Housing Choices
The Contract for Assisted Living
Course Section
Among the glossy pictures, brochures, price lists, activities calendars and floor plans you have accumulated, you also should have contracts for the facilities you are seriously considering. Of all the materials you've collected for each facility, the contract is the most critical. The contract is the legal document that states what arrangements you and the facility have agreed to, regardless of anything that was promoted or promised in conversations, brochures or other sales pitches. For example, even if a brochure says that a facility allows residents to "age in place," that is no guarantee that a resident will never have to move again.
At times, contracts ignore important issues altogether. Potential residents should request that any critical information about resident care, rights, costs and services omitted from the contract be added before signing it. This is especially important if promotional materials are vague or misleading. Detailed information concerning services and accommodations also can be included as an attachment to a standard contract. The more specific the contract, the greater your legal protections will be regarding promised services.
An April 1999 US General Accounting Office (GAO) study of assisted living facilities in four states gives consumers reason to be cautious. The study found that
- Written material often does not contain key information;
- Facilities do not routinely provide prospective residents with important documents, such as a copy of the contract, to use in decision-making; and
- Written materials that are available are sometimes confusing or even misleading.
The majority of the 721 facilities that responded to the GAO survey stated that they generally provide prospective residents written information about many of their services and costs before they apply for admission. However, only about half indicated that they provide information on the circumstances under which the cost of services may change, their policy on medication assistance, or their practice for monitoring residents' needs.
Furthermore, less than half said they provide written information in advance about discharge criteria, staff training and qualifications, or services not covered or available from the facility. Because assisted living facilities vary so greatly, it's important that the policies and services of each one be clearly outlined.
Four things to look for in a contract
I. Services
Typical services in an assisted living facility include help with
meals, housekeeping and other daily and social activities, as
well as some general supervision and some help with taking
medications. Because contracts often do not spell out in detail
the scope of services provided, it's very important to know
exactly which services are covered and which require extra
payment. For example, does housekeeping include only light
dusting and vacuuming? Do housekeepers also clean the bathroom,
floors and windows and empty the trash, or do these services cost
extra? How frequent is the cleaning?
You also should find out whether residents and their families are notified in advance and in writing of any changes in services and related charges and whether they are involved in making decisions about these things. It's important to know if a resident can contract separately for services that the facility doesn't provide. Below is a list of how services may be described in a brochure and questions to ask about how services are covered:
Service: General Assistance
The Brochure says – "assistance with activities
of daily living provided"
Does the Contract say – Which activities? For
example, do they include personal grooming and, if so, does that
mean help with shaving and brushing teeth and hair? Whether
assistance is available around the clock or only during certain
hours? Who provides the assistance and how many staff people are
on duty to provide it? Whether bathing must be at certain times?
How often bathing assistance is available? How incontinence needs
are handled?
Service: Health/medical
The Brochure says – "medication assistance
provided by skilled staff; health or nursing services
available"
Does the Contract say – Whether help with medication
is a verbal reminder or hands-on assistance and how often it is
available? Whether nursing services are provided by registered
nurses or nurse assistants? Whether nursing services and
assistance with taking medication are available around the clock?
Whether a nurse or another staff person is available to
coordinate or oversee visits from doctors, therapists or other
health care professionals? Whether these providers come to the
facilities? Whether help is provided setting up doctor
appointments and transporting residents to doctors' offices?
Whether the facility uses physical or chemical restraints or both
on residents and under what circumstances?
Service: Written care plan
The Brochure says – "facility caters to
individual needs; each resident has a written care agreement or
service plan"
Does the Contract say – The same thing? How specific
the plan is and who develops the plan? How involved the resident
is in developing the plan? How often it is reviewed and by whom?
Who can change the plan? What happens if a resident wants to do
something outside the scope of the care plan--for example, smoke?
Service: Levels of care
The Brochure says – "facility provides levels
of care according to resident's needs"
Does the Contract say – Anything about levels of
care? Often, the contract will say very little about this. A
potential resident should know which services are provided in
each level; how many levels of care there are; who determines
which level of care a resident will receive; under what
circumstances a resident would need to change levels; who is
consulted when a resident's level is changed; and whether a
resident can appeal a decision regarding a level change.
Potential residents also should know how often their physical and
mental condition is assessed and who performs the assessment--for
example, a doctor, nurse or some other staff member.
Service: Special needs
The Brochure says – "the facility offers
special care to residents with special needs, such as
Alzheimer's disease"
Does the Contract say – Whether there are special
units, wings or buildings for these residents or whether all
residents with different levels of need are housed together?
Whether there are special staff, and separate dining rooms and
activities, for residents with special needs? Whether there are
restrictions on special populations and, if so, what they are?
Service: Meals
The Brochure says – "three delicious,
nutritious meals a day provided"
Does the Contract say – Seven days a week? Whether
meals are provided only in the dining room, or whether residents
are served in their rooms if they are ill or choose not to eat in
the dining room? Whether there are only three designated meal
times, or whether residents can eat at another time if they wish
to or must? Whether residents can choose something that is not on
the menu? Whether special cultural or dietary preferences are
honored? Whether snacks and drinks are served, or whether
residents can help themselves anytime they choose? Whether a
nutritionist or dietitian helps plan or review menus?
Service: Laundry
The Brochure says – "laundry services
provided"
Does the Contract say – How often? Whether bed
linens and towels are provided? Whether linens are just laundered
or whether they also are taken off and put back on the bed?
Whether this service is included in the monthly fee? Whether
personal laundry is also included? Whether residents or family
members can do laundry if they choose?
Service: Transportation
The Brochure says – "transportation services
provided to enhance independence"
Does the Contract say – Whether these services cost
extra? How often transportation is provided (any time, daily,
weekly, evenings, weekends) and to what destinations? For
example, will a van go to a particular grocery store or shopping
mall, but not to individual doctor appointments? Whether
residents must schedule rides in advance, and if so, how far?
Whether vehicles are equipped to accommodate residents with
varying levels of physical mobility? Whether residents can have
their own vehicles and whether there's a parking fee?
Service: Activities
The Brochure says – "full calendar of
activities providing numerous opportunities for social
interaction"
Does the Contract say – Who is responsible for
developing and supervising activities? Whether staff are full or
part time and what kind of training they have? What kind of
activities are provided and how often? Whether
religious/spiritual activities are offered? Whether they are at
the facility or whether residents are taken to places of worship?
II. Costs, fees and payments
Assisted living is costly, and most residents—more than 80
percent—pay for it out of their own pockets. Monthly
payments can range from $1,200 to as high as $5,000 for private
rooms, depending on geographic area, unit size and services
provided. Shared rooms generally cost less, ranging from about
$850 to $2,000 per month.
Medicare, the federal health insurance program for older people, does not cover assisted living, and while more states are beginning to cover some services under Medicaid or other government programs, public payment is not common in the assisted living industry. State Medicaid agencies can provide information about eligibility and covered services. Some private long-term care policies cover assisted living, but only about 5 percent of Americans have such insurance.
By now, you should have figured out whether you can afford these monthly payments over an extended period, keeping in mind that fees most likely will increase. For instance, monthly costs will rise if additional services are necessary to meet a resident's changing needs over time. Fees also are subject to monthly or annual cost-of-living increases.
Promotional materials might only discuss fees in a general way, so it's important that a contract spell out in detail all costs and expected payment methods and timetables.
The Brochure says – "monthly rates that are
cheaper than nursing homes"
Does the Contract say – What services and appliances
the monthly rates cover? Whether health care services are
included? Whether utilities, such as telephone, cable, water, gas
and electricity are included? Whether there are any up-front
costs, such as entrance fees, security deposits or waiting list
deposits, and whether these are fully or partially refundable if
a resident cancels an application or later leaves the facility?
Whether there are maintenance and repair fees or renter's
insurance fees? How rate increases and late payments are handled?
Under what conditions monthly payments can be increased and how
much notice residents receive?
III. Transfer and discharge policies
Assisted living facilities often stress their commitment to
allowing residents to "age in place." It's not
uncommon for residents and their families to believe that an
assisted living facility will be the residents' final home.
But residents who develop physical or mental conditions that
facilities are not equipped to handle could be sent to nursing
homes or otherwise discharged. The most common reason for
residents to be discharged from assisted living facilities is the
need for nursing home care. In fact, more than 40 percent of
residents eventually move to a nursing home for more care. It is
critical to understand under what circumstances a facility may
transfer residents, within the facility or to another one, or
discharge them entirely.
The Brochure says – "facility allows residents
to age in place; facility will accommodate changing patient
needs"
Does the Contract say – What will happen if
residents need other/additional services? Under what
circumstances residents are transferred or discharged? How
transfer and discharge decisions are made and by whom? Whether
there is an appeal/grievance process? Whether there is a
room-hold policy for hospitalization or other reasons? Whether
residents have to pay for rooms if they're not using them?
How much notice is given to residents who are asked to leave? How
much notice residents who decide to leave must provide the
facility? What is the refund policy?
IV. Residents' rights
Residents' rights outline facility rules that affect
residents' personal conduct and entitlements. For example,
residents' rights might state a facility's policy on
overnight guests, bringing furnishings or appliances from home,
or initiating legal action. Always request a copy of the
residents' rights, as they may not be included as part of the
contract. If a facility has no list or handbook of residents'
rights, see if they are required under state regulations. If they
are, any facility you are seriously considering should provide
you with one.
The Brochure says – "facilities are designed to
maximize resident choice and independence"
Does the Contract say – How they ensure this?
Whether a resident has a right to:
- Make special requests, such as newspaper delivery?
- Smoke and/or use alcohol responsibly?
- Have a pet, car or personal furnishings?
- Help select a roommate if sharing a room?
- Seek reimbursement for theft or damage to personal property?
- Handle personal finances?
- Come and go at will and have personal visitors come and go (with a place other than the resident's room to entertain them)?
- Deviate from the standard meal schedule when desired?
- Terminate a contract (or what a resident's rights are if the facility decides to terminate a contract)?
- Negotiate risks related to individual care and service choices?
- Voice a concern through a resident council or other internal grievance process?
- Bring legal action against the facility for injury, negligence or other cause?
- Reside at the facility--i.e., do monthly fees cover a specific unit designated in the contract or simply entitle you to reside at the facility?
Other things to consider
In addition to the list above, there are several other aspects to consider in your search for an appropriate assisted living facility.
Staffing. Find out staff members' qualifications and whether they are qualified to deliver the services the facility offers; what kind of training the facility requires or provides and how often; what the staff-to-resident ratio is during the day and in the evening, because it varies (most states do not specify a ratio for assisted living facilities); and whether there is special training for staff to learn how to care for those with Alzheimer's disease or other memory impairments, or to assist with medications.
Licensing. Most states require that assisted living facilities be licensed or certified to operate, although, in many cases, these facilities are licensed under another name, such as "board and care home." If your state has requirements, make sure any facility you are considering complies with them. Check with your state licensing agency, Area Agency on Aging, and long-term care ombudsman's office to see whether any complaints have been filed against the facility or if the facility ever had its license revoked or suspended and why. Ask to see the facility's most recent inspection report. Even if a facility is not required by state law to disclose its report, a reputable one should willingly do so.
Financial viability of facility/parent company. Whether they are for-profit or not-for-profit, assisted living facilities operate like businesses. They provide a product and services to customers, advertise, hire employees, have CEOs or administrators, budgets and a bottom line, and sometimes stockholders. It's always important to find out the financial viability of a company before you give them your money. It's especially important for assisted living because it's so expensive and because it's for an extended period--their product is your home!
Before you sign a contract, be sure to check business references on the facility and the parent company, if there is one. You might want to contact the Better Business Bureau, local chamber of commerce, and residents and their families to get a sense of what the company's business philosophy is, how financially secure the organization is, and whether any complaints have been filed against it.
Things to remember about contracts in general
As you navigate your way to the best assisted living facility you can find, remember that the contract is the most important document. Despite what other written materials say or what administrators or other staff tell you, a facility is legally bound to provide only what is stated in the contract. The contract also might be the only document that addresses such issues as reasons for discharge or circumstances under which fees would change.
The most important things to look for in a contract include:
- Fees (services they cover, when they're due, penalties, when they're increased, refunds);
- Duration of contract (and renewal terms);
- Termination of contract;
- Residents' rights and other rules;
- Policy regarding internal and external resident transfers; and
- Obligations/responsibilities of facility.
Additional Resources
American Seniors
Housing Association (ASHA)
ASHA provides a publication entitled "Assisted Living
Residency Agreements: Key Points to Consider When Choosing a New
Home." It outlines questions to ask related to services and
a review of care, pricing and payment and other issues.
Consumer Consortium on Assisted
Living (CCAL)
CCAL is a national, grassroots consortium of providers, consumers
and long-term care professionals concerned about quality issues
in assisted living.
National Citizens'
Coalition for Nursing Home Reform
The National Citizens' Coalition for Nursing Home Reform
provides information, educational materials and training and
strategies for family members, consumer advocates, ombudsmen and
others who are working to help assure quality care and life for
people living in nursing homes and other long-term care settings.
