ASSISTED LIVING IN MARYLAND
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ASSISTED LIVING
IN MARYLAND
WHAT YOU NEED TO KNOW
A cooperative effort of:
The Legal Aid Bureau, Inc.
- Assisted Living Project
Maryland Attorney General’s Office
Maryland Department of Aging
Maryland Department of Health
and Mental Hygiene
Maryland Department
of Human Resources
Maryland State Bar Association
University of Maryland School of Law
- Law and Health Care ProgramASSISTED LIVING IN MARYLAND:
WHAT YOU NEED TO KNOW
A cooperative effort of:
The Legal Aid Bureau, Inc.
- Assisted Living Project
Maryland Attorney General’s Office
Maryland Department of Aging
Maryland Department of Health and Mental Hygiene
Maryland Department of Human Resources
Maryland State Bar Association
University of Maryland School of Law
- Law and Health Care Program
Assisted Living in Maryland: What You Need to Know - 3Copyright 2002 University of Maryland School of Law 4 - Assisted Living in Maryland: What You Need to Know
TABLE OF CONTENTS
Chapter 1 An Introduction to Assisted Living ............................................... 3
Chapter 2 Choosing an Assisted Living Provider ........................................ 11
Chapter 3 What Will It Cost and How to Pay for Assisted
Living Services .......................................................................... 21
Chapter 4 Before You Sign a Contract . . . Read This ................................. 27
Chapter 5 Your Rights Under the Law ........................................................ 33
Chapter 6 How to Complain When Quality of Care Is
Lacking ..................................................................................... 37
Chapter 7 Enabling Others to Make Health Care and Financial
Decisions for You ...................................................................... 39
Chapter 8 Alternatives to Assisted Living ................................................... 47
Chapter 9 Where to Get Help .................................................................... 53
Assisted Living in Maryland: What You Need to Know - 5ASSISTED LIVING IN MARYLAND:
WHAT YOU NEED TO KNOW
COMMITTEE MEMBERS
Joan L. O’Sullivan, Committee Chair William Dorrill
University of Maryland School of Law Office of Health Care Quality
515 W. Lombard Street Department of Health and Mental Hygiene
Baltimore, MD 21201 Spring Grove Hospital
Bland Bryant Building
Denise Adams 55 Wade Avenue
Senior Assisted Living Program Manager Catonsville, MD 21228
Maryland Department of Aging
301 W. Preston Street, Room 1007 April Seitz
Baltimore, MD 21201 Department of Human Resources
311 W. Saratoga Street, Room 259
Elizabeth Binckes Baltimore, MD 21201
Department of Health and Human Services
Aging and Disability Services Kevin Simpson
410 Hungerford Drive, 3 floor
rd
Office of the Attorney General
Rockville, MD 20850 Health Education and Advocacy Unit
200 St. Paul Place
Rachel Cohen Baltimore, MD 21202-2022
Assistant Attorney General
Maryland State Retirement & Pension System Susan Shubin
120 E. Baltimore Street Chief Attorney
Baltimore, MD 21202 Nursing Home and Assisted Living Program
29 W. Susquehanna Avenue
Stephanie Edelstein Towson, MD 21204
ABA Commission on Legal Problems of the
Elderly Tamara Z. Catchpole
740 15 Street NW
th
Assistant Attorney General
Washington, DC 20005-1022 Maryland Department of Aging
301 W. Preston Street, Room 1007
Morris Klein, Esq. Baltimore, MD 21201
4550 Montgomery Avenue, Suite 601N
Bethesda, MD 20814
6 - Assisted Living in Maryland: What You Need to KnowCHAPTER 1
AN INTRODUCTION
TO ASSISTED LIVING
If any of the following scenarios seem laws and regulations. It also discusses
familiar to you, assisted living may be other options available, legal protec-
an option to explore. Your arthritis tions for residents, and area resources
prevents you from cooking, and some where you can get more information. In
days it is so bad that you cannot even addition, there are tips to assist you in
feed or bathe yourself. You cannot keep the following areas: deciding if assisted
your medications straight even with the living is for you, electing an assisted
pill reminder system your daughter living provider, entering into a
bought you. Or perhaps you contract for care, and paying for
cannot get around anymore on care.
your own, even with a walker,
and there is no family around What Is Assisted Living?
to help you regularly. In short,
it is getting harder to manage Assisted living is a way to
on your own, and you, your provide care to people who are
friends, or your family are having difficulty living inde-
beginning to worry. pendently, but do not need the
daily nursing services provided
Deciding whether assisted living in a nursing home. Assisted
is the best solution for you is not living providers furnish a place to live,
easy. To arrive at the best answer you meals, and assistance with daily activi-
should: ties, such as dressing, bathing, eating,
and managing medications. People
1. Read the rest of this booklet; who live in assisted living facilities
2. Explore options other than assisted generally have less complicated medical
living; problems than people in nursing homes.
3. Think about your abilities, your Assisted living facilities also tend to
needs, and your finances; and have a less institutional look than
4. Visit some assisted living facilities. nursing homes. However, these facili-
ties are not as highly regulated by the
This booklet explains the role and government as nursing homes.
function of assisted living providers,
but does not take the place of applicable
Assisted Living in Maryland: What You Need to Know - 7In Maryland, an assisted living provider is defined as: If a person is mentally
A residential or facility-based provider that provides sharp, only takes medica-
housing and supportive services, supervision, person- tion for arthritis pain, and
alized assistance, health-related services, or a combi- only needs assistance with
nation of these services to meet the needs of residents dressing and bathing he or
who are unable to perform, or who need assistance in she would be classified as
performing, the activities of daily living or instrumen- needing a low level of
tal activities of daily living, in a way that promotes
care. A person would need
optimum dignity and independence for the residents.
a high level of care if he or
she is mentally confused
Code of Maryland Regulations 10.07.14.02B(10).
by dementia, has a compli-
cated list of powerful
There is a wide variety of assisted living medicines that must be given
providers in Maryland. They range from at different times each day,
large, corporate-managed facilities where
hundreds of people live in their own
apartments to small, private homes in WAYS IN WHICH ASSISTED
which the owners provide services to two LIVING PROVIDERS DIFFER:
residents who may share a bedroom.
What all of these providers have in com- ❖ Facility size;
mon, however, is they all offer their ❖ Staff qualifications;
residents some level of assistance with ❖ Location;
their daily activities, like dressing, bathing ❖ Fees, what is included in the monthly
and eating. fee varies widely;
❖ Sponsorship: non-profit vs. for profit
Levels of Care vs. religious affiliation;
Assisted living facilities in Maryland ❖ Free standing facility vs. a campus
are licensed to provide up to three type setting;
levels of care. ❖ Experience and reputation of pro-
vider;
The levels correspond with how much ❖ Private room vs. semi-private room;
assistance residents need. Licensure at ❖ Private bathroom vs. common bath-
level one means the provider is autho- room;
rized to take care of residents with low ❖ Provider participation in Medical
care needs. A level two license means Assistance;
the provider can also take care of ❖ Ability to age in place: levels of care,
residents with moderate care needs, and potential for level of care
a level three license allows a provider waivers;
to care for residents with high-level ❖ Visiting hours; bedtimes; wake-up
care needs (as well as residents with times; mealtimes.
low or moderate needs).
8 - Assisted Living in Maryland: What You Need to Knowand requires assistance with bathing, Functional Assessment
eating, walking, dressing, and toileting. The assisted living manager must
Such a person could only be accepted by conduct a functional assessment. A
a provider with a level three functional assessment measures
license. and records various kinds of
information, such as your
Most providers are licensed at ability to take care of your
level three, which means they daily needs and how much
can accept residents with low, help you need from others.
moderate, or high care needs. It also records current
If you have a progressive symptoms you have that
condition and do not want to would have to be moni-
have to move repeatedly, you tored by an assisted living
should look for a provider provider. In addition to
with a level three license your physical needs, the
even if you only need a low functional assessment also
level of care now. looks at things like your ability
and desire to participate in group
Assessment and Service Plan activities.
Before you move into an assisted living
facility, the assisted living manager Service Plan
must assess the level of care you require The manager must also develop a plan
and whether you qualify for admission for your care based on the overall
under the provider's license. For assessment. This plan is called the
example, if you need a moderate or “service plan.” A service plan must
high level of care and the provider is state what services you are to be pro-
only licensed to provide a low level of vided, when they are to be provided,
care, the provider will not be able to and who will provide them. You are
admit you. There are two parts to an entitled to participate in the develop-
assessment: the Resident Assessment ment of your service plan. Moreover, a
and the Functional Assessment. service plan must be updated every six
months or more frequently, if there are
Resident Assessment changes in your needs. Your service
A resident assessment is based on a plan is very important because it speci-
physical examination made by a medi- fies precisely what services you will
cal professional. It records a lot of get, when you will get them, and how.
basic medical information. Each assisted living manager must
Assisted Living in Maryland: What You Need to Know - 9make sure that every resident is monitored Laundry and Housekeeping
daily to see that a resident’s care is Housekeeping and laundry services are
provided in accordance with the service required services that must be offered
plan. by every provider. Typically a certain
amount of these services are covered by
Activities of Daily Living and Other the basic monthly fee. What that
Required Services amount is varies greatly from provider
to provider.
Activities of Daily Living
A large part of what assisted living Facilitating Access to Healthcare and
providers do is provide assistance with Social Services
"activities of daily living,” which While a few assisted living providers
include: may employ part time nurses, most
providers do not supply the kind of
❖ Eating; medical care offered by licensed health
❖ Grooming, bathing, oral hygiene, care professionals. However, every
shaving, and combing hair; assisted living manager is “responsible
❖ Walking or getting around, with or for facilitating access to appropriate
without assistive devices; health care and social services,” such as
❖ Toileting; and physicians, nurses, social workers,
❖ Dressing in clean, weather-appro- dentists, hospice care, etc. “Facilitat-
priate clothing. ing access” is a flexible phrase so
different providers implement this
Often this type of assistance is called requirement in widely different ways.
“personal care” or “personal care Some providers only provide help with
service.” scheduling appointments, and you will
have to arrange for your own transpor-
Other services that assisted living tation. Others will arrange appoint-
providers in Maryland are required to ments and provide transportation, while
deliver include: some providers go so far as to arrange
for services to be delivered at the
Meals facility. You will want to ask providers
Meals must be served in a common how they facilitate access to health care
dining area three times a day seven days and social services.
a week. Snacks also must be
offered at intervals each day.
While every assisted living
provider must try to accom-
modate special diets, a
provider does not have to
provide a special diet that is
beyond its capabilities.
10 - Assisted Living in Maryland: What You Need to KnowSocial and Spiritual Activities Medication Management
The manager of each provider must During the initial assessment process
provide or arrange opportunities for the assisted living manager must deter-
activities that will promote the physical mine if: (1) you can handle your own
and mental health of each resident. medications, (2) you need assistance
This includes facilitating access to with your medications or reminders to
spiritual and religious activities. Typi- take them, or (3) need someone to
cally providers satisfy this requirement administer your medications for you. If
by conducting activities in the facility you need assistance
and by arranging transportation to with your medications
activities outside the facility. Card or need someone to
games, bingo, and sing-alongs are the administer them for
kind of activities you will find in many you, the provider must
facilities. Typical activities outside a have specially trained
facility may include trips to the mall, staff to supply that help
grocery store, and local worship ser- to you.
vices. Transportation charges may
apply, and when they do, they can vary
widely.
Assisted Living in Maryland: What You Need to Know - 1112 - Assisted Living in Maryland: What You Need to Know
CHAPTER 2
CHOOSING AN ASSISTED
LIVING PROGRAM
Choosing a high quality assisted living ❖ What types of living units are
provider that meets your needs and your available?
lifestyle can be quite a challenge. ❖ If none, do you have a waiting list?
Assisted living providers in Maryland ❖ What is your monthly fee?
range in size from small, family-style ❖ Do you require a deposit?
homes with two people sharing a ❖ What services do you provide?
bedroom, to large apartment complexes ❖ What services are included in the
housing several hundred residents. The monthly fees?
services they offer can be just as varied. ❖ What services are extra?
Getting Started Request a brochure, a price list, and a
copy of the Resident Agreement (con-
To find out what facilities exist in the tract) so that you can review those
area you are interested in, ask your items before you visit. Do not rely on
friends and other acquaintances, check what the brochure says. Read the
with your local agency on aging, and contract closely, paying special atten-
look at newspapers, retirement tion to costs, services provided, and
living guides and other publi- discharge policies. Chapter 4
cations. The resources listed contains detailed information
in Chapter 9 will help. If on what to look for in a Resi-
possible, try to choose a dent Agreement.
facility that is near your
family or friends. Also, request a copy of the
assisted living provider's Disclo-
Once you have a general sure Statement. This disclosure state-
idea of what setting, services, and price ment must include information about
range you prefer, call several facilities other facilities operated by the same
in the location you are considering. organization, the organization's reli-
Ask the manager or administrator the gious or charitable affiliations, the
following preliminary questions to help name of the manager, and a description
you narrow your search: of special programs offered. There is
no cost for this document.
❖ What is the size of your facility?
❖ What level of care are you licensed
to provide?
Assisted Living in Maryland: What You Need to Know - 13Before you make any decisions, visit as Visits can be exhausting. After a while
many facilities as you can. Take a tour, the different providers and their facilities
talk to residents and to may start to blend
staff, and ask a lot of in your memory.
questions. Have a
WHEN YOU VISIT The checklist on
friend or family mem- pages 14 - 19 will
❖ Ask the manager to show
ber go with you to be help you organize
you around the building and
another set of eyes and your visit, ask the
grounds.
ears. You can com- right questions, and
❖ Consider the overall atmo-
pare notes later. record your obser-
sphere of the facility.
If you need help vations. The
❖ Talk to members of the staff:
selecting a facility, you checklist is lengthy
are they friendly and help-
may want to hire a so you must review
ful?
geriatric care manager. it before you go
❖ Chat with residents, their
Geriatric care managers and highlight or
friends, and families.
are professionals who mark the questions
❖ Observe how the staff
specialize in assessing a that are the most
interacts with residents.
person’s needs and important to you.
❖ Eat a meal. (There may be a
arranging housing and Make as many
charge for the meal.)
services to meet those copies of the
needs. See Chapter 9 checklist as you
for the telephone like. You should
number of the National Association of
Professional Geriatric Care Managers,
which can refer you to a local care man- DOCUMENTS TO GET
ager. AND READ
Visiting Facilities If you do not already have them by the
time you visit, be sure to get a copy
Once you have decided which facilities to of the:
visit, call to make an appointment. Try to
visit each facility more than once, to get ❖ Resident Agreement (contract),
a better sense of what life is like for ❖ List of services offered,
residents. Plan your first visit for a week- ❖ Notice of resident's rights,
day, during late morning or at midday if ❖ List of costs,
possible, and another on a weekend or in ❖ Disclosure statement, and
the evening. Make the second visit ❖ Any other documents that resi-
unannounced. Be concerned if the dents must sign at admission.
provider will not allow you to make an
unscheduled visit. You may even want to Carefully review these documents
ask about spending the night to get a sense and read Chapter 4 before signing
of how the facility is run during off-peak any papers!
hours.
14 - Assisted Living in Maryland: What You Need to Knowuse one copy for each facility you visit. whether the provider has received com-
Use a notebook for additional information plaints, and how those complaints were
and questions. The answers to the resolved. See Chapter 9 for the number
checklist questions can be used to com- for your local Long Term Care Ombuds-
pare facilities once you have visited them. man.
If you are not able to get all the questions
answered during one You can also ask an assisted living
visit, visit again or provider you are considering for a
call on the telephone copy of its most recent inspection
to get the answers. report. The law requires providers
to make copies available.
Judging Quality
Certain factors contribute to quality
You will learn a great care. They include:
deal by visiting a facility, asking
questions, reviewing the Resident Agree- ❖ Consistent and responsive ownership;
ment, and reviewing other written materi- ❖ Stable, well-trained staff;
als. But you will also want to consider the ❖ The number of residents per staff
quality of the services and care provided. member;
You can go to see or request copies of ❖ Interaction with the community;
inspection results and plans of correction ❖ A provider philosophy that empha-
from the Office of Health Care Quality. sizes residents’ dignity and indi-
(There may be a charge for copies and it vidual needs;
may take as long as 30 days to get them.) ❖ A mission to eliminate restraints, or
See Chapter 9 for the address. You will to use them only when no individu-
want to find out: alized care plan works.
❖ Teamwork between management
❖ How recently was the provider and staff; and
inspected? ❖ Respect and advocacy for residents'
❖ Were any violations found? rights.
❖ What were the violations?
❖ Have the problems been corrected? Keep these factors in mind during your
visits and while reviewing any inspec-
Remember to focus on the seriousness of tion reports.
any violations, not just the number of
them.
Your local Long-Term Care Ombudsman
Program may also have information about
a particular service provider, including
Assisted Living in Maryland: What You Need to Know - 15Checklist for Selecting an Assisted ❖ What is the current amount of the
Living Facility1 basic (usually monthly)
fee?
The complete checklist that follows is ❖ What services are
organized into eleven sections: available for an addi-
tional charge?
1. Costs & Contracts ❖ What is the amount of
2. Personal Care each additional
3. Health Care charge?
4. Transportation ❖ Is there a refund policy in
5. Activities & Socializing cases of transfers, discharges,
6. Meals changes in ownership, or an
7. Housekeeping & Laundry assisted living facility closing?
8. Safety/Choice ❖ When will any refunds be paid?
9. Facility Initiated Discharge ❖ What behaviors, conditions, or other
10. Licensure circumstances can result in termination
11. Special Care/Dementia Units. of services?
❖ What type of living unit will I have?
1. Costs and Resident Agreement ❖ What are the rights of residents?
(Contract) ❖ What is the provider’s grievance
The Resident Agreement is a legal procedure; and what alternatives are
contract, obligating you to potentially there if I am not satisfied with the
pay very large sums of money for care. results of the procedure?
Ideally, you will have gotten a copy of ❖ What, if any, initial payments are
the Resident Agreement and reviewed it required?
before you visit. Chapter 4 explains ❖ If any are required, how much are
what to look for in a Resident Agree- they and what are they for?
ment. ❖ What happens if my funds run out?
❖ What is the provider’s policy on
If you have not gotten a copy before relocating residents in the facility?
you visit, make sure you get a copy and ❖ If I am away from the facility for a
during the visit ask any of the following period of time, (e.g., visiting family, in
questions that are important to you. a hospital, or temporarily in a nursing
Later review the Resident Agreement home) what fees stop?
carefully with Chapter 4 in hand before ❖ Is there a charge to hold a bed during
you agree to sign. an absence?
❖ If there is a charge, when does it
❖ Is the print large enough for you to begin?
read? (If not ask for a copy that is.) ❖ How long will you hold a bed for me?
❖ What services are provided for the ❖ When, how often, and why can the
basic (usually monthly) fee? fees be changed?
❖ When fees are changed, who is
informed, and how?
16 - Assisted Living in Maryland: What You Need to Know❖ How much advance warning is pro- accessible to people with walkers or
vided of fee changes? 2
wheelchairs?
❖ Does the provider ❖ If rooms are shared, what does the
participate in the provider do if there are problems
Medicaid waiver between roommates?
program?
Written Service Plan
2. Personal Care ❖ What professionals/staff will be
Take into consideration involved in the development of my
that you may need more written service plan?
care in the future than you need now. If ❖ How often is the plan revised?
you do not want to move again, ask ❖ How will my family and I be in-
questions about care that you do not volved?
need now, but may in the future. In any ❖ What involvement does a confused
event, you will want to ask the ques- resident have?
tions below. ❖ What happens if I do not agree with
the service plan?
Meeting Individual Needs
❖ How often will my level of care be Staffing
reassessed? ❖ How many staff are there for each
❖ How many residents are you li- shift?
censed to serve? ❖ What are their responsibilities?
❖ What level of care are you licensed ❖ What is the training/certification of
to provide? the people who care for residents?
❖ How will the provider meet my ❖ What other duties do direct care
current care needs (e.g., inconti- staff have?
nence, insulin shots, etc.)? ❖ Which direct care staff on each shift
❖ What happens if my needs change - is fluent in my native language?
I need more help, become inconti- ❖ Is there special training for staff
nent, become confused? about dementia and Alzheimer's
❖ How does the provider tailor sched- disease?
ules for preferences of residents ❖ How is staff trained to deal with
(like bathing and waking times)? aggressive individuals?
❖ How does the provider help resi- ❖ How is staff trained to deal with
dents maintain their abilities to wanderers?
toilet, dress, and eat? ❖ What if I do not like the staff person
❖ Is there a schedule for staff to check assigned to me?
on each resident's whereabouts and ❖ What is the staff turnover rate?
well being?
❖ What resources does the provider 3. Health Care
have to address difficult behavior? While most assisted living providers are
❖ Are bedrooms, hallways, doorways, not designed to provide medical care, a
bathrooms, and common areas fully
Assisted Living in Maryland: What You Need to Know - 17provider must make sure residents have Medication Management
access to health care either on or off ❖ What safeguards are in place to
site. It is important to evaluate the ensure that I get the appropriate
provider’s capacity to manage or coor- medications on time and in the correct
dinate health care needs because you dosage?
may need more help in the future. ❖ Who is responsible for having pre-
scriptions filled?
Provision and Monitoring of Health ❖ Must I use the provider’s pharmacy,
Care even if it costs more than my phar-
❖ What kinds of health monitoring macy?
checks are available (e.g. weight ❖ Who gives out medications?
change, glucose levels, etc.)? ❖ If not a nurse, how are staff trained
❖ If a nurse is not on staff, are there and supervised about medications?
regularly scheduled visits by a nurse ❖ If I am able, will I be allowed to take
or other health provider? care of my medications on my own?
❖ If so, what medical services do they
provide? 4. Transportation
❖ How will the provider facilitate my Questions to ask about transportation
access to health care and social include the following:
services?
❖ Will the provider schedule routine ❖ Is any trans-
medical appointments for me? portation
❖ Will the provider schedule transpor- provided?
tation to and from medical appoint- ❖ If so, how often
ments? (daily, weekly,
❖ What health services are available evenings, weekends)?
on site: e.g. nursing care, lab work, ❖ To where is transportation provided
physical therapy, wound care, (grocery stores, shopping malls,
hospice, social work, podiatrist, medical appointments)?
etc.? ❖ Will the provider call and arrange for
❖ What health services does the transportation it does not provide?
provider furnish, and what does it ❖ Is transportation available if I want to
arrange for outside agencies to go to an event by myself or with a
provide? friend?
❖ Under what circum- ❖ Are there fees for using the provider’s
stances and when will transportation or transportation
the provider call my arranged by the provider?
family? ❖ Is transportation wheelchair acces-
❖ Under what circum- sible?
stances and when will
the provider call my doctor?
18 - Assisted Living in Maryland: What You Need to Know5. Activities and Social-
izing ❖ What times are meals served?
When looking at the ❖ What happens if I am late, miss a
activities a facility offers, meal, or refuse a meal?
think about your prefer- ❖ How will any special dietary needs I
ences. Some people enjoy have be met?
scheduled activities, such as ❖ When can I have a tray delivered to
current events discussions, crafts, bingo, my room?
card games, etc. Others have never been ❖ Is there an additional charge for tray
“activities people” and will not care to service?
participate. They would rather read a ❖ If I do not like a meal, what are the
book. You may want to go on trips and alternatives?
outings. Look at a monthly activity ❖ When are snacks available?
schedule to see if the activities appeal to ❖ May I see the printed menu for the
you. Inquire about the following: past month?
❖ How do you make sure each resi-
❖ How often are activities in the dent is taking in adequate nutrition?
community sched-
uled? 7. Housekeeping and Laundry
❖ Will staff attend with ❖ How often will my room be
me? cleaned?
❖ Are there protected ❖ How often will my linens be
or enclosed walking changed?
areas for residents? ❖ Will the provider do my personal
❖ How are resident’s laundry?
religious or spiritual ❖ Are washing machines available for
needs met? me to use at the facility?
❖ Who develops and supervises recre- ❖ If so, is there any cost to use them?
ational activities? ❖ What extra charges, if any, are there
❖ How do residents have input into for additional housekeeping or
the activities offered? laundry services?
❖ What is the provider’s policy on
pets? 8. Safety and Choice
❖ What is the policy on visitors? Assisted living providers should em-
phasize independence and choice. They
6. Meals also have rules and procedures designed
Meals are important to residents of to protect residents from harm. It is
assisted living because they are usually important to match your ability with the
dependent on the food provided by the extent of choices and opportunities
provider. So sample a meal on your offered by a provider, as well as the
visit to see how it tastes. Questions to limitations it will impose upon you.
ask include the following:
Assisted Living in Maryland: What You Need to Know - 19Questions to ask include: ❖ What if I want an exception to a
policy, e.g. signing in and out, smok-
Safety ing, or eating foods that are not on a
❖ What safety measures are in place to prescribed diet?
protect resident's personal property ❖ What is the
from being stolen? provider’s policy on
❖ What safety measures are in place to smoking?
protect residents from wandering ❖ Will the provider
away? require that I partici-
❖ Are exit doors alarmed? pate in any particular activity or
❖ Are there call bells in each room and program?
bathroom?
❖ Are the floor coverings made of 9. Facility Initiated Discharges
nonskid material? Answers to these questions will help you
❖ Is there a fire emergency plan? clarify a provider’s ability to care for
❖ What are the safety arrangements for people with health and behavior conditions
people in wheelchairs to escape in that can be difficult to manage. It will also
case of fire? help you determine if you have recourse if
❖ How often are there fire drills? you are asked to leave.
❖ How do residents with limited mobility
participate in fire drills? ❖ What are the possible reasons for
❖ Are emergency plans publicly dis- discharge?
played? ❖ Is there an internal appeal process?
❖ What is it?
Emergencies ❖ How many days notice is given and to
❖ What kind of emer- whom? 3
gencies are staff ❖ How does the facility assist you if it
expected to handle proceeds with discharge?
and how are they ❖ Is there a refund if there is a dis-
trained for them? charge?
❖ Who decides whether to call
911? 10. Licensure
❖ May I have a copy of any written ❖ When was the provider last inspected
policies about how that decision is by State licensing authorities?
made? ❖ What, if any, violations have been
❖ Will my family be notified immediately cited by the authorities in the past two
if 911 is called? years?
❖ Did the provider submit a plan of
Choice correction?
❖ How much of my own furniture and ❖ May I have a copy of the inspection
personal possessions may I bring? results and any plans of correction?
20 - Assisted Living in Maryland: What You Need to Know11. Special Care or Dementia Units ❖ How much space is there to walk
This section is directed to family members around on the unit?
or other interested persons, because it ❖ Are the room’s private or semipri-
would be unusual for the person who vate?
needs a special care unit to be asking ❖ When rooms are shared, what does
these questions. the provider do if there are prob-
lems between roommates?
❖ Is there a separate ❖ What is the cost difference between
area specifically for special care and regular units?
people with demen-
tia? _________________________________________________________________
❖ How do services in 1
Copyright © 2001 Consumer Consortium on
the special care unit Assisted Living. The Consumer Consortium on
differ from services Assisted Living (CCAL) originally developed
in the rest of the this questionnaire with assistance from the
facility? Arlington Area Agency on Aging and the
❖ What is the differ- Northern Virginia Long Term Care Ombuds-
ence in staff train- man Provider. Other professionals and
ing? potential consumers reviewed it as well. It
❖ What is the staff-to- has been significantly modified for use in
resident ratio? Maryland.
❖ Is there a special out door area for 2
By Maryland law at least 45 days notice is
residents with dementia to use? required.
❖ What techniques do you use to 3
By Maryland law, at least 30 days notice of a
ensure that the resident is getting discharge is required except in emergencies.
proper nutrition?
❖ Do you offer decaffeinated drinks
throughout the day?
❖ Does the calendar of activities look
appropriate for the resident?
❖ What is the provider’s policy on
restraints, both chemical and physi-
cal?
Assisted Living in Maryland: What You Need to Know - 2122 - Assisted Living in Maryland: What You Need to Know
CHAPTER 3
WHAT WILL IT COST AND HOW TO PAY
FOR ASSISTED LIVING
What Will It Cost fee,” “community fee,” “deposit,” “activity
fee,” or any other of a number of names.
While assisted living is usually more Depending on the contract, you may
affordable than a nursing home, assisted recover all, part, or none of an initial or
living can be very expensive. The cost monthly fee when you leave.
of assisted living varies greatly, ranging
from under $1,000 to over $5,000 per Most facilities base their fee on how
month. The average cost for a month is much care you need. The facility
about $2,000. The variation is based on evaluates you at the time of admission,
many factors, including: and conducts re-evaluations regularly
while you continue to live there. The
❖ The kind of and number of services more care that you need, the higher the
offered; fee. A facility may have several "levels
❖ The size, design, and amenities of of care" for which it charges. These
the facility; “levels” are not always identical to the
❖ Whether your room is private or is three levels of care the State uses to
shared; and license and regulate assisted living
❖ The geographic location. facilities. When they are not identical,
confusion can result so make sure to
Most assisted living facilities charge a ask enough questions to make sure you
daily rate and bill you monthly. Provid- understand.
ing care is labor intensive, and rates
usually go up each year
due to increases in Read the Resident Agreement or
operating costs and contract carefully to learn if you
labor. will receive a refund of any initial
fees or monthly fees you have paid
While most assisted should you decide to leave the
living facilities charge a facility. Any refund policy must be
monthly fee, some may described in the Resident Agreement. It
also require an addi- should state, if, how, and when you can
tional fee before or obtain a refund should you decide to
shortly after you move leave the facility. Consider having an
in. These initial fees attorney look at it.
may be called “entrance
Assisted Living in Maryland: What You Need to Know - 23In addition to the basic monthly fee for How To Pay For Assisted Living
each “level of care,” an assisted living
facility may charge you for what it Except in the few situations mentioned
considers to be additional or extra below, very few government programs
services that are not included in the pay for assisted living. Almost all
monthly charge. No standard exists for assisted living services are paid for by
what is an “extra” service, and each residents (or their families) out of their
facility sets its own policy. Such personal funds. Long term care insur-
“extras” may include: ance generally will pay for assisted
living, but the insurance must be pur-
❖ Nursing service; chased in advance and paid for from
❖ Incontinence care; personal funds.
❖ Extra assistance with daily tasks not
covered by the basic fee; Health Insurance, Medicare, and
❖ Medication administration; Medicaid
❖ Special diets, snacks, and room
service meals; Many people think Medicare or private
❖ Maid service; health insurance help pay for assisted
❖ Laundry; living and other long-term care ser-
❖ Cable television; vices. This is wrong. Medicare
❖ Private telephone line and and private health insurance
utility services; usually will not pay for
❖ Personal services like the costs of assisted
barber or beauty parlor living.
services; and
❖ Transportation. If you have limited
resources, Medicaid may
The cost of assisted living provide financial assis-
care may very well exhaust tance under certain
your savings. Assisted living limited circumstances.
facilities are not obligated to continue Ordinarily, Medicaid is available for
to keep you if you cannot pay for long-term care only if you reside in a
services. Nonpayment will be a ground nursing home. However, Maryland has
for discharging you. It is important for a new Medicaid program that can pay
you to consider what would happen if for assisted living services if you meet
your money ran out while you lived in its strict eligibility requirements. The
assisted living, and to have a plan for new program is called the Medicaid
that possibility. Home and Community Based Waiver
Services for Older Adults (“Medicaid
Waiver Program”). It serves a limited
number of people. If all the openings
are filled, Medicaid will not be able to
pay for your assisted living services.
24 - Assisted Living in Maryland: What You Need to KnowTo qualify for the Medicaid Waiver Senior Assisted Living Group Home
Program, you must be at least 50 years Subsidy Program
old and meet both the medical and
financial eligibility standards. To The Maryland Department of Aging has
satisfy the medical standard, you must a limited subsidy program that you may
require enough care to qualify to live in be eligible for if you are elderly and live
a nursing home (even though you plan in an assisted living facility that partici-
to live in assisted living). pates in the subsidy program. Only
facilities that have between four and
The financial eligibility standards are an sixteen beds participate in this program.
income test and asset test. You must There are often waiting lists for the
have limited income and assets to be program.
eligible. The financial eligibility rules
are complex, but basically, your assets To be eligible you have to have limited
have to be less than $2,500 or $2,000, assets and income. While the numbers
depending on eligibility category, and change from year to year, in order to be
your monthly income cannot exceed eligible at the time this booklet was
three times the SSI amount for a single printed in 2002 your monthly income
person. This number is adjusted annu- would have to be less than $1,945 and
ally for inflation and is $1,635 in 2002. your assets less than $11,000. To apply,
Medicaid will not count as assets, your or or for more information, contact your
your spouses’s, cars or pre-arranged local agency on aging. See Chapter 9
funerals. Also, under certain circum- for the agency on aging closest to you.
stances, your spouse can keep up to half
of your joint assets. Long-Term Care Insurance
The eligibility standards are too Long-term care insurance can
complex to be summarized in pay for assisted living. The
this booklet so for more cost of long-term care insur-
information on eligibility ance varies greatly, depending
for the Medicaid Waiver on the options you select and
Program call the Legal Aid your medical condition. If
Bureau’s Assisted Living Project or you already need assisted living ser-
your local agency on aging. You can vices, you probably will not be able to
also get an application from your local purchase a policy. If you are over age
agency on aging. See Chapter 9 for the 85, even if you are in good health, you
agency on aging closest to you and the may also have a hard time finding a
contact information for the Legal Aid policy.
Bureau. You can also get information
from the Legal Aid Bureau’s website at
www.mdlab.org.
Assisted Living in Maryland: What You Need to Know - 25The older a person is when a policy is Tax Deductions
purchased, the more expensive the Long-term care insurance premiums
policy will be. However, even if it is may be deducted from your federal
too late for one spouse to purchase income taxes. The deduction is based
coverage, it may not be too late for the on the age of the person insured. The
other spouse to buy a policy. deduction covers only a small part of
the actual insurance policy cost, ranging
Annual premiums can range from a few from about $220 for persons age 40 or
hundred dollars for a healthy 40-year less to about $2,700 for persons over
old to thousands of dollars for a 70-year age 70, but it should not be overlooked.
old. Most policies offer premiums that
are "level," that is, the rates do not Maryland offers a one-time state in-
change as you age. However, an insur- come tax credit of up to $500 for your
ance company typically can raise rates purchase of long-term care insurance.
for a group of policyholders if it can A credit is different from a deduction in
show the rates are too low. that the full amount is taken directly out
of the amount of taxes owed to the
Long-term care insurance policies are State.
offered in many different options. It is
very important for you to understand For More Information
what a particular policy covers, as well For more information about long-term
as the rules affecting when the policy care insurance, contact the United
goes into effect. Seniors Health Cooperative, 409 3rd
Street SW, Suite 200, Washington, D.C.
What services are covered 20024, telephone (202) 479-6678; the
Make sure the insurance policy includes Maryland Insurance Administration at
assisted living care. It is a good idea to (410) 468-2000 or 1-800-492-6116; or
buy a policy that covers all types of your local Senior Health Insurance
long-term care: home care, day care, Assistance Program. See Chap-
assisted living, and nursing home ter 9 for information on your
services. Long-term care insurance local Senior Health Insurance
may not necessarily include assisted Assistance Program.
living services, although most policies
written in the last few years will. Older Reverse Mortgages
policies may be limited to nursing home Reverse mortgages enable you
care or at-home care. The “assisted to convert the equity in your
living” concept was not common until home to cash. The cash can be
recently so many older policies do not spent to pay for assisted living.
mention it or cover it. However, in most cases, to
qualify for a reverse mortgage, there
must be one borrower living in the
26 - Assisted Living in Maryland: What You Need to Knowhome. So, if you are single, a reverse a resident must be “chronically ill” and
mortgage probably will not help with receive care prescribed by a doctor or
assisted living expenses. another health care provider. See IRS
Publication 502 for more information.
A reverse mortgage is based on your
age, the value of your home, and inter- To be considered “chronically ill” your
est rates. Reverse mortgages are avail- doctor or other licensed health care
able to you if you are at least 62 years practitioner must determine that you are
of age. The value of the home will be unable to perform at least two activities
less after you take out a reverse mort- of daily living for at least 90 days
gage. This means that your heirs will without substantial assistance from
receive less money than they would if another or that you have a severe
there was no reverse mortgage on your cognitive impairment (such as
home. Alzheimer's disease) and need substan-
tial supervision to be protected from
Banks, mortgage firms, and financial threats to your health and safety.
service companies offer reverse mort-
gages. You should do a lot of research You can only deduct medical expenses
to make sure you find a reputable that are more than 7.5% of your ad-
reverse mortgage lender. There have justed gross income. Thus, you can
been unscrupulous people using the only have a deduction for assisted
reverse mortgage idea to scam seniors. living costs if your total medical ex-
You should also shop around to com- penses, including your assisted living
pare options. For more information, costs, exceed 7.5 % of your adjusted
contact the National Center for Home gross income.
Equity Conversions at (651) 222-6775
or visit their website at Consult your tax advisor for more
www.reverse.org. Reverse mortgages information about the tax deductibility
can have substantial financial ramifica- of assisted living services.
tions so you should contact a financial
planner, accountant, or attorney before
entering into one.
Tax Deductions and
Credits
If you are paying out of
your own pocket, some or
all of the cost for assisted
living may be tax deductible as a
medical expense. To get the deduction,
Assisted Living in Maryland: What You Need to Know - 2728 - Assisted Living in Maryland: What You Need to Know
CHAPTER 4
BEFORE YOU SIGN A
CONTRACT . . . READ THIS
Before you move into an assisted living an assisted living provider. You should
facility, you and the provider must sign use that same list as you review the
a contract, called an assisted living Resident Agreement.
Resident Agreement.
Start by reading the Agreement straight
It is very important that you read the through once. Then go back and reread
Resident Agreement carefully and it with the checklist questions in hand.
understand it before you sign. The The only section of the checklist ques-
contract—not the facility's salespeople tions in Chapter 2 that will not be
or brochures—will determine what helpful are those in Part 10, “Licen-
services you will receive, and at what sure.” If the answer to a question in
cost. In most cases, an assisted living Chapter 2 is important to you and you
provider is only legally required to want the provider to be bound by its
supply what is stated in the Resident answer, then the answer needs to be
Agreement. What the sales brochure or somewhere in the Resident Agreement.
sales person said seldom counts. If it is not, you will need to add lan-
guage to the Agreement to make your
Read the Resident Agreement carefully. understanding with the provider clear.
Is the print large enough for you to If you add or delete language to or from
read? If not ask for a copy that is. If a preprinted Resident Agreement be
you can, before you sign the Agree- sure that both you and the facility
ment, have it reviewed by a lawyer who representative write your initials and the
is familiar with assisted living. You date in the margin
may obtain help finding such a lawyer next to each change.
by calling the local bar association for
your county or city or by viewing the Responsible Party
roster of the Maryland State Bar
Association’s Elder Law Section on the A provider may ask
internet at www.msba.org/sec_comm/ you to have a family
elder/roster.htm. The Legal Aid office member or friend
will review the contract at no cost if sign the Resident
you are eligible. Agreement as an
“agent,” “responsible party,” or other
Chapter 2 contains an extensive list of similar name. Your family member or
questions designed to help you choose friend should not sign the Agreement
Assisted Living in Maryland: What You Need to Know - 29without understanding completely what The Rest of This Chapter
that means. What the word or phrase
means should be clear from the lan- The rest of this chapter sets forth a
guage of the Agreement. If a represen- number of questions to ask yourself as
tative of the provider has to tell you you review the Agreement. Many of
what the word or phrase means, either the questions in this Chapter deal with
(1) do not sign the Agreement or (2) the same issues as the Checklist Ques-
strike out the word or phrase before tions in Chapter 2. You should read this
signing. The Agreement should make Chapter anyway because doing so will
completely clear whether the person emphasize the issues that a Resident
signing as “agent,” “responsible party,” Agreement should cover.
“representative,” etc. is required:
What to Check For - Generally
1. To pay for your care using only your Check carefully for the following:
funds; or
❖ What are there extra fees for:
2. To pay for your care using his or To remind the resident to take
her own funds. medication?
Incontinence care?
Needless to say, there is a big differ- Assisting with bathing?
ence! People’s lives have been seri- Laundry?
ously affected by a few slippery words Anything else?
in this area, so be very careful!
❖ What if you run out of money to
pay the monthly fee? How much
time does the facility give you
before it discharges you? (A study
Many sons and daughters have been of people leaving assisted living
surprised to learn that an assisted living reported that one in ten left because
provider maintains that the Resident they had run out of money.)
Agreement obligates them to pay for their
parent’s assisted living care out of their ❖ What happens if your health prob-
own personal funds. Make sure the
lems become more serious? Will
Agreement is completely clear about the
the facility keep you on with private
financial obligations of anyone signing
nurses in attendance or will they
the Agreement as an “agent,” “personal
require you to move to a more
representative,” or other similar phrase.
intensive health setting?
30 - Assisted Living in Maryland: What You Need to KnowDoes the resident agreement clearly and make sure the Residence Agree-
describe: ment is clarified in writing to your
satisfaction.
❖ What services are provided for the
basic (usually monthly) fee? What to Check For - Services
❖ What services are available for an Levels of Care
additional charge? As explained more
❖ The amount of each additional fully in Chapter
charge? One, assisted living
❖ Whether there is a charge to hold a facilities may be
bed during an absence? licensed to provide
√
❖ A refund policy in cases of trans- up to three levels of
fers, discharges, changes in owner- care to their resi-
ship, or closing? dents: a low level of
❖ Behaviors, conditions, or other care, a moderate level of care, or a high
circumstances that may result in level of care. Levels of care are set
termination of services’? based on an assessment of what ser-
❖ The type of living unit you will vices a resident needs. The Agreement
have? must explain what levels of care the
❖ Rights of residents? facility is licensed to provide. If you
❖ A grievance procedure; and alterna- move into a facility licensed to provide
tives if you are not satisfied with the low or moderate levels of care, and you
results of a grievance? later require a high level of care, the
❖ What, if any, initial payments are facility may no longer be able to pro-
required (e.g. entrance fee, deposit, vide you care. The Agreement should
move in fee, community fee, activ- explain how your level of care will be
ity fee, security deposit, etc.)? determined, how often your level of
❖ What happens if your funds run care is reviewed and by whom, and who
out? can change your level of care.
❖ Internal relocation policy?
❖ When any refunds will be paid? Assistance with Activities of Daily
❖ What happens if you have to leave Living
the assisted living facility for a You should be informed of exactly what
medical emergency? Do you get services are available, what level of
your money back? assistance will be provided, and at what
cost. The Agreement should at least
If after reading the Resident Agreement promise assistance with the following
carefully the answer to any of the above activities if you need them: eating,
questions is “No,” be wary. Raise your bathing and grooming (including
concern with the provider’s manager brushing teeth, shaving, and combing
Assisted Living in Maryland: What You Need to Know - 31hair), dressing, toileting, and mobility. Laundry/Housekeeping
Often, facilities will provide different The Agreement should explain how
levels of assistance depending on your often laundry and housekeeping is
level of care, and charge different rates provided, and whether these services
for each level. Some facilities may are included in the basic monthly fee.
charge a separate fee for additional help Does the provider provide linen service
with some activities. only, or will it handle your personal
laundry? Are washing machines avail-
Health/Medical able on the premises? Are the machines
Care coin-operated?
The Agreement
should explain what Transportation
type of assistance The Agreement should discuss transpor-
with medications is available, such as tation services. Do transportation
verbal reminders or hands-on assis- services cost extra? How often is
tance. The Resident Agreement should transportation provided (daily, weekly,
also explain whether doctors and other evenings, or weekend), and to where
health care professionals come to the (grocery stores, shopping malls, indi-
facility or whether the facility will help vidual medical appointments)?
you arrange transportation for your
doctor visits. What to Check For—Fees
and Payment
Meals Monthly Fees
Meals should be Most facilities charge a basic monthly
available three fee which covers your room and some
times a day, services. The challenge is to make sure
seven days a you understand which services are
week, and there covered by the basic monthly fee and
should be additional snacks each day. which are not. The Resident Agreement
The Agreement should explain how you should explain exactly what services
are charged for meals. Usually they are are included in the monthly fee, and
included in the basic monthly fee. The whether you pay extra for services, such
Agreement should also state whether as personal laundry, housekeeping, or
meals are provided in the dining area transportation. Are utilities, such as
only or whether you may be served in telephone, cable television, water, gas,
your room in certain circumstances. and electricity included?
Are there designated meal times, or can
you eat at another time if you wish? Are different fees charged depending on
Will your dietary preferences be consid- your level of care? In other words, will
ered? What about medically required your basic monthly fee go up if you
special diets?
32 - Assisted Living in Maryland: What You Need to Knowchange from a level one to a level two that you must give the provider not less
classification? With most assisted living then 30 days notice if you decide to move.
providers, your monthly fee will be higher The Agreement must also explain whether
if you start receiving a higher level of care. any portion of a fee may be refunded, and
under what circumstances.
“Fee for Service,” Prepaid Fees, and
Other Fees If the Facility Decides to Terminate the
A Resident Agreement must explain all Contract
fees that you may be charged for The Resident Agreement must explain
services that are not included in the circumstances under which a
the monthly fee. It must facility may discharge you. One such
also explain whether reason is if you require a higher
there are any other level of care than the facility is
costs or initial fees, licensed to provide. At times,
such as “entrance fees,” a provider may obtain a
“security deposits,” “wait- waiver from the State to
ing deposits,” or “mainte- keep you in its facility, if
nance or repair fees.” If there you need a higher level of
are refundable fees, check to see care than the level for which the
if there are any hidden costs or provider is licensed and you do not
restrictions to terminating the con- want to move.
tract that would limit the amount of, or
prevent you from getting, your refund. If a provider decides to discharge you
without your consent, it must give you at
Rate Changes least 30 days notice, except in a health
The Agreement must explain whether fees emergency or if there is a substantial risk
may be increased over time, and under to the health or safety of other residents or
what circumstances. Maryland law staff. The Resident Agreement should
requires that you be given at least 45 days clearly explain the procedures the facility
written notice before any rate increase. If will follow if it decides to discharge you or
the cost of your care increases because terminate your Agreement. Is there an
you need a higher level of care, that is not internal appeal process? If the facility is
considered a rate increase. discharging you because you need more
care (such as nursing care), will it help you
What to Check For—Termination arrange for care at another facility? Will
and Discharge there be any refund of any fees?
If You Want to Terminate the Contract
The Resident Agreement should explain
the termination requirements, for example
Assisted Living in Maryland: What You Need to Know - 33BEFORE YOU SIGN A RESIDENT
AGREEMENT, YOU SHOULD—
1. Get a copy of the Resident Agreement ahead of time and read it in the privacy of your own
home. If the facility will not give you a copy, ask why not. You should reconsider whether
you want to live at such a facility.
2. Ask a lawyer to review the Agreement with you or get advice from any of the agencies listed
in this booklet in Chapter 9. You may also be eligible because of age or income to get free or
reduced fee legal information or assistance. Contact the Maryland Senior Legal Hotline at
(800) 999-8904 for more information.
3. Ask the assisted living facility about any part of the Agreement you find confusing or unfair.
If you change the terms, be sure that both you and the facility representative write your
initials and the date in the margin next to each change.
4. Make sure that there are no blank spaces and that the contract is complete and correct at the
time you sign it.
AFTER YOU SIGN AN AGREEMENT, YOU SHOULD—
Get an original signed copy (or a photocopy) of the contract after it has been filled in and signed
by both you and the facility representative.
The Office of Health Care Quality does
not require that a provider obtain the
Office’s approval before the provider
begins to use a Resident Agreement.
However, if you believe that a Resident
Agreement includes illegal terms, or
that it does not meet all legal require-
ments, call the Office of Health Care
Quality at (410) 402-8217 or toll free at
1-877-402-8220.
34 - Assisted Living in Maryland: What You Need to KnowYou can also read
