Weak federal oversight endangers health and safety of assisted living residents
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This week’s GAO report shines a long-overdue light on Medicaid-funded assisted living. Federal funding of assisted living is large and growing, but to this point the federal government has not adequately ensured the quality of assisted living care. This lack of oversight has had tragic consequences for an unfortunately large number of older Americans. The GAO report was requested by a bipartisan group of senators, and its publication should prompt Congress and CMS to take action.

We all require additional help as we age. Assisted living is one way of addressing those needs, while still allowing people to remain in their communities. An assisted living facility provides help with daily activities such as dressing, bathing, using the toilet and taking medication. In addition, depending on the state, an assisted living facility may be able to provide a significant level of needed health-related care.


As the GAO reports, Medicaid covers assisted living in 48 states, and annually pays over $10 billion nationwide for assisted living services for high health need, low-income individuals who would otherwise qualify for Medicaid-funded nursing home care. This funding assists over 330,000 low-income persons in paying for critical services that they otherwise could not afford.

Despite the $10 billion spent annually, the federal government has not adequately ensured the quality of Medicaid-funded assisted living, and has made little meaningful data available to the public and policy makers. For example, state Medicaid programs must report “critical incidents” to the Centers for Medicare & Medicaid Services (CMS), but 26 of the 48 states could not report the number of critical incidents occurring in assisted living facilities. Further, states varied widely in classifying “critical,” and did not necessarily include such troubling events as unexplained deaths, injuries leading to hospitalization, attempted suicide, or suspected criminal activity by the care provider.

The GAO recommends that CMS establish stronger standards for how states report critical incidents and deficiencies, and enforce more rigorously a requirement of annual reporting. Each of these recommendations is positive, but the Medicaid assisted living system has structural defects that demand more than data-related improvements.

As the GAO report points out, the federal government does not have standards for assisted living. Each state issues licenses with its own term for “assisted living,” and with state-specific quality standards and enforcement methods. In one state, an older person might be living in a “personal care home” staffed by unlicensed employees and “proxy caregivers” who have authority to administer medication and perform health maintenance activities. In another state, the same person could be residing in a “residential care facility for the elderly,” where she administers her own medications but receives assistance from unlicensed staff with 40 hours of initial training. Further, in a third state, the same older person might be residing in an “assisted living residence” and receiving daily assistance from certified nurse aides.

These vastly divergent models are problematic enough for any older person seeking assistance with daily activities, but the difficulties are magnified in the Medicaid context, since Medicaid-funded residents by definition have care needs qualifying them for nursing home care. Such persons are more likely to suffer a fall, develop an infection, or react negatively to a medication, and are more reliant on direct-care staff that is trained to identify and address such problems.

The GAO report identifies significant problems in CMS’s current operation of Medicaid assisted living. However, these problems can be solved if Congress and CMS work together to develop federal standards in line with residents’ level of need, and provide a common baseline that the states can work within. Increased quality standards and better data about critical incidents can work hand in hand to help us improve these systems. We can and should ensure that the 330,000 older adults residing in Medicaid-funded assisted living facilities receive the care they need to remain safe and be vital members of their communities.

Kevin Prindiville is Executive Director of Justice in Aging