Report to Congressional Requesters

United States General Accounting Office 

GAO 

April 2004 ASSISTED LIVING

Examples of State 

Efforts to Improve 

Consumer Protections

GAO-04-684 
www.gao.gov/cgi-bin/getrpt?GAO-04-684.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Leslie G. 

Aronovitz at (312) 220-7600. 

Highlights of GAO-04-684, a report to 

congressional requesters 

April 2004

ASSISTED LIVING

Examples of State Efforts to Improve 

Consumer Protections 

Consumers faced with choosing an assisted living facility often do not have 

key information they need in order to identify the one most likely to meet 

their individual needs. Such information includes staffing levels and 

qualifications, costs and potential cost increases, and the circumstances that 

could lead to involuntary discharge from the facility. Initiatives in Florida 

and Texas have made critical data for consumer selection among facilities 

more readily available. Florida has created a Web site that enables 

consumers to learn about all of the facilities in their vicinity and identifies 

those providing the services the consumers are seeking at a specified price 

range. Texas has mandated a standardized disclosure statement for assisted 

living facilities, giving consumers concise and consistent data that facilitates 

comparisons across providers regarding services, charges, and policies. 

Assisted living facilities are more likely to meet and maintain licensing 

standards if they can obtain help in interpreting those standards and in 

determining what concrete changes they need to make to satisfy them. 

Washington State established a staff of quality consultants to provide such 

training and advice to assisted living providers on a voluntary basis. 

Evaluations of the program 6 months after its start and 2 years later 

documented improvements in provider compliance as well as resident health 

and safety. However, a statewide budget crisis led to a decision to stop 

funding the program, in order to maintain traditional licensing enforcement 

functions. 

Assisted living residents sometimes need help to pursue any complaints that 

they may have with their providers, especially when faced with an 

involuntary discharge. Long-term care ombudsmen are available in all 

states, but nursing home residents claim most of their attention. Georgia has 

legislated an extensive array of procedural remedies specifically for assisted 

living residents that provide them multiple means for seeking redress of their 

complaints. The existence of these remedies also strengthens the position of

residents in the informal negotiations through which most such disputes are 

resolved in practice. Massachusetts has created a small staff of ombudsmen 

dedicated exclusively to serving assisted living residents. This allows them 

to specialize in addressing the particular problems that arise in assisted 

living facilities. 

Assisted living facilities provide 

help with activities of daily living in 

a residential setting for individuals 

who cannot live independently but 

do not require 24-hour skilled 

nursing care. In 2002, over 36,000 

assisted living facilities served 

approximately 900,000 residents. 

The states establish and enforce 

licensing standards for these 

institutions. Because states have 

taken widely differing approaches 

to regulating and supporting 

assisted living, they can potentially 

learn from each other’s 

experiences as they consider 

changes to their own policies. 

GAO was asked to review 

challenges faced by consumers and 

providers of assisted living and 

seek out notable state initiatives 

addressing those challenges in 

three selected areas: (1) disclosure 

of full and accurate information to 

consumers, (2) state assistance to 

providers to meet licensing 

requirements, and (3) procedures 

for addressing residents’ 

complaints. We identified specific 

examples of individual programs in 

Florida, Texas, Washington, 

Georgia, and Massachusetts that 

highlighted different approaches in 

these three areas, which other 

states might wish to consider 

emulating. 
Page i GAO-04-684 Assisted Living 

Letter 1

Results in Brief 2

Background 3

State Efforts to Enhance Consumer Information on Facility 

Options 7

State Efforts to Facilitate Provider Compliance with Licensing 

Requirements 14

State Efforts to Strengthen Residents’ Complaint Procedures 20

Concluding Observations 27

Comments from the States 28

Appendix I Key Sources Consulted 29 

Appendix II Florida Affordable Assisted Living “Find-a-Facility” 

Consumer Search 32 

Appendix III Texas Assisted Living Disclosure Statement 34 

Appendix IV GAO Contact and Staff Acknowledgments 39 

GAO Contact 39

Acknowledgments 39

Contents 
Page ii GAO-04-684 Assisted Living 

Abbreviations 

ADL activities of daily living 

DOEA Florida Department of Elder Affairs 

DSHS Washington Department of Social and Health Services 

EOEA Massachusetts Executive Office of Elder Affairs 

ORS Georgia Office of Regulatory Services 

OSAH Georgia Office of State Administrative Hearings 

QIC Washington Quality Improvement Consultation Program 

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Page 1 GAO-04-684 Assisted Living 

April 30, 2004 

The Honorable Larry E. Craig 

Chairman 

The Honorable John B. Breaux 

Ranking Minority Member 

Special Committee on Aging 

United States Senate 

The Honorable Ron Wyden 

United States Senate 

A growing number of elderly Americans who can no longer live 

independently have turned to assisted living as an alternative to nursing 

homes. Assisted living facilities provide help with activities of daily living 

(ADL) in a residential setting for individuals who do not require 24-hour 

skilled nursing care. In 2002, over 36,000 assisted living facilities served 

approximately 900,000 residents. In contrast to nursing homes, with their 

extensive federal rules and mandates, the federal government exercises 

minimal oversight of assisted living facilities. The states establish and 

enforce licensing standards for these institutions. 

For a number of years, the Senate Special Committee on Aging has 

monitored developments in the assisted living industry. In 2001, the 

committee asked a broad-based group of stakeholders to form a 

committee, known as the Assisted Living Workgroup, to develop 

recommendations that could help states and other entities ensure the 

quality of assisted living services across the country. The Workgroup 

issued its report in April 2003. It contained 110 specific recommendations 

covering a wide range of topics, each supported by two thirds or more of 

the 48 participating organizations. These recommendations included 

proposals to enhance the information provided to potential residents as 

they choose among assisted living facilities, to have states consider 

offering providers technical assistance to address state licensing 

standards, and to expand federal and state support for assisted living 

residents who have complaints about their facilities. 

United States General Accounting Office 

Washington, DC 20548 
Page 2 GAO-04-684 Assisted Living 

Subsequently, you asked us to review state efforts in these three selected 

areas: (1) disclosure of full and accurate information to consumers, (2) 

state assistance to providers to meet licensing requirements, and (3) 

procedures for addressing residents’ complaints.1

 As you requested, we 

agreed to examine the challenges faced by consumers as well as providers 

in these three areas and then seek out notable state initiatives intended to 

address these issues, outlining for each selected program or policy its 

main features, intended benefits, and perceived effectiveness. 

In addressing these objectives, we interviewed experts from academia and 

selected assisted living organizations representing for-profit and nonprofit 

providers, consumer advocates, and state regulators. (See app. I.) Working 

largely with the information obtained from these interviews, combined 

with available research and evaluations on assisted living and guides to 

applicable state regulations, we chose five specific initiatives from Florida, 

Texas, Washington, Georgia, and Massachusetts to highlight. We based 

this selection on evidence that the chosen program or policy in that state 

differed in defined ways from approaches typically taken by other states. 

We did not undertake a formal evaluation of these programs or policies, 

nor did we systematically compare them with alternative approaches 

adopted in other states. For each of the selected initiatives, we conducted 

additional interviews with responsible state officials as well as 

representatives of providers and consumers in that state. We also drew on 

any relevant studies, tracking data, or related public documents. We 

reviewed relevant laws and regulations in the five states with initiatives 

selected for study. References to assisted living laws and regulations in all 

other states are based on secondary sources. We performed this work 

from November 2003 through April 2004 in accordance with generally 

accepted government auditing standards. 

Consumers faced with choosing an assisted living facility often do not 

have key information they need in order to identify the one most likely to 

meet their individual needs. Such information includes staffing levels and 

qualifications, costs and potential cost increases, and the circumstances 

that could lead to involuntary discharge from the facility. Initiatives in 

Florida and Texas have made critical data for selection among facilities 

more readily available to prospective assisted living residents. Florida has 

 1

In this report, we use the term “complaint procedure” to encompass state policies that 

refer to either complaints or grievances. 

Results in Brief 
Page 3 GAO-04-684 Assisted Living 

created a Web site that enables consumers to learn about all of the 

facilities in their vicinity and identifies those providing the services the 

consumers are seeking in a specified price range. Texas has mandated a 

standardized disclosure statement for assisted living facilities, giving 

consumers concise and consistent data that facilitate comparisons across 

providers regarding services, charges, and policies. 

Assisted living facilities are more likely to meet and maintain licensing 

standards if they can obtain help in interpreting those standards and in 

determining what concrete changes they need to make to satisfy them. 

Washington State established a staff of quality consultants to provide such 

training and advice to assisted living providers on a voluntary basis. 

Evaluations of the program 6 months after its start and 2 years later 

documented improvements in provider compliance as well as resident 

health and safety. However, a statewide budget crisis led to a decision to 

stop funding the program, in order to maintain traditional licensing 

enforcement functions. 

Assisted living residents sometimes need help pursuing any complaints 

that they may have with their providers, especially when faced with an 

involuntary discharge. Long-term care ombudsmen are available in all 

states, but nursing home residents claim most of their attention. Georgia 

has legislated an extensive array of procedural remedies specifically for 

assisted living residents that provide them multiple means for seeking 

redress of their complaints. The existence of these remedies also 

strengthens the position of residents in the informal negotiations through 

which most such disputes are resolved in practice. Massachusetts has 

created a small staff of ombudsmen dedicated exclusively to serving 

assisted living residents. This allows them to enhance their expertise in 

addressing the particular problems that arise in assisted living facilities. 

Over the last decade, assisted living has emerged as an increasingly 

popular long-term care option. Within the continuum of long-term care, 

assisted living facilities typically provide a level of care between 

independent living and nursing homes for persons who need assistance 

with one or more ADLs, such as bathing or dressing.2

 However, states vary 

 2

Independent living facilities generally provide elderly people a residential setting that 

offers meals, housekeeping, laundry, transportation, and social and recreational activities, 

according to the American Seniors Housing Association. These facilities do not provide 

personal care or health services. 

Background 
Page 4 GAO-04-684 Assisted Living 

in the term they use for assisted living—it appears in the licensing 

regulations of most states but some refer instead to personal care homes, 

boarding homes, residential care facilities, adult homes, and homes for the 

aged3

—and in the characteristics of the facilities encompassed by the term 

used. A 2002 study of assisted living policies in each of the 50 states and 

the District of Columbia showed that states differ in the facilities included 

under their assisted living regulations based on facility size, services 

provided, and whether or not the facilities offer specified types of 

accommodations such as private apartments.4

 In addition, the study found 

that many states incorporate a distinctive philosophy of care in their 

regulation of assisted living facilities to emphasize residents’ choice, 

independence, dignity, and privacy. Specifically, 28 states have included an 

assisted living philosophy statement in their regulations, but specifics of 

the statements vary. 

Unlike nursing homes, which are subject to extensive federal regulations, 

assisted living facilities generally have considerable flexibility to 

determine the resident populations that they serve and the services they 

provide. As a result, assisted living facilities vary widely on both of these 

dimensions. Nevertheless, most facilities provide housing, meals, 

housekeeping, laundry, supervision, and assistance with some ADLs and 

other needs, such as medication administration. The majority of assisted 

living residents are between the ages of 75 and 85 and more than two 

thirds are females. About a quarter of assisted living residents need help 

with three or more ADLs.5

 Eighty-six percent of residents require or accept 

help with medication.6

 Facilities differ in the extent to which they admit 

residents with certain needs (including residents who meet the criteria for 

admission to nursing homes) and whether they retain residents as their 

 3

American Seniors Housing Association, Seniors Housing: State Regulatory Handbook, 

(Washington, D.C.: March 2003). Thirty-three states and the District of Columbia refer to 

assisted living in their licensing regulations. 

4

Robert Mollica, State Assisted Living Policy: 2002 (Portland, Me.: National Academy for 

State Health Policy, November 2002). 

5

In contrast, among nursing home residents, about 83 percent require assistance with three 

or more ADLs. Catherine Hawes et al., A National Study of Assisted Living for the Frail 

Elderly: Results of a National Survey of Facilities (Beachwood, Ohio: December 1999), 

Prepared for the Assistant Secretary for Planning and Evaluation, Department of Health 

and Human Services. 

6

Residents need differing levels of assistance with medication, such as supervision of selfmedication or medicine storage and dispensing. National Center for Assisted Living, 

Assisted Living: Independence, Choice, and Dignity (March 2001). 
Page 5 GAO-04-684 Assisted Living 

needs change. For example, a 2000 study found that less than half of the 

assisted living facilities are willing to admit or retain persons who require 

assistance to transfer from bed to chair or wheelchair.7

 This study also 

found that less than half of the facilities would admit or retain residents 

with moderate to severe cognitive problems.8

The type, size, and cost of assisted living facilities also vary widely. Some 

facilities are freestanding while others are located on a campus that 

contains multiple units offering different levels of care (such as nursing 

homes and independent living residences). Those built in the 1980s 

generally provide semiprivate accommodation while the newer facilities 

typically offer private apartments. Facilities range in size from a few beds 

to over a thousand. The average facility in a nationwide study had 53 

beds.9

 Many facilities are independently owned while others belong to 

regional or national chain corporations. Assisted living fees vary widely 

across and within states depending on the facility’s size, service, and 

location. For example, the average monthly base rate ranged from $1,020 

in Mississippi to $4,429 in Washington, D.C., according to a recent industry 

survey.10 Residents often pay additional fees for special care units and 

other services, such as medication administration and transportation. Two 

thirds of assisted living residents pay out-of-pocket, but many states use 

 7

Catherine Hawes et al., A National Study of Assisted Living for the Frail Elderly: Final 

Summary Report (Beachwood, Ohio: November 2000), Prepared for the Assistant 

Secretary for Planning and Evaluation, Department of Health and Human Services. 

8

The Alzheimer’s Association concluded from the most recent available research that at 

least half of elderly assisted living residents have some degree of cognitive impairment, 

though most of them do not live in specialized dementia care units. The Association based 

its estimate of the prevalence of cognitive impairment on state and national studies 

conducted between 1997 and 2002. See Alzheimer’s Association, People with Alzheimer’s 

Disease and Dementia in Assisted Living (Advocacy and Public Policy Division) Aug. 13, 

2003; Alzheimer’s Association, Special Care Units in Assisted Living, (Public Policy 

Division) August 2003. 

9

Catherine Hawes et al., A National Study of Assisted Living for the Frail Elderly: Results 

of A National Survey of Facilities, (Beachwood, Ohio: December 1999). 

10The MetLife Market Survey of Assisted Living Costs, MetLife October 2003. LifeCare Inc. 

conducted this survey for MetLife. It was not based on a representative national sample, 

though it included 87 major markets in all 50 states and the District of Columbia. According 

to this survey, the national average monthly base rate for an assisted living facility resident 

in the United States is $2,379 ($28,548 per year). 
Page 6 GAO-04-684 Assisted Living 

Medicaid and other federal and state funds to help finance such care.11 As 

of October 2002, 41 states used Medicaid reimbursement to cover assisted 

living or related services for more than 102,000 people.12

The federal government exercises minimal oversight over assisted living, 

leaving to the states primary responsibility for ensuring that assisted living 

residents have adequate protections.13 Some states fulfill this responsibility 

by establishing licensing standards, inspection procedures, and 

enforcement measures. Nevertheless, the regulatory approaches to 

assisted living adopted by states vary widely in scope and structure. For 

example, some states delineate the services that assisted living facilities 

may or may not provide—sometimes with multiple tiers of licenses for 

more specialized care—while others grant broad flexibility to providers to 

meet the individual needs of residents and their families.14 All states have 

long-term care ombudsmen with potential jurisdiction over assisted living 

facilities. Among other things, ombudsmen may provide services to 

protect assisted living residents and resolve complaints that they file. 

Ombudsmen may monitor quality of care, educate residents about their 

rights, and mediate disputes between residents and providers. 

 11Assisted Living: Independence, Choice, and Dignity, National Center for Assisted Living 

(March 2001). To help pay for assisted living services such as personal care and 

homemaker services, states typically use Medicaid waivers, specifically the Home and 

Community Based Services Waiver. These waiver payments do not cover room and board. 

States have considerable flexibility in determining the type of services and recipients 

covered under these waivers with limited reporting requirements to the federal 

government. For details on reporting requirements, see U.S. General Accounting Office, 

Long-Term Care: Federal Oversight of Growing Medicaid Home and Community–Based 

Waivers Should be Strengthened, GAO-03-576 (Washington, D.C.: June 20, 2003). 

12Robert Mollica, State Assisted Living Policy: 2002 (Portland, Maine: National Academy 

for State Health Policy, November 2002). 

13Although a number of federal agencies have jurisdiction over certain aspects of consumer 

protection and quality of care in assisted living, few federal standards or guidelines 

specifically govern assisted living. In general, the role of federal agencies in this area is to 

administer laws that relate to the funding of certain programs, such as Medicaid 

reimbursement for the direct care services component of assisted living and funding the 

state-run long-term care ombudsmen program. The federal government grants broad 

discretion to the states in carrying out their oversight responsibilities. For further details 

see U.S. General Accounting Office, Long-Term Care: Consumer Protection and Qualityof-Care Issues in Assisted Living, GAO/HEHS-97-93 (Washington, D.C.: May 15, 1997). 

14Robert Mollica, et al, State Assisted Living Practices and Options: A Guide for State

Policy Makers, (Washington, D.C.: Development Corporation: September 2001). 
Page 7 GAO-04-684 Assisted Living 

Prior GAO reports have addressed a number of consumer protection and 

quality of care issues that remain at the forefront of public concerns about 

assisted living.15 These reports raised questions about the adequacy of 

information available to prospective consumers to help them choose a 

facility that meets their needs. The 1999 report also discussed states’ 

varying approaches to oversight and the type and frequency of consumer 

protection and quality of care problems that state agencies identified. 

Given the wide diversity among assisted living facilities in the services 

they offer and the populations they are prepared to serve, prospective 

assisted living residents can have difficulty finding an appropriate—let 

alone the most appropriate—facility to meet their individual needs. 

Initiatives such as the Florida “Find-a-Facility” Web site and the Texas 

standardized disclosure statement help consumers make better choices by 

providing them the information they need in an easier-to-absorb format. 

Available studies and interviews with our experts indicate that consumers 

choosing among their assisted living options often lack the information 

they need to make a fully informed selection. The limitations in the 

information currently provided to consumers relate to both its substantive 

content and mode of presentation. To make appropriate choices among 

the wide range of facility options available in the market, consumers need 

to learn about facility services, costs, and policies that impact residents. 

Moreover, they need this information to be not only complete and 

accurate, but also presented in a timely way and in a form that they can 

understand. When consumers do not receive adequate information before 

selecting an assisted living facility, they are less likely to find a facility that 

can satisfactorily address their personal care needs. 

In making selection decisions, consumers rely on facility information that 

they receive in various ways, including marketing brochures, facility tours, 

and interviews with providers. Consumers also rely on the advice of 

family, friends, or health care professionals. Our 1999 report stated that 

marketing materials, contracts, and other written materials that facilities 

give consumers were often vague, incomplete, or misleading. Specifically, 

 15U.S. General Accounting Office, Assisted Living: Quality-of-Care and Consumer 

Protection Issues in Four States, GAO/HEHS-99-27 (Washington, D.C.: Apr. 26, 1999) and 

GAO/HEHS-97-93. 

State Efforts to 

Enhance Consumer 

Information on 

Facility Options 

Consumers Often Lack Key 

Information to Make 

Appropriate Choices 
Page 8 GAO-04-684 Assisted Living 

the report found that facilities’ written materials often did not contain key 

information, such as a description of services not covered or available at 

the facility, the staff’s qualifications and training, circumstances under 

which costs might change, assistance residents would receive with 

medication administration, facility practices in assessing needs, or criteria 

for discharging residents if their health changes. Subsequent studies, 

including the 2003 Workgroup report, as well as experts that we 

interviewed, indicate that consumers continue to have difficulty obtaining 

full disclosure of the information they need.16 In response to this 

deficiency, 18 states have instituted information disclosure policies, such 

as requirements on the use of uniform disclosure statements or the 

contents of written materials provided to prospective residents.17

Our expert interviews and the studies we reviewed identified information 

about staffing levels and qualifications, costs and potential cost increases, 

and facility policies regarding discharge criteria as critical to informed 

decision making. Consumers need to know, for example, whether a facility 

has staff to provide full 24-hour service to address recurring care needs, 

such as assistance administering medications, as distinct from a facility 

whose overnight staff is only available to deal with emergency situations. 

While some facilities reportedly disclose only aggregate staffing data, the 

most important information for consumers concerns the number of staff 

directly involved in providing care to residents. Expert interviews and 

reviewed studies also indicated that consumers do not always receive 

information clearly explaining the circumstances under which resident 

costs can increase. Similarly, according to a consumer advocate 

organization, providers do not always inform consumers about the 

circumstances under which they could be involuntarily discharged from 

their facility, even when state regulations dictate that residents must leave 

if their needs reach a certain level. 

The experts we interviewed underscored the importance of conveying 

critical information about assisted living choices in a way that consumers 

can readily absorb. The experts explained that prospective residents and 

 16White Paper on Assisted Living, National Academy of Elder Law Attorneys, Inc. (Tucson, 

Az.: 2001). Deanna Okrent and Virginia Dize, Ombudsman Advocacy Challenges in Assisted 

Living: Outreach and Discharge (Washington, D.C., National Association of State Units on 

Aging: March 2001). 

17See State Assisted Living Policy: 2002 (Portland, Maine: National Academy for State 

Health Policy, November 2002), section 1.5. 
Page 9 GAO-04-684 Assisted Living 

family members often have difficulty grasping the information presented 

to them, especially when they have to make decisions quickly to address a 

crisis situation. Under these circumstances, consumers often do not know 

what questions to ask or how to assess and compare the responses that 

they receive in order to identify the facility that can best meet their 

individual needs. 

When consumers do not get complete and accurate information on the 

assisted living alternatives available to them, in a form that they can 

understand, they run the risk of choosing a facility that cannot adequately 

meet their personal care requirements. A likely consequence is that they 

will have to move again within a short time. Both consumers and providers 

benefit if they can minimize this risk by ensuring that the consumer has, 

and can use, the critical information relevant to making an informed 

choice among different facilities. 

In the summer of 2003, Florida’s Department of Elder Affairs (DOEA) 

launched its Affordable Assisted Living Web site to enhance public access 

to information on assisted living.18 One of its features is called “Find-aFacility,” a search tool that allows anyone with internet access to identify 

those Florida assisted living facilities that match the preferences set by the 

user. The available options include geographic location, price range, 

housing configurations (such as private apartments), whether the facility 

accepts residents with government subsidies or certain disabilities, and 

clinical and social services offered. (For examples of the Web site pages, 

see app. II.) Once the user selects his preferences among the available 

options, the site generates a list of licensed facilities, with those most 

closely matching the chosen preferences ranked highest. For each of these 

facilities, the user can print out a one-page description that includes the 

facility’s contact information, number of beds, specific government 

subsidy programs it participates in, any specialized care licenses, and all of 

its entries on the list of selection options. 

Development of the Web site occurred through a collaboration of public 

and private entities. It began under Florida’s Coming Home Program, 

sponsored by the Robert Wood Johnson Foundation. DOEA established a 

committee comprised of representatives of providers, consumers, and 

regulators. They found a need for a comprehensive information 

 18Found at www.floridaaffordableassistedliving.org. 

Florida Sponsors an 

Internet-based Facility 

Locator 
Page 10 GAO-04-684 Assisted Living 

clearinghouse to inform both providers and consumers about assisted 

living options and the multiple long-term care and housing assistance 

programs designed to make these options more widely available. The 

“Find-a-Facility” feature developed from discussions with social workers 

and case managers who had helped elderly clients find appropriate 

assisted living residences. They underlined the need to identify the 

facilities that met their clients’ needs and preferences and that the clients 

could afford, often with the assistance of government subsidies. Many had 

been relying on placement agencies, which would only list facilities that 

had paid the agency a fee. Larger, more expensive, private pay facilities 

were more likely to sign on with the placement agencies, meaning that 

prospective residents were less likely to find out about smaller, less 

expensive, or subsidized facilities in their area. 

Several state agencies then joined together in the technical development 

of the Web site. Specifically, DOEA, the Florida Agency for Health Care 

Administration, and the Florida Housing Financing Corporation 

contributed staff time and services, in addition to state funding of about 

$29,000. The state tested the prototype site for several months with 

different consumer groups, such as Alzheimer caregivers and visitors to 

neighborhood senior centers. Based on the feedback received, state 

officials made further refinements in the wording of entries, their 

organization, and the instructions provided to users. DOEA subsequently 

developed a Spanish-language version of the site, which came into 

operation in April 2004. 

To promote the Web site, the state informed providers and potential 

residents of assisted living facilities about the site and how to use it. DOEA 

took care to contact professionals who typically help place residents in 

assisted living, distributing brochures to social workers and hospital 

discharge planners as well as local area agencies on aging. Consumer 

advocacy groups such as AARP and the Alzheimer’s Association were also 

encouraged to help get the word out about the Web site. Usage rates have 

increased steadily, reaching about 250 visitors a day by February 2004. 

DOEA also provided training to assisted living providers, to help them 

enter much of the data presented on the Web site. All licensed facilities are 

included in the basic database, with information on facility location, 

number of beds, state licenses held, and contact information downloaded 

from Agency for Health Care Administration files. However, providers 
Page 11 GAO-04-684 Assisted Living 

voluntarily enter virtually all of the descriptive information on price range, 

housing configurations, populations served, and services offered.19 A 

provider representative indicated that entering the Web site data initially 

takes 10 to 15 minutes. Providers can update their information at any time. 

By February 2004, approximately 40 percent of assisted living facilities had 

filled in their data fields. DOEA receives about two inquiries a week from 

providers asking for assistance, but in general the providers find this 

process relatively easy. Initial skepticism among some providers has 

diminished as they hear from providers already in the system and they 

recognize the inherent advantage of free advertising. This is especially 

beneficial for smaller, independent facilities that cannot match the 

commercial advertising of the national and regional chains. 

A state administrator noted that maintenance of the Web site requires 

some continuing effort. With substantial turnover among facility providers 

and professionals assisting prospective residents, outreach and training is 

an ongoing process. DOEA also tries to spot-check at least some key data 

elements entered into the system, even though the Web site itself 

prominently displays a disclaimer that provider-entered data have not 

been verified for accuracy. 

No formal evaluations of the Web site have yet been undertaken, but 

informal feedback has been uniformly positive according to both provider 

and consumer representatives, as well as the state official responsible for 

its operation. Consumers, and those acting on their behalf, are finding that 

the Web site has several distinct advantages over previously available 

information sources. Most importantly, it provides a way to efficiently 

narrow their search. They can quickly identify the universe of facilities 

within a given area and determine which offer the services they are 

looking for at a price they can afford. Current information about 

participation in government subsidy programs is especially valuable for 

many prospective residents of limited means. In addition, because “Find-aFacility” is on the internet, out-of-state family members can actively 

participate in the process of locating an appropriate facility. Similarly, the 

Web site makes it much easier for professionals assisting elderly clients, 

such as social workers and hospital discharge planners, to determine the 

full list of available placement options. 

 19DOEA is working to facilitate provider access to the internet. It has helped that a

substantial number of assisted living facilities already had acquired internet access in

response to earlier state incentives for submitting Medicaid bills electronically.
Page 12 GAO-04-684 Assisted Living 

In 1999, Texas enacted a law requiring assisted living facilities to provide 

each prospective resident a consumer disclosure statement that follows a 

standard format approved by the Department of Human Services.20 Its 

purpose is to enable consumers to better compare facilities by describing 

their policies and services in terms of uniform categories. However, its 

effectiveness depends not only on its content but also on how and when 

facilities distribute it to consumers. 

This five-page checklist form addresses many of the topics identified in 

our expert interviews as critical for consumers choosing among 

alternative assisted living facilities. It describes the services and amenities 

provided to all residents, as well as those offered at additional cost. (See 

app. III.) The form also lists circumstances that could lead a resident to be 

discharged from the facility and the training received by staff. It includes a 

chart showing the number and type of staff on duty for each daily shift, 

which is also posted in public view at the facility. 

While a number of other states have developed similar forms—particularly 

for specialized dementia units—Texas is notable for having been among 

the first to develop a standardized disclosure statement for all assisted 

living facilities, and to include detailed information on staffing levels. The 

standardized response categories specified by the form make the 

furnished information consistent across facilities, allowing consumers to 

make comparisons more readily among them. The checklist format means 

that consumers see what services the facility does not provide as well as 

those it does. There is one version of the form for assisted living facilities 

in general and another, covering many of the same topics, adapted 

specifically for units specializing in dementia care. Neither form, though, 

has been translated into any languages other than English. 

State officials described the process of developing these forms as 

proactive on their part—rather than in response to external complaints—

and relatively uncontroversial. The disclosure statement for specialized 

dementia units emerged from a state-organized advisory committee 

including provider and consumer advocates. That served as the model for 

the more generic assisted living form issued by the department shortly 

thereafter. Since then, according to both state officials and an official of a 

state provider association, providers have accepted both forms without 

complaint. State officials believe that this extensive involvement of 

 201999 Tex. Gen. Laws ch. 233 §1 (Tex. Health & Safety § 247.026 (2003)). 

Texas Requires Facilities 

to Distribute Standardized 

Disclosure Statements 
Page 13 GAO-04-684 Assisted Living 

providers, along with consumer representatives, in the development of the 

form, contributed greatly to its wide acceptance among providers as a 

whole. 

Providers vary considerably in the way they distribute the form. Some 

send it out to people making phone inquiries, some provide it when 

prospective residents or their family members visit the facility, and some 

wait to distribute it when the contract is signed. Although the form states 

that copies should be provided to anyone who requests information about 

the facility, providers are only held accountable for ensuring that those 

who ultimately become residents in their facility received the completed 

form by the time they were admitted. According to the consumer 

representative we interviewed, residents who obtain the disclosure 

statement during the admissions process often pay little attention to it 

given all the other papers they receive and sign at that time. 

Once instituted, the Texas disclosure form has imposed few burdens on 

either assisted living providers or state officials. According to the provider 

association official we interviewed, it takes no more than 20 to 30 minutes 

to complete. The biggest challenge is remembering to revise affected 

entries on the form when a facility changes its services or staffing 

patterns. Such revisions happen perhaps four or five times a year, on 

average. To meet regulatory requirements, providers need to document 

that residents have seen the form prior to their admission.21 As part of their 

annual inspection of licensed assisted living facilities, state inspectors can 

assess whether a facility has a form ready to distribute and that current 

residents received the disclosure form before signing their residence 

agreement. However, the inspection process does not include an explicit 

examination of the accuracy of the information provided on the form. 

Available evidence suggests that the assisted living disclosure statement 

provides useful information to prospective residents, though it does have 

certain limitations. None of the state, provider, or consumer 

representatives we spoke with knew of any formal studies conducted on 

the effectiveness of the form in enhancing consumer decision making on 

assisted living facilities. However, the anecdotal evidence they conveyed 

was largely positive. The consumer and provider representatives we spoke 

with generally thought that the form was clear and covered the major 

topics that consumers need to know about. Nonetheless, the consumer 

 2140 Tex. Admin. Code § 92.41(d). 
Page 14 GAO-04-684 Assisted Living 

representative indicated that some residents and their families still 

encountered “surprises” after the resident was admitted. These typically 

involved the conditions under which residents could be discharged or 

aggregate charges assessed. According to this representative, such 

misunderstandings reflected, in part, the intrinsically subjective nature of 

certain decisions, such as whether a facility could continue to meet the 

needs of a resident whose level of disability may have increased over time. 

The provider official we interviewed suggested that the form itself could 

be revised to more clearly convey how increases in services used would 

affect the resident’s total charges. 

The Texas disclosure form addresses several challenges that consumers of 

assisted living can face. The categories of information provided on the 

form help to describe for consumers, who often know little about the 

industry and may need to make a decision quickly, what facilities can and 

cannot do for their residents. They also highlight important issues, such as 

the facility’s discharge criteria, that prospective residents and their 

families should pay attention to in making their selection. In addition, 

having comparable information in a concise format for multiple facilities 

should make it easier to identify key differences among the facilities under 

consideration. However, these benefits depend on when the residents or 

their representatives receive the form. If facilities do not distribute the 

form to consumers until they sign a contract, it cannot help them in 

deciding among available facilities. 

Assisted living providers may fall short of meeting state licensing 

standards in part because they lack a full understanding of what the 

standards require and how to meet them. The experience of Washington 

State, which for 2 1⁄2 years employed a staff of consultants to advise and 

train assisted living providers, shows the potential benefits of licensing 

assistance programs in improved provider compliance and resident 

outcomes, as well as the challenge of sustaining them over time. 

State Efforts to 

Facilitate Provider 

Compliance with 

Licensing 

Requirements 
Page 15 GAO-04-684 Assisted Living 

Regulations that address consumer protection and quality of care 

generally cover such areas as admission and discharge criteria, services 

and level of care provided, staffing levels and staff training, safety and 

health standards, and resident rights.22 To examine regulatory compliance, 

states periodically conduct inspections of assisted living facilities. To 

ensure that facilities correct their deficiencies, states may require the 

facility to prepare a written plan of correction. In addition, states may 

conduct reinspections and impose financial penalties, license revocations, 

and criminal sanctions. Generally, when deficiencies are found, the facility 

has an opportunity to correct them. However, regulatory agencies expect 

providers to determine how to accomplish this, drawing on outside 

technical advice, if needed, to resolve the issue. According to experts we 

interviewed, state agencies face the challenge of inspecting a rapidly 

increasing number of assisted living facilities with limited resources. While 

national data are not available, a number of inspection reports and media 

articles indicate that typical problems relate to inadequate care, 

inappropriate discharges, insufficient staffing and training deficiencies, 

improper drug storage or errors dispensing medications, and other safety 

issues.23

One way to facilitate compliance with licensing regulations is to help 

providers achieve a better understanding of what the regulations actually 

require. The experts that we interviewed stated that providers often 

express confusion about actions they need to take to meet state policy or 

regulatory requirements. They noted that providers perceive ambiguities in 

regulations that can lead to inconsistent interpretations among different 

facility managers as well as individual state inspectors. Moreover, the 

rapid industry expansion has brought many new providers into the 

assisted living industry whose administrators may not fully understand 

what they need to do to meet regulatory requirements. Experts also said 

that uncertainties about state requirements could have negative effects on 

 22American Seniors Housing Association, Seniors Housing: State Regulatory Handbook 

(Washington, D.C.: March 2003); Robert Mollica, State Assisted Living Policy: 2002 

(Portland, Maine: National Academy for State Health Policy, November 2002) Section III; 

Stephanie Edelstein and Karen Gaddy, Assisted Living: Summary of State Statutes

(Washington, D.C., AARP Public Policy Institute: 2000). 

23Florida Agency for Health Care Administration, Nursing Home and Assisted Living 

Facility: Adverse Incidents & Notices of Intent Filed, Report to the Legislature May 2003 

Status Report published in June 2003; Texas Department of Human Services, Fiscal Year 

2003: Long Term Care Regulatory Annual Report, November 2003; American Bar 

Association, Assisted Living: Federal and State Options for Affordability, Quality of 

Care, and Consumer Protection, Bifocal Vol. 23. No. 1, Fall 2001; GAO/HEHS-99-27. 

Providers Are Sometimes 

Uncertain about 

Regulatory Requirements 
Page 16 GAO-04-684 Assisted Living 

consumers. For example, confusion about state rules could induce some 

providers to drop out of the market, which might lead to access problems 

in some areas, particularly in rural communities that tend to have fewer 

assisted living providers to begin with. 

According to experts we interviewed, state licensing agencies or other 

entities can help providers understand regulations by providing guidance 

and training. Licensing assistance can take various forms, including 

informal phone conversations, on-site consultation and technical advice, 

or training courses. Such assistance may be especially critical for 

administrators who are new or relatively inexperienced in the assisted 

living industry. Even for established managers, helping them to keep their 

facilities in compliance with regulatory requirements benefits consumers 

by preventing potentially serious health and safety problems. While many 

experts we interviewed noted the value of combining such assistance with 

traditional regulatory enforcement measures, not all agreed that state 

agencies should provide it. Several noted that industry associations could 

also furnish this kind of support for their members. Moreover, 

representatives from one advocacy organization argued that efforts by 

licensing agencies to provide technical assistance to providers could draw 

scarce resources away from their primary responsibility of enforcing state 

licensing standards. 

Washington enacted a law in 1997 to establish a consultative approach to 

help assisted living providers meet state licensing requirements.24 In 2000, 

the state put this approach into operation with the Quality Improvement 

Consultation (QIC) program, which created a staff of consultants within 

the state’s Department of Social and Health Services (DSHS) to provide 

training and advice to individual providers. The staff of nine regionally 

based consultants conducted site visits, led training sessions, and 

responded to telephone inquiries from assisted living providers throughout 

the state. These activities continued for 2 1⁄2 years until, in the midst of a 

state budget crisis, the state stopped funding the program. 

The QIC program came about in response to provider concerns about a 

major structural reorganization in the state’s regulation of assisted living. 

In 1995, the state moved licensing and oversight responsibility for assisted 

 241997 Wash. Laws c. 392 § 213 (Wash. Rev. Code § 18.20.115 (2003)). In Washington, 

“assisted living facilities” are referred to as “boarding homes.” 

Washington Employed 

Consultants to Assist 

Providers with State 

Licensing Requirements 
Page 17 GAO-04-684 Assisted Living 

living from the Department of Health to DSHS. Because DSHS also had 

enforcement authority over nursing homes, providers anticipated that the 

state would approach assisted living regulation as it had nursing home 

oversight and lobbied for a more consultative approach. The state 

legislature responded by requiring DSHS, within available funding, to 

develop the QIC program. DSHS expected the program to enhance 

provider and resident satisfaction, improve resident safety and quality of 

care, and prevent compliance problems. 

A quality improvement advisory group consisting of representatives of 

providers, consumers, and the state came together to develop the QIC 

program. Most of the group’s discussion revolved around the meaning of 

“consultation.” Provider and consumer representatives differed on 

whether providers could be required to participate in the program. 

Providers insisted that the program be entirely voluntary, while some 

ombudsmen believed that the providers most in need of help might be 

least likely to ask for it.25 Provider representatives also expressed concern 

about the relationship of the consultants with the DSHS inspectors who 

enforced the state’s licensing regulations. In particular, they worried that 

inspectors could have access to private information that providers had 

shared with a consultant, leading to enforcement actions rather than 

assistance. In addition, they wanted to prevent such information from 

appearing in public records. 

After much discussion, the group reached consensus to make the QIC 

program voluntary and to define the consultants as adjuncts to, but 

separate from, the licensing enforcement process. The consultants would 

not forward information to inspectors unless they identified a situation 

involving immediate harm to residents. In addition, information obtained 

from providers would not be released publicly except in aggregated form. 

The state hired nine quality improvement consultants who had extensive 

education and experience in quality improvement, training, and 

consultation in the assisted living industry. The consultants conducted 

onsite facility visits initiated by providers in order to help them develop 

and implement quality improvement plans that addressed identified needs. 

They also led regional provider training and were available by telephone to 

respond to provider inquiries. 

 25Washington providers specifically rejected the model of a technical assistance program 

that would authorize state licensing inspectors to refer facilities for consultation on a 

specified topic. 
Page 18 GAO-04-684 Assisted Living 

Two evaluations of the QIC program indicated overall positive results in 

meeting its goals.26 The first evaluation took place 6 months into the 

program. It measured effectiveness through analysis of resident outcomes 

and responses to satisfaction questionnaires completed by residents, 

ombudsmen, providers, facility staff, and consultants. The second 

evaluation occurred 2 years later. It assessed provider compliance with 

licensing regulations and satisfaction levels among providers and 

ombudsmen who participated in the onsite portion of the program. 

After 6 months of operation, about 82 percent of providers voluntarily 

participated in the QIC program in some way.27 Moreover, in both 

evaluations, a large majority of participating providers expressed 

satisfaction with the QIC program. Over 90 percent of those providers 

indicated in the first evaluation that the program had effectively assisted 

them with compliance. Although this level of satisfaction declined slightly 

to about 79 percent 2 years later, providers indicated in the second 

evaluation that consultation in a voluntary, mutually respectful, and 

collegial manner was the program’s most beneficial component. 

Assisted living residents also reported positive outcomes from the 

program. In the first evaluation, 90 percent of residents expressed 

satisfaction with the results of the program’s on-site visits. Among those 

residents assessed by consultants on more than one visit, 86 percent 

showed improvement in identified areas of concern. These areas involved 

a variety of quality of care issues, including administration of medications 

and ADL assistance. Similarly, with respect to safety issues, 65 percent of 

the residents seen on more than one visit demonstrated improvement in 

areas such as prevention of falls. 

Finally, both providers and the state attributed improvements in 

regulatory compliance partly to the work of the QIC program. The second 

evaluation included an analysis of statewide provider compliance prior to 

(1998 to 2000) and after implementation (2001 to 2002) of the QIC 

program. Although there was a slight increase in the number of state 

 26Alice Mahar Dupler; Neva L Crogan; Robert Short, “Pathways to quality improvement for 

boarding homes: A Washington state model,” Journal of Nursing Care Quality; Jul 2001; 

15(4), 1-7; Alice Mahar Dupler, “Quality Improvement Consultation Program in Assisted 

Living Facilities, A Washington State Pilot Program: Phase II,” unpublished, no date. 

27Among all the state’s assisted living facilities, 25 percent engaged in on-site visits, 

approximately 36 percent participated in training sessions, and about 20 percent received 

telephone consultation. 
Page 19 GAO-04-684 Assisted Living 

inspections conducted, the number and percentage of facilities that had 

penalties imposed fell substantially. The state imposed fewer civil fines, 

conditions on licenses, license revocations, and summary suspensions. 

Finding fewer problems during inspections also meant that each 

inspection required less time to complete and document, thereby allowing 

more efficient use of inspection resources. 

Despite its broad support and favorable outcomes, the QIC program ended 

in July 2002. After 2 1⁄2 years of operation, it lost its state funding and has 

since remained an unfunded program. According to state officials and 

consumer representatives, the program’s end was primarily due to funding 

constraints. A severe state budget crisis in 2002 put significant pressure on 

DSHS to cut costs while maintaining its core functions of conducting 

inspection and complaint investigations. The department decided that it 

needed more inspectors for this work, and that licensing assistance 

through the QIC program had lower priority. However, the provider 

representative emphasized that insufficient trust between providers and 

the state also contributed to the program’s end. While the evaluation 

results pointed to substantial success overall in building functioning 

relationships, the provider representative described several incidents of 

broken confidentiality between providers and consultants that tended to 

undermine the providers’ willingness to participate in the program. A state 

official as well as consumer and provider representatives noted that the 

QIC program required collaboration and the sharing of sensitive 

information. Such collaboration depended on providers and consultants 

developing and sustaining trust among themselves, as well as between 

consultants and other state officials, such as inspectors and ombudsmen. 

Washington’s QIC program illustrates both the challenges and potential 

benefits of state efforts to provide licensing assistance to assisted living 

providers. A large number of providers chose to take advantage of the 

consultative services and training offered by the program. Moreover, the 

documented improvements in resident outcomes and in provider 

compliance with regulations demonstrate the impact that programs of this 

sort can have. However, the staff resources needed to provide this level of 

assistance make these programs highly vulnerable in times of budgetary 

constraint. 
Page 20 GAO-04-684 Assisted Living 

Some assisted living residents have difficulty pursuing complaints with 

their providers, particularly in cases involving an involuntary discharge. 

Georgia has established a spectrum of procedural remedies specifically for 

assisted living residents that appear to strengthen their bargaining position 

vis-a-vis providers. Massachusetts created a separate ombudsman staff 

dedicated to assisted living residents. As a result, these staff members 

have become expert in dealing with the particular problems of assisted 

living residents. 

Concerns about problems in assisted living facilities reinforce the need to 

ensure that consumers have adequate mechanisms to raise complaints 

about the care they receive in these facilities.28 For the most part, these 

mechanisms fall into two broad categories: 

• Internal procedures, which specify how residents may lodge complaints 

with the facility’s management and how management may respond. 

• External procedures, which designate an entity outside of the facility to 

hear resident complaints and decide on an appropriate resolution. The 

outside entity may be a state agency or an independent third party. Such 

procedures are most commonly applied to major disputes, such as 

involuntary discharges. 

A national study found that some states require assisted living facilities to 

establish internal complaint procedures, some offer residents a venue for 

external appeals, and some offer both.29 In addition, it noted that some 

states take measures to ensure that assisted living residents are aware of 

these rights, for example by requiring that facilities prominently post 

appropriate telephone numbers and the list of resident rights in that state. 

However, the national study also found that in 2000 over half of the states 

had no requirements that assisted living facilities establish procedures for 

residents to voice complaints or appeal provider decisions that adversely 

affect them. 

 28For information about significant care and safety problems in assisted living see 

GAO/HEHS-99-27; Policy Principles for Assisted Living (April 2003); Assisted Living 

Workgroup, Assuring Quality in Assisted Living: Guidelines for Federal and State 

Policy, State Regulation, and Operations (April 2003). 

29Stephanie Edelstein and Karen Gaddy, Assisted Living: Summary of State Statutes

(Washington, D.C., AARP Public Policy Institute: 2000). 

State Efforts to 

Strengthen Residents’ 

Complaint Procedures 

Residents Often Have 

Difficulty Raising 

Complaints about Their 

Facilities’ Services and 

Policies 
Page 21 GAO-04-684 Assisted Living 

Regardless of their rights to file complaints either internally or externally, 

many residents may hesitate to do so for fear of retribution. According to 

the experts we interviewed and studies of ombudsmen programs, many 

assisted living residents do not want to risk alienating their providers. 

Even when state agencies permit the residents to file complaints 

anonymously, they may find it difficult to maintain their anonymity, 

especially in smaller facilities. 

Among the avenues for residents to seek redress of their complaints is 

through the long-term care ombudsmen program in each state. The Older 

Americans Act directs ombudsmen to represent the interests of residents 

of long-term care facilities, including nursing homes and assisted living 

facilities.30 The act authorizes the ombudsmen to serve as advocates to 

protect the health, safety, welfare, and rights of residents of long-term care 

facilities. One of the main responsibilities of ombudsmen is to investigate 

and resolve complaints.31 Ombudsmen involvement in assisted living varies 

considerably depending on state policies and the resources available to 

address the myriad complaints that they receive from all types of longterm care facilities. However, experts we interviewed noted that most 

ombudsmen focus the bulk of their limited resources on nursing homes. In 

fiscal year 2002, ombudsmen received four times as many complaints 

against nursing homes as assisted living facilities.32

Ombudsmen can help overcome the factors that may inhibit assisted living 

residents from filing complaints. During scheduled visits to assisted living 

facilities, ombudsmen have the opportunity to educate residents on their 

right to file complaints and encourage them to do so. In addition, while the 

ombudsmen are on-site they can receive such complaints discretely. 

 3042 U.S.C. § 3058g (2000) (originally enacted as § 712 of the Older Americans Act of 1965 

by Pub. L. No. 102-375, § 702, 106 Stat. 1195,1275 (1992)). 

31Ombudsmen may receive complaints from residents, family, friends, or facility staff. 

Ombudsmen may also initiate a complaint based on their own observations. Depending on 

state regulations and the nature of the complaint, ombudsmen may refer the complaint to 

another agency, such as the state licensing agency or adult protective services. 

32There were 208,762 nursing home complaints compared to 49,463 assisted living 

complaints in FY 2002, according to data from the U.S. Administration on Aging, 

representing over twice as many complaints per resident for nursing homes as for assisted 

living facilities. Among the top categories of complaints for assisted living were discharges, 

billing charges, staffing shortages, resident care and safety issues. U.S. Administration on 

Aging, National Ombudsman Reporting System Data FY 2002. 
Page 22 GAO-04-684 Assisted Living 

However, financial constraints may limit the frequency with which 

ombudsmen meet with assisted living residents. 

In 1994, Georgia strengthened procedural remedies available to residents 

in assisted living facilities by enacting the Remedies for Residents of 

Personal Care Homes Act.33 These remedies provide additional consumer 

protections beyond the investigation of complaints by its licensing agency, 

the Office of Regulatory Services (ORS) within the Department of Human 

Resources. The state gave assisted living residents specific procedural 

rights to have their complaints heard and redressed. The remedies include 

the right to an internal complaint procedure, an administrative hearing, 

and specified actions in court. According to consumer advocates, the 1994 

law has enhanced the ability of assisted living residents to resolve disputes 

informally with assisted living providers. 

At the time Georgia passed this legislation, assisted living facilities had 

recently come under heightened public scrutiny. Consumer advocates and 

the media had raised concerns about the lack of adequate oversight, as 

evidenced by facilities that maintained extremely poor sanitary conditions 

or that admitted residents who required far greater care than the facility 

could provide.34 In response, the state legislature sought to provide 

assisted living residents with additional consumer protections by creating 

procedural remedies specifically for them. In its legislative findings, the 

state legislature recognized that residents often lacked the ability to assert 

their rights and stated that full consumer protection required that 

residents have a means of recourse when their rights were denied. 

According to the state official, the legislature modeled the act’s procedural 

remedies after remedy options given to nursing home residents through 

both state and federal law. 

 331994 Ga. Laws 461, § 2 (Ga. Code Ann. §§ 31-8-130 et seq. (2003)). In Georgia, “assisted 

living facilities” are referred to as “personal care homes.” 

34The absence of state regulatory authority over assisted living facilities exacerbated these 

problems. At that time, local public health districts had oversight responsibility for assisted 

living facilities, but according to the state official we interviewed, they lacked the resources 

and expertise to perform this function effectively. In 1994, ORS assumed responsibility for 

regulating assisted living facilities. 

Georgia Strengthens 

Procedural Remedies for 

Assisted Living Residents 
Page 23 GAO-04-684 Assisted Living 

The remedies provided in the 1994 legislation include an internal 

complaint procedure and an administrative hearing.35 Residents36 may 

submit an oral or written complaint to a facility administrator, who must 

either resolve the complaint or respond in writing within 5 business days. 

If residents do not find the response satisfactory, they may submit an oral 

or written complaint to the state long-term care ombudsman. Residents 

also have the right to request an administrative hearing under the Georgia 

Administrative Procedure Act.37 They are not required to use any other 

legal remedies before requesting such a hearing. The Office of State 

Administrative Hearings (OSAH) must conduct the hearing within 45 days 

of receiving the request, although state officials may refer the request to an 

ombudsman for informal resolution pending the hearing. If the resident 

alleges that the provider acted in retaliation for the resident exercising his 

or her rights, OSAH must conduct the hearing within 15 days of receiving 

the request. The facility cannot transfer a resident before he has exhausted 

all appeal rights unless he develops a serious medical condition or his 

behavior or condition threatens other residents. 

The act also gives residents access to different types of court proceedings. 

A resident may file a lawsuit seeking compensation from an assisted living 

facility. The resident need not exhaust any of the other legal remedies 

before bringing such a suit. This remedy includes a provision designed to 

protect residents from retaliation by a provider. If the provider attempts to 

remove the resident involuntarily from the facility within 6 months after 

the resident exercises one of the available remedies, the court presumes 

retaliation in an action by the resident making that claim unless the 

provider presents “clear and convincing evidence” to the contrary. 

Residents may also file a lawsuit requesting that the court order a facility 

to refrain from violating the rights of a resident. Finally, residents may file 

a lawsuit for ‘mandamus’—a court order to ORS to comply with laws 

relating to an assisted living facility or its residents. 

These procedural remedies appear to have their greatest effect in 

strengthening the position of residents during informal resolution of 

disputes. The legal aid representatives we interviewed noted that they 

 35The legislation uses the term grievance. 

36A representative or legal surrogate of the resident may also pursue the remedies on behalf 

of the resident. 

37Ga. Code Ann. §§ 50-13-1 et seq. (2003). 
Page 24 GAO-04-684 Assisted Living 

resolve most issues between assisted living residents and providers 

informally. Advocates for residents said that these procedural remedies 

give the advocates added leverage as they negotiate with providers. 

However, advocates also stated that they rarely take the next step of 

actually filing for administrative hearings or court proceedings, in part 

because legal aid cases generally do not reach that step and also because 

they believe that the substantive rights of assisted living residents in 

Georgia are not strong. For example, a resident objecting to an involuntary 

discharge is unlikely to prevail in an administrative hearing because 

providers exercise broad discretion in deciding when they can no longer 

properly care for a resident. However, by requesting a hearing, residents 

can postpone the date by which they must move out, thereby gaining more 

time in which to find a suitable place to relocate. Moreover, according to 

one legal aid attorney, providers often prefer to resolve a dispute 

informally rather than take their chances with an administrative hearing, 

because providers typically have little experience with hearings and prefer 

to limit their costs for legal representation. 

Strengthening Georgia’s procedural remedies for assisted living residents 

required action by the state legislature, but once approved, the procedures 

have imposed minimal costs to the state. An agency to deal with a wide 

range of state administrative issues already existed, and with few hearings 

involving assisted living residents actually conducted, these cases 

represent a small portion of OSAH’s operating expenses. Similarly, the 

state’s long-standing advocates for assisted living residents—long-term 

care ombudsmen and legal aid lawyers—have served to inform both 

providers and residents about these legal remedies while carrying out their 

normal functions. In fact, providers and residents may remain unaware of 

their existence, until the advocates have reason to bring these remedies to 

their attention in the course of resolving disputes. 

In 1994, Massachusetts passed an assisted living statute38 that established a 

statewide assisted living ombudsman program. The program is a key 

element of the statute, which created a certification system for assisted 

living separate from the state’s nursing home regulatory and licensure 

system. According to the state official we interviewed, the primary 

purpose of this ombudsman program is to maintain the quality of life, 

health, safety, welfare, and rights of assisted living residents by 

 381994 Mass. Acts 354, § 3 (Mass. Gen. Laws Ann. ch. 19D, § 7 (2004)). 

Massachusetts Established 

an Ombudsman Program 

for Assisted Living 
Page 25 GAO-04-684 Assisted Living 

designating ombudsman staff specifically for assisted living. It provides a 

means for assisted living residents and family members to file and resolve 

complaints relating to the quality of services and to residents’ quality of 

life. However, the program’s exclusive reliance on state funding, under 

circumstances of state budgetary constraint, has resulted in limited staff 

resources available to perform these tasks. 

Assisted living ombudsmen serve primarily as mediators and advocates. As 

mediators, they receive, investigate, and attempt to resolve problems or 

conflicts that occur between a provider and residents. They act as 

advocates for residents by referring their cases to the assisted living 

certification office or elder protective services, when warranted. In 

addition, the ombudsmen respond to inquiries by consumers considering 

assisted living as a long-term care option. They also respond to providers 

requesting advice. To accomplish these tasks, the ombudsmen make site 

visits to assisted living facilities, typically in the context of a serious 

complaint allegation and sometimes together with certification staff. 

The organizational placement of the ombudsman program within the 

state’s Executive Office of Elder Affairs (EOEA) is designed to balance 

program autonomy and coordination with related programs. EOEA 

oversees both the assisted living ombudsman and certification programs. 

According to the state official, staff members from both programs 

coordinate activities, communicate often, and refer cases to each other. 

This working relationship has helped give the ombudsman more leverage 

when dealing with providers. However, representatives for both the state 

and assisted living providers agree that the ombudsman program should 

remain separate organizationally from the certification program because 

they perform different functions. Previously, when the staff of the two 

programs had reported to the same individual in EOEA, providers became 

confused about the programs’ respective roles during a visit. A subsequent 

restructuring of EOEA placed the certification and ombudsmen in 

separate divisions. 

Shared EOEA administration also links the assisted living ombudsmen to 

other programs serving elderly clients, such as elderly protective services 

and the long-term care ombudsmen program. The state has emphasized 

coordination with elderly protective services to ensure that assisted living 

residents found in abusive situations quickly receive the help they need.39

 39 See U.S. General Accounting Office, Nursing Homes: More Can Be Done to Protect 

Residents from Abuse, GAO-02-312 (Washington, D.C.: Mar. 1, 2002). 
Page 26 GAO-04-684 Assisted Living 

In addition, by placing assisted living ombudsmen in the same office of 

EOEA as long-term care ombudsmen, Massachusetts has attempted to 

maintain a degree of communication and coordination across the different 

long-term care settings. As described by the provider representative we 

interviewed, this arrangement allows for “cross-fertilization” between the 

different programs. Although the programs differ substantially in their 

approach to ensuring quality care, assisted living ombudsmen can 

nevertheless draw upon the decades-long experience residing in the longterm care program.40

Massachusetts’ assisted living ombudsman program regulations41 called for 

a structure similar to that of the existing long-term care ombudsman 

program. According to the state official, the long-term care ombudsman 

program has a full-time training position and several regional coordinators 

responsible for recruiting, training, and overseeing volunteers who make 

site visits to nursing homes on a regular basis throughout the state. 

However, according to the state official, the assisted living ombudsman 

program never received sufficient funding to develop this type of 

structure. Although the regulations authorized a similar network of 

volunteers, the program staff has consisted of no more than three 

professionals, later reduced to two, who handle complaints and inquiries 

for 172 assisted living facilities. That left no one available to recruit, train, 

and supervise volunteers, and consequently, visits to facilities only 

occurred in response to complaints and not on a routine basis. 

The Massachusetts legislature funded the assisted living ombudsman 

program by creating an assisted living administrative fund,42 which 

received the fees paid biennially by facilities as part of the certification 

process. The ombudsman shared these funds with the assisted living 

certification staff. However, in response to statewide budgetary pressures, 

the legislature eliminated this fund in fiscal year 2003 and redirected the 

 40The state official we interviewed described how the state’s vision of assisted living 

follows the “social model,” while the Department of Public Health applies the “medical 

model” to nursing homes and related institutions. The social model seeks to create a 

homelike environment that emphasizes independence over the provision of health care 

services or personal care assistance. The medical model focuses more on clinical issues, 

such as proper medication and nursing services. The state’s long-term care ombudsman 

program correspondingly follows the medical model approach while the assisted living 

ombudsman program adheres to the social model. 

41Mass. Regs. Code tit. 651, §§ 13.00 et seq. 

421995 Mass. Acts 38, § 45 (Mass. Gen. Laws Ann. ch. 29, § 2BB (1995)). 
Page 27 GAO-04-684 Assisted Living 

certification fees to the state’s general revenues.43 Meanwhile, the longterm care ombudsman program continued to operate largely with federal 

funds, authorized under the Older Americans Act. 

The state and provider representatives we spoke with agreed that having a 

separate assisted living ombudsman program led its staff to become 

increasingly knowledgeable about assisted living and the particular 

problems that arise within it. Both providers and residents benefit from 

the fact that assisted living ombudsmen do not have to balance the needs 

of residents from different types of long-term care facilities. However, the 

decision to fund the program solely through the state made it especially 

vulnerable to budgetary cutbacks when Massachusetts faced constrained 

fiscal circumstances. Although the federally supported state long-term 

care ombudsman programs also contend with scarce resources 

nationwide, the Massachusetts assisted living ombudsman program 

highlights the difficulty of sustaining this type of program with state funds 

alone. 

Florida, Texas, Washington, Georgia, and Massachusetts have each found 

ways to enhance the experience of assisted living residents in their states. 

They have done so by developing information resources, expanding 

complaint mechanisms, or allocating state resources to assisted living 

programs. However, those initiatives that required increases in state staff 

or funds fared less well during periods of fiscal constraint. The demise of 

the Washington QIC program, despite its well-documented favorable 

outcomes, and cutbacks in the popular Massachusetts assisted living 

ombudsman program, reflect the vulnerability of any discretionary state 

program to budget reductions. Florida’s Web site, Texas’ disclosure form, 

and Georgia’s procedural remedies, by contrast, have benefited from the 

important advantage that none of these programs required substantial 

resources to initiate and maintain. These examples from five states can 

perhaps aid other states in developing their own approaches to helping 

senior citizens take full advantage of assisted living alternatives to nursing 

home care. 

 432003 Mass. Acts 26, §140 (effective June 30, 2003) (Mass. Gen. Laws Ann. ch. 29, § 2BB 

(2004)). 

Concluding 

Observations 
Page 28 GAO-04-684 Assisted Living 

We sent sections from an earlier draft of this report to state officials in 

Florida, Texas, Washington, Georgia, and Massachusetts and asked them 

to check that the section accurately described the development and 

implementation of their state’s program. Officials from all five states 

responded and provided technical comments that we incorporated where 

appropriate. 

As agreed with your offices, unless you publicly announce the contents of 

this report earlier, we plan no further distribution of it until 30 days from 

its date. At that time, we will send copies of this report to interested 

parties. In addition, this report will be available at no charge on GAO’s 

Web site at http://www.gao.gov. We will also make copies available to 

others upon request. 

If you or your staff have any questions about this report, please call me at 

(312) 220-7600. An additional contact and other staff members who 

prepared this report are listed in appendix IV. 

Leslie G. Aronovitz 

Director, Health Care—Program 

 Administration and Integrity Issues 

Comments from the 

States 
Appendix I: Key Sources Consulted 

Page 29 GAO-04-684 Assisted Living 

National Organizations and Academic Experts

Alzheimer’s Association 

American Association of Homes and Services for the Aging 

American Bar Association Commission on Law and Aging 

American Seniors Housing Association 

Assisted Living Federation of America 

Association of Health Facility Survey Agencies 

Consumer Consortium on Assisted Living 

National Association for Regulatory Administration 

National Association of State Long-Term Care Ombudsman Programs 

National Association of State Units on Aging 

National Center for Assisted Living 

National Citizens’ Coalition for Nursing Home Reform 

NCB Development Corporation, The Coming Home Program 

Catherine Hawes, Texas A&M University 

Robert Mollica, National Academy for State Health Policy 

Janet O’Keeffe, Research Triangle Institute 

Major Studies on Assisted Living

Catherine Hawes, et al., A National Study of Assisted Living for the Frail 

Elderly: Results of A National Survey of Facilities (Beachwood, Ohio: 

December 1999). 

Maureen Mickus, “Complexities and Challenges in the Long Term Care 

Policy Frontier: Michigan’s Assisted Living Facilities” (Michigan State 

University Applied Public Policy Research Program: September 2002). 

Robert Mollica and Robert Jenkens, State Assisted Living Practices and 

Options: A Guide for State Policy Makers (National Academy for State 

Health Policy and NCB Development Corporation: September 2001). 

Janet O’Keeffe, et al., Using Medicaid to Cover Services for Elderly 

Persons in Residential Care Settings: State Policy Maker and 

Stakeholder Views in Six States, Research Triangle Institute, prepared at 

the request of the U.S. Department of Health and Human Services 

(December 2003). 

Appendix I: Key Sources Consulted 
Appendix I: Key Sources Consulted 

Page 30 GAO-04-684 Assisted Living 

Charles D. Phillips, et al., Residents Leaving Assisted Living: Descriptive 

and Analytic Results from a National Survey, prepared at the request of 

the U.S. Department of Health and Human Services, Office of the Assistant 

Secretary for Planning and Evaluation, June 2000. 

Brenda Spillman et al., Trends in Residential Long-Term Care: Use of 

Nursing Homes and Assisted Living and Characteristics of Facilities 

and Residents, Washington, D.C.: Urban Institute, prepared at the request 

of the U.S. Department of Health and Human Services, Office of the 

Assistant Secretary for Planning and Evaluation, November 2002. 

U.S. General Accounting Office, Assisted Living: Quality-of-Care and 

Consumer Protection Issues in Four States, GAO/HEHS-99-27

(Washington, D.C.: Apr. 26, 1999) 

U.S. General Accounting Office, Long-Term Care: Consumer Protection 

and Quality-of-Care Issues in Assisted Living, GAO/HEHS-97-93

(Washington, D.C.: May 15, 1997). 

Guides on State Assisted Living Regulations

American Seniors Housing Association, Seniors Housing: State 

Regulatory Handbook, March 2003. 

Lyn Bentley, Assisted Living State Regulatory Review 2004, National 

Center for Assisted Living (March 2004). 

Stephanie Edelstein, et al., Assisted Living: Summary of State Statutes

(in 3 volumes) AARP, 2000. 

Robert Mollica, State Assisted Living Policy: 2002 (Portland, Maine: 

National Academy for State Health Policy, November 2002). 

State-level Entities

We interviewed officials or individuals associated with the following 

entities: 

Florida Department of Elder Affairs 

Florida Assisted Living Affiliation 

Senior Resource Alliance (Florida) 

Texas Department of Human Services 

Texas Assisted Living Association 
Appendix I: Key Sources Consulted 

Page 31 GAO-04-684 Assisted Living 

Texas Assisted Living Advisory Committee 

Washington Department of Social and Health Services 

Washington Health Care Association 

Washington Long-term Care Ombudsman Program 

Georgia Long-Term Care Ombudsman Program 

Georgia Legal Aid Program 

Senior Citizens Law Project (Georgia) 

Assisted Living Association of Georgia 

Massachusetts Executive Office of Elder Affairs 

Massachusetts Assisted Living Facilities Association 

State-level Studies

Alice Mahar Dupler, Neva L Crogan, and Robert Short, “Pathways to 

quality improvement for boarding homes: A Washington state model,” 

Journal of Nursing Care Quality; Jul 2001; 15(4), 1-7. 

Alice Mahar Dupler, “Quality Improvement Consultation Program in 

Assisted Living Facilities, A Washington State Pilot Program: Phase II,” 

unpublished, no date. 
Appendix II: Florida Affordable Assisted 

Living “Find-a-Facility” Consumer Search 

Page 32 GAO-04-684 Assisted Living 

To begin your search, please enter a zip code or select a county: 

 Zip Code OR County 

Select payment option(s): 

□ Private Pay 

□ Government Subsidies Accepted 

Select monthly price range: 

□ under $800 

□ $800-$1200 

□ $1201-$1600 

□ $1601-$2000 

□ Over $2000 

Select residential unit preference(s): 

□ Single Occupancy Unit 

□ Double/Multiple Occupancy Unit 

□ Individual Apartment with Kitchen 

□ Fully Furnished 

□ Private Bath 

□ Pets Allowed 

□ Dementia (Secured) Units 

Select all services you are seeking: 

□ Adult Day Care Service 

□ Alzheimer’s Disease / Dementia Care 

□ Assistance with Medications 

□ Assistance with the activities of daily living (ADLs) 

□ Assistance with Transferring 

□ Escort Service for Medical Appointments 

□ Incontinence Care 

□ Individual Personal Care Attendant 

□ Kosher Meals 

□ Licensed Nurse on Duty 

□ Medication Administration by Licensed Nurses 

□ Respite (Short term) Care 

□ Special Diets 

□ Special Language Preference 

Appendix II: Florida Affordable Assisted 

Living “Find-a-Facility” Consumer Search 
Appendix II: Florida Affordable Assisted 

Living “Find-a-Facility” Consumer Search 

Page 33 GAO-04-684 Assisted Living 

Select all special accommodations and services you are seeking: 

□ ALE Medicaid Waiver Provider 

□ Emergency Placement 

□ Extended Congregate Care Services 

□ Full Laundry Service 

□ Independent Living Units 

□ Limited Nursing Services 

□ Skilled Nursing Unit 

□ Transportation Service 

□ Wellness Center 

Select special residency requirements: 

□ Catheter 

□ Developmentally Disabled 

□ Diabetic 

□ Hospice (Must meet admission criteria) 

□ Stage 1 or 2 Decubitus Ulcer (Pressure Sore) 

□ Visual/Hearing Impairment 

□ Wheelchair-bound 

Source: http://www.floridaaffordableassistedliving.org
Appendix III: Texas Assisted Living Disclosure Statement 

Page 34 GAO-04-684 Assisted Living 

Appendix III: Texas Assisted Living 

Disclosure Statement 
Appendix III: Texas Assisted Living Disclosure Statement 

Page 35 GAO-04-684 Assisted Living 
Appendix III: Texas Assisted Living Disclosure Statement 

Page 36 GAO-04-684 Assisted Living 
Appendix III: Texas Assisted Living Disclosure Statement 

Page 37 GAO-04-684 Assisted Living 
Appendix III: Texas Assisted Living Disclosure Statement 

Page 38 GAO-04-684 Assisted Living 
Appendix IV: GAO Contact and Staff 

Acknowledgments 

Page 39 GAO-04-684 Assisted Living 

Rosamond Katz, (202) 512-7148 

Eric Peterson, Carmen Rivera-Lowitt, and Janet Rosenblad made major 

contributions to this report. 

Appendix IV: GAO Contact and Staff 

Acknowledgments 

GAO Contact 

Acknowledgments 

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