she was going to kill herself. When
> the RSC asked her how she was going to kill herself, the resident
> responded that she was going to "drink bleach."
>
>  **Response to** **Emergency Scenario**
>
> In any emergency, it is critical to contact the appropriate crisis
> service immediately. The crisis services available, depending on the
> situation, include the police, the fire department, crisis
> stabilization, emergency rescue, etc. If you believe that the
> appropriate course of action is calling the police, you may request
> that they bring a mental health crisis team with them.
>
> After contacting the appropriate agency, document as accurately as
> possible your observations. In a housing situation, the property
> manager should be notified as soon as possible.
>
> After the resident has met with the crisis service, the emergency
> contact listed in the resident's file should be notified, along with
> family members. During your phone conversation with the family member
> and/or the emergency contact, share your concerns, the list of your
> documented observations, and how the behavior or situation might
> affect the resident's housing status.
>
> The immediate safety of the resident, staff, and community is
> paramount. If the resident's behavior is "dangerous," the police have
> the authority to transport the resident to the emergency room for
> evaluation by a qualified medical professional.
>
> If the behavior is ongoing and significant, and the family, emergency
> contact, and crisis services are of limited assistance, a referral to
> the Department of Human Services/Adult Protective Services may be
> necessary.
>
> If the resident is transported to the hospital, call the emergency
> room of the hospital and give them the list of the documented,
> observable behaviors and your concerns. Follow this conversation up
> with a written fax directed to the appropriate person. Additionally,
> request that if the resident is admitted to the hospital you would
> like to be invited to any discharge planning meeting prior to the
> resident's release.
>
> Your discussion with the emergency contact and family members might
> include an overture to assist with exploring alternative housing
> options. It is also important to review with the family the impact of
> the behavior on the resident's housing status, your safety concerns,
> and what steps might be taken next.

On the following page is a flowchart showing the appropriate sequence of
responses to an emergency situation with no release of information.

#### 

#### 

#### 

#### 

#### 

#### 

####  

***Non-Emergency Scenario***

> **Example: Non-Emergency Scenario with No Release of Information**
>
> An elderly resident begins wandering into closets off the community
> room, mistaking them for apartment doors. He also begins seeking food
> in the community room refrigerator, mistaking it for his own. He
> reported being hungry and was unable to remember when he last ate.
> Other residents observed him picking up small objects in their
> apartments and pocketing them as his own. He started smoking in the
> hallways, although he had always been aware that this behavior was a
> violation of house rules.

### 

###  Response to Non-Emergency Situation

> In many instances, housing professionals may observe resident behavior
> that is not threatening or dangerous, but is cause for concern. Some
> examples are:

-   Changes in appearance or behavior

-   Agitation

-   Confusion

-   Change in the condition of apartment or living quarters.

> The RSC's response is largely dependent on whether or there is a
> signed Release of Information as the following scenario illustrates:

On the following pages are two flowcharts showing the appropriate
sequence of responses to a non-emergency situation. The first flowchart
depicts the scenario with a signed Release of Information; the second
flowchart depicts the same scenario without a signed release.

###   {#section-15 .unnumbered}

### Dealing with Neighbors

In senior housing projects neighbors often take on the role of family
caregivers for each other. Sometimes the helping relationship is a
mutual give and take. Other times a resident's need for assistance is
easily accommodated ( for example, a reminder of upcoming events or
running an errand or two). Over time the need for assistance, especially
if the resident has dementia, may escalate to the point where the
helpful neighbor feels overextended and overwhelmed. The neighbor may
feel unable to set limits with the needy resident and reluctant to
report the situation to management for fear of getting the resident
kicked out. When this happens, neighbors run the same risk of caregiver
stress and burnout as family caregivers do.

### 

### Caregiver Stress

More than 80 percent of Alzheimer caregivers report that they frequently
experience high levels of stress, and nearly half say they suffer from
depression. Many caregivers don't recognize their needs, fail to do
anything about them, or simply don't know where to turn for help. Too
much stress can be damaging to the health and well-being of caregivers.
Recognizing the signs and learning how to reduce stress can help.

 **Warning signs of caregiver stress**

-   Denial

-   Anger

-   Social withdrawal

-   Anxiety

-   Depression

-   Exhaustion

-   Sleeplessness

-   Irritability

-   Lack of concentration

-   Health problems

 **Tips for reducing caregiver stress**

-   Educate neighbors about dementia and caregiver stress via flyers and
    small information sessions with invited guest speakers from the
    Alzheimer's Association, local support groups and other appropriate
    community organizations.

-   Provide information to all residents about the RSC's role, and
    explain how the RSC can help if residents become concerned about the
    well being of a neighbor or their own role as a helper to a resident
    with Alzheimer's disease.

-   Be alert to the signs of caregiver stress in situations where you
    know that someone has taken on a caregiver role for a neighbor.

-   Encourage neighbors to call the Maine Alzheimer's Association
    Helpline at 1-800-660-2871, any time day or night, for specific
    coping strategies as well as a safe place to express their feelings
    and concerns.

-   Encourage neighbors to be realistic and firm about what they can and
    cannot do.

-   Involve family (if available) and community providers so that the
    neighbor can reduce his/her involvement without feeling guilty about
    abandoning a resident in need. Get help from family, friends, and
    community resources

-   Encourage neighbors to take care of their own health needs.

-   Give neighbors credit for what they have done up to this point.
    Don't do or say anything to make them feel guilty about needing to
    step back now. Give them explicit encouragement and permission to
    take care of themselves.

### 

### Dealing With Family

Families provide the majority of care (75%) to their loved ones with
Alzheimer's disease and related dementias. The financial, emotional and
physical drain on their resources is incalculable. They are truly the
hidden victims and unsung heroes of this disease. However, residents of
senior housing may be without family support either because the family
is non-existent or uninvolved.

### 

###  Tips for Involving Families

-   Encourage the resident to sign a release of information allowing you
    to talk with the family (a release is not necessary in an emergency
    or lease-violating situation)

-   Notify the family of your concerns citing specific situations and
    behaviors.

-   Encourage the family to be involved in the diagnostic process for
    their relative.

-   Encourage the family to call the Maine Alzheimer's Association for
    information and support.

###  

# Resources And Further Reading

# 

1.  *Service Coordination and Consumer-Driven Services in Senior
    Housing*, published by the Maine State Housing Authority in June
    of 1996. For more information about this publication, please contact
    the Maine State Housing Authority at 1-800-452-4668.

2.  *York-Cumberland Housing Resident Service Coordination Policies and
    Procedures,* Revised Edition, January 2000. For more information
    about this publication, please contact Susan Gay at 1-800-339-6516.

3.  *Preservation Management\'s Supportive Services Policies and
    Procedures Manual,* for more information, please contact Mary Weiss,
    Director of Resident Programs at (207)774-0501.

4.  *A Handbook on the Legal Obligations and Rights of Public and
    Assisted-Housing: Providers under Federal and State Fair Housing Law
    for Applicants and Tenants with Disabilities,* by Debbie Pitch,
    J.D., Pitch Associates, Inc. in consultation with Ann Anderson,
    M.M.H.S., Massachusetts Housing Finance Agency, and Patricia M.
    Ender, J.D., Pine Tree Legal Assistance, Inc. Revised April 1995.
    This publication was produced under the Department of Housing and
    Urban Development\'s Fair Housing Initiative program Grant.

5.  *Fair Housing: Guidebook for Owners and Managers of Apartments,*
    sponsored by the National Affordable Housing Management Association.
    For more information, or to order copies of the guidebook, call
    877-563-4605.

**Appendix 6.1**

> **[Sample: Release of Information]{.underline}**

I hereby authorize the release of information to be used by the Service
Coordinator at to link me with programs and services that will assist me
in remaining independent and self-sufficient.

is authorized to receive information pertaining to benefits or services
provided to me. \[He/She\] is authorized to provide information to the
following service providers in order to access or maintain the services
I desire. This authorization will remain in effect for one year, and
expires on .

 Area Agency on Aging  Family Members

 Home Health Agencies  Mental Health Agencies

######  Substance Abuse Agencies  Department of Human Services 

######  Social Security Administration  Veterans' Administration

######  Physician 

######  Physician 

######  Other 

###### I understand that the use of this information is strictly confidential, and that it may only be shared with those agencies and/or individuals involved in the delivery of services I desire, and with state or federal agencies who may need this information to monitor the quality of services provided to me. I also understand that I have the right to revoke this consent at any time. 

###### 

###### Name: Date: 

###### 

###### Signature: 

###### 

###### I, , revoke this authorization of confidential information. 

###### 

###### Signature: Date: 

Source: Bureau of Elder and Adult Services, Portland, Maine.

**Appendix 6.2**

**[Sample: Incident Report]{.underline}**

Site Name: Date:

Resident Name: Apt:

####### Incident Report By: 

 Staff (title): Other:

###### 

###### Date of Incident: Time: a.m./p.m.

###### Description of Incident 

###### Who was notified about this incident? 

 Management Office  Physician

 Police  Family

 Fire  Other:

 EMS  Other:

###### Witness Information

Name: Phone:

Name: Phone:

Staff response to incident:

Follow-up action:

 Letter to resident Date:

 Conference with resident Date:

 Agency contacted: Date:

Prepared by: Date:

Source: Mary Fowler, Property Manager, Woodcock Management, Inc.,
Portland, Maine.

# Appendix 6.3

**[Lease Violation Letters]{.underline}**

Below and on the following page you will find two sample **Lease
Violation** letters you may wish to use in the event of you need to
notify a resident that he or she is in violation of the facility's lease
agreement. You should amend the letters, where appropriate, to reflect
the particular circumstances at hand. If possible, print the letter in a
type size (14 point minimum) that will be easy for an elderly resident
to read.

**If you have an RSC on your staff, you may want to insert a referral to
the RSC in your standard lease violation letter and forward a copy to
your RSC.**

> \[Date\]
>
> \[Mr./Mrs./Ms. Resident's Name
>
> Street Address and Apartment \#
>
> City, State and Zip Code\]
>
> Dear Mr./Mrs./Ms./ \[Name\],
>
> \[A brief description of the lease-violating behavior.\]
>
> \[Explicit citation of the section of the lease that is being
> violated.\]
>
> Referral to RSC.
>
> **A referral has been made to Jane Doe, the Resident Service
> Coordinator. She will be contacting you to discuss any services or
> information you may need.**
>
> Sincerely,
>
> Name
>
> Property Manager
>
> \[Name of housing facility\]
>
> cc: name of RSC

** Important.** Consider softening your standard lease-violation
letter. Please be aware that an abrupt, cold, and threatening letter
will be less effective with a person with dementia than one that is
simple, uncluttered with "legalese," and expresses genuine concern for
the resident's well being. An excellent example of this type of letter,
excerpted below, is provided by Mark Alper, Director, Fair Housing
Compliance, National Center for Housing Management, in his article "How
To Get Help For Elderly Residents Who Violate The Lease," (Brownstone,
1999.) The entire article is reprinted with permission in Appendix 5.

> **Model Letter**
>
> Here's an example of a letter to send to an elderly resident who's
> having trouble coping and who has violated her lease. The letter
> points out the problem the resident is causing -- in this case leaving
> the bathroom faucets on. It informs the resident that she's
> endangering herself and violating the lease. And it tells her than
> you'd like to discuss the situation with her.
>
> Dear Jane Resident:
>
> It has come to our attention that you have repeatedly left your
> bathroom faucets running and flooded your bathroom. The residents in
> the apartment below you have observed water leaking from their
> ceiling. A member of our maintenance staff investigated and determined
> that the water came from your apartment when you left the faucet on.
>
> Leaving the water running creates a danger to you and to other
> residents. You could slip on the wet floor. The residents below might
> be injured by a falling ceiling. These repeated incidents violate your
> lease. We would like to speak to you about the situation. Please give
> us a call or come into our office so we can discuss how we can help
> you. We will call you in a few days if we do not hear from you.
>
> Yours truly,
>
> John Manager

### Tips For Writing An Effective Lease-Violation Letter

-   Make the letter easy for the resident to read.

-   Use large-print (14 point) type. Use large print on the envelope,
    too.

-   Use the least amount of "legalese" possible, and no jargon or
    acronyms.

-   Use short sentences with uncomplicated words.

-   Periodically, insert the resident's name into the body of the letter
    as a reminder that the content of the letter is addressed to him.

-   Use a direct but warm tone.

-   Think about your own parents reading this letter.

# Appendix 6.4

**[Service Coordinator Referral]{.underline}**

Date:

Name of Resident:

Name of Property:

Apartment: Phone Number:

Social Security Number: Income:

Referred by: Title:

**Reason for the Referral (check all that apply)**

 Move-in  Other:

 Services  Other:

 Lease Violation  Other:

####### 

####### Brief Description

**RSC Response (RSC will complete below this line)**

Date: (Codes )

**Action Taken:**

**Follow-up Required?**  Yes  No

If Yes, follow-up action is required by:  Property Manager  RSC 
Other

### 

### Follow-up Action:

Source: Maine State Housing Authority.

# Appendix 6.5

**How To Get Help For Elderly**

**[Residents Who Violate The Lease]{.underline}**

# 

Reprinted with permission from the Site Manager's Complete Guide to
Assisted Housing (1999). Copyright, Brownstone Publishers, Inc., 149
Fifth Ave., New York, N.Y. 10010-6810. For a free sample issue, call
1-800-643-8095.

What do you do when an elderly resident's inability to care for himself
result in lease violations? Many assisted sites have elderly residents
in this situation. Ill health, senility, poor eyesight or hearing -- all
the ravages of age -- have acted against these residents. They've
stopped cleaning, let bathtubs overflow, forgotten to pay rent, or left
burners on.

Eviction isn't a desirable answer. In fact, many of these residents may
have been model residents for years. But if you don't take preventative
steps, the consequences could be disastrous, not only for the residents
and your building but also for other residents who can hold you
responsible.

You're in a difficult situation. "Housing professionals aren't social
service workers or doctors," says Mark Alper, director of fair housing
compliance at the National Center for Housing Management and a former
property manager. Most aren't trained to deal with an elderly resident
in trouble. But they face the problem more frequently as the population
ages and more elderly live on their own.

To address the problem before it becomes an emergency, consider
following our three-step procedure. These steps have worked for top
property managers who've used them at their sites. They'll also help you
avoid fair housing lawsuits, says Alper (see box below).

### Step #1: Contact Resident

Start by writing a letter to the resident detailing the lease
violations. While you don't want to threaten an 80-year-old with
eviction, you want the resident to understand the seriousness of the
situation, says Alper. You also want to offer your help. Ask the
resident to come and talk to you about the situation. We've put together
a Model Letter to help you do this (see Model Letter that follows). Our
letter explains to the resident that she's caused a problem at the site
and asks her to contact management to discuss it.

*Continued*

If you don't hear from the resident in a few days, follow-up your letter
with a phone call asking the resident to come in to speak to you. When
you meet with the resident, tell her you're concerned about her
well-being. Ask her to please be more careful and the mention the lease
violations. Ask if she needs help. The resident may say she's fine and
needs no help. But if she admits she needs help, ask what she needs.

> **Model Letter**

### Send Letter to Elderly Resident to Discuss Lease Violations

> Here's an example of a letter to send to an elderly resident who's
> having trouble coping and who has violated her lease. The letter
> points out the problem the resident is causing -- in this case leaving
> the bathroom faucets on. It informs the resident that she's
> endangering herself and violating the lease. And it tells her than
> you'd like to discuss the situation with her.
>
> Dear Jane Resident:
>
> It has come to our attention that you have repeatedly left your
> bathroom faucets running and flooded your bathroom. The residents in
> the apartment below you have observed water leaking from their
> ceiling. A member of our maintenance staff investigated and determined
> that the water came from your apartment when you left the faucet on.
>
> Leaving the water running creates a danger to you and to other
> residents. You could slip on the wet floor. The residents below might
> be injured by a falling ceiling. These repeated incidents violate your
> lease. We would like to speak to you about the situation. Please give
> us a call or come into our office so we can discuss how we can help
> you. We will call you in a few days if we do not hear from you.
>
> Yours truly,
>
> John Manager

### Step #2: Call Family Members

If the situation doesn't improve, or if the resident asks for help, call
family members. (You may have their names in the resident's files.) This
strategy worked at one property Alper managed. An elderly resident was
extremely anxious, and her mental condition appeared to be
deteriorating. She would awaken in a panic in the middle of the night
and pull the fire alarm. The fire department had to send trucks to the
apartment community 15 to 20 times a month. Obviously, the resident was
creating a nuisance, and other residents were upset.

*Continued*

The property manager spoke to the resident and wrote to her expressing
concern. The false alarms continued, and the property manager called the
resident's son to arrange a meeting. When the son, the community's
staff, and the resident met, the resident explained that she hadn't
wanted to bother her son when she felt panicked because she knew he was
very busy. Her son told her to call him whenever she felt panicked
rather than pull the fire alarm. The false alarms ceased, and the
resident was able to continue living in her apartment.

### Step #3: Contact Services for Elderly Residents

If contacting family members doesn't work, or if there are no family
members to contact, seek help from social service agencies. Your state
or locality probably has special agency for assisting the elderly, often
called "the Department for the Aging." These agencies can either provide
services directly to residents to help them care for themselves or refer
you to an agency that can help. Ask staffers in your local HUD office if
they can refer you to an agency, or check the government listings in
your phone book.

You could also try calling a private agency directly. Many private
agencies are associated with religious organizations but get funding
from government agencies. They offer their services to any elderly
person who needs them. For instance, in New York City, the Federation of
Protestant Welfare Agencies, Catholic Charities, and the Jewish
Association for Services for the Aged all help. You can also try
community-based organizations such as Meals on Wheels, which may also
get government funding.

If you have trouble locating an agency to help, you can call the
Eldercare Locator at

1-800-677-1116 for a referral to an agency in your area. This number is
a service of the National Association of Area Agencies on Aging.

### 

### How Agencies Help

Here are some examples of how getting for a resident can help:

**Housekeeping.** An arthritic resident can't tie his garbage bags tight
enough. The garbage is attracting cockroaches and rodents. Solution: An
agency worker comes in, bags the garbage, and cleans up the apartment.

**Money management.** A resident has become forgetful and her eyesight
is poor. She has several uncashed Social Security checks in her
apartment. This resident, who has never missed a rent payment, now owes
you for two months. Solution: An agency worker takes the resident to the
bank, helps her endorse the checks, deposit them, and write the rent
checks.

**Personal care.** An older man falls asleep after turning on the
bathtub faucet. He floods his bathroom and the bathroom below. Solution:
An agency worker, trained to take care of an older person's physical
needs, comes to help bathe the man.

*Continued*

Alper remembers an 80-year-old resident with Alzheimer's disease who
began to wander around without clothes in below-freezing weather. First,
management sent a letter to the resident noting the incidents and
expressing concern for her welfare. A manager then spoke to the resident
about the incidents, but she couldn't remember them when she was lucid.
The manager called the resident's family, but they didn't want to be
involved. Finally, management called a social service organization for
the elderly. After the organization became involved, the woman's
daughter became embarrassed and stepped in to help. The woman was able
to stay on as a resident with her daughter's supervision.

**A safer living situation.** Other times, the ending may not be as
happy, but at least you'll help the resident live in a more appropriate
environment than your site. For example, management consultant Ed Kelley
describes an elderly woman who hung newspapers and cans from strings on
her ceiling. As she accumulated more and more newspapers, her apartment
became a fire hazard.

Management wrote a letter to the resident, then spoke to her about the
danger. She refused to remove the papers and strings because she
believed they were protecting her from being "super-gassed." Since the
resident had no family to contact, management called a state agency.
After conducting an evaluation, the agency placed the resident in a home
and helped her move.

### 

### Tips on What to Say

 **Don't diagnose the problem.** When speaking to the resident, family
members, or agencies, don't offer your opinion on what the resident's
problem is, advises Alper. Simply describe what the resident does. Don't
say, "Mrs. Jones is senile and can't take care of herself." Instead say,
"We discovered that Mrs. Jones has accumulated 50 garbage bags in her
kitchen." And when speaking to agencies, let staff members decide what
kind of help to give.

 **Describe the danger to the resident.** When speaking to the
resident, family members, and social service agencies, express your
concern in terms of the resident. Social service agencies are interested
in the welfare of the elderly resident, not in what happens to your
site. When you call an agency, describe the problem in terms of the
danger the resident poses to himself and other rather than to your
physical property.

For example, suppose a resident leaves the gas jets on. When you call an
agency, don't say: "I'm afraid the resident may burn down my building."
Instead, say something like this: "I understand your agency can help
elderly people who are endangering themselves. A resident at my site
keeps forgetting to turn off the gas jets on his stove. I'm afraid he
may asphyxiate or burn himself, or start a fire and die. I'd appreciate
it if you could come to his apartment to investigate."

Continued

> **Three-Step Procedure Helps Avoid**
>
> **Discrimination Lawsuit**
>
> Following our recommended three-step procedure for dealing with
> elderly residents who can't cope can help you avoid fair housing
> trouble. Here's why:
>
> Under federal law, you must make a "reasonable accommodation" for
> someone with a disability if he requests one. This means making
> reasonable changes in rules, policies, practices, or services to give
> a disabled person equal opportunity to enjoy a dwelling. If you seek
> to evict a resident with a mental disability before trying to
> reasonably accommodating him, you could be found to have violated the
> Fair Housing Act.
>
> Example: The owner of a Section 202 site in North Carolina recently
> agreed to settle a case with a 90-year-old mentally disabled resident.
> The owner had tried to evict the resident because she had disturbed
> neighbors and interfered with management of the apartment complex. The
> resident claimed that her actions were the result of her mental
> disability and the owner had failed to reasonably accommodate her. The
> owner agreed to issue a new lease and to train resident managers about
> their legal duty to accommodate for mental disabilities \[Country
> Village v. Knudson\].
>
> To help you avert a similar outcome, first try our three-step
> procedure. If you've written and talked to a resident, contracted the
> family if possible, and gotten in touch with a social service agency
> for help, that should be enough to back up your decision to evict the
> resident if problems persist, advises Alper.

Sources:

Mark Alper: Director, Fair Housing Compliance, National Center for
Housing Management, 1010 Massachusetts Ave., NW, Suite. 400, Washington,
D.C. 20001.

Ed Kelley: President, E.N. Kelley & Associates, 1526 E. 55 St., Chicago,
IL 60615.

*Legal Citation*

Country Village Apts. v. Knudsen: No. 92 CVD 5270 (N.C. Dist. Ct.
12/6/93.)

# Appendix 6.6

**Making the Decision:**

**[When is the Right Time for Facility Care?]{.underline}**

It is difficult to know when to begin looking for facility care for a
resident with Alzheimer's or a related dementia. The most important
thing to remember is that there is no "right" time for everyone. Each
person and family situation is different, and there are several factors
to consider. To discuss these factors, the RSC may wish to facilitate a
meeting including family, care providers, Adult Protective Services (if
necessary) and the person with Alzheimer's. Use the checklist below to
assess the resident's situation.

 **What Are The Important Issues?**

-   Safety

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-   Nutrition

-   Personal hygiene

-   Lease-violating behaviors

-   Time and energy

-   Financial concerns

-   Caregiver issues

-   In-home options.

#### Safety

-   Does the resident forget or refuse to use safety equipment such as
    wheelchairs, walkers, or grab bars?

-   Is the home environment becoming more difficult for the person with
    Alzheimer's (e.g., stairs, accessible doors, dark hallways)?

-   Has the resident had accidents with the stove, appliances, or other
    household items?

-   Has the person with Alzheimer's had trouble getting around the house
    without falls or extensive help walking?

-   If the resident smokes, has he or she had smoking accidents (for
    example, forgetting to extinguish a cigarette or cigar, burning
    holes in clothing)?

### Nutrition

-   Does the resident have trouble preparing meals or eating
    independently?

-   Is it difficult to encourage the resident to eat appropriate,
    nutritious foods?

-   Is the resident having health problems associated with poor
    nutrition -- vitamin deficiency, dehydration, weight loss, illness?

-   Has eating and swallowing become difficult for the resident with
    Alzheimer's?

*Continued*

### Personal hygiene

-   Is it difficult for the resident to get to the bathroom when needed?

-   Is the resident with Alzheimer's unwilling or unable to bathe?

-   Is the resident unwilling or unable to change clothing when needed?

-   Is the resident unable or unwilling to help with personal care
    tasks?

-   Have care needs for the resident become too difficult or too
    demanding for his spouse or caregivers?

**Behavioral concerns**

-   Has the resident ever wandered away from home or been lost?

-   Is the resident combative, suspicious, angry, or refusing care?

-   Has the resident physically harmed himself, a caregiver, or anyone
    else in the past?

### Time and energy

-   Does the resident need help with most Activities of Daily Living
    (such as eating, bathing, dressing, personal hygiene)?

-   Do housekeeping duties need to be done so frequently that care
    becomes an excessive demand?

-   Is the spouse or caregiver struggling with fatigue, depression, or
    stress?

### Access to in-home care

-   Can the family afford sufficient in-home services to address her
    needs?

-   Can home-care agencies reliably staff the resident's care needs?

-   Have the financial strains of caregiving put a strain on the
    family's budget?

-   Can the family provide more care for the resident?

### Caregiver issues

-   Is the spouse or caregiver's health at risk as the result of
    caregiving responsibilities?

-   Is the spouse or caregiver unable to manage the household, pay bills
    on time, etc.?

-   Is there frequent conflict between household or family members
    related to caregiving issues?

-   Have in-home services such as housekeeping, personal and companion
    care, or overnight care been unsuccessful?

-   Does the resident with Alzheimer's resist attending adult day
    programs?

If you answered "yes" to many of these questions, you, the resident, and
the resident's family may need to begin thinking about alternative care
options. These are just some of the factors to consider when making this
difficult decision. Individual personalities, family, history, and
outside support should always be a part of the decision.

Source: Amelia Schafer Grundy, Oregon Trail Chapter, Alzheimer's
Association, Inc.