It’s no secret that the largest population of older adults is about to come knocking on senior living’s door. What worries dementia care expert Teepa Snow is how unprepared operators may be to handle the incoming “dementia shockwave.”

In a recent webinar on the state of dementia care hosted by workforce education provider Relias, Snow, an occupational therapist and CEO of Positive Approach to Care, said that there are 120-plus types, causes and forms of brain change under the dementia umbrella. 

In 2020, approximately 7 million people aged 65 or more years were living with dementia. That number is anticipated to increase to 9 million by 2030, and 12 million by 2040. And Snow said that 60% to 70% of people moving into long-term care have cognitive changes consistent with the early signs of various forms of dementia. According to the Centers for Disease Control and Prevention’s National Center for Health Statistics, 42% of assisted living residents have Alzheimer’s disease or another form of dementia.

Communities are unprepared

Senior living communities are missing the signs of the disease because they aren’t preparing staff members to recognize them at the earliest stages, Snow said. 

In most cases, she added, certified nursing assistants are required to have the most dementia training of staff members, but that requirement averages only six hours. Most skilled care providers are not required to have any dementia care training, she said. 

“The challenge is, when we’re talking about somebody whose brain is dramatically shifting and abilities are variable, we are asking people to step forward into this role without preparation,” Snow said, adding that the situation sets up staff members for job dissatisfaction. “If we can’t get people to want to work with us, we can’t serve the population.”

The brains of people with dementia change over time, taking an average of 10 years to change from a neurotypical brain to a brain with Alzheimer’s disease, Snow said. And 80% of cases of individuals experiencing brain changes are not identified in the early stages, when interventions would be most effective, she said.

Providing truly person-centered care involves supporting the right culture and environment, building competence through education and training and practice, and working with families, Snow said. The “state of dementia care” is not where it needs to be, she added, but she said she knows it can get to where it needs to be — with collaboration. 

Adding family to the care team

Senior living communities may be admitting people who have more complex care needs than anticipated, resulting not only in untrained and unprepared staff members but unprepared families, Snow said. 

The baby boomers aging into long-term care, she added, will be moving in at a more advanced age than members of previous generations, will have more chronic conditions and will be at higher risk for dementia.

“Not only are there more of us getting older; there are more of us getting older and having brain changes,” Snow said, opining that society already is poorly equipped to understand what aging typically looks like, let alone understand the brain changes that come with dementia.

Educating residents’ family members about the progression of dementia is just as important as training staff, she said. 

“Somewhere around 75% to 80% of family members have little to no awareness that the diagnosis of dementia is going to lead to somebody’s gradual decline no matter what we do,” Snow said. “It will change their ability to live their life.”

Family members are additional team members and need to be involved and engaged with creating a care plan for their loved ones, she said.

The LCS Foundation has announced a partnership with the Granger Cobb Institute for Senior Living to provide an annual scholarship to add more professionals to the senior living industry.

The institute was announced for Washington State University in 2017 and dedicated in 2019 to focus on building the future senior living workforce through academic programs, industry partnerships and research. It is named for the senior living industry executive who helped build the Washington State University senior living curriculum and taught a course in senior housing administration before he died in 2015. The senior living management program, launched in 2020, offers industry-driven courses, immersive learning, community operations expertise and industry-expert connections before graduation. 

In December, the program celebrated its first graduate, who earned the degree through the institute’s global campus. Six students have completed the senior living minor, which began in fall 2021, and 25 students are in the pipeline working on a senior living major or minor, according to GCISL founding director Nancy Swanger, PhD. Since offering an elective class in senior living management in 2010, almost 800 students have taken the course, with many now working in the industry. 

“Our program is quite unique in that it is housed in a hospitality school within an accredited college of business. The industry loves the business acumen and relationship-building foci in our curriculum,” Swanger told McKnight’s Senior Living. “The program at Washington State University is relatively new, and having such generous support for our students from LCS lends tremendous validity and credibility to what we are trying to build.”

Swanger added that many industry providers have given their “time, talent and treasure to help the program grow,” and that the LCS scholarship is one of three specifically for students studying senior living.

Swanger is on the board of trustees of the Vision Centre, which is supported by several industry associations — including the American Health Care Association / National Center for Assisted Living, the American Seniors Housing Association, Argentum, LeadingAge and the National Investment Center for Seniors Housing & Care — and working to create university and college programs and facilitate internships to prepare future generations of aging services leaders.

Since 2017, the LCS Foundation has awarded more than $450,000 in scholarships and professional development programs. The foundation also has collegiate partnerships with the University of Northern Iowa, Northwood University and the University of Wisconsin-Eau Claire. Those partnerships have placed senior living experts on advisory boards, developed curricula and helped provide students with interactions to advance their learning.

Other senior living-focused academic programs include an assisted living/senior housing administration concentration at George Mason University, a Master of Arts degree in senior living hospitality at the University of Southern California Leonard Davis School of Gerontology, an undergraduate degree in senior living management in University of Central Florida’s Rose College of Hospitality Management, and Boston University’s concentration in senior living in the Masters of Management in Hospitality degree program.

A senior living community’s approach to finding the best wellness technology should begin with an examination of the needs of its residents and staff members, according to a new report developed with a group of providers and other experts.

A International Council on Active Aging Forum think tank of 60 leaders in senior living, community-based services and technology companies met in the fall to formulate recommendations on helping communities develop a wellness technology, or well tech, vision, as well as implementation strategies. The group’s work was compiled in “The promise of well-tech,” a report released Tuesday by ICAA.

“It was extremely valuable to have both the senior living leadership and the technology companies in the same room,” ICAA CEO Colin Milner said in a press release. “The providers detailed what they look for when selecting a technology, and the companies shared insights from their points of view. Everyone walked away with a better understanding of needs and opportunities.”

Well tech, according to ICAA, includes resident-facing technologies that enable communication, engagement and self-care; technologies that enable staff members to communicate and engage with residents; and technology that helps organizations deliver services and lifestyle opportunities.

The report outlines eight principles that participants said should guide every community’s technology vision, including:

1. Technology strategies should serve the organization as a whole.
2. Involve people who will use the technology in decision-making.
3. Examine the utility and usability of technology for each user.
4. Technology must include troubleshooting, training and long-term support.
5. Long-term partnerships between providers and technology companies are necessary to maximize value.
6. Data should be analyzed to find meaningful patterns and trends.
7. Training on data collection and interpretation for staff members and leaders is a must.
8. Cross-functional teams must analyze data to track wellness outcomes.

Well tech can generate data to prove the value of wellness, personalize services for residents and increase self-care, all while enhancing communication among staff members, according to the report.

The document outlines a planning process that communities can use when considering wellness technology, including discussion question examples and a toolkit of checklists for developing a vision, performing an audit and needs assessment, implementing technologies and evaluating outcomes.

“Technology has tremendous potential to help aging services providers deliver the wellness opportunities that make life worth living,” Milner said. “Grounded by an alignment of mission and values, organizations that buy and companies that sell can develop products and services that benefit the users they are intended for and the businesses themselves.”

A relatively new ordinance in one Michigan city is getting pushback from some senior living communities that are being charged for nonemergency 911 calls. The ordinance, they say, does not distinguish between the offerings of various levels of service and care nor recognize that some settings do not employ caregivers.

The city of Sterling Heights, MI, passed an ordinance last March that charges independent living communities, assisted living communities and nursing homes an $800 fee for a lift assist and a $500 fee for a nonemergency medical response. The Detroit suburb moved to implement the fees after noticing an increase in those types of calls, which they label a “misuse” of 911. The city said that the fees allow some of its costs from these calls to  be recouped.

After adoption of the ordinance last March, the city conducted in-person visits to communities and facilities in April to educate them about the fees before enforcement began on May 1. The ordinance states that nonemergency calls to “residential living facilities that are compensated to maintain staff to assist their residents is an inappropriate and unwarranted drain on city resources, which at times has caused delays in response to true emergencies.”

The city pointed out that operators can buy devices to help staff members lift residents if they fall, according to The Detroit News. 

A city attorney told the media outlet that the fire department handles more than 240 lift assists annually, on average, in assisted living communities and an average of more than 400 nonemergency medical responses, including calls to transfer residents to the hospital because they ran out of medication. 

The ordinance further states that nonemergency ambulance transports are regularly provided by first responders due to “a lack of facility staffing, a disinterest by the facility in addressing these needs for their residents, a lack of proper equipment at the facility, or other reasons that do not warrant or justify the use of city emergency responder resources.”

No caregivers employed

Waltonwood Senior Living contends that the ordinance should not apply to the independent living community at its Waltonwood Lakeside campus in Sterling Heights, which also offers assisted living and memory care. Waltonwood Director of Operations Steven Tyshka told The Detroit News that he agrees with the city of Sterling Heights on charging assisted living communities, but he argued that the ordinance should not be applied to unlicensed independent living, where caregivers are not employed.

A Waltonwood spokesperson told McKnight’s Senior Living that it is committed to transparent communication with residents and their families, “ensuring they understand the specifics of the services we provide at each level of care.”

“We are working to proactively address the Sterling Heights ordinance, emphasizing the clear distinction between independent and assisted living in our communities and navigate these changes effectively,” the spokesperson said. “We are dedicated to upholding the highest standards of care and compliance while also ensuring our residents are informed and supported every step of the way.”

The Michigan Assisted Living Association agreed, saying that independent living residents are “clearly not contracting for any personal care or assistance,” adding that those residents often sign up strictly for room and board.

“It is frustrating that Sterling Heights does not acknowledge the difference between independent living and assisted living,” MALA General Counsel Robert L. Stein told McKnight’s Senior Living.

Not a statewide trend

Fortunately, the Sterling Heights ordinance is not a statewide trend, Stein said, adding that MALA is hopeful that the issue will be resolved “favorably and fairly” for independent living residents. 

“We are aware of providers using private ambulance companies in lieu of calling the city responders for these types of services,” Stein said. “This approach is not a permanent solution but offers some flexibility and cost savings.”

In response to the fees, Waltonwood Lakeside informed its independent living residents in November that it would institute an $800 charge to residents who receive a lift assist from the city to recover its costs, according to the Detroit News.

Tacoma, WA, implemented a similar ordinance in 2019. The Washington Health Care Association and LeadingAge Washington partnered with city safety forces to decrease the number of 911 calls for lift assistance for long-term care facilities. The organizations educated first responders on the training and staffing requirements of assisted living communities compared with skilled nursing facilities, and provided education to community and facility staff members.

An increase in the number of solo agers — older adults living alone — can provide an opportunity for senior living providers looking to attract yet another demographic.

In a new research brief based on survey responses from 805 individuals aged 55 or more years, the Mather Institute explored how solo agers plan to address their needs and concerns related to aging. 

According to the US Census Bureau, in 2021 there were 22.1 million solo agers in the nation — unmarried and childless adults who live alone and don’t have immediate family to rely on as they age. By identifying the unique needs of solo areas, the report authors said, policy makers, healthcare providers and community organizations can develop targeted long-term services and supports.

For senior living providers, the demographic presents an opportunity to sell “peace of mind” regarding future care needs for solo agers currently living in the general community, according to Mather Institute Director of Research Jennifer L. Smith, PhD. 

“An advantage of moving into senior living for a solo ager is that there is a team of people available to handle things like maintenance, clearing, cooking, etc.,” Smith told McKnight’s Senior Living. “Life plan communities, which offer a continuum of care, can provide peace of mind that there’s a path for receiving additional levels of care if it’s needed — not to mention the wellness benefits senior living communities provide to solo agers by way of socialization and engagement through programming and interactions with neighbors and team members.”

According to the report, solo agers living in the greater community reported lower well-being, including lower life satisfaction and mental health, than their “supported” agers — older adults who are married or in a long-term relationship, do not live alone, and/or have adult children on whom they can rely.

Solo agers also expressed a wide range of concerns, but their most pressing concerns — maintaining mobility and independence — were similar to those of other older adults. Other concerns included maintaining dignity, mental engagement and social connections.

Senior living providers can use the report as a wakeup call to determine whether residents who are solo agers have any additional needs the community can help address, Smith said. Actions can include providing comfortable options for residents who may not always have a dining partner, or examining whether residents who became solo agers later in life due to the loss of a spouse and/or child are receiving the support they need.

When it comes to planning for the future, there are few differences in how solo and supported agers were preparing, except for plans related to identifying caregivers, according to the report. Fewer solo agers had identified future caregivers or planned to make those arrangements, potentially delaying decisions because they plan to age in place and don’t anticipate needing care.

Smith said that it’s important for solo agers to plan for their future housing needs, whether that involves modifications to their current homes or relocating to different residences.

The report includes strategies to support solo agers’ ability to age well, including maintaining and improving physical and psychological health to help delay the need for higher levels of care in the future, cultivating a strong social support network, and creating a plan for the future that includes financial and legal considerations, housing needs and support network.

Expanding the ability to enforce penalties on assisted living communities that violate a resident’s rights is a new goal for Maryland’s top attorney.

Attorney General Anthony G. Brown last week unveiled his top legislative priorities for the new year, including expanding the rights and protections under the nursing home Patients’ Bill of Rights to assisted living settings. 

Brown is proposing to expand his office’s ability to seek relief and penalties when certain rights and guarantees in the Bill of Rights are violated, including a resident’s right to receive care and services, freedom from mental and physical abuse, freedom from physical and chemical restraints, and the ability to manage personal finances.

In announcing his priorities, Brown said that his initiatives are aimed at increasing transparency and accountability in the healthcare sector as well as recovering damages in certain environmental and other public welfare cases in a more equitable way to hold wrongdoers responsible in proportion to the amount of harm they are deemed to have caused.

“Our legislative agenda is focused on protecting the health, safety and well-being of Marylanders,” he said in a statement.

State senior living associations said they are reviewing Brown’s proposed legislation and update to the Patient Bill of Rights.

Ensuring that Maryland’s older adults have access to high quality care and services is a high priority for LeadingAge Maryland and its members, who have been actively engaged on a variety of regulatory and legislative efforts related to assisted living providers.

“Assisted living providers fill a critical need in our healthcare system,” LeadingAge Maryland President and CEO Allison Roenigk Ciborowkski told McKnight’s Senior Living. “Though we have not yet seen the final bill language, the actions proposed in draft form and as shared by AG Anthony Brown in the recent press release seem reasonable and to mirror what is already in place in nursing homes.”

She added there are hundreds of smaller assisted living providers in the state serving nine or fewer individuals, so it will be important for the state to weigh how any changes might affect these small providers.

“I have tremendous respect for Maryland Attorney General Anthony Brown, and we share a longstanding partnership and commitment to patient rights,” Health Facilities Association of Maryland / Maryland Center for Assisted Living President and CEO Joe DeMattos told McKnight’s Senior Living.

Similarly, LifeSpan Network CEO Kevin D. Heffernan told McKnight’s Senior Living that he would refrain from comment until a bill is introduced in the Maryland General Assembly.

“LifeSpan’s highest priority will always be the care and safety of residents, and we look forward to the opportunity to work with AG Brown, as always, on issues that involve Maryland’s most vulnerable older adults,” Heffernan said.

Other initiatives on Brown’s list of legislative priorities center on holding corporations accountable in proportion to the actual amount of environmental, health, safety and other public welfare harm they cause to the state, and requiring prior notice and consent for out-of-network procedures and hospital outpatient facilities fees.

A provision in state law cited in a class action lawsuit against a continuing care retirement community only applies to food-related fraud and, therefore, cannot be used by residents and families to secure entrance fee refunds, a court ruled Wednesday.

The refund provision in New Jersey’s Consumer Fraud Act is limited in scope and does not entitle the plaintiffs to full refunds of their entrance fees, monthly fees or services provided during their residence in the life plan community, the New Jersey Supreme Court ruled.

Princeton, NJ-based Springpoint Senior Living is accused of consumer fraud over allegations that it misrepresented the return of entrance fees once residents leave a CCRC. The lawsuit, filed in 2014, alleged violations of the state’s Consumer Fraud Act and the Continuing Care Retirement Community Regulation and Financial Disclosure Act. Springpoint asserted that the right to a refund under the state CFA only applies to a portion of the statute involving food served at restaurants, hotels or lunch counters.

“Those allegations [in the class action suit] pertain entirely to misrepresentations about fees charged by a senior living facility,” Justice Douglas M. Fasciale wrote in a unanimous opinion. “None of the plaintiffs’ allegations are related to misrepresentations of food.”

A Middlesex County Superior Court Judge denied a motion for partial summary judgment in December 2022, rejecting Springpoint’s argument that only the state health department had the right to file a lawsuit to obtain a refund of community entry fees. Springpoint appealed the decision to the state’s high court with the hope of clarifying the limited scope of the refund provision.

The New Jersey Supreme Court’s decision reversed the lower court ruling and remanded the case back to the trial court. DeSimone’s attorney told Law.com that class members would continue to pursue entrance fee refunds under the Continuing Care Retirement Community Regulation and Financial Disclosure Act. 

A Springpoint Senior Living spokeswoman told McKnight’s Senior Living that it was pleased with the state high court’s unanimous decision.

“The opinion clarifies the narrow scope of the Consumer Fraud Act’s refund remedy in the way that the legislature intended when it passed the law in 1980,” the spokeswoman said. “The well-reasoned decision faithfully adheres to the language and legislative history of the statute and resolves inconsistent interpretations by the lower courts.”

Filed in 2014 

William DeSimone filed the lawsuit in 2014 on behalf of his mother’s estate against Springpoint’s New Jersey-based CCRCs at Monroe Village, Springpoint at Montgomery, Springpoint at Crestwood, Springpoint at Meadow Lakes and Springpoint at the Atrium. 

According to court documents, Evelyn DeSimone had paid a $159,000 entrance fee for an independent living unit at Monroe Village. Before moving into her unit, however, she fell and broke her hip and was unable to move in. Instead, she remained in the community’s skilled nursing facility, where she lived until she passed away in April 2010.

After her death, according to the lawsuit, her estate received a refund that amounted to 50% of her initial entrance fee, less than the 90% refund that had been anticipated. 

The lawsuit alleged that Springpoint orchestrated a “bait and switch” scheme through misleading and deceptive advertising, along with “intentional misrepresentations” by sales personnel and an incomplete and misleading disclosure statement. 

The lawsuit also claimed that Springpoint failed to alert prospective residents that it was authorized to offer discounts on the subsequent re-leasing of units or to offer different payment options that effectively could reduce refunds.

The case was dismissed in 2014 for failure to state a claim on which relief can be granted, but it was reinstated in 2015 by an appellate court. The case was certified as a class action in 2021.A bill was introduced in the New Jersey legislature in February 2022 to require CCRCs to return refundable entrance fees to former residents or their estates within a year of the unit being vacated. If passed, the bill also would require that all CCRC agreements “be written in plain English and in language understandable by a layperson.”

The Joint Commission is planning to revise its infection prevention and control requirements for assisted living community accreditation as infection prevention and control regulations for the setting become more common at the state level.

The commission’s proposal focuses on the structures deemed essential to supporting quality and safety and outlines a framework for infection prevention and control programs. The suggested changes also more closely align with the the Centers for Disease Control and Prevention’s core infection prevention and control practices for safe healthcare delivery in all settings, according to the commission. 

A Joint Commission spokeswoman told McKnight’s Senior Living that the proposed revisions are a continuation of the wider infection prevention and control chapter rewrite initiative that spans all areas of accreditation.

“Broadly speaking, the goal of the IC [infection prevention and control] chapter rewrite is to align the IC standards and elements of performance more closely with law and regulation, eliminate the requirements that do not add value to surveys, and streamline the chapter,” the spokeswoman said. “The proposed revisions are currently in field review. Once approved, the revised IC chapter will replace current IC chapter requirements.”

Once the new requirements are implemented, commission-accredited assisted living communities will receive access to a new assessment tool that will outline the specific actions and processes they will need to take to meet them.

The Joint Commission is accepting comments on the proposal until Feb. 21 through an online survey.

The changes

Specifically, the changes cover assigning management responsibilities for infection prevention and control, including developing policies and procedures, coordinating competency-based training and risk management. They also require organizations to have written policies and procedures guiding infection prevention and control, including reporting duties to local and state public health authorities.

The Joint Commission also is deleting an existing performance improvement component of the accreditation program requiring assisted living organizations to provide incidence data to key stakeholders — leaders, licensed practitioners, nursing and staff members — about multidrug-resistant organisms, because it was determined to be out of scope.

The Joint Commission launched its assisted living community accreditation program in 2022 to bring “national, consensus-based standards” to the industry. Its standards address the environment, staffing, emergency management, dementia care, medication management, the provision of care and services, process improvement and more. The program also requires organizations to track and report on five standardized performance measures: off-label antipsychotic drug use, resident falls, resident preferences and goals of care, advanced care plans/surrogate decision-makers, and staff stability.

The Joint Commission also launched an assisted living community memory care certification program last year in collaboration with the Alzheimer’s Association, to promote consistent, high-quality dementia care in assisted living. 

Industry efforts

Indicative of the growing importance of infection control in assisted living, regulatory requirements related to infection control and emergency preparedness were an addition to the National Center for Assisted Living’s 2023 regulatory review report, released last week. The report noted that such regulations now are in place in a majority of states.

Industry groups devised their own guidance for infection control and prevention in 2023.

NCAL, Argentum, the American Seniors Housing Association and LeadingAge in June announced that they had joined with the National Association for Regulatory Administration to develop guidance for the industry and resources for operators, regulators, policymakers and other stakeholders. Infection prevention and control was the initial focus of the effort, called the Quality in Assisted Living Collaborative.

Other existing infection control efforts available to providers include the CDC’s Project Firstline training program for infection control and prevention, a certification for infection prevention and control professionals via the Certification Board of Infection Control and Epidemiology, and an infection prevention and control document produced by Argentum during the pandemic. Other than the Argentum document, however, most of those efforts are not focused on assisted living, and they are not strictly guidance.

And assisted living was an area where such focus was needed, according to a study published in December 2022 in JAMDA – The Journal of Post-Acute and Long-Term Care Medicine. That research found that infection control and preparedness in assisted living during the pandemic was hampered in part by limited clinical expertise and medical oversight of staff members and conflicting regulations and guidance for federal, state and local health agencies.

And in memory care settings, according to a study published in the June 2022 edition of the Journal of the American Geriatrics Society, a need existed “to bolster infection prevention capacity when caring for this especially vulnerable population.” 

Regarding overall quality, NCAL has its own National Quality Award Program, based on the Baldrige Performance Excellence Framework, that recognizes assisted living providers that meet certain goals.

NCAL also has a voluntary quality initiative for assisted living communities, with goals related to staff stability, customer satisfaction, hospital readmissions and the off-label use of antipsychotic medications.