Center for Excellence in Assisted Living CEAL@UNC

Advancing the well-being of the people who live and work in assisted living through research, practice, and policy.

Regulation/Monitoring

Public Health Response to SARS-CoV-2 in Assisted Living Facilities in New York State: March 2020-December 2022

May 1, 2024
Context: Assisted living facility (ALF) residents are especially vulnerable to SARS-CoV-2 infection due to the age and comorbidities of the resident population and the social nature of these facilities. Objective: To collate all New York State Department of Health guidance and regulations to control transmission of SARS-CoV-2 infection within ALFs from March 2020 through December […]

Public Health Response to SARS-CoV-2 in Assisted Living Facilities in New York State: March 2020-December 2022

by Lea Efird-Green

Context: Assisted living facility (ALF) residents are especially vulnerable to SARS-CoV-2 infection due to the age and comorbidities of the resident population and the social nature of these facilities. Objective: To collate all New York State Department of Health guidance and regulations to control transmission of SARS-CoV-2 infection within ALFs from March 2020 through December […]

Does Assisted Living Provide Assistance And Promote Living?

May 1, 2024
Assisted living has promised assistance and quality of living to older adults for more than eighty years. It is the largest residential provider of long-term care in the United States, serving more than 918,000 older adults as of 2018. As assisted living has evolved, the needs of residents have become more challenging; staffing shortages have […]

Does Assisted Living Provide Assistance And Promote Living?

by Lea Efird-Green

Assisted living has promised assistance and quality of living to older adults for more than eighty years. It is the largest residential provider of long-term care in the United States, serving more than 918,000 older adults as of 2018. As assisted living has evolved, the needs of residents have become more challenging; staffing shortages have […]

Potential Actions to Advance Well-being in Assisted Living

Apr 23, 2024
CEAL@UNC recognizes the benefit of ongoing quality improvement in assisted living. Numerous feasible solutions have been suggested that may improve care and outcomes in assisted living, including those in this information sheet. Feel free to utilize and distribute this information sheet among your networks to advance the well-being of the people who live and work […]

Potential Actions to Advance Well-being in Assisted Living

by Lea Efird-Green

CEAL@UNC recognizes the benefit of ongoing quality improvement in assisted living. Numerous feasible solutions have been suggested that may improve care and outcomes in assisted living, including those in this information sheet. Feel free to utilize and distribute this information sheet among your networks to advance the well-being of the people who live and work […]

Home Time and State Regulations Among Medicare Beneficiaries in Assisted Living Communities

Dec 1, 2023
Background Home time is an important patient-centric quality metric, which has been largely unexamined among assisted living (AL) residents. Our objectives were to assess variation in home time among AL residents in the year following admission and to examine the associations with state regulations for direct care workers (DCW) training and staffing and for licensed […]

Home Time and State Regulations Among Medicare Beneficiaries in Assisted Living Communities

by Lea Efird-Green

Background Home time is an important patient-centric quality metric, which has been largely unexamined among assisted living (AL) residents. Our objectives were to assess variation in home time among AL residents in the year following admission and to examine the associations with state regulations for direct care workers (DCW) training and staffing and for licensed […]

A National Typology of Health Service Regulation in Assisted Living

Aug 1, 2023
Background and Objectives State-regulating agencies use 350 different licenses and certifications to govern assisted living (AL), resulting in significant variation in regulations governing health services, the scope of practice, and capacity. This lack of standardization makes it difficult to compare and contrast AL operations and residents’ outcomes across similarly regulated communities. Research Design and Methods […]

A National Typology of Health Service Regulation in Assisted Living

by Lea Efird-Green

Background and Objectives State-regulating agencies use 350 different licenses and certifications to govern assisted living (AL), resulting in significant variation in regulations governing health services, the scope of practice, and capacity. This lack of standardization makes it difficult to compare and contrast AL operations and residents’ outcomes across similarly regulated communities. Research Design and Methods […]

Online Customer Reviews of Assisted Living Communities: Association with Community, County, and State Factors

Jun 1, 2023
WHAT THIS MEANS FOR YOU: In this study, almost 150,000 on-line consumer reviews from nearly 9,000 assisted living communities were analyzed in the context of community, county, and state variables (e.g., regulatory specificity, rurality). Communities with greater proportions of Medicare/Medicaid residents had lower odds of positive reviews, but communities in states with more direct care worker hours per week per bed had higher odds of positive reviews. Higher staffing may advantage positive consumer perceptions.

Online Customer Reviews of Assisted Living Communities: Association with Community, County, and State Factors

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: In this study, almost 150,000 on-line consumer reviews from nearly 9,000 assisted living communities were analyzed in the context of community, county, and state variables (e.g., regulatory specificity, rurality). Communities with greater proportions of Medicare/Medicaid residents had lower odds of positive reviews, but communities in states with more direct care worker hours per week per bed had higher odds of positive reviews. Higher staffing may advantage positive consumer perceptions.

Paperwork, Paradox, and PRN: Psychotropic Medication Deficiencies in Assisted Living

Jun 1, 2023
WHAT THIS MEANS FOR YOU: This study analyzed 170 psychotropic medication deficiency citations from 152 Oregon assisted living communities to determine discrepancies in state licensing and oversight of psychotropic medication use. It found most deficiencies involved documentation errors; there were unclear regulations for direct care workers who distribute medications; and there was a persistent disconnect about when to seek expertise before requesting psychotropic use.

Paperwork, Paradox, and PRN: Psychotropic Medication Deficiencies in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study analyzed 170 psychotropic medication deficiency citations from 152 Oregon assisted living communities to determine discrepancies in state licensing and oversight of psychotropic medication use. It found most deficiencies involved documentation errors; there were unclear regulations for direct care workers who distribute medications; and there was a persistent disconnect about when to seek expertise before requesting psychotropic use.

State Regulations and Assisted Living Residents’ Potentially Burdensome Transitions at the End of Life

Jun 1, 2023
WHAT THIS MEANS FOR YOU: The study examined potentially burdensome end-of-life transitions (e.g., repeated hospitalizations) in relation to state regulations, using Medicare claims data for over 129,000 assisted living residents in communities with 25 or more beds between 2017-2019. There were no associations between transitions and regulations about third-party services or staffing, and small associations between transitions and medication management regulations. These inconclusive results indicate that more research is needed to understand the wide variety of end-of-life outcomes experienced by assisted living residents.

State Regulations and Assisted Living Residents’ Potentially Burdensome Transitions at the End of Life

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: The study examined potentially burdensome end-of-life transitions (e.g., repeated hospitalizations) in relation to state regulations, using Medicare claims data for over 129,000 assisted living residents in communities with 25 or more beds between 2017-2019. There were no associations between transitions and regulations about third-party services or staffing, and small associations between transitions and medication management regulations. These inconclusive results indicate that more research is needed to understand the wide variety of end-of-life outcomes experienced by assisted living residents.

Pathways into Assisted Living Communities: Admission Limitations and Assessment Requirements Across the United States

Jun 1, 2023
WHAT THIS MEANS FOR YOU: This study examined differences in who may be admitted to an assisted living community using regulatory data from 2018. Admission restrictions were categorized into 1) health-related conditions, 2) specified behavior, 3) mental health condition, and 4) cognitive impairment. Almost one-third (29%) of communities are governed by regulations limiting admission of individuals with only a health condition, and slightly fewer (24%) of communities have limitations based on all four categories. Just over 11% of AL communities have no restrictions on who may be admitted.

Pathways into Assisted Living Communities: Admission Limitations and Assessment Requirements Across the United States

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study examined differences in who may be admitted to an assisted living community using regulatory data from 2018. Admission restrictions were categorized into 1) health-related conditions, 2) specified behavior, 3) mental health condition, and 4) cognitive impairment. Almost one-third (29%) of communities are governed by regulations limiting admission of individuals with only a health condition, and slightly fewer (24%) of communities have limitations based on all four categories. Just over 11% of AL communities have no restrictions on who may be admitted.

End-of-Life Care Transitions in Assisted Living: Associations With State Staffing and Training Regulations

Jun 1, 2023
WHAT THIS MEANS FOR YOU: This study examined associations between end-of-life care transitions (meaning stays in hospitals and nursing homes in either the 7 or 30 days before death in this study) and state staffing and training requirements for nearly 114,000 Medicare beneficiaries who died in an assisted living community in 2018-2019. A higher proportion of transitions was associated with stricter regulations about licensed and direct care worker staffing, whereas a lower proportion was associated with more specific regulations about direct care worker training. Therefore, policymakers and practitioners may want to implement regulations that make staff training requirements more specific to better address end-of-life care.

End-of-Life Care Transitions in Assisted Living: Associations With State Staffing and Training Regulations

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study examined associations between end-of-life care transitions (meaning stays in hospitals and nursing homes in either the 7 or 30 days before death in this study) and state staffing and training requirements for nearly 114,000 Medicare beneficiaries who died in an assisted living community in 2018-2019. A higher proportion of transitions was associated with stricter regulations about licensed and direct care worker staffing, whereas a lower proportion was associated with more specific regulations about direct care worker training. Therefore, policymakers and practitioners may want to implement regulations that make staff training requirements more specific to better address end-of-life care.

State Variation in Antipsychotic Use Among Assisted Living Residents With Dementia

Apr 1, 2023
WHAT THIS MEANS FOR YOU: This study of almost 21,000 AL residents in 2017 revealed that those with dementia were prescribed antipsychotics during about 13% of their time residing in AL. This proportion varied by state, with Hawaii having the lowest prescription rate (8%), and Wyoming having the highest (21%). Variations may be due to state regulation of AL communities, but the study was not able to determine if prescription practices were appropriate and tied to health outcomes.

State Variation in Antipsychotic Use Among Assisted Living Residents With Dementia

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study of almost 21,000 AL residents in 2017 revealed that those with dementia were prescribed antipsychotics during about 13% of their time residing in AL. This proportion varied by state, with Hawaii having the lowest prescription rate (8%), and Wyoming having the highest (21%). Variations may be due to state regulation of AL communities, but the study was not able to determine if prescription practices were appropriate and tied to health outcomes.

Preparedness and Response of Assisted Living Facilities Toward COVID-19 Infection Control in Houston, Texas, USA

Feb 1, 2023
WHAT THIS MEANS FOR YOU: The Houston Health Department conducted onsite assessments at AL communities to assess infection prevention and control practices. Larger AL communities better implemented CDC guidelines and were more proactive in their COVID-19 response activities. For example, many medium and small communities lacked access to COVID-19 PCR testing and had lower resident vaccination rates.

Preparedness and Response of Assisted Living Facilities Toward COVID-19 Infection Control in Houston, Texas, USA

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: The Houston Health Department conducted onsite assessments at AL communities to assess infection prevention and control practices. Larger AL communities better implemented CDC guidelines and were more proactive in their COVID-19 response activities. For example, many medium and small communities lacked access to COVID-19 PCR testing and had lower resident vaccination rates.

Implementation of an Emergency Power Rule: Compliance of Florida Nursing Homes and Assisted Living Facilities

Jan 1, 2023
WHAT THIS MEANS FOR YOU: Data from 680 nursing homes (NHs) and 2940 AL communities in Florida examined compliance with an emergency power rule to have a secondary power source. The rule had higher implementation rates in AL than NH. AL communities were more likely to implement the new policy if they were smaller, did not offer memory care, accepted Medicaid, and had a mental health specialty license. Therefore, organizational characteristics and policies may help or hinder implementing new regulations.

Implementation of an Emergency Power Rule: Compliance of Florida Nursing Homes and Assisted Living Facilities

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Data from 680 nursing homes (NHs) and 2940 AL communities in Florida examined compliance with an emergency power rule to have a secondary power source. The rule had higher implementation rates in AL than NH. AL communities were more likely to implement the new policy if they were smaller, did not offer memory care, accepted Medicaid, and had a mental health specialty license. Therefore, organizational characteristics and policies may help or hinder implementing new regulations.

Now You’re Tax‐Exempt, Now You’re Not: Property Taxation of Assisted Living Facilities

Jan 1, 2023
WHAT THIS MEANS FOR YOU: Nonprofit AL communities in Florida lost their tax-exempt status in 2006 and regained it in 2017. Even when nonprofit AL communities had to pay property taxes, they provided higher-quality services than for-profit communities: more nursing staff, residents, and variety in care. In contrast, for-profit AL communities had more substantiated complaints and deficiencies, faced more sanctions after inspections, and incurred higher fines on average.

Now You’re Tax‐Exempt, Now You’re Not: Property Taxation of Assisted Living Facilities

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Nonprofit AL communities in Florida lost their tax-exempt status in 2006 and regained it in 2017. Even when nonprofit AL communities had to pay property taxes, they provided higher-quality services than for-profit communities: more nursing staff, residents, and variety in care. In contrast, for-profit AL communities had more substantiated complaints and deficiencies, faced more sanctions after inspections, and incurred higher fines on average.

Patient Safety Culture in Assisted Living: Staff Perceptions and Association with State Regulations

Dec 1, 2022
ObjectivesTo examine perceptions of patient safety culture (PSC) among assisted living (AL) administrators and direct care workers (DCWs), and their associations with state regulations. DesignWe conducted a survey using the PSC instrument developed by the Agency for Healthcare Research & Quality. Secondary data on ALs and residents were derived from the Medicare Master Beneficiary Summary […]

Patient Safety Culture in Assisted Living: Staff Perceptions and Association with State Regulations

by Lea Efird-Green

ObjectivesTo examine perceptions of patient safety culture (PSC) among assisted living (AL) administrators and direct care workers (DCWs), and their associations with state regulations. DesignWe conducted a survey using the PSC instrument developed by the Agency for Healthcare Research & Quality. Secondary data on ALs and residents were derived from the Medicare Master Beneficiary Summary […]

Promoting Quality of Life and Safety in Assisted Living: A Survey of State Monitoring and Enforcement Agents

Oct 1, 2022
Our goal was to learn about monitoring and enforcement of state assisted living (AL) regulations. Using survey responses provided in 2019 from administrative agents across 48 states, we described state agency structures, accounted for operational processes concerning monitoring and enforcement, and documented data collecting and public reporting efforts. In half of the states, oversight of […]

Promoting Quality of Life and Safety in Assisted Living: A Survey of State Monitoring and Enforcement Agents

by Lea Efird-Green

Our goal was to learn about monitoring and enforcement of state assisted living (AL) regulations. Using survey responses provided in 2019 from administrative agents across 48 states, we described state agency structures, accounted for operational processes concerning monitoring and enforcement, and documented data collecting and public reporting efforts. In half of the states, oversight of […]

Association between State Regulations Supportive of Third-Party Services and Likelihood of Assisted Living Residents in the US Dying in Place

Oct 1, 2022
Importance: Older adults are increasingly residing in assisted living residences during their last year of life. The regulations guiding these residential care settings differ between and within the states in the US, resulting in diverse policies that may support residents who wish to die in place. Objective: To examine the association between state regulations and […]

Association between State Regulations Supportive of Third-Party Services and Likelihood of Assisted Living Residents in the US Dying in Place

by Lea Efird-Green

Importance: Older adults are increasingly residing in assisted living residences during their last year of life. The regulations guiding these residential care settings differ between and within the states in the US, resulting in diverse policies that may support residents who wish to die in place. Objective: To examine the association between state regulations and […]

State Regulations and Hospice Utilization in Assisted Living during the Last Month of Life

Aug 1, 2022
Objectives: To examine the association between hospice/staffing regulations in residential care or assisted living (RC/AL) and hospice utilization among a national cohort of Medicare decedents residing in RC/AL at least 1 day during the last month of life, and to describe patterns of hospice utilization. Design: Retrospective cohort study of fee-for-service Medicare beneficiaries who died […]

State Regulations and Hospice Utilization in Assisted Living during the Last Month of Life

by Lea Efird-Green

Objectives: To examine the association between hospice/staffing regulations in residential care or assisted living (RC/AL) and hospice utilization among a national cohort of Medicare decedents residing in RC/AL at least 1 day during the last month of life, and to describe patterns of hospice utilization. Design: Retrospective cohort study of fee-for-service Medicare beneficiaries who died […]

Coronavirus Disease 2019 (COVID-19) in Assisted Living Communities: Neighborhood Deprivation and State Social Distancing Policies Matter

Aug 1, 2022
Background: Residents of long-term care facilities face significantly greater risk of contracting or dying from coronavirus disease 2019 (COVID-19). However, little is known about COVID-19 in assisted living communities (ALCs) and the potential determinants of its spread. We examined the association between COVID-19 cases in ALCs and the proportion of Medicare-Medicaid (dual) eligible minority residents, […]

Coronavirus Disease 2019 (COVID-19) in Assisted Living Communities: Neighborhood Deprivation and State Social Distancing Policies Matter

by Lea Efird-Green

Background: Residents of long-term care facilities face significantly greater risk of contracting or dying from coronavirus disease 2019 (COVID-19). However, little is known about COVID-19 in assisted living communities (ALCs) and the potential determinants of its spread. We examined the association between COVID-19 cases in ALCs and the proportion of Medicare-Medicaid (dual) eligible minority residents, […]

Class and Culture in the Making of an Assisted Living Market

Jul 1, 2022
This article examines the growing industry of elite assisted living in Chile, which represents a break with a longstanding culture of care provided at home by family members and domestic workers. How does this market, locally associated with deprivation, abandonment and standardization, become a legitimate option for the rich clientele it caters to? Drawing on […]

Class and Culture in the Making of an Assisted Living Market

by Lea Efird-Green

This article examines the growing industry of elite assisted living in Chile, which represents a break with a longstanding culture of care provided at home by family members and domestic workers. How does this market, locally associated with deprivation, abandonment and standardization, become a legitimate option for the rich clientele it caters to? Drawing on […]

Governance of Assisted Living in Singapore: Lessons for Aging Countries

Jun 1, 2022
A global trend toward aging populations means that the challenge of providing adequate long-term care to older people looms large in many countries. In Singapore, a public discourse revolving around the expansion of assisted living to create age-friendly environments in long-term care has emerged. This study examines Singapore’s experience in developing regulations for assisted living […]

Governance of Assisted Living in Singapore: Lessons for Aging Countries

by Lea Efird-Green

A global trend toward aging populations means that the challenge of providing adequate long-term care to older people looms large in many countries. In Singapore, a public discourse revolving around the expansion of assisted living to create age-friendly environments in long-term care has emerged. This study examines Singapore’s experience in developing regulations for assisted living […]

End-Of-Life Care In Assisted Living Communities: Race And Ethnicity, Dual Enrollment Status, And State Regulations

May 1, 2022
WHAT THIS MEANS FOR YOU: This study examined end-of-life care in assisted living – specifically whether residents died in the community or elsewhere and received hospice care -- and whether these were associated with select factors. Among 100,783 Medicare beneficiaries who died in 16,560 communities during 2018–2019, nearly 60% died in their community, with 84% receiving hospice care. Communities with more Medicare-Medicaid enrollment had more residents dying in the community, and white residents were more likely than Black ones to use hospice care. In states with less strict assisted living regulations (e.g., for dementia care, admission/retention, and staffing/training), residents were more likely to die outside of the community (e.g., in a hospital or nursing home).

End-Of-Life Care In Assisted Living Communities: Race And Ethnicity, Dual Enrollment Status, And State Regulations

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study examined end-of-life care in assisted living – specifically whether residents died in the community or elsewhere and received hospice care — and whether these were associated with select factors. Among 100,783 Medicare beneficiaries who died in 16,560 communities during 2018–2019, nearly 60% died in their community, with 84% receiving hospice care. Communities with more Medicare-Medicaid enrollment had more residents dying in the community, and white residents were more likely than Black ones to use hospice care. In states with less strict assisted living regulations (e.g., for dementia care, admission/retention, and staffing/training), residents were more likely to die outside of the community (e.g., in a hospital or nursing home).

Factors Associated With Assisted Living Facility Closure

Mar 1, 2022
WHAT THIS MEANS FOR YOU: This study analyzed almost 2,000 Florida assisted living communities to understand factors related to assisted living closure between 2013-2015. During this time, 7.3% of communities closed; those with increased odds of closing had fewer beds, did not accept Medicaid, and had more regulatory deficiencies.

Factors Associated With Assisted Living Facility Closure

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study analyzed almost 2,000 Florida assisted living communities to understand factors related to assisted living closure between 2013-2015. During this time, 7.3% of communities closed; those with increased odds of closing had fewer beds, did not accept Medicaid, and had more regulatory deficiencies.