U.S. GOVERNMENT PRINTING OFFICE

73–340 PS WASHINGTON : 2001

S. HRG. 107–64

ASSISTED LIVING IN THE 21ST CENTURY:

EXAMINING ITS ROLE IN THE

CONTINUUM OF CARE

HEARING

BEFORE THE

SPECIAL COMMITTEE ON AGING

UNITED STATES SENATE

ONE HUNDRED SEVENTH CONGRESS

FIRST SESSION

WASHINGTON, DC

APRIL 26, 2001

Serial No. 107–3

Printed for the use of the Special Committee on Aging

(

For sale by the U.S. Government Printing Office

Superintendent of Documents, Congressional Sales Office, Washington, DC. 20402

SPECIAL COMMITTEE ON AGING

LARRY CRAIG, Idaho, Chairman

JAMES M. JEFFORDS, Vermont

CONRAD BURNS, Montana

RICHARD SHELBY, Alabama

RICK SANTORUM, Pennsylvania

SUSAN COLLINS, Maine

MIKE ENZI, Wyoming

TIM HUTCHINSON, Arkansas

PETER G. FITZGERALD, Illinois

JOHN ENSIGN, Nevada

JOHN B. BREAUX, Louisiana

HARRY REID, Nevada

HERB KOHL, Wisconsin

RUSSELL D. FEINGOLD, Wisconsin

RON WYDEN, Oregon

EVAN BAYH, Indiana

BLANCHE L. LINCOLN, Arkansas

THOMAS R. CARPER, Delaware

DEBBIE STABENOW, Michigan

JEAN CARNAHAN, Missouri

LUPE WISSEL, Staff Director

MICHELLE EASTON, Minority Staff Director

(II)

C O N T E N T S

Page

Opening statement of Senator Larry Craig ........................................................... 1

Statement of Senator John Breaux ........................................................................ 2

Statement of Senator Jean Carnahan ................................................................... 3

Statement of Senator Ron Wyden .......................................................................... 4

Prepared statement of Representative Pete Stark ............................................... 5

PANEL I

Hon. Hillary Rodman Clinton, a U.S. Senator from New York ........................... 6

PANEL II

Emelia-Louise Kilby, Ph.D., Assisted Living Resident, Arlington, VA ............... 14

Esther Gallow, President and CEO, Booker T. Community Outreach, Inc.,

Monroe, LA ........................................................................................................... 20

Bill Southerland, Managing Partner, Bill Southerland’s Residential Care

Homes, Eagle, ID ................................................................................................. 26

Karen Love, Executive Director, Consumer Consortium on Assisted Living,

Washington, DC ................................................................................................... 33

Margaret Thompson, Board of Directors, Assisted Living Federation of America, Washington, DC ............................................................................................ 42

APPENDIX

Written Statement of Mark Schulte from the American Seniors Housing

Association ............................................................................................................ 77

Written Statement of Robert Lohr from The National Center for Assisted

Living .................................................................................................................... 84

Additional comments for the Record from Assisted Living Federation of America .......................................................................................................................... 92

(III)

(1)

ASSISTED LIVING IN THE 21ST CENTURY: EXAMINING ITS ROLE IN THE CONTINUUM OF

CARE

THURSDAY, APRIL 26, 2001

U.S. SENATE,

SPECIAL COMMITTEE ON AGING,

Washington, DC.

The committee met, pursuant to notice, at 9:06 a.m., in room

SD–562, Dirksen Senate Office Building, Hon. Larry E. Craig

(chairman of the committee) presiding.

Present: Senators Craig, Breaux, Carnahan, and Wyden.

OPENING STATEMENT OF SENATOR LARRY E. CRAIG,

CHAIRMAN

The CHAIRMAN. Good morning, everyone. Thank you for attending our Senate Special Committee on Aging hearing this morning.

I would like to thank our witnesses for agreeing to testify before

the committee on ‘‘Assisted Living in the 21st Century.’’

Two years ago, this committee held a hearing to gain a better understanding of the emerging industry of assisted living. This

emerging industry has now over 30,000 facilities in the United

States, housing approximately one million citizens. Since such

large numbers of seniors are choosing assisted living facilities, I

feel compelled as the new chairman of the Special Committee on

Aging to take a second look at this industry and evaluate efforts

to provide quality care to consumers.

Senator Breaux, my ranking colleague here, who has also seen

this as an important priority, has been involved in this and monitored it closely over the last several years. I also have a personal

reason for wanting to examine this issue. My in-laws are currently

living in a retirement community with an assisted living facility,

and I am grateful that they are in a good environment receiving

quality care. The goal of this hearing is to make sure that all residents receive high levels of care.

Two years ago, GAO issued a report to Congress that indicated

assisted living facilities did not consistently provide consumers sufficient information to determine whether a particular facility meet

their needs. Because of these results, this committee has asked the

assisted living industry to come up with solutions to provide consumers with the best information and care possible.

We are here today to evaluate progress that has been made. Currently, assisted living facilities are not regulated at the Federal

level. Instead, States are responsible for oversight. I believe in

2

most cases States should be permitted to govern without Federal

mandates. In this case, we must ask whether the States and the

industry are doing enough to protect the elderly who rely on assisted living facilities.

Today, we will hear from both industry and consumer groups

who will discuss the current status of assisted living facilities. I’d

like to thank the witnesses for agreeing to testify, and I want to

especially thank Senator Breaux for his interest in this area. As I

said, he has been involved with this issue and continues to work

on addressing its concerns.

Very early on in this hearing, I am going to need to step away

to attend another hearing, so I want to also recognize Bill

Southerland from Eagle, ID, who is on our third panel, who is providing assisted living in more rural settings, which I think is a

uniqueness of the diversity of this kind of a facility and caregiving.

With that, let me turn to our ranking member, Senator John

Breaux. John.

STATEMENT OF SENATOR JOHN BREAUX

Senator BREAUX. Good morning, Mr. Chairman, and thank you

for participating and working with us on this hearing and to show

the continued interest of the Aging Committee in this particular

area. It was almost 2 years ago, I think, to this month that this

committee under Chairman Grassley had a hearing on assisted living, and we are continuing the effort to try to monitor what is happening in this industry.

As the 77 million baby boomers out there look forward to their

golden years, we are trying to make sure that what we do as a nation is not just extend the life of our citizens, but also improve the

quality of their lives, and, of course, assisted living facilities is part

of that mix. No longer is the only option as you grow older a life

relegated to a nursing home. There are other options now and assisted living facilities are one of those options with 33,000 facilities,

almost 800,000 units.

This is a growing industry out there, and the question is do we

just sit back and sort of ignore it or do we help participate with

this industry and try to provide the quality of assisted living that

is so important at this particular time in the lives of so many of

our citizens?

I think information is important. I think that it is unfortunate

that in many areas of health care, we find out more information

about the quality of the toasters and the washing machines that

we have in society through looking at consumer reports and finding

out which ones work, which ones don’t work, how much it costs to

fix them, and we give guidance to consumers in so many different

areas with regard to the quality of products that they receive.

Certainly having the best information on the quality of assisted

living facilities is extremely important to know which ones are

good, which ones are not so good, and which ones, in fact, do not

meet the standards that we all want to have in this country.

It is interesting that about 38 States, I think, now are operating

with waivers to use the Medicaid program, which is a Federal-state

partnership, to help pay for this. This is an extremely expensive

product. And I really think it is incumbent for us in Congress not

3

just to look at how they are being run, but also try to find ways

in which we can help in providing financial assistance to cover the

very expensive costs at assisted living facilities as well as what

nursing homes charge for their services, which are very valuable

services and also very expensive services.

So we are delighted that we got a good group, delighted that Senator Clinton is our lead-off witness and will talk about the New

York experience and their involvement in this area. And I look forward to this hearing.

The CHAIRMAN. John, thank you very much. Now let me turn to

Senator Jean Carnahan.

STATEMENT OF SENATOR JEAN CARNAHAN

Senator CARNAHAN. Thank you, Mr. Chairman. I want to thank

Senator Breaux, too, for calling this hearing on assisted living and

its role in continuum of care. Senator Breaux called for the first

hearing on this subject some 2 years ago. And he has remained a

strong champion of senior citizens ever since, and I commend him

for that.

Caring for our loved ones as they grow older is an issue that hits

close to home for many in Missouri. A few years ago, I cared for

my father in my home, the last 71⁄2 years of his life, and so I understand how important it is that our senior citizens have the care

and the dignity and even the love that they deserve in their later

years.

I believe we have a moral obligation to empower our senior citizens to keep their independence and their dignity as they age. It

is the wish we all have for our own parents and for them to live

in an environment where they can maintain a high quality of life

for as long as possible.

I look forward to the opportunity to examine long-term care options to allow seniors to accomplish this goal. Assisted living is one

of those options. Assisted living strikes a balance. They offer independent living with some support services. Assisted living is a

growing phenomenon. To date, there are more than 100 such facilities in Missouri alone, and although I see assisted living as a positive long-term care option for seniors, I am troubled by recent news

reports about the lack of oversight of assisted living centers.

What concerns me most is that the health and safety of some assisted living residents may be at risk. When someone puts a family

member in an assisted living center, they should know with confidence that their loved ones will be cared for. The importance of

this issue will only increase as our country’s population ages, and

with assisted living becoming more and more prevalent, now is the

time to ask ourselves whether we are doing everything possible to

ensure quality care.

I am pleased that this committee is calling attention to assisted

living in this country today, and I hope the committee will continue

to monitor the quality of care that residents receive in these centers. We owe our loved ones no less. Thank you.

The CHAIRMAN. Senator, thank you very much. Now, let me turn

to Senator Ron Wyden of Oregon. Ron, in his private life before he

came to Congress was actively involved with seniors and has reVerDate 11-MAY-2000 13:10 Aug 15, 2001 Jkt 000000 PO 00000 Frm 00007 Fmt 6633 Sfmt 6633 C:\DOCS\73340.TXT saging1 PsN: saging1
4

mained certainly a stalwart spokesperson for them while he has

served both in the House and the Senate. Ron.

STATEMENT OF SENATOR RON WYDEN

Senator WYDEN. Thank you, Mr. Chairman. After 20 years of

friendship with you, it is very good to see you chairing this committee and working with Senator Breaux, who has done so much work

in this area. I appreciate both of you convening this hearing.

I have had an interest in this subject, as you mentioned, Mr.

Chairman, since my days as co-director of the Gray Panthers. It

was over 3 years ago when Senator Breaux and I along with Senator Grassley asked for the first set of definitions about what assisted living was in this country. What we found is that in some

States, assisted living is sort of a sponge bath. It is very modest

health care by any analysis, and in other States it is extraordinarily sophisticated health care.

When I was visiting my mother in her assisted living facility this

weekend, I thought about how far we have come on a bipartisan

basis in this committee over the last 3 years. We now have seen

the industry, for example, set up a web site and consumer protection checklists, a variety of steps that can assist families. I think

it is very appropriate that we look today at what the next steps

ought to be, and that is why it is so good to have our friend and

colleague, Senator Clinton, here because New York, of course, as in

so many areas, has been on the front lines in terms of looking at

new approaches.

I would like to ask, Mr. Chairman and colleagues, that we think

about two particular areas this morning. One is I think that it is

time to look at a model state statute in order to try to lay out a

set of baseline consumer protections for older people and at the

same time encourage the kind of flexibility that the industry needs

in order to be creative and innovative.

I do not think we need to set up some sort of one-size-fits-all Federal program. What I am talking about is not all that different,

with some of the steps that we have taken in areas like Medigap,

where there has been a modest Federal role, but insurers have

worked with the States and the insurance area with the National

Association of Insurance Commissioners. Here it would be with the

health departments, the consumer advocates, and industry. I think

it is time for us to look, and it is again an ideal opportunity for

bipartisanship, with the idea of a model state statute for assisted

living so we deal with this crazy quilt of statutes around the country. I look forward to examining that issue.

The other area that I would hope that we would look at is that

we have a dire shortage of qualified workers to do the critical services for older people in these facilities. By the way, I think we all

understand we have got a dire shortage of qualified workers across

the board in the health care area. My sense is it is particularly

acute in the assisted living facility, and I hope that we could examine that issue as well.

As Senator Carnahan has said, and she has had a family experience with Assisted Living, three of the four of us so far have

touched on our family experience, and Senator Breaux, of course,

is a long-time expert in this field. So I think it is clear that we can

5

go at this issue as we have done on so many in a bipartisan way.

I look forward to working with you, Mr. Chairman, Senator Breaux

and Senator Carnahan to do that.

The CHAIRMAN. Ron, thank you for expression of your thoughts

and ideas in this area. I would also like to make part of the record

a written statement from Pete Stark, a congressman from the State

of California.

[The prepared statement of Mr. Stark follows:]

TESTIMONY OF REP. PETE STARK

I am pleased to participate in today’s hearing on how assisted living fits into the

continuum of care for senior citizens. More and more seniors are choosing to live

in assisted living facilities (ALFs). Until something happens to a loved one, however,

few people recognize that there are no national quality standards for these facilities.

In fact, regulation varies widely from state-to-state with some States having virtually no regulation at all.

Furthermore, although originally developed as an alternative to nursing homes,

recent news coverage by the Washington Post, New York Times, and Wall Street

Journal points toward a growing industry trend to recruit the same frail seniors

that might otherwise be served by nursing homes. The simple truth is that frail elderly have significant medical needs no matter where they live.

Until recently, the industry has been almost entirely private-pay. But times are

changing and ALFs increasingly seek and receive federal funding through Medicaid’s Home and Community-Based Services waiver. In fact, overall spending for this

waiver swelled 29 percent between 1988–1999, due in part to growing numbers of

ALF placements.

In many States, industry expansion has not been accompanied by a tightening of

quality standards or accountability measures. Instead, the definition and philosophy

across ALFs varies from state-to-state and there is little consistency in state regulatory efforts. Furthermore, a 1999 General Accounting Office report found that 25

percent of surveyed facilities were cited for five or more quality of care violations

between 1996–1997 and 11 percent were cited for 10 or more problems. Frequently

cited problems ranged from providing inadequate care, particularly around medication issues, to having insufficient and unqualified staff.

I believe that it is our responsibility to take action before widespread problems

are reported. For that reason, I recently took the first step of introducing H.J. Res.

13. This resolution calls for a White House conference to pull together consumers,

industry, State officials, and other interested parties in order to develop consensus

around quality standards for ALFs. It has been endorsed by several organization active in protecting consumer interests in assisted living and other settings, including

the Consumer Consortium on Assisted Living, American Medical Directors Association, California Advocates for Nursing Home Reform, National Association for

HomeCare, and Elder Care America.

Beyond H.J. Res. 13, I am actively exploring other legislative solutions to quality

concerns within the assisted living industry. ALFs that receive federal funding

should be required to meet reasonable, commonsense quality standards to protect

residents. Frail, elderly ALF residents must be protected and sub-par facilities must

face real consequences. I look forward to working with my colleagues on both sides

of the aisle to protect frail seniors in ALFs throughout our country.

Thank you for holding a hearing on this important topic.

The CHAIRMAN. Now, we have the opportunity to hear from Senator Clinton, who is with us today to talk about the New York experience on assisted living. I am sure you are all aware that earlier

this year, The New York Times released an article on assisted living, and undoubtedly the senator, I’m sure, has heard from a good

many of her constituents on the issues that were raised in the article.

So we are pleased you are with us this morning to share your

experience and the experience of your constituents as it relates to

assisted living in New York. Welcome to the committee.

6

STATEMENT OF SENATOR HILLARY RODHAM CLINTON

Senator CLINTON. Thank you so much, Mr. Chairman. I am very

pleased to be here, and I thank you and I thank Senator Breaux

as well as Senators Carnahan and Wyden for holding this very important hearing and building on the work that you began 2 years

ago. It is very encouraging to see how we are looking at a problem

ahead of the curve, because although there are lots of issues to be

raised, I think this is one that we can address in a bipartisan way,

as Senator Wyden has just pointed out, and do some very constructive work, but as we all know, that is work that needs to be undertaken in an expeditious manner because we have to begin planning

for the continuing needs of our seniors.

Now, I want at the very beginning to say I am not an expert. You

will have some excellent witnesses today who are experts in this

area, who have been on the front lines of providing the care that

is needed and have been the recipients of such care.

But I have heard, as the chairman just referred to, from many

New Yorkers about their experiences with assisted living facilities

and with some of the questions that they have because New York

has made some very important efforts in trying to deal with and

define assisted living programs. So perhaps our experiences will be

helpful to the committee and to the rest of the country.

The popularity of assisted living speaks to the autonomy and

homelike setting that it can offer, which is, you know, very welcoming to many of our seniors and particularly to the growing population of frail elderly who need some assistance with the activities

of daily living but may not need the level of care provided in a

nursing home.

According to the New York State Department of Health in a recent report, 10 to 15 percent of the 114,000 nursing home residents

in our State could probably live more independently and sometimes

less expensively in assisted living facilities. But as we have heard

from newspaper reports, assisted living is governed by a myriad of

different state-based regulations, often with multiple regulatory

frameworks coexisting uneasily even within a single State.

Now, New York’s experience really highlights what happens

when an emerging long-term care option like assisted living outgrows the patchwork regulatory structure that has evolved over

time, and I would very much endorse Senator Wyden’s proposal for

a model statute. I think that could be an extraordinarily helpful development.

In New York, for example, there are at least, and I say at least

because we are not quite sure, but we think there are at least three

different kinds of assisted living programs in New York. Now, to

the consumer, each of these types of facilities can look remarkably

similar, offering housing with personal care services and the ability

to provide a range for nursing services and home health care.

And yet consumers are often now aware that these facilities are

held to very different standards, which is the point Senator Breaux

made. But one thing we have to do is provide information in usable

form to consumers.

In the first category, we think adult care facilities. Now they represent the modern-day evolution of the traditional board and care

homes which combine residential settings with supportive services.

7

The second category is called assisted living programs, through

which the State gives special certification to roughly 4,000 beds to

help make assisted living affordable for those who are eligible for

Medicaid and SSI.

New York sets a number of standards for both of these first two

categories on subjects ranging from services provided to staff training.

Now, however, in New York as in many other States, there is

also a third category of facilities. They are called assisted living,

‘‘look alikes’’ or, ‘‘non-licensed’’ assisted living. These facilities offer

housing and may either own or contract with a separately licensed

home health care agency. However, they do not have a license to

offer the two together in an assisted living arrangement.

Now, if you are confused already, so are many consumers in New

York, because trying to sort out the adult care facilities, the socalled ACFs, from the assisted living programs from the non-licensed look-alike assisted living programs causes a lot of confusion.

And it is not anyone’s, you know, fault. It is just that this is how

this has developed and evolved over time, which is why this hearing is so important.

The category of so-called ‘‘non-licensed assisted living’’ is an interesting example of how state specific issues affect assisted living

consumers. Now, New York has historically held licensed health

care facilities such as hospitals, nursing homes and adult care facilities accountable for quote ‘‘character and competence.’’ As a result, our State has a long-standing prohibition preventing publicly

traded business corporations from operating licensed health care

facilities. Now, that means that some of the larger assisted living

chains, which are often subject to licensing in other States, operate

under this unlicensed category in New York.

Now, that is something that has caused a lot of confusion among

consumers and even among some of the businesses, you know, because they are used to operating under licensing standards in one

State, then they come to New York, and they are no longer under

licensing standards, which is why having some kind of national

model statute which sets a framework, which, you know, all of the

good, competent facilities will want to abide by, will be a great first

step to sort out this confusion.

Now, we know that many of the providers in New York of all of

these different kinds of facilities offer very good environments for

our older citizens who appreciate the greater independence and the

individually tailored care. But consumers have no guarantee of that

and no easy way to compare facilities. So they have to operate basically blindly when it comes to making a decision and that falls usually on family members themselves who are trying to help with determining what is best for their loved ones.

Now, a story I heard recently illustrates this point. A daughter

came to New York to select what she thought was the best assisted

living facility to care for her mother who has dementia and heart

problems. The agency was an unlicensed facility with a licensed

home care agency that it owned onsite. But the daughter was not

aware of the implications of that confusing licensing structure until

it was too late.

8

At the beginning she instructed the facility that her mother

would get agitated and not take her heart medications unless they

were crushed. You know sometimes older people have difficulty

swallowing; trying to get the pills down is a problem, so, you know,

it is a rather common occurrence to crush that medication. Yet

within a mere 6 weeks, the mother was hospitalized with a diagnosis of rapid atrial fibrillation and sadly she died.

Later, the daughter found out that her mother had missed one

of her medications 15 times and another one five times. Interviews

with the nurse from the home care agency revealed that the

woman was agitated and did not cooperate with taking her medications. There was no record whether or not they had crushed the

medications. And so although the daughter had clearly instructed

the facility about this need for her mother, she did not anticipate

she might have to also separately instruct the home care agency

as well.

In the end, the home care agency was fined $3,000, but the

daughter was shocked to learn that the facility itself was not cited

for this oversight, because the State lacks oversight over the facility as a service provider. This is a typical example of how when you

have a licensed situation and an unlicensed situation, and unclear

differences as to what is expected by consumers, tragedy can sometimes ensure.

For those of us who would like to make the experience of assisted

living available to the many people who could benefit from its advantages over nursing home care, stories like this raise important

questions. And I think this committee already knows that we have

to provide answers to these questions:

Do consumers receive enough information to make wise choices?

I think we all understand that we don’t. What assurances do consumers have that the care will be adequate? That is where a model

statute/more information can make a very big difference. Does the

licensing and oversight structure as it currently exists in States exacerbate an already difficult decision? And ultimately how can we

assure access to quality assisted living facilities at an affordable

price?

I would also echo another point that Senator Wyden made, and

that is our worker shortage in health care in general—I serve on

the Health Committee. A subcommittee has recently held a hearing

on our nursing shortage. We know that that is becoming a very serious problem. Well, the shortage of workers in our assisted living

programs, our adult care facilities, and our nursing homes is reaching an acute stage of crisis. And it is not even so much as the lack

of workers and the expense of training them and keeping them, because we know that the compensation is often very low, it is also

creating that extra sense of care and love that Senator Carnahan

referred to.

I spoke recently with the directors of some of our adult facilities

in New York, and they said that they want to make sure that the

emotional component is present, and they are having a hard

enough time just finding the bodies to do the work. And then you

layer that with the need to find people who will care for our elderly, which is what everyone of us hope for. They have gone so far

in some instances to suggest that maybe we should have an option

9

for facilities and for States to provide a requirement that there be

video cameras in the rooms of our elderly so that families could

monitor from their own homes what is happening because we do

not have the staff on hand to take account of it.

I would hate to see us move toward that, but there are a lot of

worried families who don’t know what it is they are buying, don’t

know whether they have got the right information to make a good

decision, and perhaps there is something even as extreme as that

sort of monitoring that would have to be considered as an interim

measure until we take appropriate steps.

Now, as the AARP has said, and I could not agree more, there

should be no confusion about what is considered assisted living and

what it can and cannot offer older New Yorkers. I would only

amend by saying that should cover older Americans everywhere,

and I thank you for calling this hearing about an issue that is important today, but will only grow in importance in the next years,

and I appreciate the opportunity to testify before you today.

[The prepared statement of Senator Clinton follows:]

PREPARED STATEMENT OF SENATOR HILLARY RODMAN CLINTON

Thank you so much Mr. Chairman and Senator Breaux. I am so pleased to be

invited here today to talk with you very briefly about assisted living. I’m not an expert—you have some excellent witnesses today who are—but I have heard from people in New York about their experiences with assisted living facilities and I’m

pleased to have this opportunity to share some of their views and concerns with you.

The popularity of assisted living speaks to the autonomy and home-like setting

it can offer to the growing population of frail elderly who need some assistance with

the activities of daily living, but may not need the level of care provided in a nursing home. According to a New York State Department of Health report, 10 to 15

percent of the 114,000 nursing home residents in New York could probably live

more independently—and sometimes less expensively—in assisted living facilities.

As we have all heard from newspapers and from our States, assisted living is governed by a myriad of different state-based regulations, often with multiple regulatory frameworks coexisting uneasily even within a single State. And New York’s

experience really highlights what happens when an emerging long-term care option

outgrows the patchwork regulatory structure that has evolved over time.

There are at least three different kinds of assisted living in New York. To the consumer, each of these types of facilities can look remarkably similar, offering housing

with personal care services, and the ability to provide or arrange for nursing services and home health care. And yet, consumers are not aware that these facilities

are held to widely different standards.

In the first category we see adult care facilities. They represent the modern day

evolution of the traditional board-and-care homes, which combine residential setting

with supportive services. The second category is called the Assisted Living Program,

through which the State gives special certification to roughly 4,000 beds to help

make assisted living affordable for those who are eligible for Medicaid and SSI. New

York sets a number of standards for both of these first two categories on subjects

ranging from services provided to staff training.

However, in New York, there is also a third category of facilities. They are called

assisted living ‘‘look-a-likes,’’ a ‘‘non-licensed’’ assisted living. These facilities are licensed to offer housing and may either own or contract with a separately licensed

home health care agency. However, they do not have a license to offer the two together in an ‘‘assisted living’’ arrangement.

In fact, this category of so-called non-licensed assisted living is an interesting example of how state-specific issues affect assisted living consumers. New York has

historically held licensed health care facilities, such as hospitals, nursing homes and

adult care facilities, accountable for ‘‘character and competence.’’ As a result our

State has a long-standing prohibition preventing publicly-traded business corporations from operating licensed health care facilities. Thus some of the larger assisted

living chains, which are often subject to licensing in other States, operate under this

unlicensed category in New York.

10

If what I have just described sounds confusing . . . it is. And imagine how difficult it is for families to navigate this complex terrain and decide what kind of facility is best for their family members.

Certainly, many of the providers in New York offer wonderful living environments

for our older citizens, who appreciate the greater independence and the individuallytailored care. But consumers have no guarantee of that, and no easy way to compare

different facilities. In short, they have to operate on a good deal of faith. But when

it comes to protecting our elderly family members, I don’t think that kind of ‘‘faithbased program is what families need.

One story I heard recently illustrates this point. A daughter came to New York

to select what she thought was the best assisted living facility to care for her mother

who had dementia and heart problems. The agency was an unlicensed facility with

a licensed home care agency that it owns on site, but the daughter was not aware

of the implications of that licensing structure until it was too late. At the beginning,

she instructed the facility that her mother would get agitated and not take her

medications unless they were crushed.

Yet, within a mere 6 weeks, the mother was hospitalized with a diagnosis of rapid

atrial fibrillation, and, sadly, she died. Later the daughter found out that her mother missed one of her medications 15 times and another one 5 times. Interviews with

the nurse from the home care agency revealed that the woman was agitated and

did not cooperate with taking her medications. But there was no mention of whether

they had crushed the medication or not.

The daughter had clearly instructed the facility about her mother’s medications,

but did not anticipate that she might have to separately instruct the home care

agency as well. In the end the home care agency was fined $3000, but the daughter

was shocked to learn that the facility itself was not cited, because the State lacks

oversight over the facility as a service provider.

For those of us who would like to make the experience of assisted living available

to the many people who could benefit from its advantages over nursing home care,

stories like this raise important questions. Do consumers receive enough information to make wise choices? What assurances do consumers have that the care will

be adequate? Does the licensing and oversight structure exacerbate an already difficult decision? And, ultimately, how can we assure access to quality assisted living

facilities at an affordable price?

I applaud those in my State who have and will continue to work hard on addressing these fundamental, but difficult questions.

As the AARP has said, and I couldn’t agree more: ‘‘There should be no confusion

about what is considered assisted living and what it can and cannot offer older New

Yorkers.’’

Thank you so much for calling this hearing so that the expert witnesses here

today can help lend insight to the questions that many of my constituents, along

with many of yours, are asking.

The CHAIRMAN. Senator, thank you. You have obviously related

to us some of the experiences that you have heard about and the

frustrations that New York is going through and its citizens are

going through.

Two years ago, Governor Pataki recommended consumer protection for residents of assisted living facilities within the State, but

I am told these proposals didn’t make it into law. How is New York

now working to give clarity and direction to the very frustration

you spoke to?

Senator CLINTON. Well, Senator Craig, I commend our Governor

who came forward with consumer protections, additional disclosure

and information provisions, but I think that the fact is that in the

absence of a broader awareness of what the Governor was attempting to accomplish, there were a lot of questions raised, and a lot

of confusion about what should or shouldn’t be covered and who

should or shouldn’t be licensed, and New York does have this traditional provision which I think is causing us some challenges, and

that is that publicly traded companies cannot offer these services

in our State under a license.

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That doesn’t mean they can’t do business, but it just means the

State can’t license them. In effect, the State historically has not

wanted to give the seal of approval to a publicly traded for-profit

company offering such programs, and of course we have them in

New York, but they are not under aegis of the State.

So we have some particular issues we have to deal with, but the

Governor was on the right track, and I am hoping that in a bipartisan way in our State bringing together the interested parties, the

Governors’ proposals, and others who have worked on this will

come together, and we will be able to come up with some of the

statutory changes that would address the disclosure issues, the information issues, some of the licensing issues.

But I think we would be greatly aided by the kind of model statute and the work that could be done here out of this committee.

The CHAIRMAN. Well, thank you very much. I am going to turn

to our ranking member. I am also going to hand him the gavel. I

will need to step out.

Senator CLINTON. That is dangerous, Mr. Chairman, you know.

[Laughter.]

The CHAIRMAN. All I can say is don’t you wish? [Laughter.]

Only for the day. Only for the day, John Breaux. Only for the

day.

Senator BREAUX. Time will cure everything.

The CHAIRMAN. Oh, it will. Again, thank you.

Senator BREAUX. [presiding.] Let me thank also the chairman,

but also thank Senator Clinton. I think that you point out something that is confusing to you and it is confusing to us. You can

imagine how confusing it is to the average citizen who is sometimes

desperately looking for some facility to take care of a mother or a

father or a relative. As to whether it is a licensed facility, whether

it is not, you really can’t tell.

I am wondering—and Senator Wyden spoke to this, the difficulty

that New York is having in licensing these facilities I am sure is

repeated in almost every other State—if there is not some Federal

role that we can do without being too intrusive to set up some national standards and national guidelines and somehow encourage

the States to have a unified system throughout the system? You

know, if we have 50 different sets of rules and regulations for assisted living facilities, it seems like we are not really solving the

problem. Do you think that is something we can pursue here?

Senator CLINTON. Well, I would certainly encourage you to do

that, senator, because one of the underlying issues here is that because we are a very mobile country, oftentimes parents and children live in different States. You know, as I referred to in the example I gave, a daughter came from out of State, her mother did

not want to leave New York, and so her mother wanted to stay

there, the daughter came to try to make arrangements. The rules

are different from state to state, and it is a patchwork, and so I

think anything we can do to set some kind of model statute, maybe

to set some national standards and some additional recommended

voluntary provisions to encourage all of the players to come to the

table, I think from my discussions with the providers in New York,

they would welcome that, because, you know, the ones who are

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doing a good job, they want to be recognized for the good job they

are doing and they deserve to be.

They want to be separated out from, you know, those few bad apples that don’t do what should be done in taking care of our seniors. So anything we could do to set up a framework that would enable that to occur, I would be very much in favor of.

Senator BREAUX. That is an excellent point. Thank you very

much for being with us. Senator Carnahan, any questions?

Senator CARNAHAN. No.

Senator BREAUX. And Senator Wyden.

Senator WYDEN. Thank you, Senator Breaux and Senator Clinton. Excellent presentation and you know one of the reasons that

I argued for it now being the time to look at a model state statute

is what you have experienced in New York. I think it is sort of a

microcosm of this crazy quilt that we are seeing around the country

that GAO told us about more than 3 years ago when they gave us

this sort of report on the hodgepodge of definitions. I thank you for

an excellent presentation.

I hope that this committee, on a bipartisan basis, will with Senator Breaux and Chairman Craig, pull together an effort to look at

a model state statute involving consumer groups, State regulators,

the industry, and we would very much like to have you involved

in that issue.

Let me ask you about one other question—and I think New York

may have a unique ability to contribute. We all know we are having this demographic tsunami in this country with so many older

people. New York has a very high percentage of seniors already,

and I have noted over the years in my work with Gray Panther advocates up there that you have a lot of low income senior citizens.

Senator CLINTON. Right.

Senator WYDEN. There has been a debate among senior advocates with respect to how to integrate low income seniors into the

assisted living model. There has been discussion by both the advocates and the industry of using essentially the housing arm of the

government, the various housing programs, in order to stimulate

some additional services for low income seniors. Has New York

looked at that? And if so, I gather you could conceivably involve

State housing programs, HUD, conceivably even some of the government, you know, backed-up programs. I would be interested in

what New York has found with respect to housing and low income

older people.

Senator CLINTON. Well, senator, I think that you have put your

finger on one of the potential areas for exploration in the next few

years. We do do some of that in New York. Other States do as well.

Trying to provide supplemental housing for low income seniors, but

we have by no means done enough nor have we come up with a

kind of a priority list of how we proceed to provide affordable housing as people get older.

You know this is not an issue that is on the front page of the

newspaper, but everywhere I go in New York from western New

York where the aging of the population is particularly acute, because we have lost too many of our young people so our aged citizens are disproportionate in the population, to Long Island, which

is thriving economically and can’t figure out how it is going to afVerDate 11-MAY-2000 13:10 Aug 15, 2001 Jkt 000000 PO 00000 Frm 00016 Fmt 6633 Sfmt 6633 C:\DOCS\73340.TXT saging1 PsN: saging1
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ford to keep their elderly and their young people on the island because affordable housing is so scarce.

We need a housing policy in our country, as you know so well,

and one of the elements of it should be low income affordable housing for seniors, and anything we can do to try to bring that into

the debate, I would certainly favor, and I would be happy to have

my staff, working with your staff, put together the range of options

that we do in New York so that you can see what is available. I

am not so sure it is different from other places, but I think we perhaps have more State money and maybe in some areas more local

money and even some private-public partnerships that we are trying to develop.

But I am very pleased you raised that because when you look at

the reimbursement level, even in New York where the cost of living

is high, yet the State has made a great effort over the years to provide additional funding for our seniors—you know, we have got

under assisted living the permission to use combined Medicaid-SSI

financing at roughly $94 a day—that does not go very far if you

have got somebody in an unstable medical condition, chronically

bedfast or chair-fast, or who requires two people lifting, and equipment, you know, but at least we are making that effort.

And so we have got to bring more resources in, and I think the

housing sector, both the public and the private, could make a real

contribution.

Senator WYDEN. Thank you for a very good presentation.

Senator BREAUX. One of our witnesses, I would point out, a lady

from Louisiana, is going to talk about using HUD funding to build

assisted living. That will be really interesting.

Senator CLINTON. Good.

Senator BREAUX. Senator Clinton, thank you so very much.

Senator CLINTON. Thank you.

Senator BREAUX. Delighted to have you.

Senator CLINTON. Thank you very much.

Senator BREAUX. Let us welcome up our next witnesses, and

what I would like to do is to bring them all up, and we will have

them at one panel rather than divided up, and we would like to

welcome Dr. Emelia-Louise Kilby from Arlington, VA, and Ms. Esther Gallow from Monroe, LA; Mr. Bill Southerland who is managing partner of the Southerland Residential Care Homes; Ms. Karen

Love from Falls Church, VA; and Ms. Margaret Thompson. I think

we can fit in all the panel at the table.

Our first witness will be Dr. Kilby. We are delighted to have you.

I understand you have been living in an assisted living facility for

some time. And we are delighted to have your comments.

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STATEMENT OF EMELIA-LOUISE KILBY, PH.D., ASSISTED

LIVING RESIDENT, ARLINGTON, VA

Ms. KILBY. Thank you. Senator Breaux and members of the committee, I am called Lou Kilby. I am a resident of an assisted living

facility. It is my pleasure to testify today and provide a residentcentered perspective of what it is like to live in assisted living.

I am a paraplegic and assisted living has been an ideal solution

to my problems. I had not expected to spend my golden years in

a wheelchair without long-term care insurance. In assisted living,

I have had a chance to be fairly independent, to be up and about

most of the day, to order and take my own medications, and to continue in a leadership capacity serving on committees. A worrisome

thing for me is that costs go up yearly and I fear that I will outlive

my money.

Most of the 50 residents live in private apartments, complete

with their own bathroom, shower and small refrigerator. Despite

the positive aspects of an attractive home, the environment tends

to be depressing with some residents unable to communicate, uninterested in taking part in activities, and sleeping much of the day

in the common areas.

It is sad, too, when a resident dies or leaves for a nursing home

for more care. The activity program is outstanding with various opportunities for the active-minded resident. The program has consistently been an important part of my life and was of great help

in my transition from independence to assisted living.

More effort could be made by the staff to encourage attendance

of the 30 assisted living residents. Barely a third participate regularly in any activity. I am pleased to say that a number of residents regularly report for morning stretch, which I lead. My star

pupils are a 99-year-old woman and a 98-year-old man. The woman

has expressed her philosophy by saying she participates not to live

longer, but to make her days better.

The wellness nurse supervises the administration of medications

and the monthly check on weight and vital signs. Both the nurse

and the weekend LPNs only work the daytime hours. During

evening hours, the supervisors and the medication technicians,

called med techs, make decisions about 911 calls and consult with

the resident’s doctor.

There is no doctor on the premises. A well-trained med tech delivers pills and other medications such as atomizers. A resident

may receive as many as a dozen pills with a small glass of water

despite the fact that most pills say to take with eight ounces of

water. Sometimes pills are given out before the resident has had

breakfast. I wonder about the advisability of such practices.

I have concerns about the protocol practiced when a resident

falls. The resident should be carefully helped up once a determination has been made that it is safe to move them. The staff should

first check the resident’s vital signs and range of motion. This is

not always done.

Resident assistants, or RAs, provide the personal care for residents such as giving showers and baths, changing diapers, dressing, seeing that the residents get to meals and so forth. They also

do the laundry and make the beds on the assigned floor. In addition, they work in the dining room waiting on tables and doing

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dishes. All this for $7 or $7.50 an hour depending upon their experience.

For many, English is a second language and misunderstandings

do occur. Presently, since the house is not full, the RA work hours

are being cut by one full day a week. This represents a loss of approximately $56 a week. Of great concern is the unrecognized deterioration of some residents, particularly the more independent residents who do not receive daily assistance from the staff. Problems

such as depression, confusion, unsteadiness, and weight loss are

not always brought to the attention of the nurse or the executive

director.

Alert residents are frequently more aware of these resident

changes than the senior staff. The turnover in staff at all levels is

truly appalling. In my 61⁄2 years, for example, we have had seven

executive directors, six activity coordinators, and countless RAs.

The turnover is disruptive. Just as you get used to someone, she

is gone or he is gone. The work pressures, low pay, amount of work

are surely factors.

To make ends meet, some of the staff take on second jobs, and

just cutting each RA’s time not only discourages loyalty but also

sends a message that they are not important to the home.

I appreciate this opportunity to express my views about assisted

living. It has made my life, which is difficult at best, much more

pleasant. Thank you.

[The prepared statement of Ms. Kilby follows:]

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Senator BREAUX. Dr. Kilby, thank you very much for sharing

your thoughts with us, and we are delighted to welcome now Ms.

Esther Gallow from Louisiana. Delighted to have you with us.

STATEMENT OF ESTHER GALLOW, PRESIDENT AND CEO,

BOOKER T. COMMUNITY OUTREACH, INC., MONROE, LA

Ms. GALLOW. Good morning. I bring you greetings from the State

of Louisiana. I am Esther Gallow, president of the Booker T. Community Outreach, Incorporation, in Monroe, LA. Our goal is to improve the living conditions of the poor and elderly residents of the

Booker T. Community by producing affordable, safe, and decent

housing, and creating vehicles to improve the social and economic

conditions of the residents in the Booker T. area.

Booker T. is the oldest and largest neighborhood in Monroe,

where the greatest concentration of very low and low income elderly live. It has the highest concentration of deteriorated houses and

structures in Monroe. The average income of our seniors is between

$3,200 and $5,361 per year.

My organization is proud of the fact that through our efforts for

the first time in 20 years, reinvestment and revitalization is occurring. When the long-time low-income elderly in our community can

no longer live in their own homes, they literally have no place to

go, and nursing homes come into play. They have no choice about

life.

My organization believes it is important for elderly persons to

have the opportunity to stay in their communities where they can

continue to play a vital role and stay connected with their families

and friends. To address this most critical need, Booker T. has embarked on this largest project, the development of a Senior Village,

a $5.5 million project consisting of 28 units of independent rental

units and 40 units of assisted living and adult day care, all on 7.2

acres in our community.

I believe the Senior Village will serve as a national model where

no such facility has provided for low income in our State. The State

of Louisiana does not presently have a Medicaid waiver. To accomplish our goal thus far and make the dream of the Senior Village

a reality, many partnerships are involved.

First, Booker T. enjoyed a strong, positive and supportive relationship with the residents of the Booker T. community. Family

and community members will play a critical role in the ongoing

management of their family members by providing such things as

housekeeping, bathing, involvement in activities. In other words,

this is our village, these are our seniors, and we plan to take care

of them.

Booker T. is grateful to Senator Breaux, Senator Mary Landrieu

and their staffs, also Richelle from the McAuley Institute, who

were instrumental in getting Booker T. a $498,900 EDI special

project grant through HUD’s 2001 appropriations bill.

We were able to leverage this, bring in the public and private together. The Sisters of Charity of the Incarnate Word, who was one

of our major sponsors, also is one of the largest providers of health

care in the State of Louisiana and Texas, has joined forces with us.

Not only did they purchase the land for us, they have put up moneVerDate 11-MAY-2000 13:10 Aug 15, 2001 Jkt 000000 PO 00000 Frm 00024 Fmt 6633 Sfmt 6601 C:\DOCS\73340.TXT saging1 PsN: saging1
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tary donations and will also manage the assisted living which they

currently do anyway.

The Christus Help Foundation has also put up monetary of $150,000 toward this project. The city of Monroe, I just was informed last night, has agreed to do all the infrastructure on the 7.2

acres and also a commitment of $250,000 toward this project.

AmSouth will do the gap financing, if necessary, and has also cosponsored a loan application to the Federal Home Loan Bank to

support the assisted living facility.

We have applied for a 202 HUD that will support the independent facility, and through the Louisiana tax credit program, we have

applied for a loan that will take care of all of the construction costs

for the assisted living facility.

AARP is instrumental in our project also. We have opened up a

local office in our community. All of these people are coming together to help and we are not at this point through with begging

and asking for assistance. Our main concern is to get as much

money as we can into the assisted living part so that it will not

be looked upon as a profit-making but a way of helping our people.

I would like to urge the committee, No. 1, to investigate ways to

encourage States that have not yet granted Medicaid waivers to do

so.

No. 2, to promote the use of project-based Section 8 for low incomes in non–202 projects.

No. 3, to encourage HHS and HUD and other entities to work

closer together to resolve this problem.

Finally, I would like to urge this committee to press more for

Federal resources to produce these type of facilities. Our elderly

should have a choice. I thank you and welcome questions or comments.

[The prepared statement of Ms. Gallow follows:]

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Senator BREAUX. Thank you very much, Ms. Gallow, for an excellent presentation. Mr. Southerland.

STATEMENT OF BILL SOUTHERLAND, MANAGING PARTNER,

BILL SOUTHERLAND’S RESIDENTIAL CARE HOMES, EAGLE, ID

Mr. SOUTHERLAND. Good morning, Senator Breaux and Senator

Wyden. I am Bill Southerland, managing partner with Southerland’s

Residential Care in Boise and Cascade, ID. I serve as president of

the Idaho Assisted Living Association, an affiliate of the Assisted

Living Federation of America, and also am on the board of directors for the Greater Idaho Chapter of the Alzheimer’s Association.

I am honored to be here this morning to speak about some of the

issues relating to rural areas providing quality assisted living in

those areas. I have been a resident of Idaho for 40 years. I started

my business 16 years ago with my father-in-law Emerson Smock.

We currently operate four facilities in Boise, and one in Cascade,

Idaho has a population of 1,000.

I researched the area, Cascade, and found that there was an

aging population there, and if assisted living services were available, there would be enough clients to make it worthwhile. With

the help of the SBA and a local lending institution in Boise, the

project was started and completed in 1995. We opened up with five

full-time residents and it continues to operate at full capacity.

The average assisted living resident in Idaho usually needs a

minimum or stand-by assistance with ambulation and requires

help or verbal cuing with activities of daily living, and help with

bathing, dressing, and some degree of incontinence. Medication

management, housekeeping and nutritional needs are also common. Usually most residents suffer some form of memory loss.

Assisted living in Idaho also takes care of folks that have mentally ill diseases and developmentally disabled problems. They are

all under the assisted living rules and regulations. Assisted living

communities provide services to meet the needs of all of these clients, particularly elderly.

The assisted living service is greatly needed in rural communities. A lot of times the smaller communities are overlooked for

several different reasons: the ability to operate efficiently in a

small rural area; having the choice of staffing and qualified staffing; and the ability to educate the staff to provide the services longterm basis.

Assisted living provides choices for people requiring 24-hour

basic care and supervision. Elderly residents in rural areas sometimes have to leave their homes and move to larger areas to seek

these services. Families are faced with additional hardships having

to travel longer distances to see their relatives, and also it makes

the resident that has to travel to get the services feel isolated and

a lot of times depressed.

Some of the challenges facing development in assisted living in

rural areas include financing and finding and retaining qualified

staffing, educating the local agencies of laws governing assisted living. Medicaid reimbursement is very critical. A lot of times in the

rural areas a lot of folks have to depend on Medicaid reimbursement for their care in assisted living. The ability to provide training for caregivers on a continuing basis is very, very critical also.

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Assisted living communities in Idaho must be licensed. Idaho

was the first State to require licensed administrators for assisted

living communities. Regulations have been a significant tool to help

improve quality of care and assisted living. We have worked with

our association and State regulators to provide regulation from the

State level to make sure that assisted living is a safe and secure

environment for our seniors.

The Idaho Assisted Living Association worked closely this year

with the House Health and Welfare Committee in Idaho that was

formed to take a look at the existing survey process. The subcommittee’s recommendations have been passed on to the Residential Care Council for Elderly for further review and implementation. The objective of the recommendations was to make the survey

process less adversarial and more constructive. That subcommittee

was a very successful venture and we are really proud of that.

Consumer rights are very important in assisted living and are

mandated by Idaho state law. These rights are posted in each licensed assisted living residence. Included in the consumer rights is

the right to access advocates and adult protection services. Informing residents and family members of these rights is a mandatory

part of the admission process.

Medication management regulations are the responsibility of the

Idaho Board of Nursing. Rules in place now allow caregivers in assisted living to attend comprehensive medication management

courses, be tested, and following, if the caregiver or attendant

passes the test, an RN still has to give the delegation to that person in order to be able to manage the medications.

Access to current information in rural areas is critical for caregivers and administrators. Utilization of the internet to provide

education and information on a regular basis is needed.

Another challenge facing rural assisted living providers is obtaining Medicaid reimbursement levels for clients in rural areas.

Finally, rural areas could benefit greatly from a bona fide

wellness program on a consistent basis. I initially got into assisted

living for one reason: to make a living. However, I learned very

quickly that assisted living is more than just making a living. I can

make a difference in someone’s life. I can provide a home-like environment for someone who has had to move from their own home.

I can make a difference by just spending a little time to give to a

resident who is lonely and does not want to bother anyone.

I can listen to a resident explain about their past and what significance he or she played in history. I can give a person choices

when they think that no choices are left. I can give them personal

care with dignity. I got into assisted living to make a living, but

it is so much more. Thank you.

[The prepared statement of Mr. Southerland follows:]

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Senator WYDEN. Thank you. The chairman is back and why don’t

we just move to Ms. Love.

STATEMENT OF KAREN LOVE, EXECUTIVE DIRECTOR, CONSUMER CONSORTIUM ON ASSISTED LIVING, WASHINGTON,

DC

Ms. LOVE. Good morning. Thank you, Senator Breaux and Senator Wyden, for the opportunity to address this committee this

morning. I am here today on behalf of the Consumer Consortium

of Assisted Living, an organization I co-founded in 1995. We commend you for taking up this timely topic again.

I have been an administrator of an assisted living facility, two

different types, one ranging in size 60 beds, the other a 220 bed

campus. I am also a consumer. My father has Alzheimer’s disease

and resides in an assisted living facility and has for over 2 years.

According to Dr. Catherine Hawes, the author of the National

Assisted Living Study, one in four assisted living residents currently need as much help as a typical nursing home resident. One

recent caller to our CCAL helpline described the situation in which

her father had lived in an assisted living facility for over 3 years.

The father needs daily assistance with activities of daily living

such as bathing and dressing. He often goes without assistance because there is not enough staff. As a long-time resident, he has

bonded with staff and residents and is willing to accept poor care

in lieu of moving out of the facility and somewhere else where he

does not know anyone.

This creates serious conflicts for the daughter because she hates

to see her father poorly cared for, yet she understands his need to

fit in, as well as his ability to make his own decisions. Unfortunately, this is not an isolated situation. CCAL hears all too frequently about care problems. To operate a facility without sufficient trained staff to care for the contractual needs of its residents

is corporate negligence. The industry has allowed an unacceptable

margin of error for itself.

Assisted living has experienced explosive growth. At times, this

rapid growth has occurred at the cost of resident care as quality

resident services have not kept pace with brick and mortar construction.

The Census Bureau projects that the population of individuals 85

years and older will be the fastest growing part of the elderly population throughout the rest of this century and will more than double by the year 2030. This enormous growth has significant implications for assisted living as individuals 85 years and older are

those most likely to become assisted living residents.

Yet, despite the tremendous growth of the industry, frailty of the

residents and the demographic trends, as has been discussed earlier this morning, we know that there are no uniform standards or

Federal regulations to protect residents and ensure that their

needs are met.

According to a statement Dr. Hawes made last year, the combination of sicker people and low caregiver-to-resident ratios is

dangerous. These two things are on a collision course. It is just a

time bomb waiting to go off she says.

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This time bomb may have already gone off. Recent front-page

stories in The New York Times, Wall Street Journal and the Washington Post abound with stories of problems in assisted living. A

dearth of workers which we have also heard about this morning in

the long-term care industry and low occupancy rates pressuring the

need for providers to fill beds has further heightened the concerns

about quality care.

The Washington Post recently reported about a situation in

which an 83-year-old frail female resident residing in a facility of

one of the industry’s largest providers was assaulted in the day

room by a 55-year-old male resident. This vulnerable female resident died 2 days later in a hospital from injuries sustained in the

assault. Was this male resident an appropriate admission to a facility caring for vulnerable individuals or was the company simply

filling beds?

These significant problems are compounded by the uneven and

patchwork approach to State regulations and oversight producing

an increasingly alarming picture of the industry. The industry is

regulated, as has been mentioned earlier, individually by States,

but there is such a variability, even in what we call assisted living.

There are over two dozen names. For example, adult residential

services, home for the aged, domiciliary care. It is very confusing.

Senator Clinton beautifully described the confusing array of licensing options when she described what New York state alone has.

One of the problems with nursing home oversight and national

standards is that advocates have spent decades trying to catch up

to an industry that got off to a freewheeling and virtually unrestrained start. Our nation’s nursing home residents and their loved

ones have paid and continue to pay a high price for that.

The assisted living industry has been given—we are into the second decade of an unrestrained start. We believe that no further

time should pass before we really begin appropriately addressing

and responsively answering these important needs. I am so glad to

hear, Senator Wyden, this morning your suggestion about national

standards.

CCAL has begun the effort to develop what we have called model

standards, model resident-centered standards, in a process to enlarge the national dialog on assisted living and the action. This

should be encompassing of all of the stakeholders and we hope that

the industry will join us as well. Thank you.

[The prepared statement of Ms. Love follows:]

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Senator BREAUX. Thank you, Ms. Love. Next we will hear from

Ms. Thompson. Ms. Thompson.

STATEMENT OF MARGARET THOMPSON, BOARD OF DIRECTORS, ASSISTED LIVING FEDERATION OF AMERICA, WASHINGTON, DC.

Ms. THOMPSON. Good morning, Mr. Chairman and Senator

Wyden. Thank you very much for this opportunity. My name is Peg

Thompson. I am from Huntsville, AL. My family owns and operates

nine assisted living residences in small communities in Alabama,

Pennsylvania, Mississippi and Tennessee.

I am also a founding member of ALFA, the Assisted Living Federation of America, and it is in that capacity as a representative

of ALFA’s 7,000 members and 41 State affiliates that I am privileged to be here today.

This is an extraordinary opportunity, and as a provider in those

small States, I cannot tell you how heartened I am to hear the support of the committee members in making sure that assisted living

is a vital part of the continuum of care in this country.

Since ALFA’s founding in 1990, we have been committed to enhancing consumer choices in long-term care and championing quality of life issues for older people and particularly our residents. Our

assisted living communities, as you all have said, offer a needed

residential alternative for the elderly and others who need help

with the daily activities that many of us take for granted and do

without any care at all.

Mr. Chairman—excuse me—Senator Breaux and Senator Wyden,

there are three points that we as an industry think are essential

that we focus our discussions on today. First, a cherished value in

this country is independence, and independence, as Senator

Carnahan mentioned earlier, means freedom of choice. Older Americans want to choose where they live and what their daily activities

consist of and how they do those activities.

All of us as Americans have an obligation to respect and protect

their freedom to choose, even those people who need help in those

choices everyday. Assisted living offers one of those choices and for

many people it offers the choice that has advantages over living at

home. It offers the advantage of security and services and a social

life that sometimes is missing for older people in their own homes.

Second, we wholeheartedly unequivocally as an industry support

regulation. We support regulation at the State level, which is the

level that is closest to the consumer. We are heartened by Senator

Wyden’s suggestion that we look at a model statute to bring some

language consistency across the country and provide States with

some needed, not necessarily guidance, but to take the things that

really do join us together and move on from that point.

All 50 States regulate assisted living. All 50 States and the District of Columbia regulate assisted living today. We are diligently

working in the States to clarify the understanding of assisted living, to bring more consistency, particularly in disclosure, because

that is an issue, and to make improvements in staff training and

availability of staff across the country. Those are huge priorities for

us.

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But those regulations must be done in a context where they do

not restrict seniors’ choices.

Third, since we met 2 years ago, ALFA and its Informed Choice

campaign has made real progress in the areas of disclosure, staff

training, and our most serious concern which is availability of staff.

And with your permission, I would like to give you a couple of examples in each one of those areas that might amplify what really

is happening in assisted living today.

Regarding the imperative to protect older people’s right to

choose, I think I need not do anything other than point to Dr.

Kilby’s examples of the choices that she has made to make her life

dealing with chronic disabilities more possible for her. She is an example of the reason that most of us in this industry are assisted

living providers and feel privileged to provide those services everyday.

Last week, one of my residents in a community in Pennsylvania

said it this way: you know, I have never eaten breakfast at 6:30

in the morning; I don’t want to eat breakfast at 6:30 in the morning. Why can’t I choose to eat it at ten o’clock? And by the way,

someone said that in the nursing home I would have to have my

bath at ten o’clock in the evening. I don’t stay up until ten o’clock

in the evening. I have always had my bath at seven o’clock in the

morning.

Those seem like little choices, but those are choices that are very

important to our residents and we want to protect those choices.

Being at home means these things and being at home is assisted

living.

A move from a beloved home to assisted living is a huge family

choice. And that is why we are such proponents of full disclosure

before, during and at the end of someone’s residence, and I will discuss those things in just a minute.

Regarding regulation, I can’t emphasize how supportive we are

of States providing a good regulatory structure in which we can

function. We are caring for the frail of this country. We take that

responsibility seriously, and our collaborations with States have

been very successful in creating regulation at the level that impacts consumers the most, the closest level to the consumer, so that

local consumer groups, local chapters of AARP and the Alzheimer’s

Association can contribute to that process.

In my home State of Alabama, a very good example is in place

today. Over the last 8 months, we have created all kinds of regulatory structures brand new for the industry, and all people involved are now stakeholders in the success of those regulations.

In regard to staffing, ALFA has an array of programs that are

in place today including certification for administrators, which is

the biggest example, that 750 of our administrators have already

participated in. It is an example of a program that works not only

to improve the quality of the ability of our administrators but also

improves the quality of service for our residents, and ALFA has instituted ten other such programs that are being very widely accepted in the industry.

Those three points, Senators, the importance of protecting choice,

the cornerstone of state regulation in the process of maintaining

quality of care in our industry across the country, and the indusVerDate 11-MAY-2000 13:10 Aug 15, 2001 Jkt 000000 PO 00000 Frm 00047 Fmt 6633 Sfmt 6601 C:\DOCS\73340.TXT saging1 PsN: saging1
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try’s continued desire to work with regulatory agencies, with consumer groups, to make sure we are creating an option that is a

true choice of quality in this country, are critical to all of us, and

I thank you very much for the opportunity of speaking this morning.

[The prepared statement of Ms. Thompson follows:]

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Senator BREAUX. Well, let me thank you, Ms. Thompson, and all

the members of the panel for being with us and for your statements, which I think have been very interesting and very helpful.

Let me start with you, Ms. Thompson. You all have nine assisted

living facilities.

Ms. THOMPSON. Yes, sir.

Senator BREAUX. Now if I am looking at one of your facilities to

place a relative, how do I know or can I know through any type

of a structure or a system about the quality of care that your facilities meet?

Ms. THOMPSON. That is a very interesting question, and I was

listening to the Senator’s comments earlier. Right now the comparative quality issue is not one that has been addressed in a systematic way. The way that one accesses information is not a very

good way. The access is to state survey reports for an individual

facility if it is licensed.

Senator BREAUX. All of your facilities are licensed?

Ms. THOMPSON. Yes, sir.

Senator BREAUX. By the State? But I take it that license does not

have anything to do necessarily with meeting certain standards of

quality of care?

Ms. THOMPSON. No, and actually that is the reason why ALFA

has been so aggressive in creating tools for providers to allow consumers to access that kind of quality information. There is not a

system, but there are systems with ALFA’s web site, for example,

that have a very large consumer component. It has this consumer

guide included in it, Senator Breaux, and oops, I have got it upside

down.

In the middle of this consumer guide is something that my folks

use everyday, every inquiry, every visit. And it actually gives consumers the opportunity to compare apples and apples. It is a very

intimate process when one chooses an assisted living residence, and

we are very strong proponents of folks being able to compare the

pricing structures, the services that are included and not included,

the array of things that are listed in this checklist, and it is very

helpful.

Senator BREAUX. But somebody else operating across the street

from you, for instance, in a licensed facility in one of your States

does not have to do any of that if they do not think it is desirable

perhaps?

Ms. THOMPSON. Excuse me? Isn’t required to do? No. They are

not required to do so. That is why ALFA is introducing in all the

States a model disclosure act, which is part of my written testimony, and it is our goal to introduce that for just that purpose in

each one of the States.

Senator BREAUX. Excuse me. So that would be a disclosure type

of requirement, but it would not be setting standards for assisted

living facilities as to what they have to meet; is that correct?

Ms. THOMPSON. Well, there are standards in each one of the

States. And another example of one State solution to that real

problem is what the State of Kentucky has done. They have created

a consumer guide using some of the elements from this consumer

guide, and what they have done is they are requiring their assisted

living residents to provide this piece with every inquiry, and this

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piece not only has a consumer checklist describing what assisted

living is in the State, giving folks the same kind of guidance on

how to compare, but it also has the statute in this piece.

Senator BREAUX. But does the statute just require the providing

of information on what the assisted living facility does, or does it

require the assisted living facilities to meet certain guidelines and

certain standards with regard to the number of employees, the

number of med techs that operate in the facility or anything of that

nature?

Ms. THOMPSON. Yes, sir. Each one of the States has a set of

guidelines that describes facility requirements, staffing requirements, minimum staffing requirements.

Senator BREAUX. Ms. Love, you are shaking your head. You do

not agree with that. I just caught you right there in the act of disagreement so let me have you comment on what she is saying.

Ms. LOVE. There isn’t consistency. Every State does not have——

Senator BREAUX. Use the mike, if you can. You all share that.

Ms. LOVE. That is one of the problems that there is that lack of

uniformity and consistency. Not every one of the States has minimum staffing requirements or this disclosure information, but we

are wonderfully heartened to hear that the industry is working on

that. As you note, these are things that are important.

Ms. THOMPSON. I think information in this process is extraordinarily important, and we have found that the more disclosure we

provide up front, the happier resident population we have.

Senator BREAUX. Let me, the thing that is striking me, I mean

we went through this 2 years ago, and we talked to the industry

about doing some things to try and voluntarily bring themselves

into a structured situation where there were certain standards and

requirements.

Ms. THOMPSON. And we still are in that process, Senator Breaux.

I mentioned the model disclosure statement. The industry is now

requiring its members to disclose—excuse me—to support the association’s disclosure position before they become members. We are in

the process of developing with regulators, providers and consumers

a set of best practices. To do that and to do it in a way that protects the things we have described, it is a very complicated process.

And those best practice standards will be introduced for the first

time at a State regulator conference this fall.

Senator BREAUX. We had hoped that self-accreditation was going

to be the answer to this, and I note that since 2 years ago that

fewer than 20 facilities in the entire country have some type of a

self-accreditation program, whether it is through the Joint Committee on Accreditation of Health Care Organizations or what have

you.

I mean it is one thing for disclosure. I am happy that you have

made progress in disclosing what you do. But for many, I am concerned about what they do. And are they meeting a minimum

standard for the people that are in there? Are they being accredited

by some either self-accreditation program or by the State, by the

Federal Government, or by somebody?

Ms. THOMPSON. Well, I think the reason why we are so supportive of State level standards is, as I mentioned, that those level of

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standards are at the level where consumers can access them more

readily.

Second, we very much support in many States that the enforcement capability of the States be increased. That really is where, if

there is a difficulty today, Senator Breaux, it is in the enforcement

of existing regulations and not the imposition of another set of regulations.

In Alabama, for example, there are—with this change in regulations, we are, in fact, implementing very significant fines for serious problems in assisted living residences, and also tightening the

State attorney general’s ability to prosecute folks who are not providing good services.

Senator BREAUX. Well, what happens when you have 50 different

sets of regulations? You operate in more than one State yourself.

Ms. THOMPSON. Yes, sir.

Senator BREAUX. Suppose you operated in all 50 States. Is it

practical to have 50 sets of different rules and regulations and

standards that you have to meet in each State? Wouldn’t it be better to have a national standard that is enforced on a local level or

is that not the right way to go?

Ms. THOMPSON. I think if you look, actually if you look at assisted living on a state-by-state basis, the system really is working.

As I said, I think we really do need a better ability to enable States

to enforce the existing regulations. And to operate in 50 States

means that we are serving local populations in those 50 States, and

I operate in five States. Tomorrow I might operate in six States.

I really welcome the opportunity to create an environment in that

State that fits the needs of folks in that State, and the diversity,

the difference between operating a community in Mississippi and

operating a community in Pennsylvania, we operate under those

rules very successfully because we are serving people in those

States.

I see no reason why a uniform standard would do anything other

frankly than perhaps, and this is a risk for us, restrict exactly the

kind of choices and the kind of innovation that we have been

blessed to have under the current regulatory system.

Senator BREAUX. One other point and I will turn it over to Senator Wyden. Ms. Gallow, let me ask you a few things. I was very

interested and have been aware of what you all are doing in Monroe, LA. The income levels of the people you are serving are obviously very disturbing. Three thousand to $5,000 a year does not

allow a person in that category to pick and choose among the best

of assisted living facilities with that kind of an income.

Why is my State and your State and our State not eligible for

Medicaid assistance to people in your situation that you serve? I

mean every one of them would be Medicaid eligible if Medicaid had

a waiver in our State to cover assisted living facilities.

Ms. GALLOW. It is because we have a very strong lobbying group

of nursing home advocates that do not want Medicaid waivers for

assisted living.

Senator BREAUX. I mean I understand the bottom line here they

don’t want competition for their patients in assisted living facilities, but what in the world can they possibly argue publicly as to

why they would oppose having those citizens eligible?

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Ms. GALLOW. They can’t really argue effectively. What we have

been doing is lobbying down in Baton Rouge trying to get our representatives to see that the cost of putting a person in a nursing

home in Louisiana is 30 percent more than putting them in an assisted living facility, and we are hoping that within the next year,

they will hear our cries, but as of now, right now, we don’t have

it.

Senator BREAUX. Its just—it seems—— Ms. GALLOW. I know it is mind-boggling.

Senator BREAUX [continuing.] It is hard to believe. Of course, we

are both from there, and I know—— Ms. GALLOW. It is Louisiana. [Laughter.]

Senator BREAUX. And I know what you are facing down there.

Well, a number of other States are in that same situation. I think

there are 38 States that have a Medicaid eligible waiver and the

rest do not. I mean it seems to me that it is hard to understand

why we don’t.

Ms. GALLOW. Yeah. There are a number of us who have formed

a coalition from northern Louisiana and also from southern Louisiana. We went to Baton Rouge a couple of weeks ago, and we plan

to go back in about 3 weeks when they meet again because we are

screaming louder and louder. And that is all we can do.

Senator BREAUX. I will tell everyone here that if the Federal

Government is going to participate in helping to pay for the care

of these patients—— Ms. GALLOW. That is right.

Senator BREAUX [continuing.] Through a Medicaid program, I am

particularly disturbed that it could be in a facility of which there

are no national standards. If we are going to give 75 percent, which

in Louisiana is about a 75/25 Federal Government match—— Ms. GALLOW. Right.

Senator BREAUX [continuing.] For the State’s match, I do not

want to have that money being spent in facilities of which there

are no standards. I am not saying it has to be Federal standards,

but there have to be standards, and right now a lot of assisted living facilities really don’t have to meet any standards. Maybe they

do and they got some great examples of facilities that are providing

the very highest quality, but then there are some that are perhaps

not.

And if we are going to be spending tax dollars, I think we ought

to be able to ensure everyone that it is being spent in a facility that

meets certain standards.

Ms. GALLOW. I agree.

Ms. THOMPSON. Senator Breaux, can I respond?

Senator BREAUX. Yeah.

Ms. THOMPSON. I think that does show the benefit of having a

model statute because as we move forward in the process of making access possible to this type of service for even a wider array of

folks, I mean at this point 90 percent of folks in assisted living residences are paying with their own dollars or their family’s dollars,

and as we widen access with creating opportunities for folks who

will use Federal dollars, I think to have a statute, a model, to alert

States to the fact that this may be coming and create that model

approach within each one of the States is an excellent idea.

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It is not that we should have standards. We must have standards

or consumers cannot evaluate who we are and what we do. Our

point is that we want to make sure that the development of the details of those rules happen as close to the consumers as we can possibly get it.

Senator BREAUX. I appreciate that. Senator Wyden.

Senator WYDEN. Thank you, Mr. Chairman. I think your questions were excellent and I want to get into the same sort of areas.

Dr. Kilby and Ms. Gallow, thank you for excellent presentations.

Ms. GALLOW. Thank you.

Senator WYDEN. To have advocates like you on the front line is

a tremendous benefit to the nation’s seniors and we really appreciate your being out there and the work that you do and your

voices today.

I want to spend some time, Ms. Love and Ms. Thompson, looking

at the common ground between the two of you. I was struck in

many ways as I listened to the question Senator Breaux asked

about the parallels between this discussion and discussions we had

about nursing homes 25 years ago. Twenty-five years ago when I

had rugged good looks and a full head of hair, the discussion was

sort of the same as the discussions we are having right now. The

question then was how do you get the essential consumer protections for vulnerable people? The question now is how to do that and

at the same time give a critical industry enough flexibility to innovate and meet modern circumstances?

Suffice it to say today, 25 years later, both the nursing home industry and nursing home advocates are not particularly pleased

with the decisions that were made 25 years ago. So what we are

trying to do here is to avoid a replication of the next 25 years with

respect to assisted living. That is the objective, and I think both

of you would agree, and I appreciate your nodding your heads.

What would you think—because I have been talking about this

model statute—this is a question for the two of you—of this committee working with both of you, consumers, industry, State health

departments, and I also want to involve researchers in this field,

gerontologists, because they will help us get some ideas about what

is ahead, to develop a model state statute, a state statute, so that

we could have the States leading, but have strong consumer protections, and then hypothetically say we will give the States a period

of time to enact that model state statute, and if the States didn’t

do it within a period of time, then there would be some other consequences and we could work through this process to decide what

that might be?

Ms. Love and Ms. Thompson, what do you think about our trying

to go at it that way?

Ms. LOVE. I think it is an excellent suggestion, and I loved your

example earlier of the Medigap, using that, where you had all the

stakeholders kind of coming together, that the government didn’t

take predominant role, but they were certainly at the table, and I

think that your similarly suggesting something for assisted living

is right on target, that we could come up with model standards. It

is something that at CCAL we have already partnered with the

American Bar Association’s Commission on Legal Problems for the

Elderly and want to extend the net to all of the stakeholders.

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And we don’t think that model standards per se squelch the ability to have creativity and innovation. For example, we have a tremendous array of transportation, automobiles, SUVs, trucks, et

cetera, so there is lots of creativity in designing different vehicles,

but yet they all still have a similar set of standards, you know, on

health, you know, different emissions requirements, tire safety and

standards, et cetera.

I think that is something that we can include, you know, sitting

at the table and we would want to include researchers. We would

also want to include people within the States. For example, the different surveyors, the regulators, I think they would bring a lot to

the discussion as well. You brought up a wonderful example about

the nursing home 25 years ago, and that here we are 25 years later

and the industry and consumers still aren’t on the same page. And

I think that the reason for that is because they weren’t on the

same page to begin with.

The advocates were not involved. The nursing home industry got

off to a galloping start, and it was not until several decades later

that the consumer advocates really had some impact. We are unfortunately almost at the same state here in assisted living. Twelve

years and finally consumers are getting a chance, you know, to

really step up to the plate and participate in some of the discussions. Had that happened at the outset, the emergence of the industry, maybe we would not be on such different pages now, and

we hope to rectify that now.

Ms. THOMPSON. I think we are in that process. I think—I know

the industry is very supportive of helping States help us do the

best job for our consumers. I think the involvement of the State

stakeholders might be the most problematic part of designing a

model statute, Senator Wyden, because each one of the States has

so much ownership over their own processes but also over this one

because most of the States are currently very active in this arena.

This is a very big area right this minute in the States.

So we are very supportive of the process that you are describing

and we will help in any way we can to move it forward.

Senator WYDEN. I am going to interpret that as pretty much a

sympathetic answer.

Ms. THOMPSON. That is a yes.

Senator WYDEN. Good.

Ms. THOMPSON. A long yes—sorry—but it is a yes.

Senator WYDEN. One of the things that I would hope, and I think

that Ms. Love would agree with it, is that for the States that have

done a good job, and there are a number of them, the model state

statute wouldn’t change their lives very much.

Ms. THOMPSON. Right.

Senator WYDEN. In other words, we are not talking about tearing

up the concrete and starting all over. We are talking about States

that are doing a good job pretty much being able to do their thing,

recognizing that what works in Coos Bay, OR is often a little bit

different than what works in Detroit, but we would also have a tool

to get the States that haven’t provided the consumer protection

that both of you, to your credit, have said are needed.

We have a tool to get them up to speed, and that is what I would

like to work with you both on, and as I say, I am just struck by

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how similar the discussions are now about assisted living to discussions of 25 years ago on nursing homes, and both of you look like

exactly the kind of people we want to have at the table, people who

want to try to get some common ground here that is in the consumers’ interest, because of the vulnerable people we are dealing with

that lets the many people in the industry who want to do the right

thing and deserve some predictability, by the way, to know what

is going to be asked of them, to have an opportunity to do that.

And I thank you for it.

Ms. Thompson, just a couple of business questions. The news

media has been reporting, The Wall Street Journal and others, that

there is a significant oversupply of facilities in the assisted living

facility. Is that your judgment and what are the ramifications for

the Congress in looking at oversupply kinds of questions?

Ms. THOMPSON. About 4 years ago, Senator Wyden, there was a

great deal of capital that gravitated toward the idea of assisted living. And in the period from 4 years ago until about 18 months ago,

that created a great deal of creation of supply in market areas

where there had been none before.

And I think in some markets, particularly—well, really the markets are all over—the rural markets, that someone may have built

a community that is a little too big for that particular area. There

are urban areas where that has occurred as well.

When one looks at the demographics, it is a very slowly decreasing problem because capital has not been flowing into the industry

except for very mature operators for the last year. And so the market has recognized that there was some overbuilding or some not

saturated areas because of more buildings than had been in the

past, and capital has tightened. So the market actually is giving

operators the opportunity to catch up on their operations because

of the lack of capital right now.

So in terms of a long-term problem with us continuing to build

in areas that are oversaturated, the underwriting criteria that are

being used by folks lending in the industry have tightened so much

that lenders are very concerned and very conservative about the

folks to whom they will lend. So I really don’t think that it is an

issue that the Congress needs to look at at this time.

Senator WYDEN. One of the reasons that I ask it is that because

we know there are maybe 5 percent of the people in virtually every

field on the planet that are a problem—5 percent of the lawyers,

5 percent of the doctors, 5 percent of the accountants, by the way,

5 percent of the Members of Congress—and I have been concerned

about the question of whether running up these debts that have

been documented is part of the reason for the 5 percent we see in

this field, that those people get overextended, they have got to deal

with the real estate side of the equation, and then patient care suffers.

Do you think that that has been a factor in that small percentage, the 5 percent, that the industry, to their credit, has been saying they are concerned about, too?

Ms. THOMPSON. I think we are a maturing business, and there

are a lot of lessons that those of us who took on really the lion’s

share of expanding this option around the country we have had to

learn. That one has to have the same systems in place if one has

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a 100 residences as I have with nine. And they have to be of similar quality, and it is exponentially more difficult to do it with 100

than it is to do it with one or nine. And so I think that is a maturation process.

The fact that problems exist is heart-wrenching for all of us, but

I think the decrease of the capital available in the markets right

now has actually been a blessing for the industry because we have

been able to focus on those issues, and hopefully we will resolve as

much of the 5 percent as is humanly possible.

Senator WYDEN. Last question that I had dealt with this dire

worker shortage that we are seeing in assisted living and virtually

every other health care area. I would assume, Mr. Southerland,

that in rural communities that this is particularly serious. I have

well over half the communities in my State, you know, with very

modest, you know, populations, and they are having difficulty.

What are you all doing to recruit the workers that you need and

any suggestions for how we might encourage it?

One of the things that I have been looking at is the idea that we

ought to offer scholarships, particularly to low income students, to

work in the aging field. I think that this might well be seen as a

path of upward mobility, that you might, for example, in high

school begin to start concentrating on developing an expertise in

the aging field, continue it at perhaps a community college, and

one day look at, you know, being an administrator of a facility.

But I would be interested, particularly from a rural viewpoint,

what your experience has been in terms of getting qualified workers and whether you have any suggestions for the Congress about

how to address it?

Mr. SOUTHERLAND. I think, Senator Wyden, your example is a

very good example as far as scholarships are concerned. The problem exists in rural areas and large cities; it exists everywhere. It

is actually a critical situation.

I personally have tried to deal with certain bonuses for employees for attendance, for staying an extra shift, something like that,

so that we have qualified folks on duty. It is a problem, but I think

the problem obviously is they need more reimbursement, they need

more dollars per hour. That is one issue.

At the same time you are exactly correct, we need to make that

position, that caregiver or attendant position, the person that is responsible for the care at the assisted living facilities, more something to be sought after. Right now it typically is not. We need to

put a great deal of importance on those positions. They need to be

like electrical engineers or aeronautical engineers. It has got to go

to that level, and I think that is one way that the industry could

change. That is a hard situation. That is a hard thing to do, but

I think your suggestion looking at the high schools is a very good

suggestion.

I know in Eagle where my son and daughters go to high school,

they do have a class where they can actually get their CNA certification, and that is relatively new in high school. But it is a critical

step toward a career in health care and hopefully in assisted living.

So I think anything that can be done to make those areas more appealing and give them more significance is certainly warranted. It

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has to be done. That and additional dollars you can pay them hourly, I think, are two critical, critical issues.

Senator WYDEN. Let us let the consumers and the industry talk

about it. Part of what I have grappled with is that I think the additional hours/the per hour reimbursement helps you in the short

term, but I do not think you then develop a group of people who

are going to see aging as a career where they can have upward mobility, which is why Dr. Kilby’s point was so important.

Dr. Kilby described what I have seen constantly in the aging

field is that the people you see today and you get comfortable with

aren’t the people you are going to see 10 days later. If we are going

to really develop this core of people in this country who are going

to have a reason to stay in the aging field, there is going to have

to be an advancement path, a path that suggests that if you start

at the entry level in assisted living that you are going to have a

chance to get down the road and be the top dog.

And would the industry or consumer folks want to comment on

your ideas on the worker shortage?

Ms. LOVE. There was a wonderful suggestion or comment that

Dr. Kilby made earlier that I think hits to the heart of things. She

mentioned that in her particular home, because they weren’t full,

that the company had made the decision to decrease the direct care

workload by essentially 20 percent, one day a week.

Now, I think that would be very difficult for me to absorb a 20 percent increase, and I make a little more than $7 or $7.50 an

hour. To do that to a direct care workforce is a tremendous trauma

and you end up then losing those workers because they have got

to go somewhere else where they are guaranteed full-time work.

So there are, I think, some things that can be done, you know,

right at the face value of keeping workers on board, incentives for

them to stay. I love your idea, Mr. Southerland, of bonuses, and

discussion, Senator Wyden, about looking at this in high schools

and community colleges, because that gives individuals coming up

in the ranks sort of something to aspire to, something to be interested in learning about. So thanks for bringing it up.

Ms. THOMPSON. I think the answer to our workforce shortage is

working with this population must be seen of value in the culture,

and the culture has not, to this point, seen it really as a valued

position, and the place to start is in school.

In our company, as small as it is, when we identify a staff person

who comes in at that entry staff level and appears to have the

heart, as part of their evaluation process, they are given the opportunity to go to the local community college and gain an LPN license, if that is their choice. That has been a very successful program for us to stabilize our little operations, as has bonuses for

something as simple as one’s attendance everyday. That has been

very successful strategy.

But I think you are right, Senator Wyden. We must particularly

in the next decade create a culture in which service to this population is of value in the culture or we won’t create in our caregivers

the heart that it does require to do this work everyday.

Senator WYDEN. The chairman is back and he has given me a lot

of time. I think this has been an excellent hearing, an excellent

panel, and I am really hopeful that somewhere down the road, peoVerDate 11-MAY-2000 13:10 Aug 15, 2001 Jkt 000000 PO 00000 Frm 00078 Fmt 6633 Sfmt 6601 C:\DOCS\73340.TXT saging1 PsN: saging1
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ple will look back at this hearing and say that this really played

a role in coming up with the kind of solutions that folks tried to

think about with the nursing home industry 25 years ago.

The fact that the two of you have said that there is some common ground that we can find—the chairman was out of the room,

but we talked about an approach involving the consumer groups,

the industry people, researchers in the field, working on a model

state statute addressing the issues that you talked about both with

respect to consumer protection and disclosure and perhaps giving

the States a period of time to in effect meet those standards, and

then if the States did not do it, then there could be some consequences and we could look at what those consequences ought to

be.

And the fact that Ms. Love and Ms. Thompson on behalf of their

organizations are willing to work together—there were certainly no

fisticuffs at this table, and quite the opposite, there was an awful

lot of willingness to work together—encourages me, and that is

what we are going to need to have.

I mean the industry, for example, I think is right with respect

to trying to make the waiver process, you know, easier, but as we

make the waiver process easier and there are Federal dollars available, consumers have a right to say that there are going to be certain consumer protections accompanying those waivers.

So I think there has been a very constructive hearing and just

look forward to working closely with all of you and thank you for

the extra time, Mr. Chairman.

Senator BREAUX. Thank you, Senator Wyden. I think that I

would echo that it has been an informative hearing and we thank

all of you for coming and being with us. I know it has been difficult

for some of you to be with us, and we appreciate it very much.

I think that the two things that stand out in my mind is how

do we afford this type of long-term care for American citizens? We

have not answered that problem. I mean it is a very expensive, no

matter how efficient the delivery system is, this is very costly. And

it is unfortunate that right now the only assistance from a Federal

level is that you have to become so poor as to be eligible for Medicaid which doesn’t cover all States and that is a real problem.

We have introduced legislation to provide Federal tax credits to

people who purchase long-term care insurance, which is, I think,

a way to help get more people involved in planning for the time in

their lives when they will need some type of long-term care. Just

as we prepare today for having unfortunately maybe to go to an

emergency room, Americans need to be preparing for a time when

they may need to have help financially through insurance to provide for long-term care for themselves and for their families. And

we are trying to move in that direction, which I think is very important.

And the second thing that strikes me is that the standards, what

are they going to be? Are they going to be State standards? Are

they going to be local standards? Are we going to have 50 sets of

rules and standards for assisted living facilities? Or is there a way

to have a national standard that is enforced on a local level to

make sure that when we treat these people, that everybody involved is at least meeting minimum standards with regard to qualVerDate 11-MAY-2000 13:10 Aug 15, 2001 Jkt 000000 PO 00000 Frm 00079 Fmt 6633 Sfmt 6601 C:\DOCS\73340.TXT saging1 PsN: saging1
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ity of service that is being provided, particularly if tax dollars are

going to be utilized in helping to pay for it? I think that something

along these lines is needed.

I think this has been helpful. I want to make sure that if we

come back in 2 years, that we have made some real progress in this

area. And I think that we need to use the time between now and

next hearing to be more involved in trying to move in that direction

rather than less involved. So I thank all of you very, very much for

being with us. This will conclude this hearing.

[Whereupon, at 10:55 a.m., the committee was adjourned.]

(77)

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