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Assisted Living Facilities: "Best Practice Tips and Lessons Learned"
This is a collection of "Best Practice
Tips and Lessons Learned" from individuals like you, who operate small
assisted living facilities. Your
contributions are welcome.
In the fall of 2007, the editors
of this website conducted a statewide survey of local area agencies on
aging, departments of health and ombudsmen. We asked if they could
suggest local providers who operated well-run homes. We then contacted
those operators. The following tips are from those who responded.
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Starting Out and Developing Your New Facility - also see related comments When starting out, your training and experience as a manager and the training and experience of your new staff are likely to be limited. Therefore, it is a good idea to accept only a few residents rather than many. In addition, keep in mind that having 5 beds or more will require mandated manager training. Currently, the Office of Health Care Quality approves only 3 manager-training programs, and attendance means taking time and spending money new facility operators do not always have. by Joyce Williams, who operates My Second Home in Baltimore City.
Consider living in your new facility at first. This will help cut down on
overhead costs, which are especially high when starting out. Also, being on
site at all times in the initial stages of operation will help you to get to know your
new residents, staff and facility and to develop your skills as a manager.
The COMAR regulations designate 3 levels of care for assisted living residents: low, moderate and high. When starting out, it is
advisable to restrict yourself to residents requiring a low level of care.
It is not advisable to accept residents requiring a moderate or high level
of care unless you are sure you and your staff have the professional
training and experience necessary to provide these levels of care. Getting
in “over your head” may lead to violations of the COMAR regulations and
emergency suspension, as well as additional expense.
When starting out, it is a good idea to get to know the long-term-care community in your area. Volunteer for part-time work at your local senior center. Network and establish connections with other assisted living providers in the area, especially more experienced providers who can give you valuable advice and help on how to develop your new facility. by Jonathan Edenbaum, who operates Eden Homes, Inc. in Montgomery County. Also see related comments on using OHCQ support. |
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Using a placement service is not a substitute for careful background research.
When looking for new residents, using a placement service is no guarantee
that the resident will be suitable for your facility. You should still do
thorough background research on the resident, preferably with the help of
your
Delegating Nurse. You should also take care when
choosing
a placement service because placement services are not always reliable or
reputable.
by Kimberly Miller, who operates Elesy Manor in
Baltimore County.
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Pay the placement fee in 2 or 3 installments.
Many placement services will charge a fee equal to the new resident’s
first-months rent. However, there is always the chance that the new resident
will not be suitable for your facility in the long term. Therefore, you
should deal with a placement service that is willing to spread the fee out
over 2 or 3 months, which will reduce your loss in the event the resident is
in fact unsuitable for your facility.
by Joyce Williams, who operates My Second Home in
Baltimore City.
Social Environment
When interviewing, families often show concern
for the social environment of the assisted living program. You can help by
identifying possible “special companionships” among the other residents, for
example, someone with a similar social background or personality. So when
interviewing an applicant, think about the residents already in your
facility and how the new resident is likely to fit in. This is especially
important when a resident has some dementia and may tend to isolate
him/herself or perhaps show aggressive behavior. |
Tips on Dietitians & Menus
It is important to have residents’ input
into menu planning. You can manage this by having a “weekly group meeting”
with all of your residents to discuss meal planning for the coming week.
Work together to create an “interactive menu” that reconciles your
residents’ preferences with the nutritional needs required by
COMAR
10.07.14.20.
For example, work with
the residents to find substitutes for items that tend to be unpopular, such
as cauliflower. Your residents will be happier with their meals, and you
will cut down on waste.
In addition, sometimes there are problems with residents who have changes in
appetite or residents with dementia who refuse to eat and suffer weight-loss
as a result. In Charles County, the local Department of Aging will send a
Registered Dietitian (RD) out to your facility if you ask for one – free of
charge. The RD can help to address all food-related problems you may be
having with your residents.
Contact
your local Department of Aging
By Jo Anne Ricks, who operates Golden Life Assisted Living Program
in Charles County.
It is a good idea to keep detailed, daily records of individual residents.
Create charts or lists recording daily activities, especially when a
resident leaves your facility, where the resident goes, what the resident
does there, and when the resident returns. Take careful notes on your
resident’s daily routines, such as what the resident eats or drinks. Always
be sure to write down a detailed description of any unusual behavior. Then,
if a problem develops and you are unsure of the cause, you will be able to
consult your daily records and perhaps find some fact or event to explain
it.
Record Keeping. |
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Provide rooms and furnishings that have more to offer than what COMAR requires.
When designing rooms for residents, go beyond the bare minimum required by COMAR. Take extra steps to maintain resident-dignity (and insure the long-term success of your operation) by providing residents with interiors that are spacious, well illuminated (including natural and artificial light), and appointed with ample, attractive furnishings.
Legal Background - The COMAR
requirements for
Resident’s Rooms and Furnishings (10.07.14.39),
Resident Bathrooms (10.07.14.40), and
Illumination (10.07.14.41).
by Kimberly Miller, who operates Elesy Manor in
Baltimore County.
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Social Activities
When arranging for social activities for residents, go beyond the basic
requirements of COMAR for
Services (10.07.14.20). Because many residents
cannot afford adult day care, you might want to consider hiring a
recreational
therapist
to visit the facility on a regular basis. You should also encourage your
residents to visit your
local
senior center and help them get there, if necessary. |
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Have fully qualified staff and check all work carefully.
Medication management for your residents is one of the most important and challenging requirements you will face as an assisted living provider. Be sure your staff is sufficiently trained to administer medication, check carefully the medication records of each resident, and be ready for the 45 day review by your Delegating Nurse.
by Patti Madigan, Manager, Department of Housing, Baltimore County.
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Develop a good working relationship with your Delegating Nurse.
The Delegating Nurse’s
45 day review
is a minimal COMAR requirement, and a typical resident can undergo important
changes during that time. Therefore, it is important to be alert to
significant changes in a resident’s condition, changes that might require
adjustment of that resident’s medication. If you observe such changes,
notify your
Delegating Nurse immediately. In addition, in order to deal with such
changes as effectively as possible, ask your Delegating Nurse for an extra
visit or two whenever it fits into his or her schedule. Developing a
positive, friendly working relationship with your Delegating Nurse may pay
off when it comes time to ask for some extra attention.
by Kimberly Miller, who operates Elesy Manor in
Baltimore County.
Legal background: COMAR 10.07.14.04, Levels of Care, 10.07.14.17, Other Staff – Qualifications, 10.07.14.21, Medication Management, 10.07.14.47, Compliance Monitoring
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Hiring and Training Your Staff
The decisions you make when hiring staff can “make or break” your assisted
living facility. Try to find someone with professional experience, such as a
former Certified Nursing Assistant or Geriatric Nursing Assistant, Try to find someone prepared to do more than one job
(e.g. a nursing assistant who can help with paperwork).
Be sure to do a thorough criminal background check on all applicants no
matter what their professional qualifications. More on Criminal
Background Checks. Legal Background: COMAR 10.07.14.17, Other staff - qualifications and Criminal Background Check, Maryland Code Ann.Health-General § 19-1902
There are a variety of training options available for your staff, which
may include training from your
ombudsmen and local community colleges. There
are also instructional materials distributed by DHMH as well as private
organizations such as the Alzheimer’s Association and
Copper Ridge.
More on training.
It is critical to keep yourself
and your staff current on the various aspects of running a facility and
caring for residents. There are many educational opportunities that are
free, including “in-services” offered by state and county departments of
aging. Also, you may be able to get free visits and consultations with a
registered dietitian. So
when starting out, do some basic research on state and local government
resources for assisted living providers, and avoid paying for educational
services that you can get for free. |
Running a small assisted living facility is way of life, not a job!
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Your chief goal is to help your residents.
Successful small assisted living providers agree: your main motivation for becoming a provider should be to help your residents, not to make money. Keep your prices as low as possible and never “price-gouge.” This is a very competitive field, and if residents and their families feel your prices are too high, they are likely to go elsewhere.
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Don’t expect to get rich.
So don’t expect to make a lot of money, because you won’t. Instead, be prepared for some self-denial along the way and recognize that your greatest reward is the help you give to others who need it in the last years of their lives.
by Jonathan Edenbaum, who operates Eden Homes, Inc. in Montgomery County, Kimberly Miller, who operates Elesy Manor in Baltimore County, and Joyce Williams, who operates My Second Home in Baltimore City.
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Know what you are getting into
The work of operating a small
assisted living facility can be exhausting. It is important to
understand what you are getting into. For small operators, it is a 24 hours
per day, 365 days per year business. We are the ones upon whom the residents
rely. It is important that we, in turn, can rely upon other ALF operators.
You may want to network with other providers operating the same type of facilities. We are
not competitors. Strongly consider joining one of the
Maryland professional
groups where you can connect with other providers.
by Karin Lakin,
small assisted living facility operator of 5 homes and adult day programs in
Prince George's and Charles Counties (Senior Network,
Inc).
| Stay in Touch with the
Larger World & "Tech" Tools You Need We operate businesses that are regulated by the state and we cannot expect to have important information just handed to us. There are good resources for keeping track of the changing regulations on a routine basis. Finding the Law on ALF. It is also important to join one of the professional groups. In addition to finding ALF colleagues, these groups also help you keep “up to speed” with changes in the law and best practices. Technology Tools - Consider having a computer with Internet access. There is so much information on-line and it helps in communications with families and managing your business. You do not need to spend a lot of money. Computers can be pretty inexpensive since you do not need a complex machine. We buy rebuilt computers very inexpensively. In addition, a fax has really become a necessity. I use it to instantly receive changes in doctor’s orders. by Karin Lakin, small assisted living facility operator of 5 homes and adult day programs in Prince George's and Charles Counties (Senior Network, Inc). Also See -
Technology Tips for keeping ALF Records
Confidential |
Look for and Report Subtle Changes in Mental Status
My homes specialize in the care
of persons with dementia but as the Hopkins study showed, there are a lot of
residents in ALFs with undiagnosed problems as well. Also, residents change
while they are living in your home. It is important to monitor the subtle
changes in mental status that occur over time. Report these changes to the
doctor or delegating nurse. There are a lot of good resources out there for
operators to better understand what to look for.
Dealing with dementia.
Some of the signs to look for include:
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More confusion about more things over time;
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Forgetting recent events like a resident saying that s/he took a shower but s/he did not really take one;
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Talking about the past as if it were the present (this is an important sign to report);
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Asking repetitive questions; and/or
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Reversing day and night.
by Karin Lakin, small assisted living facility operator of 5 homes and adult day programs in Prince George's and Charles Counties (Senior Network, Inc). The programs specialize in the care of persons with dementia and Alzheimer’s Disease.
Regarding the Johns Hopkins Study
on Maryland
facilities, the study's estimate of the percentage of ALF residents with
dementia sounds about right. But this includes a lot of low-stage dementia
that a non-skilled care facility (ALF as opposed to nursing home) can still
deal with. We admit residents in early stages of dementia such as those who
are pleasantly confused or are often forgetful. We monitor them carefully
and watch out for those at risk of falling or wandering away. We also look
out for eating problems by always eating together at the dinner table. If
and when these risks become serious, skilled care is required and they are
not suitable for an assisted living facility. More on dealing with
dementia in an ALF.
by Kimberly Miller, who operates Elesy Manor in Baltimore County.
| Tips on
Working with Your Delegating Nurse If you can afford it, have the delegating nurse come more frequently than every 45 days. It really helps to have the advice. It can be a tough balance because you want to keep your home affordable. But you may find that charging a few dollars more to pay for more frequent visits from the delegating nurse is a good decision. Also see related comments. Note from the editors of this Resource Center: The need for more frequent visits (than every 45 days) was the most frequent comment that we received in the informal survey of smaller ALF operators that we conducted in August/September 2007. by Karin Lakin, small assisted living facility operator of 5 homes and adult day programs in Prince George's and Charles Counties (Senior Network, Inc). The programs specialize in the care of persons with dementia and Alzheimer’s Disease. It is important to develop a good
working relationship with your Delegating Nurse (DN). Arrange
for DN to be on call 24 / 7 in case a problem requiring immediate
attention arises. Be prepared any time of the day or night to take
the resident to your local hospital in the event of a problem that
you or DN cannot handle. Remember that you are not a “medical
facility.” This should also be clearly stated in your resident
agreement. |
Use OHCQ Support
The Office of Health Care Quality can be a great resource for a small
operators just starting out. If you are in the Baltimore area, the Office has
walk in-hours every week where you can just go and ask questions. You can
also make appointments. Details on OHCQ
walk-in hours and location.
by Karin Lakin,
small assisted living facility operator of 5 homes and adult day programs in
Prince George's and Charles Counties (Senior Network,
Inc). The programs
specialize in the care of persons with dementia and Alzheimer’s Disease.
| Training Resources
I have used the Senior Living University programs and found them to be very good. Senior Living University offers self-study programs for ALF operators and others managing senior living communities. Their on-line store offers materials “divided into 10-minute, ready-to-use in-services; videos and DVDs; Instructor guides for video training and in-service training and professional development for you and your team through self-study certifications and certificate programs as well as materials printed in Spanish.” In addition, they offer a self-study Administrator Certification Program approved by NAB (National Association of Boards of Long Term Care Examiners) for 47 CEU's accepted in most states. Maryland, however, only permits assisted living managers to obtain a maximum of 25 hours of the required 80 hours of training from on-line sources. by Karin Lakin, small assisted living facility operator of 5 homes and adult day programs in Prince George's and Charles Counties (Senior Network, Inc). The programs specialize in the care of persons with dementia and Alzheimer’s Disease. Note: OHCQ posted a notice on their website announcing that the Senior Living University is no longer an approved vendor for the 80 hour assisted living manager training course. Also see the approved programs offered by the Office of Health Care Quality. Tips on Mental Health Training
Resources for ALF Operators
by Karin Lakin, small assisted living facility operator of 5 homes and adult day programs in Prince George's and Charles Counties (Senior Network, Inc). The programs specialize in the care of persons with dementia and Alzheimer’s Disease. |
Good Resource for Drafting Clinical-Related Policies for your Facility
Over time I have found
that I needed to create policies on clinical issues. In areas where the
COMAR regulations do not provide guidance, I
have found a great resource. It is a book entitled ”Clinical Nursing Skills
and Techniques”. It is written for nurses and is used to teach students. It
is very long and has a lot that is above and beyond what we do in an ALF.
However, it is full of pictures demonstrating basic techniques like hand
hygiene and taking vital signs or applying an oxygen mask. It has a lot of
useful checklists and sample policies. Buying it was the best $70 I ever
spent and you can get used copies on-line for a lot less. I use it as an ad
hoc addition to my policies manual.
More details on this book: "Clinical Nursing Skills and Techniques",
6th Edition by Anne Perry, RN, MSN, EdD, FAAN, Chair, Department of Primary
Care & Health Systems Nursing, Southern Illinois University, School of
Nursing, Edwardsville, IL and Patricia Potter, PhD, RN, FAAN, CMAC ,
Research Scientist, Siteman Cancer Center, Barnes-Jewish Hospital, St.
Louis, MO, Publisher: Mosby, ISBN: 032302839X and ISBN-13: 9780323028394
by Karin Lakin,
small assisted living facility operator of 5 homes and adult day programs in
Prince George's and Charles Counties (Senior Network,
Inc). The programs
specialize in the care of persons with dementia and Alzheimer’s Disease.
| Source: Legal Aid Bureau’s Maryland Legal Assistance Network, in partnership with the Senior Legal Helpline and the Assisted Living Project under a grant from the Maryland Department on Aging to the Legal Aid Bureau |
Date last legally reviewed: 10/31//07 (MLAN/DL/AC) |
| Is this legal
advice? This site offers legal information, not legal advice. We make every effort to ensure the accuracy of the information and to clearly explain your options. However we do not provide legal advice - the application of the law to your individual circumstances. For legal advice,
you should consult an attorney. See our section on Finding Legal Help.
About this website. The Maryland State Law Library, a court-related agency of the Maryland Judiciary, sponsors this site. The website was developed (1999-2007) as part of an access to justice initiative by the Maryland Legal Assistance Network (MLAN) in collaboration with a number of legal services providers serving low and moderate income Marylanders. In the absence of file-specific attribution or copyright, the Maryland State Law Library may hold the copyright to parts of this website. You are free to copy the information for your own use or for other non-commercial purposes with the following language “Source: Maryland's People’s Law Library – www.peoples-law.org. © Maryland State Law Library, 2007.” |
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