Frequently Asked Questions about Assisted Living

What is assisted living?
What does an assisted living residence look like?
What services are provided by an assisted living residence in Massachusetts?
What is Self-Administered Medication Management?
Are there different levels of care and services in Massachusetts’ certified assisted living residences?
Is assisted living the same as a nursing home?
What nursing services are provided in an Assisted Living residence?
What food services are available to Assisted Living residents? Are special dietary needs accommodated?
What additional amenities and services do assisted living residences typically provide?
Do I have to use the residence’s personal care services staff to provide services?
What is the role of the family in assisted living?
What are the specific rights of an assisted living resident?
What food services are available to Assisted Living residents? Are special dietary needs accommodated?
What are the criteria used to determine who an assisted living residence will accept? How does the decision get
made about when to move out?
May I bring my own furniture?
What about pets?
What does assisted living cost?
Who pays for assisted living? Are there programs that can help?
Who regulates assisted living residences in Massachusetts?
Can an assisted living residence meet the needs of someone with only minor or short-term memory loss?
What type of training is required for staff?
What activities do assisted living residences offer for people with memory loss? Are residents forced to participate?
Does assisted living offer support or supervision for residents who may be forgetful about taking medication?
What if an individual’s needs change? How will we know when it is time to move from a traditional assisted living residence?

What is assisted living? - ASSISTED LIVING residences are a special combination of housing and personalized support services designed to meet the needs— both scheduled and unscheduled—of those who require help with activities of
daily living. Activities of daily living include tasks related to bathing, dressing, grooming, eating, and other similar personal care needs. Assisted living is a residential option that promotes self-direction and participation in decisions regarding care and services. As a model of supportive housing, assisted living emphasizes independence, individuality, privacy, dignity, and choice. The assisted living package of services can be tailored to meet consumer needs and preferences.

What does an assisted living residence look like?
Assisted living buildings can range from a high-rise apartment complex to a converted Victorian home or a renovated school. Residences may be freestanding or on a campus with other residential options, such as independent living or nursing home care. They may be operated by non-profit organizations or for-profit companies. Most residences have between 25 and 120 apartments which may vary in size from a studio to a 2 bedroom apartment. There is no single blueprint for an assisted living residence, because consumers’ preferences and needs vary.

What services are provided by an assisted living residence in Massachusetts? Typically, “assistance” in these residences can be defined as help with the following: Activities of daily living (or “ADLs”), such as bathing, dressing, grooming, transferring (help with moving about), toileting, and meal reminders; Self Administered Medication Management (“SAMM”), which provides the resident with reminders and assistance in taking medication. Some assisted living residences also offer Limited Medication Administration (“LMA”), often for an additional fee, whereby certain medications may be administered by a nurse; Up to three meals a day served in a common dining room, and in some cases, additional snacks; Emergency call/response systems or other ways for staff to provide emergency help; Activities and programs tailored to seniors’ needs and interests, targeting health, exercise, ocialization, recreation, and wellness; Housekeeping services, which usually include housecleaning, laundry, and other needs, such as help with accessing dry cleaning; and Transportation services, which may include taking residents on group trips, shopping or to doctor’s appointments. Assisted living residences in Massachusetts offer such services in private or shared apartments in an environment with twenty-four hour per day onsite staff capability. Grounds keeping and maintenance services are also provided. Personal care services are provided by staff often known as resident care assistants. Many residences have specialized units for those with memory loss that provide special care programming as well as environmental and technological features to support resident safety and improved function.

What is Self-Administered Medication Management?
What is Limited Medication Administration? Self-Administered Medication Management (“SAMM”) means assisting a
resident to self-administer medication. Massachusetts’ assisted living regulations state that the staff person performing SAMM must follow four steps when assisting a resident with medications: remind the resident to take medication, check the package to be sure that the name on the package is that of the resident, observe the resident taking the medication and then document in writing the observation of the resident’s actions regarding the medication (e.g., resident took medication, resident refused medication, or resident not in apartment). The resident can request staff assistance to open prepackaged medication and/or containers, respond to questions about the directions on the label and assist with over-the-counter and as needed (“PRN”) medication, provided they are part of the SAMM plan. SAMM can only be performed by an individual who has completed SAMM training. Limited Medication Administration (“LMA”) is an optional service provided by some assisted living residences, often for an additional fee. LMA allows for the administration of medication to a resident by a family member, medical practitioner, or a registered or licensed nurse. Nurses with a valid Massachusetts nursing license employed by the assisted living residence may administer non-injectable medications prescribed or ordered by an authorized prescriber by oral or other routes (e.g., topical, inhalers, eye and ear drops, medicated patches, as necessary oxygen, suppositories). If the assisted living residence chooses to provide this optional service, LMA must be performed from any container that has been properly filled and labeled by an authorized pharmacy. All medication must be kept in the resident’s unit and stored in such a manner that the nurse can adequately verify the integrity of the medication. For more information about SAMM and LMA, review the
Disclosure Statement of the residence(s) you are considering.

Are there different levels of care and services in Massachusetts’ certified assisted living residences?
In Massachusetts, there is no formal certification of different levels of care and services in assisted living. Assisted living residences in Massachusetts provide a variety of services. One residence may offer only limited assistance, while
another may offer more comprehensive services. The services provided by assisted living residences often depend on the needs and interests of the residents. Some services may be included in the monthly fee and other services
may be offered on an “a la carte” basis. This wide scope of services means that you can choose the residence that best meets your specific needs.

Is assisted living the same as a nursing home?
An assisted living residence and a nursing home are different options available to elders and those with chronic health conditions who can no longer live independently in the community. While both offer personal care services,
assisted living residences provide a residential setting with apartment-style living for residents. This residential model provides freedom of choice, independence and a quality of life experience often similar to previous living arrangements.
Personal care services offered in assisted living cover a broad range of activities of daily life to assist the resident in maintaining the highest level of dignity and independence possible. An individualized service plan is developed
for each resident and is revised as new needs arise. The service plan assures that resident needs are identified and plans are implemented to meet those needs. Because assisted living staff are not permitted, per state regulations, to
provide 24-hour skilled nursing care services, a resident may bring in any services privately, such as hospice or a visiting nurse to provide assistance with skilled care. These private services would be at an extra cost to the resident.
Nursing homes provide 24-hour skilled nursing, rehabilitative services and extensive nursing assistance or intensive therapies for those who have on-going complex or unstable medical conditions.

What nursing services are provided in an Assisted Living residence?
Massachusetts’ assisted living regulations require that a nurse perform two
functions:
1. review residents’ service plans with the personal care workers who will provide personal care services to the resident, and
2. evaluate personal care services provided by personal care staff at least twice per year. Beyond these functions, nurses may also provide wellness services and limited medication administration but cannot provide skilled nursing services such as injectable medications. Some assisted living residences have nurses in the building more hours
than others; some have resident care directors/service coordinators who are not nurses. Therefore, it is important to ask about the nursing services that are and are not provided at each assisted living residence you are considering. Also
inquire about the hours when a nurse is available on the premises and what his or her roles and responsibilities are during that time. You can learn more about the nursing services that each particular assisted living residence offers
by reviewing the residence’s Disclosure Statement.

What food services are available to Assisted Living residents? Are special dietary needs accommodated?
Assisted living residences, including those offering specialized care programs, provide up to three meals daily for residents. In addition to regular meals, most assisted living residences also offer snack foods, as well as access to common kitchen facilities. Assisted living residences are required to offer basic dietary plans (for example, sodium restricted, sugar restricted, low fat) and typically offer a variety of food choices. Dietitians are available to work with residents who choose to receive counseling regarding dietary plans. If the potential resident has any special dietary needs beyond those basic diets, you will want to ask about the residence’s ability to meet those needs.

What additional amenities and services do assisted living residences typically provide?
Assisted living residences usually feature a common dining area and other kinds of common spaces; for example, a library, private dining room, country kitchen, or similar spaces available for use by all residents. Some residences
provide a small store, barber/ beauty shop, exercise room, banking, and similar conveniences on-site. Assisted living residences also offer a variety of social and recreational programs, often including activities for those with memory loss.
Many residences provide or arrange for regularly scheduled transportation. Staff may assist in arranging for transportation to personal appointments. Outside transportation services are available in many areas, and most residences are able to assist their residents in accessing these resources. For residents with memory loss, ask if the assisted living residence provides escort services for off-site trips and what are the fees associated with this service,
if it is available. You also may want to inquire about the level of supervision that is provided for activities outside of the residence.

Do I have to use the residence’s personal care services staff to provide services?
Residents have the right to have their personal care and companion services provided by the assisted living residence, their family or by any outside companion or provider of their choice. The residence may want outside companions or providers to register with the residence.

What is the role of the family in assisted living?
In assisted living, residents select and make arrangements for the services they may want or need, and may include family members in the decision making, service planning and service delivery process. For residents with memory loss,
family members may play a greater role. However, there may be circumstances, i.e., if a resident is determined to be incompetent to make decisions and direct care, when a legal guardian or representative must be appointed. Regardless of the resident’s level of cognitive ability, families can be an important part of the“service package” – coordinating healthcare appointments, driving residents to doctor’s offices, even providing some of the direct care, such as help with bathing.

What are the specific rights of an assisted living resident?
A resident has the right to receive a description of available services and charges, the right to participate in service planning, and confidentiality of health information. The resident will be given detailed information on “Resident Rights.”

What are the criteria used to determine who an assisted living residence will accept? How does the decision get
made about when to move out?
The individual, his or her family, and the assisted living provider jointly make decisions about whether that assisted living residence is right for a particular individual. Under Massachusetts regulations, the assisted living residence is required to gather information about each potential resident to assure that it can provide the services required by the resident, and that it has the right services and staffing to meet or help arrange for the individual’s needs. You may ask to see the residence’s Disclosure Statement, which describes such criteria. Some potential residents may not be accepted by an assisted living residence in the event that, after review, it is determined that the potential resident has skilled care needs that cannot be met by intermittent contractors, such as home health agencies. As a resident’s needs change, an assisted living residence may recommend that private services be obtained to support the care of the resident or that a more appropriate place be found for the resident. The decision to move from an assisted living residence to another setting is often a hard one for everyone involved, and is governed by sections of Massachusetts’ law and the terms of the residency agreement.

May I bring my own furniture?
Most assisted living apartments are not furnished, so you may bring your own furnishings. If furniture is provided by the residence, you will be encouraged to bring personal items and keepsakes.

What about pets?
Policies of assisted living residences regarding pets vary widely, so you should ask the assisted living residence you are
considering about its policy.

What does assisted living cost?
The cost of assisted living varies with each residence. It will depend on the size and location of the apartment and the amount of services needed by a specific resident. Monthly fees are based on rent, utilities, food, housekeeping,
personal care and other optional services and amenities. Assisted living costs are generally less than those for a skilled nursing facility because nursing homes are required to provide intensive, 24-hour skilled nursing and related care.
Different residences charge for rent and services in different ways. For example, some residences charge a basic monthly fee that includes some personal care services, while others have service packages, and yet others
charge separately for all services on an “a la carte” basis. There may be charges for items such as guest meals, room service, special recreational events, transportation, personal laundry, etc. Ask each residence under consideration
for a full disclosure of costs, including how and when costs may be increased. Most assisted living residences bill on a monthly basis. In Massachusetts, monthly fees range from approximately $2,000 to more than $7,000. Because
special care units and programs for people with memory loss and/or dementia provide additional staffing and services, they are typically at the high end of the fee range.

Who pays for assisted living? Are there programs that can help?
Most people in Massachusetts today pay privately for assisted living. However, some long-term care insurance policies are now offering coverage for some of the costs associated with assisted living. Coverage provisions vary widely, so
it is important to read and compare several policies carefully. In some cases, additional financial assistance programs may also be available through specific assisted living residences. There are limited public funds available that can cover a portion of assisted living fees for financially and clinically eligible individuals. Mass Health (Massachusetts Medicaid) has programs like Group Adult Foster Care (“GAFC”) that provides daily assistance with personal care services in an assisted living setting. It is best to check directly with each assisted living residence regarding its participation in Mass Health, both generally and in its specialized programs for memory loss and dementia. Please note that Medicare (the federal insurance program that provides healthcare coverage for the disabled and elderly) does not pay for the cost of
assisted living.

Who regulates assisted living residences in Massachusetts?
Because assisted living is defined differently from state to state, each state has its own rules and regulations governing the assisted living residences and the services that may be provided by such residences within its borders. In Massachusetts, assisted living residences are governed by Chapter 19D of the Massachusetts General Laws: An Act Establishing Assisted Living Residences. Assisted living residences in Massachusetts are certified and regulated by the Executive Office of Elder Affairs. (See Part Five for contact information for Elder Affairs.) Together, the assisted living statute and related regulations provide a process for certification for assisted living units and services and minimum standards and guidelines. In addition, the Nurse Practice Act, the Consumer Protection Act and anti-discrimination laws also pertain to the operation of assisted living residences. DEMENTIA is the medical term used for a group of symptoms and conditions that result in the often progressive loss of memory and other mental functions. The most common type of dementia is Alzheimer’s disease, which is characterized by structural changes in the brain, the accumulation of plaques and tangles, as neurons die in the brain. The next most common cause of dementia is multiple small strokes – multi-infarct dementia, or transient ischematic attacks (“TIAs”). Alzheimer’s disease and multi-infarct dementia also can occur together. People with Alzheimer’s disease or other forms of dementia have many symptoms, including difficulty with acquiring new information and creating new memories, “word finding,” and understanding people when they speak
with them. As the disease progresses, sometimes walking and other physical tasks become difficult. Some people with dementia dislike their increased dependence on others, or if they are in an environment that is too challenging, they may become frustrated, restless or depressed. Despite the losses they experience, most people who suffer from dementia maintain many strengths. In fact, throughout much of the experience of living with memory loss, dementia or
Alzheimer’s disease, people can perform some everyday activities, exercise, and pursue hobbies. They can continue to
experience joy, a sense of accomplishment and pride. And they can recognize love. Finding the right supportive residential setting for a person with memory loss and other symptoms of dementia is very important. Many assisted living residences are able to offer the kind of environment and services that the resident needs and wants. With the right care in the right environment, people with memory loss and dementia may continue to function and experience a
rewarding life well into the progression of their disease.

Can an assisted living residence meet the needs of someone with only minor or short-term memory loss?
Many residents with memory loss issues function well for a period of time with the support services offered in the traditional assisted living setting. The degree of memory loss is not the only important factor; other symptoms, such as lack of safety awareness, wandering and getting lost, trouble sleeping, or resisting help may influence what kind of setting works best. Assisted living staff in both traditional assisted living and specialized programs are trained to offer the special attention people with memory loss may need without taking away their independence. In an assisted living
environment, all residents are encouraged to make decisions and choices about their lives. It is important to remember that as a resident’s needs change, and memory loss worsens, safety and wellness issues need to be continually
monitored and services adjusted in a timely and appropriate manner. Residents and families need to be aware of the risks of a person with memory loss living in a traditional assisted living setting. For example, people with Alzheimer’s
disease may wander. Some assisted living residences are designed with enclosed areas that allow a person to wander safely. If a resident’s wandering is a risk to his or her safety, additional services or relocation to a more secure setting may be required.

What type of training is required for staff?
The Executive Office of Elder Affairs requires that all assisted living residence staff — as well as all contracted personal
care workers and providers who have direct contact with residents — complete orientation and ongoing training programs. Every Registered Nurse (“RN”) and Licensed Practical Nurse (“LPN”) who works in an assisted living residence
must be professionally trained and certified. Personal care workers must complete either a Certified Nurse Assistant (“CNA”) or Home Health Aide (“HHA”) training program or be trained by their company following a training
program with a set number of hours and topics per state regulations. Assisted living residences offering specialized programs for residents with memory loss often provide additional training to their staff. For example, uncertified or unlicensed personal care staff also must complete intensive trainings on topics such as dementia/cognitive impairment, a basic overview of the disease process, communication skills and behavior management. You should expect that these skilled professionals have been taught how to interact effectively with residents, how to motivate them and how to engage them in the world around them. As you choose an assisted living residence for someone with even mild memory loss or dementia, this is a particularly important issue to consider. Observe staff to see if they seem to have enough time to interact with residents in a friendly and relaxed way, and if they know how to communicate positively, even with a resident who may be difficult or disruptive.

What activities do assisted living residences offer for people with memory loss? Are residents forced to participate?
People with memory loss and dementia often have trouble organizing their time and initiating activities. Doing things that are meaningful and enjoyable are just as important to their well-being as they are for all of us. In addition, appropriate activities can help them maintain the highest level of functioning. Assisted living residences typically offer a range of social and recreational programs, and most will have some activities that are appropriate for cognitively impaired residents. Specialized dementia programs will often have additional activities that match the interests and abilities of those in the program. Staff will usually encourage residents to actively participate in programs based
upon their personal interests and ability. However, assisted living residences will not (and cannot) force a person to
participate. You will find that different residences have different approaches and philosophies about how much a resident should be encouraged to take part in activities. One service many assisted living residences provide is an escort service or reminder to help a person with dementia get to activities they are likely to enjoy.

Does assisted living offer support or supervision for residents who may be forgetful about taking medication?
Although each resident’s personal medications are stored in his or her own apartment, many residents with dementia need help remembering how much, or when, to take each drug. Assisted living offers assistance with medication
management through a program called Self-Administered Medication Management, or SAMM, as well as
via coordination with family members or other healthcare providers. At some point, many people with memory loss or dementia may require more assistance than can be offered under SAMM. It is helpful to ask the assisted living residences that you are considering how they might handle such a situation. Some residences also offer additional administration through a program called Limited Medication Administration, or LMA (also defined earlier in Part Two), usually for an additional fee. Some residences may or may not provide LMA, which requires a nurse to administer medications. As dementia progresses, some people with memory loss may no longer be able to self-administer medications, even with the help of the SAMM program. Therefore it is important to ask if LMA is offered at the residence
you are considering. The Disclosure Statement of each assisted living residence explains how that particular community handles its medication management services.

What if an individual’s needs change? How will we know when it is time to move from a traditional assisted living residence?
Alzheimer’s disease and most of the related disorders are “progressive” diseases — the symptoms will get worse
as time goes on. Be sure to consider this as you choose an appropriate setting. As the needs of an assisted living resident change, the assisted living staff will work with the resident, legal representative, family and his or her health
care providers to decide how to best assure that his or her needs are met. As additional services are required, residents and their families may elect or need to obtain services from an outside provider or agency. Payments for outside
services are the financial responsibility of the resident and are paid privately to the service provider and/or through other private or public resources. Most residences will work closely with a resident, legal representative,
family and his or her healthcare providers to try to maintain a resident in his or her apartment. However, this may not always be possible. An assisted living residence must consider the health and safety of all of the residents.
We suggest that you review a residence’s Disclosure Statement and its policy regarding changing care needs.
If it is not possible to obtain the services needed to keep a resident healthy and safe in the assisted living residence, it may become necessary to find a setting more appropriate to his or her needs. The assisted living residence staff
will help the resident, his or her legal representative, and/or family determine the best environment to meet the individual’s specific needs.

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