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.

The status was announced Jan. 2.

“The dedicated leadership of our two entities ensures not only the expansion of services for aging adults but also a commitment to excellence in healthcare and housing for everyone we serve,” Knute Nelson CEO Mark Anderson said in an online post. “We are also strategically positioning ourselves to grow our technological capabilities and broaden our mission of enhancing lives to reach more people across our geographical regions.”

Anderson became the new president and CEO of the newly joined entity effective Jan. 1. He had led Knute Nelson for almost 20 years. Scott Riddle, former Walker Methodist CEO, retired Dec. 31.

The merger will expand the services each company provides across an integrated continuum of care, including home- and community-based services, housing options and rehabilitation/skilled nursing.

The combined entity now provides services in more than 58 counties in Minnesota, North Dakota and Wisconsin, with a portfolio of 34 communities that offer assisted living, memory care, home healthcare, wellness, a therapy continuum and hospice care. 

Before the merger, Knute Nelson operated in 43 counties in Minnesota and eastern North Dakota, whereas Walker Methodist owned and managed 19 senior living communities in Minnesota and western Wisconsin.

It’s yet another acronym senior living and memory care providers should familiarize themselves with: CCT. It stands for computerized cognitive training. 

The terminology refers to digital exercise options that older adults living with dementia can use to improve cognitive function or slow down decline. This is usually by stimulating visual, verbal or working memory.

For the most part, those kinds of exercises have been supervised by caregivers or clinicians. Older adults who took on CCT training independently, however, showed equal progress in bolstering their memory, a new study shows.

“Although the supervised approach showed greater effects,” the study authors wrote, “the unsupervised approach can improve verbal memory while allowing users to receive CCT at home without engaging as many healthcare resources.”

The report suggests that those new CCT programs could benefit older adults living independently, but senior living operators also could look to those options as a way to provide dementia interventions while dealing with staffing shortages and limited resources. 

Newer CCT programs not only are designed to be conducted without clinical supervision; some make use of virtual reality, the study noted. Overall, the CCT programs reviewed in the study required about one to two hours a week over a period of two weeks to six months. 

The researchers did qualify their meta-analysis by suggesting that most of the success stories occurred in older adults who had lower levels of dementia or early-stage Alzheimer’s disease.

Dementia is becoming a major care burden as the number of older adults increases worldwide. In the United States alone, 18% of all assisted living communities now include a specialized dementia care unit, and 11% are devoted to dementia or memory care entirely, according to the National Center for Assisted Living.

The combination of CCT, physical exercise and vitamin D makes for a true triple threat to empower older adults’ cognition, the McKnight’s Clinical Daily reported over the summer.

A new study is uncovering just how tough it can be financially to live with dementia. The report, published Dec. 29 in the Journal of the American Geriatrics Society, found that almost 56% of people with dementia face financial hardships. Those financial challenges are linked with worse reported satisfaction with life and healthcare.

Researchers used data from the Health and Retirement Study, which includes adults aged more than 52 years and spans 2010 to 2020. The study examined data from 534 participants with dementia who shared details on satisfaction with their lives and their healthcare. The researchers compared those data to information from questionnaires from 576 people with newly diagnosed cancer who were receiving treatment.  

The people were asked about financial strain in the past year of their lives and whether it was upsetting; they also were asked whether it was difficult to pay their bills. The data were compared with information from a previous study, which included information from the same people.

According to the findings, 56% of people living with dementia said that they experienced financial hardship, compared with 50.4% of people with cancer. Differences existed between groups in terms of the age of disease onset; an earlier diagnosis was linked to a higher proportion of financial hardship. 

In the dementia group, people who experienced financial hardship in the previous study were less likely to report being completely or very satisfied with life and less likely to say they were satisfied with their healthcare compared with people who didn’t report financial hardship in the previous report. Results were similar in the group of people who had cancer.

People living with dementia may have more intense financial hardship than those with cancer, the authors contended. This situation could be because the costs are incurred for longer periods of time, especially if a person receives a dementia diagnosis at a young age. The more severe hardships also could be due to the lack of long-term care insurance to assist with getting treatment for dementia.

Medicare and private insurance do not cover most long-term care services, the authors noted. Although Medicaid and private long-term care insurances do cover most such services, Medicaid coverage among adults 65+ is very low, at 7.6%, and only approximately 10% of adults have such insurance. Most older adults assume the expenses on an out-of-pocket basis, the authors added.

The commercial real estate services and investment company sought feedback from senior housing investors, developers, lenders and brokers throughout the United States. The survey was conducted in October, and results were released in December.

Seventy-five percent of survey respondents reported cap rate increases of 50, 75 or 100 basis points across all senior living and care categories during the six-month period. Thirty-one percent of the respondents noted increases of 100 basis points or more.

Skilled nursing cap rates increased by 71 basis points between April and October after falling by 34 basis points between CBRE’s previous two surveys. Aron Will, vice chairman of capital markets at CBRE, told the McKnight’s Business Daily that the turnaround in skilled nursing is likely due to Medicaid rate increases in certain states. For example, he said, Ohio increased Resource Utilization Groups (RUG) rates by approximately 50% on Jan. 1

Cap rates among independent living, assisted living and memory care communities increased by 73 basis points, on average, since the previous report. Increases were greater for Class C assets compared with Class A assets, CBRE said, noting that the finding was a reversal from the April survey, which found the biggest increases in Class A assets and core markets.

The average cap rate for active adult communities increased by 68 basis points between April and October.

For additional coverage of the survey results, including predictions about rent increases, see McKnight’s Senior Living.

The full report is available here.

In a bid to remove a “veil of arbitration secrecy,” one state attorney general filed a motion to intervene in a lawsuit alleging elder abuse at a memory care facility.

Arizona Attorney General Kris Mayes filed a motion to intervene on Friday in an abuse and neglect lawsuit against Senita Ridge, the memory care community on the campus of Ridges at Peoria in Peoria, AZ. A judge’s Oct. 31 order moved the case to arbitration, but Mayes charged that the secrecy of arbitration removes transparency in an elder abuse case, which violates the state’s Adult Protective Services Act. The act requires notification to the state’s top attorney when a lawsuit alleging elder abuse or neglect is filed, allowing the state to track and potentially join the case.

“Moving cases behind a veil of arbitration secrecy is not only illegal, it blocks me from performing one of my most important duties — protecting vulnerable adults,” Mayes said in a release. “Transparency is key to protecting vulnerable adults, which is why the legislature enacted this reporting requirement to begin with. In this case, that important process was hidden.”

Arbitration agreements are common in senior living facilities and viewed by the industry as an effective way to resolve legal disputes. But Mayes said those agreements cross a legal line when they keep secret allegations of elder abuse.

The Adult Protective Services Act gives the attorney general the right to intervene in elder abuse cases to ask the courts for remedies ranging from permanent injunctions against abusive behavior to removing facility owners to closing communities.

Mayes said families deserve to know how past residents were treated by an assisted living facility before deciding to move their loved ones into a community.

“Unfortunately, we have seen from recent news stories that the regulatory agencies do not always have the resources or the authority to punish assisted living facilities offering substandard care,” Mayes said. “Any arbitration agreement with a confidentiality clause is illegal under Arizona law, and I will ask the court to void those agreements until the facilities stop using them.”

The case behind the motion

Rose Marie Scheske moved into Senita Ridge, the memory care facility on the Ridges at Peoria campus in Peoria, AZ, on June 17, 2021. Her daughter maintained power of attorney and signed all of Scheske’s admission paperwork, which included an arbitration agreement. 

Scheske filed suit on Oct. 31, 2022, against the Ridges at Peoria and Minnesota-based The Goodman Group, which manages the campus, alleging elder abuse and neglect. The suit specifically accuses the staff of providing Scheske with overdoses of certain medications, failure to administer other medications, failure to provide a suitable diet, and failure to maintain a safe environment.

On Oct. 31, 2023, a Maricopa County Superior Court judge granted a motion to move the case to arbitration, leading to the state attorney general to intervene in the case. 

The Goodman Group did not respond to a request for comment from McKnight’s Senior Living prior to story production deadline.

A proposed rule change in response to the inclusion of “stringent language” inserted into a bill governing staffing levels in Georgia’s senior living communities goes back to the intention of the original bill of providing proper care at an affordable price, say the senior living groups behind the proposal.

Passed by the Georgia legislature in 2020, HB 987 imposed staffing, training and financial reporting requirements on the state’s assisted living communities, personal care homes and memory care communities. State senior living associations at the time supported the bill, saying that it “appropriately” enhanced safeguards designed to protect residents. 

But when the bill was written into rules, two changes were inserted that were not part of the original bill, creating what senior living groups said were significant operational inefficiencies.

Proposed changes

The first change redefined the definition of “on site.” The rules say communities must have two caregivers on site at all times, which Georgia Senior Living Association President and CEO Catie Ramp said is defined as inside of a memory care unit, separate from assisted living or the community as a whole. 

The proposed change would allow for required staff members to be present in a senior living community and available for “timely access” rather than physically present in the memory care unit at all times.

Another change to the original language added the word “per occupied floor,” which Ramp said requires communities to have staff on a floor even if there are no specific care needs for residents at the time. 

“It’s extremely inefficient,” Ramp said, adding that staff members would be required even when residents are away from floors during dining or activities.

Access to specialized memory care would be negatively affected, as the current rules are “operationally prohibitive and constrain the evolution of person-directed care,” a spokeswoman for the Georgia Center for Assisted Living told McKnight’s Senior Living.

“We believe the initial rule exceeded the intent of the legislature with the inclusion of stringent language that discourages innovation in care delivery models and inhibits center leadership to make operational decisions based upon the unique characteristics of the greater community and population served,” GCAL Communications Director Devon Barill said. “Given the workforce crisis all long-term care settings are experiencing, this rule change would allow for required staff to provide valuable care and services in other areas of the facility while on shift, in addition to the memory care unit.”

Support for original bill

In a Dec. 11 letter to the Georgia Department of Community Health Board, LeadingAge Georgia said that it advocated for passage of HB 987 and believed it was “a good bill that improved staffing ratios to reflect the needs of residents.” President Ginny Helms said that although there is recognition that there have been cases of poor care in some senior living communities that have caused advocates to oppose the revised rules, good providers should not be penalized for the poor care of other providers. 

Ramp said that the senior living industry is adamant about keeping language regarding staffing to the “specific and unique” needs of residents and called the improved staffing ratios that came with HB 987 “extremely valuable.” 

“It’s about keeping memory care residents safe, but the language that was added, in terms of on site and floor, made us now sometimes double staff or duplicate roles,” Ramp said. “The cost is significant.”

Ramp said that operators can’t absorb all of these costs, which inevitably would be passed on to residents. 

“We’re already at a place where access and affordability can feel really tight,” she said. “There’s no need for us to add more barriers to someone living in a choice-driven space.”

The comment period on the bill ended Wednesday. The measure will go before the Community Health Board for a vote on Jan. 11. Ramp said her hope is that the board will move forward with the rules as submitted.