Assisted Living Facilities: Understanding Long-Term Care Options
Are assisted living facilities really the best option for your loved ones? Many families face tough choices about long-term care. In this week’s episode, nursing home abuse attorney Rob Schenk welcomes guest Richard Mollot to talk about understanding the different long-term care options and making informed decisions.
Schenk: Understanding assisted living facility regulation in the United States, stick around out there.
Welcome back to the nursing abuse podcast. My name is Rob. I will be your host for this episode. Today we’re going to be talking about assisted living, what that means from state to state in general. And where we are in terms of how assisted living is regulated in this country, but we’re not doing that alone. We have the absolutely fantastic and prolific nursing home abuse podcast guest, Richard Mollot, to talk with us about that very subject.
We have the fantastic attorney, an advocate, Richard Mollot on the show. And typically as a part of the process of getting guests on this show, we say, hey, send us a short bio so that we can read it. And typically I’ll get bios that are seven pages long. And of course we use ChatGPT to render it down to 50 words or something like that.
Most people err on the side of giving me so much information. And the whole podcast would be the bio of the guest. Richard, on the other hand, does the exact opposite, which is, he just basically says, my name is Richard Mollot. How are you? How are you doing? Congratulations. So this is the rare instance in which I have to use ChatGPT to give me more information about the guests, even though I could probably do it off the top of my head.
Anyway, here we go. Richard Mollot is the executive director of the Long Term Care Community Coalition. He advocates for consumer rights and quality of care and long term care facilities with expertise in consumer issues, education, and government affairs. He emphasizes the crucial role of workers in ensuring quality care.
Mollot is known for his integrity and dedication to improving the long term care system. And we’re so happy to have Richard once again, back on the show, Richard, welcome to the show.
Mollot:
Thanks so much for having me.
Schenk:
I thought that you would be the perfect person to talk to about this topic. That being assisted living care in the United States, which I’ve described in the past and past episodes, is the wild west.
What is assisted living?
And because of that, it doesn’t seem like there’s any type of overarching definition. Obviously no nationwide regulation. So it’s just like from state to state, anything goes. And we’ll talk about your hearing it in Congress here in a minute, but just to set the table, we’ll talk Richard, can you tell me, and I know it’s different from state to state, what, how do you define assisted living care?
Mollot:
That’s a really good question, because it is different from state to state. I define assisted living care as any residential care that is serving a primarily senior elderly population that is not a nursing home. And the reason why, I don’t think it, I don’t know if it’s a great distinction to say senior and disabled, but I want to differentiate it between or from there are facilities that care for primarily pediatricians and those I would not consider to be assisted living.
It generally is more of a senior and a senior and adult disabled people.
Schenk:
And the care, typically, we’re talking about generalization, the care typically between assisted living facilities, assisted living care, and the care received in a nursing home, you tell me if this is, if you agree with this, but typically has to deal with the care with respect to activities of daily living.
So care, help is needed. Brushing your hair, putting your clothes on, remembering to take your medicine as opposed to wound care or some type of nursing care that you might need. Is that, is it, does that kind of, does that make sense? Or.
Mollot:
Yes. I think that is the traditional view and role of assisted living.
I think that has changed over the years and that is where a lot of our concerns or, I’m in, is that residents in assisted living more and more are, what we call, aging in place, meaning they’re staying in assisted living, even as their needs approach or meet a nursing home level of needs.
And also people are living in assisted living with significantly higher levels of dementia. And they did in the past and needed much more help. So it’s just a really, I think I was, that was a really interesting distinction is there’s a difference between medication assistance and medication management, which may not be clear to a lot of people.
And why would it be? But, medication assistance is to say, Mrs. Jones has arthritis and she can’t open up her medication, but she knows what she’s taking. She knows when she needs to take it. She just needs some help. That’s like an activity of daily living. That’s a traditional instance of living.
But what we see more of is that some, Mrs. Smith has some dementia. She doesn’t know when she is, she doesn’t know she’s taking medication. She has no idea what those medications are. And someone is actually administering that, making decisions about, or keeping track of what she should be doing.
And that’s more of a nurse’s role and tends to be obviously a higher level of care than many assisted living. Unfortunately, they are able to provide even for those residents that they accept.
How is assisted living different from nursing home care?
Schenk:
In Georgia, I know that they’re the regs for assisted living in terms of medication management is that the resident typically needs to be able to understand that they’re taking medicine, understand like they don’t have to need to know that it’s something specific like Tylenol or whatever it is, but they need to be able to go, Oh, it’s the blue one.
And essentially have a basic understanding. But in my experience, what I see, that’s almost never the case. It’s just here, Ms. Johnson take this and it’s your medicine and they don’t know none of the wiser and in Georgia I want to say this is a fairly new regulation in the last five or six years, but prior there was no aging in place you would have to qualify to be in an assisted living facility as opposed to a nursing home by typically your ability to what’s called self preserve, which I’m sure you know all about, which is, can you get out of this place in some way with limited assistance if it was on fire?
And now there are variances in waivers that assisted living facilities can do to and have a certain amount of residents that, that, that would typically not meet that criteria so long as they do other things, which in my experience, that’s what’s the wild west. They’re not doing any of this stuff. So can you tell me then, because I’ve got a lot of clients that will say I have a loved one in a nursing home and they, in their memory care unit, when in reality they’re in a memory care unit, quote unquote, of an assisted living facility. So in your experience, can you tell me what would be the difference between the care and a memory care unit and assisted living facility and that of a nursing home?
Mollot:
That’s a really interesting question. Because. Unfortunately, too often care in a memory care unit in a nursing home is not necessarily that great. In my view, memory care doesn’t really mean a lot. It’s more of a marketing term rather than something that is substantive and that’s really worrisome.
Because again, families don’t know, prospective residents don’t know why should that, it’s not shouldn’t be sorry. My dog is barking. Why should that be? Let me put it another way. We go to professionals because we expect them to have the expertise, not that we should have to have the expertise.
And when professionals let us down, unfortunately, that could be catastrophic. And just in that situation, are you getting good care in a nursing home, a so-called memory care unit, or are you getting good care in an assisted living? I think the main difference from my perspective would be nursing homes as institutional as they can be. Sometimes, for care, we have a lot of low staffing in this country, but they have to have nurses.
They have to have CNAs. They have to have licensed practical nurses. That doesn’t exist for assisted living. So you have a level of professionalism in a nursing home that may not exist in assisted living. If an assisted living has it, that can turn on a dime. It really is, in a sense, the wild west, you could have a new owner that comes in, you could have that, the nurse left, the RN left if there was one, and no one has replaced her.
So you have a lot of vagaries in assisted living that you don’t, at least on paper and professionally, have in a nursing home.
Schenk:
I think that the interesting thing, at least in Georgia, is that you’re not allowed to give medical care or nursing care and the assisted living facility itself, now you can hire people to come in and do things for you, but the assisted living facility itself cannot provide medical care, cannot provide nursing care.
However, on every website, as you mentioned. Oh, we have a registered nurse as our director of clinical services. We have a registered nurse X, Y, and Z. And that really confuses people because the nurse is, it can’t function as a nurse in Georgia and in Georgia assisted living facilities. And what’s funny is in litigation in the past, I have argued that you have a nurse.
They can’t take off their nurse hat. They’re going to be nurses and should be doing nursing. And I’ve had somebody have a motion to say, Rob, no, they can’t be a nurse. And at the same time arguing that, no, you didn’t meet the, You didn’t file your lawsuit correctly to name a professional as a defendant.
So in other words, like they’re saying they can’t provide nursing services, but they can. You just didn’t, you’re not doing the lawsuit right. It just puts the nursing or the assisted living facilities in a weird situation. And to me, it’s a, as you mentioned. It’s like a consumer issue.
It’s a consumer rights issue. Don’t say that you have a nurse if they’re not providing nursing care. I don’t know. That’s my two cents on it. All right, this is exciting for me. I don’t ever, I think I was the last time I was in Washington, DC. I don’t know. Maybe I was on a field trip.
That’s true. I think I’ve been a couple of times, but anyway, you recently, at least the past year or so, went and testified before Congress on this issue. Can you tell me about that?
Mollot:
Sure. I testified before the Senate special committee on aging and they decided to have a hearing because of essentially two investigative reports, one in the Washington Post and one in the New York Times, and one of those reports found significant financial misdoings, exploitation of residents, in other words.
And the other report found significant levels of poor care. And I think, In the back of my head as you’re talking about some of the things that you’re seeing and experiencing in Georgia, I’m thinking about, to me, a lot of this issue comes down to, yes, of course, it’s staffing and requirements around professionalism, but also the the extent to which some facilities will accept and retain people for whom they just don’t have the ability to provide care.
And that to me is essential. It’s the, as a resident advocate and as a researcher, people. It’s really the baseline of any requirements that we have for either nursing homes or assisted living is that you’re only going to take in people for whom you could provide care. And when, and there comes a point where you can no longer safely provide care, you have a, not only a moral obligation, but a legal obligation to say, I’m sorry, you, we, we need to find you another safe placement.
And too often that doesn’t happen. I think that’s really the heart of so many of these problems is that people are brought in and then either the facility can’t take care of them or becomes unable to take care of them. And we see a lot of that in assisted living.
Schenk:
How do you think that your testimony and the testimony of your colleagues was received?
Mollot:
I think it was pretty well received. I was glad from people on both sides of the aisle. I was really really glad to see that. I think it’s very hard to make change, especially in this political environment, but I’m hoping that by raising awareness of these issues that we are able, we’ll be able to make some change.
And that’s how the nursing home reform law came into being in 1987 was because there were scandals, and there was reporting about those scandals and a lot of it gets at some of the things that you just, you know, you mentioned earlier about being able to safely. Ambulate yourself out of a facility that was on fire.
If there was something else happening, there were scandals that involved resident deaths, fires, et cetera, that resulted in a lot of the rules that we’ve seen in the nursing home sector over the years. Over the years, I just hate to think of how many residents are suffering and too often suffering in silence, especially in assisted living because they don’t know, they don’t have those rights and therefore it’s very hard to get them implemented.
What do you recommend for regulating assisted living facilities?
Schenk:
So it seems to me, and that’s a great point, but the way that the scandals in the eighties manifested was in the federal Oprah regulations, because we could do that. At least the Congress has the power to do that because these facilities, the nursing homes, not assisted living facilities, but nursing homes accept federal money.
So that was our way to get our foot in the door to say, all right, if you’re going to operate a nursing home and accept Medicare dollars and Medicaid dollars, you have to do X, Y, and Z. Do you, in your organization, do you all, do you guys. advocate for a national regulation system, regulatory system like Oprah, or just a state by state, every have better regs.
What? How? How would you want to address this situation like an overarching reg or still state by state?
Mollot:
I think we need both. And we have that in the nursing home sector. The biggest rule nursing homes, of course, is the federal rules are the federal rules. There are state rules as well that improve upon them.
And sometimes those improvements become reflected in federal rules as well, like with the staffing standard that the Biden administration should be coming out with pretty soon, 33 or so states, maybe it’s 37, now have a staffing standard of some kind for nursing homes. That is, I think, for assisted living, we really need to have a baseline, consumers, especially when you’re as vulnerable as a resident in residential care, have a right to know who’s going to be providing the care that it’s meeting some basic standard, and there are federal rules already, the only federal rules around assisted living that just were promulgated, let me say about five or so years ago, relate to the community characteristics of an assisted living, so if I remember correctly, about 20 percent of assisted living is paid for by, by the government generally through Medicaid waivers.
And that’s the movement we’ve seen in this country since 1999, especially there was a Supreme Court ruling called the Olmstead Decision that said that the Americans with disabilities act applies to people, including older adults with disabilities. And from that, every state has been required to have a plan to help people become deinstitutionalized, to get out of nursing homes.
And so that’s why we’ve seen this growth of home care and of Medicaid, what’s called the Medicaid assisted living. So I think there is a hook there and I think the hook is growing because providers will follow the money, and that’s where the money is, the money is federal money.
Schenk:
So I guess it would be a matter of whether you would advocate possibly Enlarging Medicaid’s role in assisted living facilities. So in other words, like instead of having to go through the, which I think is a pretty difficult process of trying to get a waiver so that Medicaid takes care of your assisted living, if you’re on Medicaid, that pays for assisted living, which is not the case in Georgia.
Mollot:
Uh, yes, exactly. I think that we definitely would like to see that expanded when I first started and I’ve been working here for over 21 years, people saw and we were just in a New York group at that time. And people that I spoke to saw the Medicaid assisted living program. It’s a waiver plan, a state waiver plan in the States.
They saw that as being a great opportunity for people. Who could safely live in a less restrictive environment as the definition goes to access assistive living and the rates for Medicaid for assisted living are actually at least, just generally speaking, pretty good. They’re pretty close to a through private pay rate for a double room, again, just generally speaking, of course, it varies.
So it’s beneficial to the operator as well to have those people there. And I think it’s part of just the policy of helping people to avoid that institutionalized setting that most nursing, not all of them, but most nursing provides.
Schenk:
In your research and in your experience, are there any particular states that are further behind than others that you know of in terms of regulating and keeping assisted living facility residents safe?
Mollot:
There’s definitely variations. We’ve done a couple of studies that looked at what the states were doing. And we have a report we did. It was about three or four years ago now looking at promising practices that we identified from the states. I don’t recall any state in particular standing out.
And I would also just caution myself from saying anything because, just to go back to nursing homes, we have really good rules in this country for nursing homes. The reason why so much nursing home care is crappy and dehumanizing is because those rules aren’t implemented. And rules tend to be More weakly enforced for assisted living by the states and then nursing homes are for a variety of reasons.
So I would very much caution to say whether I think a state is doing a great job, but there are. In particular, there are definitely some promising practices that we’ve seen our policies that we’ve seen out there among the states that we’ve identified.
Schenk:
In Georgia, we have, it’s almost like a tier system. Like you have acute post care facilities. You’ve got nursing homes, you have assisted living facilities. Then underneath that we have what are called personal care homes, which is a degree of care, even below the assisted living facility, but we find the exact same problems. Typically the main differences between the assisted living and personal care home is the medication management.
Typically in a personal care home it’s almost as though. You’ve got to be able to know exactly what medicine you’re taking. You don’t need any help. Although, that’s a loose definition, but that’s typically where the dividing line is in your experience, is that, are there like personal care homes and other States so there’s a degree of care that’s different. It’s even lower.
Mollot:
Yes. Sometimes they’re called personal care homes, board and care. I’ve heard yes. And they really fly even further under the radar. There’s been a number of Medicaid for controlling attorney, state attorney general’s cases that I’ve seen over the years against those providers.
And, I had an uncle who was in one and had a great experience down south in Florida. But in others, it can be. You could become entrapped if you’re an adult person who has a disability and can’t get out. And some of those cases from the AG’s office are just horrific.
And I’m sure they’re private cases as well, which we wouldn’t be privy to because of course, as a lot of them settle in our public records.
Experience Testifying in the Congress
Schenk:
Sure. Richard, this was your second time as far as my count goes testifying in front of Congress. What’s that like? Was it exciting?
Were you like butterflies? Like what? Tell me. Do you like to set the scene?
Mollot:
Yeah it’s, of course, yes, it’s, of course, really exciting and a privilege to be able to be up there and to be talking to leaders and have something to go on the record. I think that’s more important than anything.
It becomes part of the congressional record, the recording and the transcripts are available. And I know that those hearings can be valuable for years to come. In fact, at that hearing, they talked about the previous hearing, which I think was 1999. I just, as I said before, I think that, when you ask, what our goals are, I think pushing awareness.
And pushing some ideas as to how to meet some of the challenges that we see now that makes it, that’s a really great opportunity. And I was very fortunate and it is exciting, of course.
Schenk:
I’d be freaking out. I don’t know who was in the panel, like who were your colleagues? And of course, who are you addressing?
Mollot:
Sure. They had a woman whose husband had been in an assisted living and her husband’s care. She wound up I think she was paying like, like 17, 000 a month that wound up because they promised, as I understood, I want to be careful, but, obviously they had, accepted him and then they were charging for all these extra services.
And that, of course, is a problem because, again, there is a difference between nursing homes and assisted living. In nursing homes, they’re expected to provide 24 hour care. In a professional manner to meet your needs since living. There’s no, there really no rules or no effective rules.
And so they can do whatever they want. And that’s what we see a lot of these charging, sometimes unfortunately, even double charging for the same services. So that was, she was really interesting. And I think it was really heart rendering to speak to her. And they had an academic researcher and a provider from the Midwest.
Who was obviously very, as providers tend to be, very anti oversight and anti rules.
Schenk:
Oh, so I guess I never, I guess I didn’t see that part because I think I only saw your kind of colleagues on the consumer side on the resident side. I guess I didn’t, I guess I didn’t listen long enough for the, or I missed him the industry representative essentially.
Mollot:
Yeah, I think she came to be, I was last and it was first, it was the family member and then the researcher and then the industry person and then me.
Schenk:
I see. Okay. I have to go back and watch and I’m going to have a link to that in the show notes. So that everybody can watch. I think it’s about an hour long.
And I can just imagine that I used to, I don’t watch a lot of television. I used to love to watch CNN and you would see the thing where it’s and now A hearing on assisted living facilities at 10 o’clock before the Department of Blue. And I could just, I don’t know, I just love that.
And that’s what preceded this one anyway. All right. Richard, thank you so much for coming on the show again and sharing your knowledge. And we really appreciate you.
Mollot:
Rob, thanks so much. I love the work you do. I love watching the snippets on Instagram. They’re great and so helpful.
And thank you. Thanks for your good work. Of course. Appreciate it.
Schenk:
Folks, I hope that you found this episode educational. If you wanted to reach out to Richard, or watch the testimony that he provided, those links will be in the show notes, but you can reach out to him at nursinghome411.org. It’s nursinghome411.org, is a fantastic website.
We’ve had a couple of podcasts dedicated to It’s just a plethora of information about nursing homes in the United States. So if you wanted to get ahold of Richard, that’s going to be the best way that you can do that. New episodes of the nursing home abuse podcast come out every Monday on every podcast platform.
I think at this point you can also watch this podcast either on our website, which is nursinghomeabusepodcast.com or on YouTube. If you have any suggestions for content, things that you want me to talk about, let me know. Or if you have a guest that you would like me to talk to, please let me know that as well.
And with that, folks, we’ll see you next time. Thanks for tuning into the nursing home abuse pod.
Nothing said on this podcast either by the host or the guest should be construed as legal or medical advice, nor is intended to create an attorney-client relationship between the host or their guest and the listener. New episodes for now are available every other Monday on Spotify, Apple Podcasts, or on your favorite podcast app, as well as on YouTube and our website, nursing home abuse podcast.com.
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