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Expanding Long-term Care Choices for the Elderly

Balancing Preference & Capacity


Andrew Aronson, Director, Long-term Care Licensing, New Jersey Department of Health and Senior Services, Trenton, NJ.

Mauro Hernandez, Public Policy Director for Quality Assurance, Assisted Living Concepts, Portland, OR.

New Jersey

In New Jersey, all assisted living facilities (ALFs) are licensed into one of three categories:

  • Assisted living residences.
  • Comprehensive personal care homes.
  • Assisted living programs, in which services are provided in publicly subsidized housing units in urban areas.

Licensing requirements for assisted living residences include the following:

  • Physical plant: Each single-occupancy unit must contain at least 150 square feet; 80 square feet must be added for a second resident. Each unit must have a full bath, kitchenette, and a lockable door.
  • Admission: Each resident signs an admission agreement (which the State reviews as part of the licensure process) that includes proposed charges, process for notification of changes in costs, right to appeal involuntary discharge, and discharge criteria. Each resident is assessed and has a care plan developed by a nurse within 14 days of entrance.
  • Services: These must be provided in accordance with care plans. There are no limits on the services the provider can/must provide to meet the care plans, thus allowing for aging in place.
  • Staff training: All direct care staff (administrators, registered nurses [RNs], medication aides, and personal care assistants) must receive orientation/training before providing care and at least annual inservice education. The curriculum for initial orientation/training was developed by the State; training programs must use this curriculum or an approved substitute in order to be approved by the State.
  • Nursing tasks: Each facility must have at least one RN available at all times. Nurses can delegate administration of medications (with certain limitations) to medication aides—who have completed Personal Care attendant (PCA) training, an initial training course, standardized exam, and continuing education requirements—with a 72-hour oversight requirement.
  • Managed risk agreements: These are developed between residents and the facility, as needed. For people who are cognitively impaired, the agreement process can include family members or friends who are caregivers; Mr. Aronson noted that this can be problematic. The Assisted Living Federation of America (ALFA) has developed a brochure presenting legal issues related to managed risk agreements, written by ALFA's general counsel, Ken Burgess, Esq.: Negotiated Risk Agreements In Assisted Living Communities, published June 2000.
  • Discharge: There is no mandatory discharge criterion set forth in regulation. The facility's discharge criteria must be included in the admission agreement and be explained to the resident.
  • Aging in place: New Jersey is the only State to require that within 36 months after initial licensure, at least 20 percent of a facility's residents shall be individuals with nursing home level-of-care needs. This aging-in-place requirement is enforced through complaints and State oversight procedures.


In Oregon, "aging in place" refers to a philosophical approach that advocates for a person to remain in his/her living environment despite the physical and/or mental decline that may occur with the aging process. For aging in place to occur, needed services are added, increased, or adjusted to compensate for the physical and/or mental decline of the individual.

State policymakers and providers wishing to facilitate aging in place are faced with a number of challenges within existing regulatory systems, which can limit such efforts. These include:

  • Admission/discharge criteria that create restrictions around such issues as ambulation and evacuation capacity, episodic/intermittent nursing needs, prohibited health conditions, and eating/feeding.
  • Scope-of-service limitations that may restrict direct nursing and/or delegation, medication administration, ADL dependence, and services related to moderate or severe cognitive needs.

Given the wide range of stakeholders, providers face significant conflicts in expectations among stakeholders with conflicting interests. They also must deal with variable expectations over time and persons. For example, residents often complain about other individuals who are more frail than they may be, and a home health agency may become very uncooperative in coordinating a resident's nursing needs.

Providers and consumers also report problems with the long-term care (LTC) survey process, such as the incompatibility of the protective health/safety model with autonomy and risk, and priorities that match professional rather than consumer values. For example, a surveyor may feel strongly that a resident who is prone to falling may no longer be suitable to remain in a facility.

Faced with these obstacles, the following are recommended strategies that have been proven effective in other States:

  • Creating permissive rather than restrictive "move-out" language (e.g., New Jersey, Oregon, Arizona models), which allows providers to recognize their upper limits in providing services and to work within those limits.
  • Setting the "floor" of minimum required services rather than a "ceiling" of maximum allowable services.
  • Formalizing expeditious facility-wide waiver and/or individually based exception procedures.
  • Relating oversight to performance history and impairment levels.
  • Stressing consumer education and disclosure in marketing information, while encouraging providers to maintain a dialogue about residency issues with residents through the service-planning process.
  • Rethinking surveyor training and process, such as focusing on balancing quality of life and quality of care issues, community-based care challenges, etc.

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