How Assisted Living Facilities are Different from Nursing Homes and Personal Care Homes
Are all long-term care facilities the same? Many families don’t realize that assisted living facilities (ALFs), nursing homes (NHs), and personal care homes (PCHs) follow different rules and offer different levels of care. These differences can have a big impact on safety, services, and legal rights. In this week’s episode, nursing home abuse lawyer Rob Schenk welcomes guest Ms. Kayla Meek to talk about what sets ALFs apart from NHs and PCHs, and what families need to know when choosing care for a loved one.
Meek:
In assisted living in personal care homes, they are not able by regulation, quote unquote, restrain somebody. Individuals who have memory loss can still read and they are highly motivated, so they can read the sign that says, Hey, if you hold this door down for 15 seconds, it will release. But quite honestly, it is very difficult to protect against what we call an elopement.
Schenk:
Hello out there. Welcome back to the Nursing Home Abuse podcast. My name is Rob. I will be your host for this episode this week. We’re talking about the differences in care. Between nursing homes, assisted living facilities and personal care homes, and I know that assisted living facilities and personal care homes are called different things in different states because they’re regulated differently from state to state.
But in general, who the residents are that are in these places and, what services you can expect to receive in them. But we’re not doing that alone. We have the fantastic, Kayla Meek who’s gonna, who’s gonna join us in a minute to talk about these issues.
We have the absolutely fantastic Kayla Meek to discuss that with us. Kayla Meek is the owner of Athene Consulting, a senior living nurse consulting group focused on risk management, fractional leadership and legal nurse consulting. Prior to Athene Kayla had several vice president positions throughout her 13 years ex of experience in various aging services industries, including independent living assisted living.
And memory care Within her roles, Kayla has advocated for clinical exper excellence, holistic health, and quality of life for older adults through the creation of numerous nationally implemented wellness programs. We’re so lucky to have her today. Kayla, welcome to the show.
Meek:
Hi. Thank you so much for having me.
Happy to be here.
What are the main differences between ALFs, NHs, and PCHs in Georgia?
Schenk:
I had a conversation, it’s probably been at least a couple years now with Richard Mullet. On the idea of how personal care homes and assisted living facilities, whatever they’re referred to as in the different states, but that’s what they are in Georgia. It’s kinda like the wild west.
There, there doesn’t, there’s not federal oversight of these places. It’s state by state. And I think at least. In my experience, that’s what leads to at least some of the confusion about what happens at these places. So this is my opening salvo is what is in general the difference between a nursing home and an assisted living facility or personal care home?
Like what level of care are you getting in these places?
Meek:
Yeah, that’s a great question. I, and I think I’ll probably be a little bit long-winded on that one, if that’s okay. That’s because it’s hefty. Yeah, go for it. So for personal care homes and assisted living and nursing homes, think of it like a tier of service providers and you start with personal care homes at the bottom.
They’re typically smaller, they’re more homelike. Think of it like having. A private or a shared room. Typically you’re right around 25 quote unquote beds or less. They have differing regulations depending on how many individuals can live there. Oftentimes, they’re family owned, locally operated. I think of ’em as more like a mom and pop shop.
You can build that. Relationship with the in-house team, they’re really probably best suited for individuals who are largely independent, but may need some occasional support with activities of daily living, like dressing, grooming, showering, toileting, meal preparation, housekeeping. Really, you can’t do much medical services in a personal care home outside of basic first aid and some medication assistance.
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They normally don’t have any licensed medical professionals on staff, and any nursing services would need to be provided by an external provider like Home Health or hospice. And then if you go up the tier a little bit, you’re looking at an assisted living facility, which is most often larger than a personal care home.
It’s still residential. It’s very homelike. Typically the suites are bigger. So if that’s a. Pertinent factor in the decision. You have more of an apartment style room. Assisted living services can accommodate a little bit of a higher level of care than maybe some personal care homes, but they’re still lower than nursing homes.
Services typically include things like. Again, activities of daily living, dressing, grooming, showering, toileting. They may be able to provide some more significant support though. Maybe if someone were towards the end of their disease process needing a specific like memory care quote, unquote unit or neighborhood, they can provide some more stringent oversight with medication assistance because they do have a regulation that requires them to have at least.
Some level of nursing oversight or support. And that typically is in like a leadership position, like a director of nursing. So I would say of the three personal care homes in assisted living are probably the most commonly associated. And then you jump to nursing homes, which is a whole different.
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The environment’s definitely more clinical. I would say it resembles in most cases a hospital. They strive, although they do strive for more homelike feel in a lot of places. They typically the patient profile is someone who needs more serious chronic medical attention. They have a chronic condition or disability.
They are federally regulated and they have to be able to support 24 7 medical supervision, skilled nursing care. And in addition to nursing support, they also have typically some element of supportive rehabilitation like. Pt, which is physical therapy, occupational therapy, speech therapy on site. And you can receive those services at a higher rate than what you would see at like a assisted living or personal care home where you would typically only get visits by a visiting home health that could do, one to two times of PT physical therapy a week.
How do care levels vary between an Assisted Living Facility and a Nursing Home?
Schenk:
So what is the, what is the typical, you mentioned this is a great word, I don’t think I’ve heard this before, but a patient profile, like what is the patient profile for personal care versus assisted living?
Meek:
Yeah. I would say probably a personal care home. The best suited resident is someone who’s largely independent.
They may need some occasional support. They might be not really successful at doing those. More, we call ’em independent activities of daily living. The bigger things like. Meal prep they no longer drive or need some assistance going to appointments. They need some housekeeping assistance, laundry assistance but they really prefer a more intimate, smaller setting is best suited for someone with in personal care.
Homes, definitely not anyone who has a skilled need like a colostomy bag service or anything that would require general oversight of a nurse in assisted living. It’s. Similar, but I think they can accommodate just a little bit more. They can accommodate, of course, the activities of assisted of daily living.
They can accommodate meal prep. That’s their bread and butter, right? That’s what they’re best suited for. But then it just takes it up a little notch with the level of supervision that’s provided. So someone who might have a more complicated medication or an injection, definitely those, the individuals who are diabetic that need some routine monitoring of blood glucose, there are some levels of supportive services that can be provided in assisted living for individuals who have skilled needs. But it’s. Very specific. Typically what we see in assisted living is that the onsite staff don’t perform those skilled services, something like a colostomy wafer change, whereas they may partner with a home healthcare provider to really do those services.
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Now, when you get into the patient profile of skilled nursing, all of those services are provided. In house by in-house staff whenever is needed. So say for example, you have a resident in assisted living who’s maybe there towards the end of their disease process with memory loss, but they do have that colomy bag and they’re removing it.
They wouldn’t be best suited for assisted living. ’cause assisted living doesn’t have 24 7 skilled staff to replace it, right? That person may be better suited for a nursing environment that can have those medical professionals to attend to those needs as needed when needed.
Schenk:
I think that is, at least in my experience, a big point of confusion for the public and for the people that call my office.
It’s, they even refer to the assisted living facility to the home as a nursing home, thinking that absolutely there are nurses on staff, things like that. So that mean that there, there’s, I, in my opinion, there should be a lot more education to the public about what, as you mentioned, what these places are actually allowed to do, which is not very much in terms of nursing or medical.
Meek:
I would 1000% agree. It causes great confusion. Even within the aging services industry, people who work at personal care homes may not understand the differences in assisted living in personal care homes. And the same thing for nursing. You even see that sometimes with regulators, the individuals who are charged, withholding the facilities accountable for the state regulations.
In some states, they regulate both nursing homes and assisted living, and they. They get confused between the two and it is very difficult in different states because they are very similar. But it’s important to be educated on where to properly place an individual so that they receive the care services that will support the trajectory of their healing.
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Schenk:
If you had a family sitting in front of you and they were trying to decide. What level of care their loved one needs, like what, how would you help guide them along to select personal care, home versus assisted living, versus nursing home?
Meek:
Yeah, I say it is so very difficult because it’s not really apples to apples with a lot of these places and you can’t get a lot of the information you need unless you either pick up the phone and call somebody or you go and physically take a tour of these places.
When you’re looking at a skilled facility, I think that’s a little bit easier to be an informed consumer. Researching for skilled, because they’re federally funded, they have all of their information is. Open source, right? You can go to care compare.com. You can pull up their quality metrics for their falls percentages, their pressure injury percentages, but because.
Personal care homes and assisted living facilities are private pay. They’re not federally funded. They don’t, they’re not held to the same standard for producing that information to the public. Really the only information that the public can get about a personal care home or an assisted living facility is their surveys.
And you can go on and you can read their survey history. But surveys are open to interpretation too. It’s very difficult to get a feel of what a facility might be like without actually, setting your feet in the community to get that idea. I always advocate for the service. There are some really great companies and that’s all they do is suggest placement for residents and they’re a free service to families.
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What they do is they take. Intake information from a family member who may be struggling to find somewhere and they say, what’s most important to you? What are the needs of your loved one? What’s your price point, your budget for monthly care services. And then they do all the research and they help to pull together a presentation to families to say, these are the top three places I would recommend.
Could I schedule some tours for you, make you some referrals, and then it really takes the stress off of the family. ’cause they’re already probably in a compromised state of mind, dealing with a loved one who’s having some issues or struggles with their health. And then at that point it takes the brunt of the work off the family.
You have a person who can help guide you and it’s a free service. It’s really hard to say no to.
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What regulations govern ALFs, NHs, and PCHs in Georgia?
Schenk:
In a nursing home. The nursing process, when there’s a new admin typically goes like this, you get you, you’re admitted. There’s a comprehensive head to toe assessment. Then there’s a comprehensive care plan.
The care plan is put in place. Everybody knows what they’re doing in terms of the clinical interventions for the resident, and that gets revised whenever there’s a significant change or at regular intervals. Tell me about. That process or the a similar process? ’cause I guess we can’t technically call it nursing.
Sure. But what is the process of evaluation and assessment and planning in an assisted living facility?
Meek:
Same, but different. It’s mostly how it goes. I think in skilled the onsite staff don’t necessarily get as much time to prepare for the oncoming admission. Typically, admissions happen same day from in a skilled facility.
They get a referral from a discharge planner at a hospital. The resident they comb through their medical record. They look for some red flags to see. Should they admit? Should they not admit? They choose to admit. And then at that point they get them on site, they can see them head to toe and move forward with their assessment and care planning process.
I think in the personal care, home and assisted living process, it can be a little bit more in depth on the front end, which is really nice. And helpful because personal care, homes and assisted living facilities are not as equipped to deal with difficult cases, so there’s a little bit more of a runway.
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In personal care homes and assisted living, primarily residents move in from either the home or another assisted living or personal care home. And what a nurse or the director of nursing or the individual who’s charged with overseeing the care services will typically do is they’ll make an appointment with a family to come out to the home and do an in-person assessment.
It’s really great ’cause they can see what they’re like in their homelike environment. What sort of like. Medical devices, do they have there, do they see that they have a pill reminder box and that helps to prompt them for questions a little, it’s a little bit more personalized, and then the family can then start that relationship building with the leadership team at the personal care home or the assisted living.
They complete their assessment. They make a decision on if. That person is applicable for admission. They should have their assessment fully completed before the resident moves in. That’s a typical regulation of assisted living facilities. They also have to have a review by a provider, like a primary care physician, nurse practitioner.
They have to fill out a state required form checks and boxes that in the medical provider’s opinion, the. The person is applicable and safe to say in that level of care, they then move forward with creating the care plan, which is the instruction sheet for how do you properly care for the person.
Care plans are the end all, be all of care services and senior living. If it’s not in the care plan, then the care providers don’t know what to do or how to implement it. They also can’t chart on it. And then typically what a family should expect. Is routine communication from their personal care home or their assisted living.
They should hear from them. Every time that there’s a quote unquote incident, mom or dad falls, grandma, grandpa leaves the facility unattended. Those should prompt communication. They should prompt a reassessment. It should prompt a care plan meeting. And so they should really be working hand in hand as partners to really develop that plan of care.
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Schenk:
I think that there sometimes there is a lot of the ball being dropped between that initial physician assessment that says you are qualified or not qualified for assisted living and the actual admin. So in my experience, what I mean by that is that a physician might sign off. And that’s all the n that’s all the assisted living facility needs in their mind.
But in reality, that’s not true. First of all, the physician can mess up. Sure. And the buck stops with the personal care home, with the assisted living facility, meaning that even if somebody says, this person’s good, you still have to do an evaluation. And I find that sometimes it’s, people are getting admitted to these places that don’t.
That still don’t qualify. And one of the qualifications in the regs is the ability to basically, to be able to ambulate and react if there’s an emergency. And especially in like memory care units, that might not be the case. Like you the individual might not be mobile like even in a wheelchair.
They won’t they couldn’t move themselves. And even if you said there’s a fire, let’s get outta here, they wouldn’t be able to understand how to get out or know what’s going on. I feel that’s, I feel like that is a, that’s a major problem in these places at the admission process.
Meek:
I would a thousand percent agree.
I think it, that probably is a whole new podcast topic, right? Is the downfall of the partnership of the family and the physicians group. Not that they don’t wanna do the right thing, and not that you know it, it’s not in their best interest and they have the. The goal, the same goals as a family.
It’s just a little bit difficult in today’s healthcare environment to get the time with the provider and for the provider to really have that intimate knowledge of the potential resident to be able to accurately complete the form. A lot of the questions require conversation and really in-depth investigation, and a provider just can’t quite frankly, complete the entirety of the form.
Accurately unless they’ve really sat down and have built that relationship with the resident.
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How does the cost of care compare between these senior living options?
Schenk:
Okay, so you mentioned earlier private pay. Versus, I guess Medicaid is probably the primary payer nursing homes, but what are the costs if a family wanted to move their loved one into an assisted living or personal care home?
Meek:
Sure. So I think personal care homes are definitely a little bit more economical of the choice of the three. They’re primarily private pay, although some. Some might accept some Medicaid waiver or veterans benefit. I would say they’re probably in the ballpark between 2000 to $4,000 monthly, whereas then you go up your tier again to your assisted living, which is also private pay, but you find that a lot of assisted living facilities will accept long-term care insurance.
Long-term care insurance has nothing to do with Medicare, Medicaid. It’s a private insurance provider that typically someone has paid into for many years. They are often in the ballpark of 3,500. To maybe up to 6,000 a month. I think one thing to really keep in mind when you’re looking at assisted living facilities is that there’s two kind of price points in assisted living facilities.
Some may advertise that they’re, quote unquote, all inclusive. All inclusive means one price for the whole month for everything you need here, which includes. Meals, housekeeping care, all of it. Whereas some assisted living facilities will break it down into two major price points. They’ll say you have a base fee, which is the same month over month for the entirety of the year, and then you have a care fee.
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The care fee is based off of the needs of the resident and can increase. As the care increases, that’s a little bit scary to somebody who really needs pricing stability and is planning finances into the future. So it’s ideal to find a facility that really. If that’s of importance to find somewhere that is all inclusive pricing.
And then also, one thing I always tell people to keep in mind as far as pricing points for assisted living is it is very industry standard for them to have a pricing increase each year. Typically somewhere between three and 5% year over year. Although when we were in the crux of Covid, you could see pricing increases up to 10%.
Year over year, and that was because of staffing challenges, costs of the PPE was really weighing heavily on the operator. And unfortunately the operator’s cost is passed down to the resident costs. And then you have skilled nursing homes are heavily regulated by both the state and federal regulations, and so they receive federal reimbursements for Medicare, Medicaid, Medicare.
May pay for some short term stays after hospitalization, but for very limited time. There’s a lot of rules around insurance reimbursement, the timeframe in which they’re willing to pay. Typically, that they will pay for less than 30 days. Then after your short term stay. If you’re applicable because of your financial status, Medicaid can cover the cost of long-term care for qualifying individuals dependent on assets.
And man, that would probably be another really good podcast topic. ‘Cause it gets very complicated. And how you spin down and what. Constitutes an asset. Is it land, is it liquid funds? But if a individual doesn’t qualify for Medicaid, and they do need some long-term skilled services, it unfortunately transfers to private pay.
And also long-term care can be accepted as well. Those price ranges can range anywhere from probably 7,000 a month to upwards to 10,000 a month.
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Schenk:
Talk to me about an assisted living facility or a personal care home that has a memory care unit. What are the challenges in terms of. Main, like providing care within the confines or the regulations.
But it’s somebody that has dementia or Alzheimer’s, right? Like I feel like it’s a tough, it’s a tough situation to be in. It’s ’cause somebody, I feel like that qualifies for a memory care unit and it’s, this length of facility is on the verge of just going to the nursing home.
Yeah. So can you talk about that?
How can families decide which senior care option is right for their loved one?
Meek:
Yeah, so memory care communities can get very complicated as far as their level of security in which they’re able to provide. So in assisted living and personal care homes, they’re not able by regulation to quote unquote restrain somebody. They’re also obviously regulated by a state fire marshal.
So the doors, while they can be a. A secure unit, they cannot be a locked unit. Secure unit basically means that the doors have an egress on them somewhere around 15 seconds, and they are required to have a sign that says, hold for 15 seconds, and the door will release. A lot of individuals who have memory loss can still read and they are highly motivated persons.
So they can read the sign that says, Hey, if you hold this door down for 15 seconds, it will release, which poses a risk to ensuring the safety of not only that resident who has. Opened the door and potentially exited, but for the surrounding residents who have been identified as needing a secure environment.
So while a community can provide some safeguards with doors that have delayed release, they can have additional safeguards like. Wander guards, which provide an additional level of security to the doors. They can provide window limiters, which will reduce the spacing in which a window can open. Typically it’s about six inches that they will allow the window to open.
I always tell people nothing is pull foolproof in any environment. And it is just quite simply. Not legal to restrain a person to a specific space, a bed, a chair without allowing them free range. So then unfortunately these memory care units can get quite large, 30, 40, 50 residents in a single space.
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When you have 40 individuals who have compromised cognition. Yet they’re highly motivated and want to return home, and you only have three or four staff members. Those three or four staff members do have other care services that they have to provide, which pulls them away from others. Maybe they’re giving someone a shower, they’re passing medications.
It’s just not a level of one-on-one supervision, which can. A thousand percent ensure that the general wellbeing of an individual is known all day at all times. So there’s a lot of alarms, tools, resources, wellness, being checks, policies that can be put into place. But quite honestly, it is very difficult to protect against what we call an elopement.
Schenk:
Kayla, that was extremely informative that this episode has just flown by and I really appreciate you coming on the show and sharing your knowledge with us.
Meek:
Yeah, thank you so much for having me. Happy to do it anytime. It’s been great.
Schenk:
Folks, I hope that you found this episode educational. If you have an idea for a topic that you would like for me to talk about, please let me know. If you have an idea for someone that you would like for me to talk to as a guest, please let me know that as well. New episodes of the Nursing Home Abuse Podcast come out every single Monday. Also, be sure to enter to win the Nursing Home Abuse podcast mug.
I think as of today as I record this, I don’t think we’ve even had any. Participants. So the chances of you winning if you participate, at least as of right now, very high. So if you want a fancy Pants coffee mug, absolutely free. Participate. And with that, folks, I. We’ll see you next time.
Ms. Kayla Meek’s Contact Information:
- Athene Consulting