Assisted Living

Assisted Living in Minnesota
Assisted Living Checklist
Choosing Assisted Living - What Do I Need to Know?
Minnesota's Housing-with-Services Contract Act
Minnesota's Housing-with-Services Contract Act - Questions and Answers
Minnesota's Revolutionary Approach Toward Assisted Living
What Minnesota Consumers Should Know About Assisted Living

ASSISTED LIVING IN MINNESOTA
Contrary to popular belief, assisted living is a service concept, not a "place." In Minnesota, assisted living encompasses a wide range of building types and service packages. A variety of settings offering assisted living services are available, giving consumers a wide range of options:

• Some market rate apartments have been designed specifically to serve frail seniors, while other "independent" buildings have made assisted living services available to residents who are "aging-in-place";
• Some subsidized apartment buildings now make assisted living services available to their residents who are aging-in-place;
• Licensed board and lodging establishments, which offer private or semi-private rooms without kitchens and basic services such as three meals per day and housekeeping, may also provide a full range of health-related assisted living services;
• Licensed adult foster care homes offer a full range of services to consumers who want a very small, home-like setting. A few adult foster care "suites" have been created within larger apartment buildings. Most of the corporate foster care homes in Minnesota are designed specifically to serve those with memory loss.

The service packages in these buildings can range from very light care to a full range of supportive and health-related services. Light care programs typically offer 1-2 meals per day, housekeeping, some assistance with activities of daily living (ADLs), assistance with transportation and laundry, recreation and socialization activities, and emergency call service. In addition to these services, more service-intense programs serving a very frail population usually provide all meals plus snacks; a full range of home care services, including medication administration and assistance; assistance in making and traveling to medical appointments; 24-hour staffing; and more.

Minnesota's system to insure quality for consumers living in these settings and using assisted living services has two components:

1) Building Requirements. Any building serving seniors that offers or provides certain supportive services or any type of health-related (i.e., home care) service is required to register with the Department of Health and must have a written contract with all residents. The contract must cover 17 pieces of information needed by consumers, such as:

• what services are included in the basic rent and what are available for an additional fee;
• how to amend the contract;
• how to make complaints;
• what criteria residents must meet in order to live in the building; and more.

In addition to this contract, buildings must comply with building/fire codes, must have a licensed kitchen in order to prepare congregate meals, and must meet a variety of other state and federal statutory requirements. Board and lodging establishments and foster care homes must carry a state license.

2) Service Requirements. Any health-related services provided in these buildings, such as help with dressing, grooming or bathing, assistance with self-administration of medications, administration of medications, central storage of medications, or other nursing or delegated nursing services, must be provided under a Minnesota Department of Health home care license. A home care license may be obtained by the same entity that owns the building, or the building may develop an arrangement with an outside home care agency to provide the assisted living services.

Source: Minnesota Health & Housing Alliance

CHOOSING ASSISTED LIVING - WHAT DO I NEED TO KNOW?

If you are thinking of a move to assisted living for yourself or a family member, how do you know the most important questions to ask? What key information will tell you whether a particular assisted living program is right for you or your loved one? How do you choose from among the many options available? Although you should think about your own needs and preferences and develop your own questions, the questions below focus on some key concerns that many consumers feel are important in making an informed decision on assisted living.

Rent and Other Fees

• What is the rent or monthly fee? If my need for services stays about the same, how much should I expect to pay in the next year toward rent or monthly fees?
• How often does the rent increase? What have the rent increases been over the past two years?
• What services are included in the rent or monthly fee?
• What services cost an additional amount, and what are those fees?
• How often do these additional fees increase, and how much have these fees increased over the past two years?
• How much notice will I get before the rent or other fees goes up?
• What kind of payments do you accept? Private insurance? Medicaid? Medicare? Group Residential Housing? Other? Can my family help pay for my services?
• If meals are included in the rent, do I have to pay for meals that I don't eat?
• Do I have to pay for rent or services for times that I'm away, for example, out of town or in a hospital or nursing home?
• What additional costs above the rent or fees we've discussed should I plan on?
• What happens if I run out of money?

Services Available

• What is the meal plan? Is there a choice of menu items? Can my family join me for a meal? What is the cost?
• Who decides what services I need? What if I disagree? What if I can't pay for these services? Can I refuse to take services you think I should have?
• Can I include a family member in discussions about my services? Will you have regular meetings about the services I need with my family and me?
• Who decides when my services will be scheduled? What if I want to make a change in the schedule?
• What types of staff provide these services? What type of training is provided to various types of staff? Who supervises the staff and how often?
• Are caregivers in the building round-the-clock? Can I get help any time, day or night? How do I call for help?
• When is a licensed nurse in the building?
• Are there services I might need that you don't provide? Can I hire someone else to provide these services?
• Do you provide special services for those with memory loss? If so, what are those special services?
• Do you serve people who wander or have behavior problems? How do you handle these problems?

Moving Out

• If I decide to move out, for example, to another assisted living or to a nursing home, how much notice do I have to give?
• If I have to go to the hospital or a nursing home for a while, can my room be held for me?
• Can you ask me to move out? Why would you ask someone to move out of the building?
• If I need to move, does anyone help me find a new place to live? How much time will I have to make these arrangements?

Other Questions

• Who can help me if I have a problem or complaint? What if I'm not satisfied with the response?
• If I have to share a room, who picks my roommate? What if we don't get along? What if I need some privacy for family visits or when I'm receiving services?
• Can I lock my door or protect my personal things? How is my medication safeguarded?
• What other safety measures does the building provide?

You should be able to find answers to most of these questions in the assisted living provider's housing-with-services contract, lease or other written documents. Be sure to ask to see these materials and review them with the provider.

There are many other questions you may want to ask when you visit a particular assisted living program. You will find that each program may be very different in the services provided, the costs and the pricing. To help you keep track of information as you compare assisted living programs,

Source: Minnesota Health & Housing Alliance

MINNESOTA'S HOUSING-WITH-SERVICES CONTRACT ACT
The Minnesota Health & Housing Alliance developed the Housing-with-Services Contract Act to create a new model for quality assurance in residential settings serving frail seniors. In looking at how to provide the necessary consumer safeguards for assisted living, MHHA's research showed widespread consensus that neither consumers nor providers wanted to impose an institutional, nursing-home style regulatory system on Minnesota's assisted living communities. Much of assisted living's popularity with consumers stems primarily from the fact that it has an emphasis on independence, choice, flexibility and individualized services.

Thus, the quality assurance model created by the Housing-with-Services Contract Act, passed in 1995 and effective in 1996, takes a consumer-driven approach. It uses contracts between the housing provider and the consumer or resident as the primary mechanism for quality assurance. Through the process of reviewing the information in the contract and negotiating any items that may vary from one resident to another, consumers are provided the information they need to make informed decisions about where they want to live and the services they choose to use. Once the housing contract is signed, the consumer has a legal document that sets out standards for the housing-with-services provider and, if necessary, can use the legal system if the provider fails to meet those promised standards.

In Minnesota's system, if the resident wants to obtain health-related services from a home care agency, the resident has a separate contract with important information, such as the services that will be provided, the cost of the services, which staff will provide the services, who will supervise the services and how often. The owner of the residential building may carry a home care license, or home care services may be available from a separate organization. Either way, residents will have the opportunity to work with the home care staff to negotiate and plan their services.
While the overall quality assurance mechanism for housing-with-services is under the control of the resident, the Minnesota Department of Health (MDH) does step in to regulate and inspect health-related (home care) services. In addition, MDH has the authority to intervene if it appears that a building is out of compliance with the Contract Act or Minnesota's 2006 assisted living law. There are other laws and government agencies with an interest in the wellbeing of housing-with-services residents. These include the Vulnerable Adult Act, Tenant-Landlord law, fire and building codes, and others.

Unlike other states, Minnesota neither requires housing-with-services establishments to conform to specific physical plan specifications, nor does it mandate a specific package of services that can be provided. As long as building code and occupancy requirements are met, buildings may serve as few as five residents in a small, home-like setting; may offer private or shared sleeping rooms in settings where all meals are provided in a congregate dining area; or may serve hundreds of residents living in private apartments. Providers are free to design their buildings, to choose from an array of possible "supportive" and "health-related" services, and to develop their own service packages based on the needs of their community and their target market. This means that a variety of options--some providing only a little assistance and some that provide very "heavy" care--are available to consumers.

In understanding all of the potential options, consumers can rely on the written contract to explain exactly what a particular setting provides and any of its specific requirements and procedures, as well as the knowledge that the state will oversee the quality of any health-related services. In addition, as part of Minnesota's assisted living law, buildings that offer assisted living services soon will be required to complete a standardized form called the Uniform Consumer Information Guide. This guide includes information that consumers can use to decide which providers they want to visit and learn more about. The standard format of the guide will enable consumers to more easily compare several different buildings and their services. Finally, the guide includes helpful information and resources about consumer rights. Assisted living providers must begin distributing the completed Uniform Consumer Information Guide by January 1, 2008, but many providers will have it available before that date.

What Does the Housing-with-Services Contract Act Require?
The Contract Act applies to most types of residential settings not licensed as nursing homes that: (1) primarily serve persons age 55 and older; and (2) arrange or directly provide two or more supportive services or any health-related services to residents.
Supportive services are defined in the Contract Act as:

• help with personal laundry;
  
• handling or assisting with personal funds of residents; or
  
• arranging for medical services, health-related services, social services, or transportation to medical or social services appointments.

Health-related services include:

• professional nursing services;
  
• home health aide and home care aide tasks performed by unlicensed staff (as defined in the Minnesota home care rules); and
  
• the central storage of medications for residents.
  The Contract Act requires all housing-with-services establishments to:
  
• register each year with the Minnesota Department of Health for a $35 fee;
  
• execute a written contract (lease) with all residents of the building; and
  
• obtain a home care license if the establishment will directly provide any health-related services.

In addition to being consistent with Minnesota's tenant-landlord statutory requirements and other statutory requirements for contracts (e.g., "plain language"), the establishment's contract with residents must address 17 specific pieces of information:

1. Name and address of the establishment;
   
2. Name and address of the owner(s) of the establishment;
   
3. Name and address of the establishment's managing agent, if different from the owner(s);
   
4. Name and address of at least one person authorized to act on behalf of the owner(s) or management agent;
   
5. Statement describing the registration and licensure status of the establishment and any provider providing health-related or supportive services under an arrangement with the establishment (e.g., restaurant license, home care license, housing-with-services registration);
   
6. Term of the contract;
   
7. Description of the services to be provided to the resident that are included in the base rate to be paid by the resident (i.e., services included in the basic monthly charge);
   
8. Description of any additional services, including home care services, available for an additional fee from the establishment directly or through arrangements with the establishment and a schedule of fees charged for these services;
   
9. Description of the process through which the contract may be modified, amended or terminated;
   
10. Description of the establishment's complaint resolution process available to residents and the toll-free complaint line for the Ombudsman for Long-Term Care (1-800-657-3591, TDD/TTY call 711);
    
11. The resident's designated representative, if any;
    
12. The establishment's referral procedures if the contract is terminated;
    
13. Requirements of residency used by the establishment to determine who may reside or continue to reside in the building;
    
14. Billing and payment procedures and requirements;
    
15. Statement regarding the ability of residents to receive services from service providers with whom the establishment does not have an arrangement;
    
16. Statement regarding the availability of public funds for payment for residence or services in the establishment; and
    
17. Statement regarding the availability of and contact information for the county long-term care consultation services.

In addition to these requirements, if the housing-with-services establishment has an arrangement with a home care provider to provide services to residents, then the establishment must give the following information about the home care provider to prospective residents:

1. the name, mailing address and telephone number of the home care provider (including the establishment's own agency if it holds a home care license);
   
2. the name and mailing address of at least one person who is authorized to accept service of process on behalf of the home care agency;
   
3. a description of the process through which a home care service agreement or service plan between a resident and the home care provider may be modified, amended or terminated;
   
4. The arranged home care provider's billing and payment procedures and requirements; and
   
5. Any limits to the services available from the arranged home care provider.

MINNESOTA'S HOUSING-WITH-SERVICES CONTRACT ACT - QUESTIONS AND ANSWERS

Why was the Housing-with-Services Contract Act needed?
Beginning in the mid-1980s, the state was increasingly concerned that many frail elderly persons who once would have lived in nursing homes were now living in a variety of unregulated residential settings (senior housing). In order to assure that these frail persons receive appropriate and adequate services, the Minnesota Department of Health proposed that many of these settings be regulated as residential care homes, with requirements modeled after nursing homes. After reviewing this institutional type of regulatory system, MHHA met with hundreds of providers, consumers and others and concluded that a consumer-driven model, using the well-understood concept of a legal contract, would be preferable. This model makes a distinction between the building and supportive (non-health related) services-which are monitored primarily by the consumer-and health-related or home care services-which are licensed and surveyed by the Minnesota Department of Health.

How does this differ from the traditional model?
Traditionally, when residentially-based services for the elderly have been regulated, the government has assumed the role as chief decision-maker. The classic example is the Minnesota nursing home, in which government determines the physical plant specifications, the services to be offered, the clientele to be served, the qualification of the employees, and the amount the residents may be charged for their care. Under the Housing-with-Services Contract Act, existing fire codes, building codes, consumer protection laws, licensure requirements, and professional standards continue to apply, but no new regulatory requirements are created that mandate specific types of buildings, service packages, or clients. Decisions on physical design and amenities, service configuration, admissions requirements, and price are decided by the consumer and the provider.

Doesn't this leave the consumer unprotected from unscrupulous or inept operators?
The state and federal government have many protections in place for its consumers, including those living in HWS settings. The Minnesota Department of Health, using its home care licensing requirements, controls who may provide health and personal services, sets the minimum standards they must meet, and provides a method for handling problems. Current fire codes, building codes and occupancy requirements address issues of life safety in the buildings. The Fair Housing Act, the Americans with Disabilities Act, landlord-tenant law, the Vulnerable Adults Act, consumer contract law, and civil remedies are all examples of protections that currently and adequately protect individuals in HWS and other residential settings. In addition, the Contract Act spells out the need for the specification of dispute resolution measures. Finally, the Contract Act gives the Minnesota Department of Health standing to bring action against any provider for non-compliance.

In order to have a valid contract between a provider and a resident, the resident must be competent. Aren't most of the residents of these buildings frail, vulnerable and incapable of making decisions?
It cannot be assumed that just because residents are elderly that they are vulnerable or incapable of making decisions, and vulnerability should not be confused with incompetence. While it is true that questions of competence occur more frequently in these settings than in other types of housing, to assume that all residents are incompetent would result in a system where autonomy and choice are replaced by dependence and loss of options. In those cases in which the individual's capacity is not sufficient, society intervenes in various ways, through family members, friends, neighbors, guardians, providers, the court and government agencies. While on the surface, this may not appear to be a very efficient system, it enables society to develop unique solutions to individual problems and situations, allowing individuals to retain as much autonomy and independence as possible.

But what happens to those persons who are incompetent in this system?
First of all, the Contract Act makes specifically allows residents to designate a representative to assist them in making decisions and negotiating the contract with the provider. Frequently, a family member provides this assistance, and in cases where the court has determined that an elderly person is not competent, a legal guardian or other court-appointed representative would work with the provider and sign the contract. Where a consumer's capacity to make decisions is in question, there are a variety of entities that may become involved such as family and friends, county adult protection, the individual's physician and other health-care providers, the Ombudsman's' office, the courts, and others. A number of other laws, such as the home care law and the Vulnerable Adults Act provide protections to residents who may be incompetent.

In some cases, don't we need government to step in and close down a bad provider?
The Contract Act, along with other laws and rules, allows government to step into such situations by enforcing the Vulnerable Adults Act, the home care law and licensure requirements, building and fire codes, and other existing state and federal laws. However, it is rare that government goes to the extreme (and time-consuming) measure of shutting down a bad provider. Instead of giving government the unilateral power to control a provider's quality, the Contract Act also gives consumers, using their contracts, an ability to hold providers accountable for the promises made about services that will be provided. Residents needing assistance in holding a provider accountable can receive help from a variety of sources, including family members, mediators, the Ombudsman, legal aid, and the courts. By using informal and formal means of negotiating with providers and, in extreme cases, taking the provider to court, consumers can enforce their own quality standards effectively.

The consumer wants it. It keeps the primary decisions about where to live, what services to purchase, and whether the provider's services are satisfactory with the consumer, rather than with the government. In addition, it uses the mechanism of the contract-a concept that consumers understand and are able monitor themselves. It provides more flexibility in responding to consumer preferences. It promotes autonomy and independence.

Why do it this way?

What buildings and providers are covered by the Contract Act?
The Contract Act applies to a variety of residential settings for the elderly-senior apartments, board and lodging and corporate adult foster care homes-where health-related services or specific types of supportive services are offered or provided. Senior residential buildings that neither provide nor arrange any health-related or supportive services specified in the Contract Act (e.g., senior apartment buildings where the residents themselves arrange for all of their own services from an outside provider) are not covered. Under 1999 legislation, non-certified boarding care homes were also covered by the Contract Act, although certified boarding care homes as well as nursing homes continue to be exempt. Also exempt are: supervised living facilities; board and lodging facilities with a Minnesota Department of Human Services program license (e.g., Rule 36 facilities); shelters for battered women and similar settings; family adult foster care homes; condos and coops; home-sharing arrangements; and private homes in which the residents receive services from family members.

What services trigger the requirement that a housing provider register with the Department of Health and execute a contract with all residents that complies with the Contract Act?
If at least 80 % of the housing establishment's residents are 55 years of age or older and the establishment offers or provides one or more health-related service or two or more supportive services listed in the Contract Act, it must comply. The Contract Act covers both buildings that directly provide services and those that arrange for services to be provided by another entity. Under the Contract Act, health-related services are defined as: professional nursing services, home health aide tasks and home care aide tasks (as defined in the home care rule) and the central storage of medications. The Contract Act defines supportive services only as: (1) arranging for medical services, health-related services, social services or transportation to medical or social services appointments; (2) help with personal laundry; or (3) handling or assisting with personal funds of residents.

What is a housing establishment covered by the Contract Act required to do?
The building must execute a contract with each resident. The contract and its supporting documents must address each item identified in the Contract Act, such as a listing of the services to be provided to the resident, the fee schedules, the billing arrangements, the process to modify or terminate the contract, etc. For many buildings, the existing lease will address many, and perhaps all, of the elements. The building must register each year with the Minnesota Department of Health and pay an annual $35 registration fee. The registration provides some basic information such as the name and address of the owner(s) and management agent. If the building directly provides any health-related services, it must obtain a home care license that covers these services. The building may also choose to have these health-related services provided by another agency with a home care license.

What is the role of the Minnesota Department of Health under the Act?
MDH receives the registration forms submitted by establishments covered by the Contract Act. If MDH receives information that an establishment or a service provider has failed to comply with a legal requirement, MDH must refer the issue to the appropriate governmental agency. MDH may also make referrals to other public or private agencies that may be able to assist or mediate. In these efforts, the Department can communicate with any of the affected parties. In case of a serious problem that cannot be resolved in other ways, the Commissioner of Health has standing to bring an action for injunctive relief in the appropriate district court to compel the establishment to meet the requirements of the Contract Act or other applicable state, county or local requirements. Finally, MDH licenses and surveys any health-related services provided in these settings under the home care law.

What are some of the other laws that apply to establishments covered by the Contract Act?
In addition to the requirements of the Contract Act, these establishments are also covered by a variety of other state and federal laws, such as Minnesota's Vulnerable Adults Act, the Nurse Practice Act, landlord-tenant law, criminal background check laws, contract law, and civil rights laws such as Fair Housing and the Americans with Disabilities Act. State and local building and fire codes, lodging licensing, food/restaurant licensing, adult foster care licensing, zoning and other local requirements would also continue to be applicable.

Source: Minnesota Health & Housing Alliance

MINNESOTA'S REVOLUTIONARY APPROACH TOWARD ASSISTED LIVING

With the passage of the Housing-with-Services Contract Act, Minnesota initiated a revolutionary approach toward quality assurance in assisted living settings. Taking a different path than most states and diverting from its traditional approach to quality assurance measures, Minnesota made a conscious decision to avoid a detailed, prescriptive regulatory system. In addition, Minnesota chose to avoid a narrow and prescriptive definition of what is and isn't "assisted living." Instead, Minnesota adopted a flexible, consumer-driven model based on the concepts of consumer choice and negotiated risk that allows consumers and providers to select from a variety of physical settings and service packages (and enables providers to develop new configurations not yet seen). This new approach is particularly remarkable in Minnesota, which has a tradition of extremely detailed and strict regulatory standards, as evidenced in both state nursing home and home care requirements-which go far beyond most states' level of regulation.

Quality Assurance Under The Housing-with-Services Contract Act Model

Under the Contract Act, which became effective in 1996, the primary quality assurance mechanism is a written contract between the housing-with-services establishment and the resident. This contract must address 17 items specified in law, although no specific format is required. These 17 contractual items are intended to assure that the establishment provides prospective residents with all the information they need to make good decisions about where to live and what services to purchase. These items include: information about the owner and manager of the building; what services are available; the fees for the services; how to amend or terminate the contract (e.g., the process the establishment will follow when changing its fees); how to make complaints; the term of the contract; the establishment's continued stay criteria, if any; billing and payment procedures; and the availability of public assistance at the setting. The state does not approve these contracts but may review them upon request. The Contract Act gives the Minnesota Department of Health the authority to intervene if there is evidence that the establishment is not meeting the requirements of the Contract Act or other state or federal law.

Armed with the information in the written contract, the resident is empowered to take action if the establishment fails to live up to its promises. If the establishment fails to live up to its promises or if its services are adequate, a resident can take steps to enforce the contract-negotiating with the provider and, if necessary, going to court. State agencies may get involved anytime there are violations of state law-if there is abuse or neglect of a vulnerable adult, for example-and the services of the ombudsman or others may come into play in negotiations between the establishment and a resident. However, consumers play the primary role in determining whether the provider is meeting its contractual obligations.

The Contract Act covers a broad spectrum of senior housing in Minnesota. "Housing-with-services establishments" are defined as residential settings in which 80 percent or more of the residents are age 55 or older, and which offer or provide for a fee (either directly or indirectly through a contract with another provider) either:

1. two or more supportive services; or
2. one or more health-related services.

The term "housing-with-services establishment" was chosen because it is general and can apply to a wide range of settings and levels of services. Furthermore, it avoids the confusion that would be created by using a term like "assisted living," which has been defined and used in a variety of ways by regulators and developers.

Supportive services that trigger the Contract Act's requirements are narrowly defined to include only:

1. help with personal laundry;
2. handling or assistance with personal funds of residents; or
3. arranging for medical services, health-related services, social services, or transportation to medical or social services appointments.

Very purposefully, housekeeping services, meal programs, routine van transportation to shopping or recreational activities were not defined as supportive services that would obligate a provider to meet all the requirements of the Contract Act.

Health-related services in housing-with-services establishments include:

• professional nursing services;
• nursing services delegated to aides (such as medication administration, bathing and other personal cares);
• other services that may be performed by paraprofessional staff (such as escort services, reminders, and stand-by assistance with dressing or grooming); and
• central storage of medications.

The Contract Act requires that any entity providing health-related services in a housing-with-services establishment must do so under a Minnesota home care license or other appropriate license. When Minnesota's home care license requirements were implemented, only services in single-family homes and apartments were covered. Although the Contract Act created no new licensing program, it did extend the existing home care requirements over some additional types of residential settings (e.g., board and lodging establishments and adult foster care homes, if they meet the Contract Act criteria).

While the overall quality assurance mechanism for housing-with-services is under the control of the resident, the state does step in and regulate health-related services, which are considered to be especially risky and critical to the well-being of frail residents. Unlike other states, Minnesota neither requires housing-with-services providers to fit into specific physical plant specifications, nor does it mandate a specific package of services that can be provided. As long as building code and occupancy requirements are met, buildings may serve as few as five residents in a small, home-like setting; may offer private or shared sleeping rooms in settings where all meals are provided in a congregate dining area; or may serve hundreds of residents living in private apartments. Providers are free to design their buildings, to choose from an array of possible "supportive" and "health-related" services, and to develop their own service packages based on the needs of their community and their target market. This means that a variety of options-some providing only a little assistance and some that provide very "heavy" care-are available to consumers. In understanding all of the potential options, consumers can rely on the written contract to explain exactly what a particular setting provides and any of its specific requirements and procedures, as well as the knowledge that the state will oversee the quality of any health-related services.

Philosophical Considerations Underlying the Contract Act

The Minnesota Health & Housing Alliance (MHHA) developed the Housing-with-Services Contract Act over a four-year period in response to a proposed facility license that would impose nursing home-type standards on some types of housing-with-services settings. The proposed facility license would have mandated requirements for physical plant, service provision and staffing of affected buildings. Yet it was clear that these types of settings were proliferating precisely because of consumers' strong preference for home-like environments over highly regulated, institutional nursing homes. Instead of institutional standards, a more flexible and consumer-driven approach toward quality assurance was needed in these settings.

Four different quality assurance models-a contract approach, a traditional regulatory system, voluntary quality standards and a community standards approach-were evaluated through extensive meetings with providers, consumers and others. Ultimately, MHHA determined that our goals for a quality assurance system-and the goals expressed by consumers-could best be met through a model based on a written agreement negotiated between the establishment and the resident. First, MHHA wanted an approach that was flexible enough to meet the needs of very different types of communities and consumers and that would allow providers to be innovative and creative in meeting those needs. The contract approach clearly allowed for this type of flexibility, since no specific physical plant or minimal service requirements were mandated. Secondly, MHHA wanted to built on existing law and requirements, and avoid the creation of new and unnecessary regulatory systems, since Minnesota providers already operate in a highly regulatory environment. The contract approach enabled us to build on existing contract law, as well as other state regulatory requirements, without creating a new licensing system. Finally, MHHA sought a system that was consumer-driven and consumer-friendly. The concept of a contract-familiar to anyone who has ever purchased a house, taken out a loan, rented a car or apartment, or hired a contractor-met this final concern.

In our deliberations over this model, both consumers and providers identified choice as a value that should be a dominant aspect of any quality assurance system for housing-with-services providers. Important aspects of choice were:

1. People have a right to make choices for themselves.
2. People should be assumed to be competent to make their own choices. Those who may not be competent should receive assistance.
3. Consumers have a right to be educated and informed, including clear information on the provider's policies and procedures and the services they are purchasing.
4. Any system focusing on choices must consciously accept that choices entail risks and that consumers will sometimes make decisions that others perceive as "bad choices."

The primary premise underlying the contract model is that consumers are competent to make their own decisions if given adequate information. However, the question of competence was a difficult one. While it was clear that most residents in these settings will be competent, there will also be residents whose levels of competence vary and change over time. Although, as the Contract Act was developed, there was agreement that for anyone living in the community (whether in a single-family home or a senior housing setting) there must be a presumption of competence absent a court determination to the contrary, many regulators and providers nevertheless were uncomfortable with this assumption, knowing the frailty and limits of some elderly residents in these settings.

To resolve this dilemma about competence, MHHA compared the impact of the assumption of competence (as in the community) and the assumption of incompetence (as in an institutional setting) on the setting and its residents. Looking at nursing homes and other kinds of institutions, the presumption of incompetence quickly leads to a system in which residents' choices are restricted. The basic package of services presented to nursing home residents is based not on their wishes, but on their level of dependency and service needs as determined by "professionals," not themselves. Residents quickly lose control of many trivial as well as major decisions as the professional care-givers (or legislators and regulators) make choices about acceptable risks and the residents' well-being. It is in this type of institutional regulatory system that has resulted in survey citations of nursing homes for allowing residents to keep their own furniture, nicked from years of use in their own homes, and because residents continued to keep their toothbrushes in their bathroom cups as they always had done at home.

Outside institutional settings, where people are assumed to be competent, they continue to make decisions until family or friends decide that assistance is needed. Staff from a county or private agency may function as a surrogate decision-maker if there are no family or friends available, or there may be a court-appointed guardian. When someone's decision-making ability becomes impaired in the community, referrals and intervention may come in a variety of ways-through family and friends, doctors, clergy, professionals who are designated as mandatory reporters under Minnesota's Vulnerable Adults Act, and others. While the informal and formal support systems that can assist people living in the community with decision-making are not always clear nor always perfect, they generally seem to work well for most vulnerable people. Although it is possible that someone may "fall through the cracks," a system based on the assumption that consumers (or their designated representatives) are competent to make decisions about their living situation and services nevertheless seemed far preferable to the alternative-a system in which autonomy and choice are reduced for all just to insure that those who are not competent receive adequate care. Finally, we are forced to admit that even competent people may make "bad" decisions and to understand that no system that starts with choice as a fundamental value will be fail-safe.

Implementation of the Housing-with-Services Contract Act

Once providers, regulators, legislators and consumers came to a clear understanding that the choices inherent in the contract approach to quality assurance also entailed risks, the Housing-with-Services Contract Act was passed in 1995. The passage of the Contract Act meant that all parties-providers, consumers, legislators and regulators-had accepted the notion that, despite the risks, this was the best way to provide quality assurance in an industry that was still growing and developing new prototypes in response to its market. Minnesota's revolutionary move toward a consumer-centered system for determining acceptable quality-and away from a system tightly controlled by regulators-will not been an easy one. State agency staff, legislators, providers and consumers alike have been accustomed to a highly-regulated long-term care system where little is left to discretion, risk to consumers is minimized as much as possible, and there is much comfort in having everything spelled out in black and white. Under this new system based on choice and consumer control, residents are free to take risks, and some will choose to make decisions that professional care-givers believe are unwise. But older consumers have made it very clear that they want to retain their independence and the freedom to make choices and evaluate risks for themselves. As implementation of this quality assurance "experiment" continues, the challenge will be to see if regulators, providers, and even seniors' families are willing to give older consumers the choice and autonomy they so dearly want.

Source: Prepared by the Minnesota Health & Housing Alliance

WHAT MINNESOTA CONSUMERS SHOULD KNOW ABOUT ASSISTED LIVING

What is Assisted Living?

"Assisted living" is a coordinated program of services that can be found in a variety of residential settings for seniors. In Minnesota,these residential communities are called "housing-with-services establishments." These settings may be:

• Apartment buildings, where each resident has a private living space, kitchen and bathroom;
  
• Small homes, licensed as adult foster care homes, serving five residents or fewer and offering private or shared bedrooms and bathrooms and family-style dining;
  
• Small or large buildings, licensed as board and lodging, where residents have private or shared bedrooms and bathrooms and family-style dining; and
  
• Licensed boarding care homes with private or shared bedrooms and bathrooms and central dining.

If operators of these types of buildings advertise that they provide assisted living, they are required by Minnesota law to offer to residents at least the following services:

• Two meals each day;
  
• Housekeeping and laundry service available at least once a week;
  
• Help in arranging transportation to medical and similar appointments;
  
• Help in arranging social services and in accessing other community resources;
  
• Opportunities for socializing;
  
• Either assistance with self-administration of medications or administration of medications;
  
• Assistance with at least three of the following activities of daily living: bathing, dressing, grooming, eating, transferring, continence care and toileting;
  
• A system to check on each assisted living client at least daily;
  
• A system that enables assisted living clients to request and receive assistance with health or safety needs round-the-clock;

• An awake person, available round-the-clock to respond to assisted living clients' requests for assistance (In small settings with 12 or fewer clients, the person responsible for responding to requests is allowed to sleep if adequate safeguards are in place);
  
• Staff in an assisted living building must be able to reach a registered nurse 24 hours per day, seven days a week, regarding any health issue that may arise for a resident.

If you move to a setting that offers assisted living services, you are not required to use all of the services listed above. You can choose which services you want to receive. Many assisted living programs will offer many more services in addition to those minimum services listed above. Assisted living providers will provide you with a list of all the services they offer and the cost of these services.

If you move into a building with an assisted living program, you will pay a monthly base fee that covers your rent. Sometimes this monthly base fee will include some services, such as some meals or housekeeping services. In addition, you may have to pay additional fees for services not included in the monthly base fee--such as personal care services. Sometimes these additional services are "bundled" or grouped together and provided in "service packages," with a set charge for each type of package. Sometimes you may be able to purchase a single service for a set fee, "cafeteria style." As you consider assisted living services, be sure you get a good estimate of your total costs for rent and needed services. If you have limited resources, ask whether the provider accepts payments from any assistance programs and how to apply for these programs.

If you move into a building with assisted living services, you will probably sign many documents, including two types of contracts:

• You will sign a lease or residency agreement that lists the requirements you must meet to live in the building and spells out the services that the landlord promises to provide in exchange for the monthly rent or base fee.

If you will be using any personal care or health-related services, you also will sign a home care service plan or agreement that provides specific information about the services you are purchasing from the home care provider, which staff will provide the services, the cost of the services and more. The building owner or landlord may have a home care license and provide these services to you directly, or the landlord may arrange to have another agency with a home care license bring those services to you. If you need services that this provider doesn't offer--or you simply want a different home care provider--you can contract with another agency to provide the services you need. These documents are legal contracts and it is important to read them carefully and ask questions if there's something you do not understand. Many seniors ask a family member or trusted advisor to review these documents as well.

How Does Minnesota Regulate the Buildings Offering Assisted Living Services?
There are a variety of laws and regulations designed to protect the rights of people who live in senior housing and use assisted living services. Some of these requirements include:

• Minimum services that must be available in any building that advertises assisted living services, as well as other legal requirements for assisted living providers.
  
• Rights and responsibilities of both landlords and residents. A summary of these laws, Landlords and Tenants: Rights and Responsibilities, is available at
• Disclosure of written information on 17 important topics must be given to prospective residents by any housing-with-services establishment, including assisted living. This critical consumer information includes:
  • The basic monthly cost and what services are included What additional services are available and what these services cost
  • The building's residency requirements
  • Whether the building accepts any forms of public assistance, and more.
• Residential buildings offering memory care or dementia programs must give prospective residents and their families detailed, written information about the memory care program, such as specially-designed building features and memory care training given to staff. All of this required information is designed to give consumers the information they need to decide whether a program is right for them.
• Fire codes, building codes and other state laws are designed to make sure that the buildings people live in meet safety requirements. Some residential buildings are licensed as lodging establishments, adult foster care homes or boarding care homes and are inspected by the licensing agency. Kitchens where food is prepared for a number of residents must be licensed and inspected regularly.
• The federal Fair Housing Act and the Minnesota Human Rights Act prohibit discrimination in housing based on race, national origin, sex, disability, and other factors. The federal Americans with Disabilities Act provides additional protections for persons with disabilities. If you believe you have been the victim of discrimination, call the Minnesota Human Rights Commission at 651-296-5663 or 1-800-657-3704. [TTY: 651-296-1283.]

How Are Assisted Living Services Regulated?
Health-related services in an assisted living program--such as help with dressing, grooming and bathing or assistance with medications--must be provided under a Minnesota Department of Health (MDH) Class A or Class F home care license issued by the Minnesota Department of Health (MDH). MDH regulates and surveys home care providers. The license requirements spell out the services the agency is allowed to provide and all of the staff training, supervision and other requirements that the agency must follow.

Minnesota requires that a registered nurse (RN) must assess a client's needs and develop a home care service plan or agreement before staff provide any nursing services. The service plan describes all of the home care services to be provided, what they will cost and other important information. Assisted living providers are required to offer to have the RN do an assessment and develop a proposed service plan before the consumer makes a final decision about moving to an assisted living community. If you are considering an assisted living program, it's a good idea, if time and circumstances permit, to have this assessment completed before signing a residency agreement so that you have as much information as possible before making any final decisions. You can also request an assessment from your county's Long-Term Care Consultation staff.

If you receive home care services, the Minnesota Home Care Bill of Rights lists specific rights that you have as a consumer, such as:

• The right to choose your home care provider, within limits of insurance or financial assistance programs;

• The right to take an active part in developing your service plan;
• The right to know the charges for the services, and more.

Your home care provider will give you a copy of the Bill of Rights. In addition to the list of rights you have, the Bill of Rights includes information on how to contact the Office of Health Facility Complaints and the Office of Ombudsman for Older Minnesotans if you should have a complaint about your services. In addition to Minnesota's assisted living and home care requirements, home care providers must comply with other state and federal laws:

• If the home care agency is Medicare-certified, it must comply with federal Medicare requirements in addition to state licensing requirements.
• Registered nurses (RNs) and licensed practical nurses (LPNs) who provide nursing services and have supervisory and other responsibilities in home care agencies must comply with the Nurse Practice Act, monitored by the Minnesota Board of Nursing.

Other services that are part of an assisted living program and other staff working in these programs may be covered by other state license requirements. Social workers, van drivers and even barbers and beauticians must be appropriately licensed by the state.

Other Protections for Seniors in These Settings
Minnesota's Vulnerable Adult Act (VAA) provides important protections for adults who may be unable to provide for their basic care without assistance and who may not be able to protect themselves from maltreatment. The VAA requires certain professionals, such as home care staff and social workers, to report suspected maltreatment to the designated county agency for investigation. Consumers also may make VAA reports.

Other consumer protection laws include state laws dealing with "truth in advertising" and laws requiring criminal background checks on home care workers and certain housing staff.

Some seniors may want to identify a family member or other trusted person to help them make decisions about their services, where to live and their finances. This can be done informally, or you can work with an attorney and use a formal legal process to give someone you trust specific legal powers, such as a power of attorney. Under Minnesota's law for advance directives for health care, you can spell out the health care services you want or don't want, and can designate a "health care agent" to make decisions if you are not able.

Where to Get More Information or Assistance
Many resources are available to assist seniors in getting information about service options, obtaining needed services or enforcing their rights:

• If you need help in determining what services you need, where you can obtain these services, or help in paying for rent or services, call Senior LinkAge Line toll free at 1-800-333-2433. Senior LinkAge Line may direct you to your county's Long-Term Care Consultation staff for more specific assistance.
• The housing manager, nurse, social worker or other staff in your building may be able to help you access information or additional services that you need. If you have a concern or problem with your assisted living services, ask the housing manager or other designated housing staff member for assistance. Both your housing provider and your home care service provider must provide you with written information about their process for handling and resolving complaints.
• The Minnesota Office of Ombudsman for Long-Term Care can provide information about your rights and can act as an advocate for older persons. This office may be contacted toll free at 1-800-657-3591.
• Consumers with concerns about the services provided by a home care provider or assisted living program may also contact MDH's Office of Health Facility Complaints toll free at 1-800-369-7994.

Source: Minnesota Health & Housing Alliance

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