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

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.

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.

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 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
WHAT THIS MEANS FOR YOU: A total of 714 administrators and direct care workers in 257 assisted living communities reported that direct care workers had a more negative perception of patient safety culture (PSC) than administrators. Stricter state regulations, particularly regarding staffing, were associated with better perceptions of PSC among direct care workers.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A total of 714 administrators and direct care workers in 257 assisted living communities reported that direct care workers had a more negative perception of patient safety culture (PSC) than administrators. Stricter state regulations, particularly regarding staffing, were associated with better perceptions of PSC among direct care workers.

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

Oct 1, 2022
WHAT THIS MEANS FOR YOU: Surveys from regulatory administrators in 48 states indicated that in more than half of states, regulatory monitoring was handled by at least three agencies with differing resources (e.g., budget, staffing) and methods (e.g., inspections). Less than half of the states compiled data from inspections, violations, and penalties, and fewer than 10 made this information easily available to the public.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Surveys from regulatory administrators in 48 states indicated that in more than half of states, regulatory monitoring was handled by at least three agencies with differing resources (e.g., budget, staffing) and methods (e.g., inspections). Less than half of the states compiled data from inspections, violations, and penalties, and fewer than 10 made this information easily available to the public.

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

Oct 1, 2022
WHAT THIS MEANS FOR YOU: Medicare data from nearly 170,000 residents from over 8,000 assisted communities with more than 25 beds who died between 2017 and 2019 indicated that in states with regulations supportive of third-party hospice services, residents were significantly more likely to die in assisted living than in a hospital or nursing home.

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

WHAT THIS MEANS FOR YOU: Medicare data from nearly 170,000 residents from over 8,000 assisted communities with more than 25 beds who died between 2017 and 2019 indicated that in states with regulations supportive of third-party hospice services, residents were significantly more likely to die in assisted living than in a hospital or nursing home.

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

Aug 1, 2022
WHAT THIS MEANS FOR YOU: Medicare data from 23,000 residents in more than 6,000 assisted living communities found that 56% received hospice care during their last month of life. Communities in states with more supportive hospice regulations had significantly more hospice use, especially a more intense type called continuous home care (CHC). Modifications to state regulations to be more supportive of hospice care/CHC might increase the number of residents who use hospice, which might improve quality of life in the days immediately preceding death.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Medicare data from 23,000 residents in more than 6,000 assisted living communities found that 56% received hospice care during their last month of life. Communities in states with more supportive hospice regulations had significantly more hospice use, especially a more intense type called continuous home care (CHC). Modifications to state regulations to be more supportive of hospice care/CHC might increase the number of residents who use hospice, which might improve quality of life in the days immediately preceding death.

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

Aug 1, 2022
WHAT THIS MEANS FOR YOU: Using confirmed COVID-19 cases from 5 states, assisted living communities with a higher population of Medicare/Medicaid dual-eligible minority residents were more likely to have COVID-19 cases, as were those located in more socioeconomically deprived neighborhoods. Communities in states with stricter social distancing policies had significantly lower numbers of cases.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Using confirmed COVID-19 cases from 5 states, assisted living communities with a higher population of Medicare/Medicaid dual-eligible minority residents were more likely to have COVID-19 cases, as were those located in more socioeconomically deprived neighborhoods. Communities in states with stricter social distancing policies had significantly lower numbers of cases.

Class and Culture in the Making of an Assisted Living Market

Jul 1, 2022
WHAT THIS MEANS FOR YOU: A qualitative study of high-end assisted living communities in Chile based on 40 staff, resident, and family interviews found that managers explain these communities’ purpose as meeting the need for household help, making it a class privilege for wealthy residents. Residents view their communities as a luxury and emphasize their choice to live there, indicating control and independence. This research highlights how social class influences perceptions and acceptance of different forms of care.

Class and Culture in the Making of an Assisted Living Market

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A qualitative study of high-end assisted living communities in Chile based on 40 staff, resident, and family interviews found that managers explain these communities’ purpose as meeting the need for household help, making it a class privilege for wealthy residents. Residents view their communities as a luxury and emphasize their choice to live there, indicating control and independence. This research highlights how social class influences perceptions and acceptance of different forms of care.

Governance of Assisted Living in Singapore: Lessons for Aging Countries

Jun 1, 2022
WHAT THIS MEANS FOR YOU: In Singapore, assisted living regulations relate to required physical infrastructure, admission assessments, and staffing requirements. They are primarily practice guidelines, with a plan to make them legislatively explicit and permanent by 2023. Other regulations remain missing, such as staff training requirements and a monitoring structure, and must be addressed if assisted living is to be a safe and viable option for quality care.

Governance of Assisted Living in Singapore: Lessons for Aging Countries

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: In Singapore, assisted living regulations relate to required physical infrastructure, admission assessments, and staffing requirements. They are primarily practice guidelines, with a plan to make them legislatively explicit and permanent by 2023. Other regulations remain missing, such as staff training requirements and a monitoring structure, and must be addressed if assisted living is to be a safe and viable option for quality care.

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.

State Variation in Potentially Burdensome Transitions among Assisted Living Residents at the End of Life

Feb 1, 2022
WHAT THIS MEANS FOR YOU: There are significant differences in the quality of end-of-life care in AL. Research on 37,668 deceased Medicare beneficiaries who lived in AL found that 1 in 5 experienced challenging transitions including frequent hospitalizations before their death. Burdensome transitions, especially in the last three days of life, varied widely among states, which may be associated with state-level regulations.

State Variation in Potentially Burdensome Transitions among Assisted Living Residents at the End of Life

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: There are significant differences in the quality of end-of-life care in AL. Research on 37,668 deceased Medicare beneficiaries who lived in AL found that 1 in 5 experienced challenging transitions including frequent hospitalizations before their death. Burdensome transitions, especially in the last three days of life, varied widely among states, which may be associated with state-level regulations.

Prevalence and Persistency of Deficiency Citations in Florida Assisted Living Facilities

Jan 1, 2022
WHAT THIS MEANS FOR YOU: State inspection data from 957 large assisted living communities in Florida showed that 87% were cited one or more times from 2012 to 2018. For-profit communities, those with more than 100 beds, and those with a limited mental health license were cited more often. Over 40% of communities were cited in two or more years for the same deficiency category, meaning that repeat citations are common.

Prevalence and Persistency of Deficiency Citations in Florida Assisted Living Facilities

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: State inspection data from 957 large assisted living communities in Florida showed that 87% were cited one or more times from 2012 to 2018. For-profit communities, those with more than 100 beds, and those with a limited mental health license were cited more often. Over 40% of communities were cited in two or more years for the same deficiency category, meaning that repeat citations are common.