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Published in final edited form as: J Aging Soc Policy. 2020 Jun 4;32(4-5):334–342. doi: 10.1080/08959420.2020.1770037

The Unique Challenges Faced by Assisted Living Communities To Meet Federal Guidelines for COVID-19

Debra Dobbs 1,*, Lindsay Peterson 2, Kathryn Hyer 3
PMCID: PMC10454985  NIHMSID: NIHMS1596720  PMID: 32496899

Abstract

This perspective addresses the challenges that assisted living (AL) providers face concerning federal guidelines to prevent increased spread of COVID-19. These challenges include restriction of family visitation, use of third-party providers as essential workers, staffing guidelines, transfer policies, and rural AL hospitalizations. To meet these challenges we recommend that AL providers incorporate digital technology to maintain family-resident communication. We also recommend that states adopt protocols that limit the number of AL communities visited by home health care workers in a 14-day period, appeal to the federal government for hazard pay for direct care workers, and to extend the personal care attendant program to AL. It is further recommended that states work with AL communities to implement COVID-19 comprehensive emergency management plans that are well-coordinated with local emergency operation centers to assist with transfers to COVID-19 specific locations and to assist in rural areas with hospital transfers. Together, these recommendations to AL providers and state and federal agencies address the unique structure and needs of AL and would enable AL communities to be better prepared to care for and reduce those infected with COVID-19.

Keywords: COVID-19, Assisted Living, Long-Term Care Facilities, COVID-19 Federal Guidelines

Introduction

Since one of the first COVID-19 cases in the United States was confirmed January 21, 2020, in a Washington state nursing home, there have been at least 1.15 million confirmed cases and close to 70,000 deaths as of May 3, 2020 (Centers for Disesase Control, 2020). Approximately 83% of the deaths from COVID-19 in the U.S. have occurred in the 65 and older population (National Center for Health Statistics, 2020). The approximately 2.16 million adults who live in long-term care facilities (including nursing homes and assisted living (AL) communities) and cared for by 1.24 million staff (Gardner et al., 2020) are most at risk for infection from COVID-19. Nationally, it is reported that about one-fifth of all deaths have been in nursing homes, and in some states as many as half of the deaths are in long-term care facilities (Stockman et al., 2020).

Since the outbreak occurred in the United States a number of articles have been published about how COVID-19 has affected residents and staff in long-term care settings (Dosa et al., 2020; Gardner et al., 2020). Media reports have focused more on the challenges in nursing homes than in AL communities, particularly at the larger outlets. For example, the Washington Post reported that 40% of 650 nursing homes with COVID-19 cases identified by State health departments had been cited more than once for infection-control deficiencies in the last four years (Cenziper et al., 2020). The New York Times has reported widely on the numbers of deaths in nursing homes (e.g. Harris, Leland, & Tully, 2020).

This perspective argues that more attention needs to be paid to AL, which has been a dominant sector of long-term care for more than 20 years. It highlights the unique characteristics of AL communities relative to nursing homes in the U.S. It then outlines federal guidelines for long-term care facilities for COVID-19. The challenges those guidelines pose for AL with respect to visitation, third-party providers, staffing, transfers, and rural settings are then highlighted together with recommendations in light of those challenges.

The Assisted Living Sector: A Primer

There are an estimated 30,200 licensed AL communities across the United States, providing care to more than 835,000 residents (Sengupta et al., 2016). AL has a philosophy to enable a person to age-in-place for as long as possible by providing 24-hour supervision for unscheduled needs for activities of daily living but not nursing care (Chapin & Dobbs-Kepper, 2001). AL also provides programming for socialization and at least 2 meals a day. Unlike federally regulated nursing homes, AL communities are regulated at the state level and therefore vary widely in the services they provide and types of residents they may accept based on licensure type. For example, some states have separate licensure for AL communities that serve persons with psychiatric illnesses or provide memory care, while other states license AL communities to serve only less-impaired individuals.

There are wide state variations in staffing, with fewer than one-third of states requiring any specific numbers or types of licensed staff in their regulations (Roberts et al. 2020). Compared to nursing homes, where infection control programs are federally mandated, AL has varying degrees of regulation for infection control based on the state; only one-fourth of all states have an actual infection control program (Zimmerman et al., 2020) which has consequences for COVID-19. Bucy and colleagues (2020) reported that 31 states required infection control policies in AL, but the requirements varied in level of detail. Only six states directly referenced isolation practices for residents with communicable diseases.

Federal Guidelines in Long-Term Care Facilities for COVID-19

The Centers for Disease Control Long Term Care Team and Infection Control Team have published webinars on how to prepare nursing homes and assisted living communities for COVID-19 (Centers for Disease Control, 2020). The Centers for Medicare and Medicaid (CMS) also recently released guidelines for long-term care facilities to reduce the spread of COVID-19 (CMS, 2020). The federal recommendations and guidelines apply equally to AL as to nursing homes. However, while similar in some of the services provided and population cared for, nursing homes and AL communities are different in philosophy, regulation and design. The National Center for Assisted Living recently offered clarifications to AL providers in response to federal guidance about state requirements for reporting COVID positive resident and staff cases and the need for personal protective equipment (PPE) (National Center for Assisted Living, 2020).

Relative to nursing homes, AL communities face several challenges in following federal guidelines for COVID-19. These challenges relate to: 1) restrictions on family visitation; 2) use of third-party providers as essential workers; 3) lower levels of direct care staffing; 4) limitations in facilitating transfers; and 5) additional challenges for rural AL communities. These challenges are discussed next along with recommendations for addressing them.

Challenge to Restricting Family Visits to Resident Care

Federal guidelines have been established to restrict visitation from family and other nonrelatives. This is particularly challenging for AL communities that do not have the amount of activity, social work and direct care staff as nursing homes do, to fill the void created by these limitations. Family plays a vital role in providing additional care and socialization for AL residents (Port et al., 2005). Family members are the ones who make sure their loved ones get out into the community on a regular basis. The visitation limits are an even a greater challenge for AL residents with dementia, who may not understand why the one person whom they may remember, their spouse, daughter, or son, is no longer coming to see them.

Recommendation

Technology can be one solution to maintaining socialization and well-being within AL. AL administrators have reported using Google hangouts, Skype and Zoom video to facilitate family and resident daily communication. More staff time needs to be devoted to assisting with technology needs, especially for residents with dementia, as they do not have the cognitive capability to use this technology without assistance. Access to wifi can be spotty in residents’ rooms and is reported to be costly to upgrade (Zimmerman et al. 2020). In contrast to AL, nursing homes have a program through CMS to pay for service upgrades to wifi whereby Civil Money Penalty (CMP) Reinvestment funds are set aside to provide residents with adaptive communicative technologies (Indiana Health Care Association, 2020). The CMP funds can also be used for upgrades to wifi connections for any type of communication including telehealth visits. Finally, AL communities should take advantage of apartment style privacy that include individual rooms with patios and large windows that can enable families to communicate in person through windows or social distancing on patios when the weather permits and family members wear protective masks.

Challenge of Third-Party Providers as Essential Workers and the Risk of Infection

Another difference between nursing homes and AL communities is the increased risk of infection in AL communities because of third-party providers and home health care visits. Home health care workers are deemed essential during the pandemic. All states allow the use of third-party providers in AL as this policy allows residents to receive services that states do not permit residential care providers to perform, such as skilled nursing services or assistance with activities of daily living that typically are provided only twice a week by AL staff (Carder et al., 2015). Home health care workers are at greater risk of spreading infection if they work in more than one AL community.

Recommendation

States need to adopt protocols that limit the number of AL communities visited by home health care workers in a 14-day period during this pandemic to help reduce the spread of infection from one AL community to another. An adequate supply of personal protective equipment (PPE) needs to be available for home health care workers, including masks, gloves and gowns for each new resident they care for. Some AL communities across the country are housing direct care workers on-site and paying them bonuses so they can contain the spread of infection (Belanger, 2020). This may not be feasible for all ALs, but for those who can afford it, is worth considering.

Challenge for AL to Meet Federal Staffing Guidelines

CMS has recommended the use of separate staffing teams for COVID-19 positive residents and consistent assignment of staff to the same set of residents . The AL industry faces challenges to meet these guidelines because of low levels of direct care staff, a lack of nursing staff and lack of infection control programs for airborne illness such as COVID-19. Staffing shortages will continue to rise with increased care demands due to COVID-19 and low wages. Personal care aides in AL on average make even less than certified nursing assistants in nursing homes, approximately two dollars less per hour (Payscale, 2020). There is a real fear among some AL administrators that direct care staff will weigh the benefits and rewards of their jobs caring for a highly vulnerable population and decide it is not worth the risk. What is making that decision more likely is the fact they could earn more money with the CARES Act stimulus funding ($1,200.00 plus $500.00 dollars per child for workers who have adjusted gross income less than $75,000 in addition to unemployment benefits) (Department of Treasury, 2020).

Recommendation

The implementation in AL of infection control programs for COVID-19 and educating staff about the importance of social distancing, handwashing and wearing PPE during each resident encounter is essential. Also important is increasing what workers are paid, given they are expected to care for highly vulnerable residents, in many cases without the PPE necessary because AL is not given priority. Any state requests for federally funded hazard pay for essential workers (e.g., police, firefighters, hospital nurses) should include long-term care nursing and direct care staff. In the face of staff shortages, some states have enacted COVID-19 Personal Care Attendant Programs to provide nursing homes with additional staff to care for residents during a State of Emergency and to train new workers to obtain skills necessary to become a certified nursing assistant (Florida Health Care Administration, 2020). States should extend this to AL communities.

Challenge For AL in Transfer Policies

Transfer policies have also been developed by CMS for COVID-19 (CMS, 2020) that recommend collaboration with state and local leaders to designate distinct facilities or units within a facility to separate COVID-19 negative residents from COVID-19 positive residents and individuals with unknown COVID-19 status. These transfer policies are more likely to be successfully implemented in large chain, corporate-owned AL communities that already have existing relationships with other AL communities from the same owners. Smaller, independently-owned AL communities will struggle to find alternate locations or space within their existing communities for COVID-19 wings or units.

Recommendation

States agencies should develop a template for AL communities as well as nursing homes for a COVID-19 comprehensive emergency management plans (CEMPs) similar to those required for disaster planning (Peterson et al., in press). CEMPs are helpful planning tools and provide a framework that addresses emergency prevention, preparedness, response, recovery and mitigation. Because CEMPs are already in existence in states for disasters, it would not take long to modify for COVID-19. Local emergency operation centers would need to assist in the coordination of shared shelter agreements for AL communities that do not have alternate locations or spaces for COVID-19 positive residents. Shared shelter agreements could be with another AL or nursing home designated specifically for COVID-19 positive patients.

Additional Challenges for Rural AL Communities

COVID-19 also has affected long-term care facilities in rural areas where a lack of available hospital beds has increased the likelihood of spread of the infection. Circumstances are dire in some places. One rural Florida community reported that “the local hospital is scheduled to close at the end of the month and the next closest hospital is 30 minutes away” (Klas, 2020). Another study reported a case in Idaho where a patient had to travel for nine hours to reach the hospital (Henning-Smith et al., 2017). Nursing homes, by comparison, may be part of existing networks of healthcare providers that can coordinate hospital transfers (McSweeney-Feld et al., 2017).

Recommendation

State agencies should assist AL providers in rural areas to make sure hospital arrangements are in writing in a COVID-19 CEMP. AL providers should coordinate with nursing homes in their areas to develop relationships to facilitate emergency transfers due to COVID-19 infections. Emergency operation officials should be tasked with a role in facilitating these arrangements.

Conclusion

This perspective has outlined some challenges AL communities face in their attempt to adhere to COVID-19 federal guidelines developed for long-term care facilities. Among these challenges are meeting the needs of residents who have traditionally relied on family members for socialization and care. This is especially critical for residents with dementia. The use of technology, with the assistance of staff, to coordinate family communication is essential to maintain resident well-being. Furthermore, AL communities need to work closely with home health care agencies to reduce the spread of COVID-19 infection as they travel from community to community. Challenged by low staffing potentially worsened by the COVID-19 threat, AL communities need to train staff on how to protect residents and themselves from infection. Higher pay is also needed, considering the risk to the direct care staff. Federal hazard pay may be a viable temporary solution. Another answer may be to extend the personal care attendant program that is available to nursing homes to the assisted living sector. Concerning preparation, emergency operations centers in local counties need to coordinate with AL communities in the transfer of residents who need to be isolated during a pandemic emergency. Rural AL providers should be given special assistance, working with local nursing homes, health departments and hospitals in other counties to provide care for those in need of treatment for COVID-19. The implementation of COVID-19-specific CEMPs could facilitate preparation for both transfers and rural hospitalizations due to COVID-19. Together, these recommendations to AL providers, state and federal agencies address the unique structure and needs of AL and would enable AL communities to be better prepared to care for those infected with COVID-19.

Key Points.

  • Federal guidelines for COVID-19 need to take AL policies and structure into account.

  • Digital technology with staff assistance is key to resident-family communication.

  • AL providers should appeal to the federal government for hazard pay for direct care workers.

  • The Personal Care Attendant Program in nursing homes should be extended to AL.

  • COVID-19 comprehensive emergency management plans are needed for COVID-19 related transfers.

Funding acknowledgement:

This work was supported by RO1 AG060581-01 (Hyer, K. PI) Strategic Approaches to Facilitating Evacuation by Health Assessment of Vulnerable Elderly in Nursing Homes II

Contributor Information

Debra Dobbs, School of Aging Studies, Florida Policy Exchange Center on Aging, University of South Florida, Tampa, FL, USA.

Lindsay Peterson, School of Aging Studies, Florida Policy Exchange Center on Aging, University of South Florida, Tampa, FL, USA.

Kathryn Hyer, School of Aging Studies, Florida Policy Exchange Center on Aging, University of South Florida, Tampa, FL, USA.

References

  1. Belanger T (2020). The Coronavirus is killing too many nursing home residents: Here’s one idea for protecting them . Retrieved May 4, 2020 from https://www.nytimes.com/2020/05/03/opinion/coronavirus-nursing-homes.html.
  2. Bucy T, Smith L, Carder P, Winfree J, Thomas K (2020). Variability in State Regulations Pertaining to Infection Control and Pandemic Reponse in US Assisted Living Communities. Journal of the American Medical Directors Association, 21(5) 701–705. doi: 10.1016/j.jamda.2020.03.021 [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Carder P, O’Keeffe J, & O’Keeffe C (2015). Compendium of residential care and assisted living reguation and policy: 2015 edition. Washington, DC [Google Scholar]
  4. Centers for Disease Control and Prevention. (2020). Coronavirus 19 U.S. Cases. Retrieved May 4, 2020 from https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html
  5. Centers for Disease Control. (2020). Preparing Nursing Homes and Assisted Living Facilities for COVID-19. Retrieved April 20, 2020 from CDC.gov/COVID-19
  6. Centers for Medicare and Medicaid. (2020). COVID-19 Long-Term Care Facility Guidance CDC. Retrieved April 18, 2020 from https://www.cms.gov/files/document/4220-covid-19-long-term-care-facility-guidance.pdf [Google Scholar]
  7. Cenziper D, Jacobs J, & Mulcahy S (2020). Hundreds of nursing homes with cases of coronavirus have violated federal infection-control rules in recent years. Washington Post. Retrieved April 22, 2020 from https://www.washingtonpost.com/business/2020/04/17/nursing-home-coronavirus-deaths [Google Scholar]
  8. Chapin R, & Dobbs-Kepper D (2001). Aging in place in assisted living: Philosophy versus policy. The Gerontologist, 41(1), 43–50. doi: 10.1093/geront/41.1.43 [DOI] [PubMed] [Google Scholar]
  9. Indiana Health Care Association. (2020) Civil Money Penalty Reinvestment Application Coronavirus Disease 2019 (COVID-19) Communicative Technology Request. Retrieved May 4, 2020 from https://www.ihca.org/wp-content/uploads/2020/04/496260d9-e5bf-4760-8191-b1d166e5c8eb.pdf
  10. Dosa D, Jump RLP, LaPlante K, & Gravenstein S (2020, Mar 13). Long-Term Care Facilities and the Coronavirus Epidemic: Practical Guidelines for a Population at Highest Risk. J Am Med Dir Assoc. 10.1016/j.jamda.2020.03.004 [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Florida Health Care Association, 2020. Temporary COVID-19 Personal Care Attendant Program. Retrieved April 23, 2020 from https://www.fhca.org/facility_operations/pcaprogram.
  12. Gardner W, States D, & Bagley N (2020). The Coronavirus and the Risks to the Elderly in Long-Term Care. Journal of Aging & Social Policy, 1–6. 10.1080/08959420.2020.1750543 [DOI] [PubMed] [Google Scholar]
  13. Harris AJ, Leland J, Tully T (2020). Nearly 2,000 Dead as Coronavirus Ravages Nursing Homes in N.Y. Region. New York Times. Retrieved April 26, 2020 from https://www.nytimes.com/2020/04/11/nyregion/nursing-homes-deaths-coronavirus.html [Google Scholar]
  14. Henning-Smith C, Casey M, Prasad S, & Kozhimmanil K (2017). Medical Barriers to Nursing Home Care for Rural Residents. Minneapolis, MN: University of Minnesota Rural Health Research Center. [Google Scholar]
  15. Klas M (2020). ‘There was an outbreak’: Rural Florida nursing home overwhelmed by COVID-19. Tampa Bay Times. https://www.tampabay.com/news/health/2020/04/10/there-was-an-outbreak-rural-florida-nursing-home-overwhelmed-by-covid-19/ [Google Scholar]
  16. McSweeney-Feld MH, Molinari C, & Oetjen R (Eds.). (2017). Dimensions of Long-Term Care Management (2 ed.). Health Administration Press. [Google Scholar]
  17. National Center on Assisted Living. NCAL Issues Guidance on Reporting COVID-19 Cases in Skilled Nursing Facilities and Assisted Living Communities. Retrieved April 25, 2020 from https://www.ahcancal.org/News/news_releases/Pages/AHCANCAL-Issues-Guidance-on-Reporting-COVID-19-Cases-in-Skilled-Nursing-Facilities-and-Assisted-Living-Communities.aspx.
  18. National Center for Health Statistics. (2020). Provisional Death Counts for Coronavirus Disease. https://www.cdc.gov/nchs/nvss/vsrr/covid19/index.htm [Google Scholar]
  19. Payscale. (2020). Hourly Rate of Certified Nursing Assistants. Retrieved April 22, 2020 from https://www.payscale.com/research/US/Job=Certified_Nurse_Assistant_(CNA)/Hourly_Rate.
  20. Peterson LJ, June J, Sakib N, Dobbs D, Dosa D, Thomas K, Jester DJ, & Hyer K (in press). Assisted living communities during Hurricane Irma: The decision to evacuate or shelter in place and resident acuity Journal of the American Medical Directors Association. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Port CL, Zimmerman S, Williams CS, Dobbs D, Preisser JS and Williams S 2005. Families filling the gap: comparing family involvement for assisted living and nursing home residents with dementia. Gerontologist, 45(Spec 1): 87–95. [DOI] [PubMed] [Google Scholar]
  22. Roberts M, Peterson LJ, Hyer K (2020). State of the states’ assisted living websites: Information available to consumers. The Gerontologist. doi: 10.1093/geront/gnz174 [DOI] [PubMed] [Google Scholar]
  23. Sengupta M, Valverde R, Lendon JP, Rome V, Caffrey C, & Harris-Kojetin LD (2016). Long-term care providers and services users in the Untied States - State estimates supplement: National study of long-term care providers, 2013-2014. Hyattsville, MD. [PubMed] [Google Scholar]
  24. Stockman F, Richtel M, Ivory D, & Smith M (2020, April 17, 2020). They’re Death Pits’: Virus Claims at Least 7,000 Lives in U.S. Nursing Homes. New York Times. https://www.nytimes.com/2020/04/17/us/coronavirus-nursing-homes.html [Google Scholar]
  25. United State Department of Treasury. 2020. The CARES Act works for all Americans. Retrieved April 24, 2020, from https://home.treasury.gov/policy-issues/cares.
  26. World Health Organization. (2020). Coronavirus situation report no. 92. Retrieved April 21, 2020 from https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200421-sitrep-92-covid-19.pdf?sfvrsn=38e6b06d_4.
  27. Zimmerman S, Katz P, Kunze M, O’Neil K, & Resnick B (2020). The Need to Include Assisted Living in Responding to the COVID-19 Pandemic. Journal of American Medical Directors’ Association, 21(5), 572–573. [DOI] [PMC free article] [PubMed] [Google Scholar]

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