Ask about . . . Services and Staffing—in housing for older people
In New York, whether a housing development requires licensure and regular oversight by a government social services or health agency depends upon the types of activities, services, and care provided by the development or arranged for by the development.
Non-licensed Developments:
If a housing development provides ONLY "supportive services," but does NOT provide health-related or personal care services, that housing development and those supportive services do NOT require government licensure.
A housing development may provide one or more of the following supportive activities and services, which provide a supportive environment for residents, but which do NOT require licensure by a government agency:
- Housekeeping services
- Linen and laundry service
- Transportation
- Recreational or social activities
- Educational programs
- A resident advisor
- Amenities, such as beauty shop, convenience store, computer room, etc.
- Assistance with instrumental activities of daily living (IADLs), such as help filling out benefit forms, changing light bulbs, contacting family members, paying bills, etc.
- Safety features, such as buzzer entry system, non-slip flooring, emergency response systems, outdoor night time lighting, etc.
- Universal design features, such as walk-in showers, stoves with automatic shut-off features, single-lever faucets, grab bars, sit-to-work space, etc.
- Congregate dining or meals program (the development's food preparation facilities do, however, require oversight by the County Health Department in the same way as a restaurant or other facility providing food to the public)
Licensed Developments:
In New York, housing developments that provide "hands-on care" (personal care, health-related care, nursing care) are licensed and overseen by the New York State Department of Health. These developments include Enriched Housing Programs, Adult Homes, three levels of Assisted Living, the Assisted Living Program (ALP), and Continuing Care Retirement Communities. The services, staff-to-resident ratio, staff qualifications, staff training, and environmental requirements for each of these are regulated by the State Health Department. Family Type Homes for Adults are certified and overseen by county Social Services Departments.
In addition to the supportive services listed above, licensed developments will also provide one or more of the following personal and health care services, which DO require licensure:
- Personal care—help with:
- Bathing
- Dressing
- Grooming
- Eating
- Toileting
- Transferring between bed and wheelchair or wheelchair and toilet
- Health aide care
- Case management
- Medication management
- 24-hour supervision
- Monitoring
- Skilled nursing
- Physical, speech, and occupational therapy
For residents of Enriched Housing, Adult Homes, and Assisted Living who meet low-income eligibility guidelines: rent and services are subsidized by New York State's Supplemental Security Income Program (SSI). For residents of the Assisted Living Program (ALP) who meet low-income eligibility guidelines: rent and services are subsidized by the SSI Program and health-related care is subsidized by the Medicaid Program. In all these developments, private pay residents (whose income is above the low-income eligibility guidelines) pay the market rates set by the development's owner.
Licensed developments will generally conduct an assessment of a potential resident's health and functional ability to determine if that person meets the development's health eligibility criteria.
Sometimes a development will not accept a new resident whose health and functional status is too frail to be appropriately cared for by the development's level of staffing and services. If a resident has been living in the development for some time and his health or functional status deteriorates, some developments will discharge that resident, while other developments will work with the resident and his family to provide additional care from a community agency or from family members in order to allow the resident to continue living in the development safely and with appropriate care.
Be an informed consumer when making a housing decision:
Examples of things you should ask about when considering supportive housing or licensed developments:
The residency agreement for all types of non-licensed and licensed developments should spell out which activities, amenities, services, and care are provided by the development, which ones are provided by community agencies, which ones and how much of each are included in the monthly charges, whether residents can privately purchase additional services and care from community agencies, and conditions under which residents will be asked to leave the development because of their physical or mental health status. Some developments may use a short standard lease or residency agreement, with all of these details spelled out in a Disclosure Form.
In non-licensed supportive housing and in licensed developments, different developments will provide varying types and amounts of activities, services, personal care, or health-related care and may charge for these services in different ways. For example, personal care and health-related services might be available in an unlimited quantity and on demand, or for a specific number of hours per day or per week, or for a limited number of days. Residents may or may not be allowed to accumulate unused hours of services or care for later use.
Supportive, personal care, and health-related services might be provided by the housing development's staff or they might be provided by another organization or agency from the surrounding community. Residents might be given an option, or be required, to select an agency from which to purchase the services.
The dining/meals program might be one that is restricted to the residents of the building, or it might be offered as a restaurant-style option that is provided, for a fee, to both the residents of the building and people living in the surrounding community. Meals might be cooked and delivered by the housing development's staff, or meals might be cooked elsewhere and brought into the development's common dining room. The meals program might be a subsidized nutrition meal site that is located in the building and operated by the local office for the aging for the building's residents and for those living in the surrounding community.
A development might provide no meals program, or it might provide one, two, or three meals per day. Residents might be given the option of electing from among several meal plans—for example, one meal every day, or dinner every weeknight but not on weekends, or 20 meals a month to be chosen at the resident's discretion.
A specific number of meals might be included in everyone's monthly charge regardless of whether a resident eats them or not, or a resident-chosen meal plan might be included in the monthly charge regardless of whether the resident eats all the meals paid for, or meals might be paid for as they are used.
Some developments will include the rent, utilities, meals, and services/care in one monthly fee. Others may charge separately for the rent/utilities and for the services/care. Still others may include some services in the monthly fee and provide other services at an extra cost as they are used by the resident.
A development's amenities, services, and care are typically listed in its public relations materials, although there is generally not enough room to explain completely what exactly is offered in each service. They may not be sufficiently described in the residency agreement or the disclosure form. In addition, a layman's understanding of what a service includes may be different from how a service is defined in law or defined in the development's policies. Or, a layman's expectations from a specific service may differ from what is actually provided by the development. For example—
Some questions you might consider about "transportation service" are:
- Is transportation provided on demand, or is it provided on a structured schedule arranged by the development? Will that schedule accommodate your needs for doctors' appointments, church services, meetings and programs?
- Is transportation only provided curb-to-curb; or is additional assistance provided at the destination of a trip, such as help getting into and out of the doctor's office, or up and down stairs in a building?
- Is the transportation van wheelchair-accessible?
- Is the transportation service really feasible for a resident with dementia or confusion? Does a staff person accompany residents on the van? Are residents expected to find their own way into and out of the shopping mall? Does the driver make sure that everyone is back on the van for the return trip?
- Is there a limit on the number of trips each resident is entitled to per month?
- Is the transportation limited to health-related appointments, or does it include social activity trips?
- Is transportation included in the monthly charge, or is it paid for on a fee-per-trip basis?
Other examples to stimulate your thinking about the types of questions to consider:
- What types of services and care are provided by the development? Which are provided by the development's staff and which ones are provided by agencies from the surrounding community? What are the training and qualifications of the staff providing those services and care? What are the staff-to-resident ratios?
- What exactly is meant when staff will provide "medication management"? Do you have a choice of taking care of your own medication needs? Are medications kept in a locked box? Does someone remind you to take your pills? Does someone actually help you take your medications? Is someone watching out for adverse reactions to medications?
- What exactly is meant by "assistance with bathing"? Does this mean help getting in and out of the tub, but actual help washing your hair or your back would cost extra money or is not available?
- What exactly is meant by "residents get help with personal care"? Is this care limited to a specific amount of time per day or per week? Can an hour of care be provided in four 15-minute segments throughout the day? If you are allowed an hour of care per day and you use only a half hour on one day, can you add the remaining half hour to another day? How is the personal care paid for—included in the monthly fee regardless of whether it is used? Paid for as used, in 15-minute increments? How flexible is the scheduling of personal care services—scheduled by you, or must you fit into the development's schedule for taking a bath or getting help with eating your meal?
- What does it actually mean if a development allows residents who develop Alzheimer's Disease or other memory loss to continue living in the development? Will you stay in your same apartment, or will you be asked to move into a specialized dementia wing with others who have memory loss? Will you continue to eat your meals and engage in activities with the rest of the residents, or will you be segregated? Do staff have special qualifications and training to interact appropriately with residents who have cognitive impairments? Will your monthly charges increase if you need additional attention for memory loss?
- What is meant by "meals will be provided"? Are special diets accommodated (for example, no-salt or vegetarian)? Do special diets cost extra? Is there tray service to a resident's room if the resident is recuperating from a hospitalization? Does tray service cost extra? Is tray service limited to a certain number of days? Do residents have any input into creating the menu? Will there be a selection of entrees for each dinner? What happens if, every once in a while, you just cannot eat what has been prepared—can you ask for a substitute? Is any attempt made to respond to cultural preferences for meals? How flexible is the time period for serving breakfast, lunch, and dinner? What are the arrangements for inviting a guest for dinner?
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