Improving Quality in Assisted Living

Improving Assisted Living

Like many of you, we have been increasingly concerned over the past few years about safety issues in assisted living communities. The number of residents with moderate to severe dementia or chronic medical problems has increased, and many facilities have not been well prepared to handle the challenges created by this. The reports of infection control deficiencies in assisted living centers during the COVID-19 pandemic has greatly heightened safety concerns.

The U.S. Government Accountability Office (GAO) has been reporting on this issue for well over a decade; media reports have detailed unsupervised patients ingesting cleaning supplies and staff with only 8 hours of training caring for patients with dementia. In 2018, the GAO’s concerns grew into a call for action with a report titled “Medicaid Assisted Living Services: Improved Federal Oversight of Beneficiary Health and Welfare is Needed.” However, the industry still lacks standards and quality issues will likely intensify.

The Joint Commission is launching an Assisted Living Community Accreditation Program and will begin accepting applications on July 1, 2021.  The program will help assisted living communities deliver consistent, highly reliable care in critical areas, impacting the quality and safety of their residents and staff.  

Unique standards for assisted living environments

As we get closer to the launch date, we will make the full set of standards available. For now, I will just briefly highlight some standards that I think are particularly important for the unique and nuanced quality and safety issues in assisted living.

Resident autonomy and choice are core values for assisted living communities, and our standards are fully consistent with these values. Assisted living centers are homes first and locations of health care delivery second. Residents must be able to control their private space and their participation in activities.

The main domains of this accreditation program are:

  • Environment of care

  • Emergency management

  • Human resources

  • Infection prevention and control

  • Information management

  • Leadership

  • Life safety

  • Medication management

  • Provision of care

  • Performance improvement

  • Records of care

  • Rights and responsibilities of the individual

Environment of care and life safety

Most of these standards center around minimizing safety and security risks in the environment as well as preventing and addressing fires and other environmental hazards to avoid resident injury. However, numerous environmental issues related to visitors have surfaced during the COVID-19 pandemic and need to be addressed, including processes for family communication and informing visitors about hand and respiratory hygiene. 

Standardization is also needed around visitor restrictions and when to lift these restrictions, as well as provision for remote communication to prevent resident isolation and the mental health issues that result from this. 

This program’s environment of care standards will also track care providers. It’s estimated that 40% of infections were brought into facilities by personnel moving between physical therapy, home care, and nursing homes. This illustrates the need for tracking who enters facilities.

Emergency management

Assisted living communities have been hit by fires and floods, and the residents are often not able to care for themselves in the event of an emergency. The facility’s emergency management plans must include:

  • Obtaining medical supplies

  • Transferring key information when residents must be moved

  • Obtaining and replenishing food

  • Identifying individuals susceptible to wandering after emergency measures are initiated

  • Coordinated community response

Human resources

State regulations mandate that credentials of care providers must be verified, but we’ve all heard reports about people falsely claiming to be health care providers. Joint Commission standards help ensure that these people can no longer access assisted living residents and potentially provide injury. 

The pandemic has also highlighted the need to screen staff for exposure to infectious diseases and keep them informed of infection control surveillance, prevention, control, and reporting.

All-staff education will be required in subject areas, such as early warning signs of change in condition or cognitive decline and person-centered care. In addition, some residents may be receiving early warning signs of a change in a resident's condition and how to respond to a resident's decline in condition (including interventions for residents receiving palliative care).

Infection control

The last year has taught us there needs to be a response plan for large numbers of infected patients. COVID-19 won’t be the last epidemic. Infection control plans must encompass things such as:

  • Procedures to transfer patients with infectious disease

  • Staff safety protocols

  • Policies to prevent spread by cohorting

  • Staying informed of the latest public health information

The assisted living environment also creates unique challenges, such as dealing with animals in the facility. Policies should address issues with cleanliness and waste.

Medication management

An overwhelming number of individuals in assisted living are taking medications. Medication management programs must address:

  • Look alike/sound alike medications

  • Preventing diversion, which is critically important for organizations because penalties can be staggering

  • Safety controls for when patients and families bring in medications

Provision of care

It is quite important for organizations to disclose which services an assisted living community is capable of providing. It’s very common for individuals to enter a community and plan to stay throughout their remaining years, only to later learn the organization does not provide, say, hospice care.

Assisted living communities also need to attain resident histories with regard to dementia before move-in.  Moving is incredibly stressful on an individual with dementia and it’s critical to have an individualized care plan for these individuals.

Performance improvement & measurement

Monitoring performance will be at the center of this program, and assisted living communities will be required to submit data on:

  • Resident and family satisfaction 

  • Significant medication errors

  • Hospitalizations

  • Other performance improvement priorities as determined by leadership

Accredited organizations will have the opportunity to see peer-to-peer comparison data via the Data Analytics for Safe Healthcare (DASH) initiative on metrics including:

  • Staff turnover

  • Off-label anti-psychotic medication use

  • Residents experiencing one or more falls with injury

  • Discussion of advance directives/advance care planning

  • Treatment preferences

  • Goals of care

The Joint Commission will be providing assisted living communities with guidance at every step of the journey. We are honored to have the opportunity to partner with the assisted living community in the name of improving care. For more questions, please contact the Nursing Care Center and Assisted Living Community Services Business Development team at 630-792-5020 or [email protected].


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