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Developing Risk-Management Protocols in Assisted Living

November 1, 2005
by root
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Plaintiffs' attorneys have this sector in their sights. Don't let them target your facility by Sandi Petersen, RN, MSN, CLNC
BY SANDI PETERSEN, RN, MSN, CLNC Developing risk-management protocols in assisted living
Assisted living has its own litigation traps for the unwary
There are many misconceptions about long-term care. It is truly very different from living at home even as much as we try to normalize the lives of residents. As providers, we strive to ease that transition and make residents comfortable. As providers, we know that this is easier if everyone knows what to expect before they sign on the dotted line. We cannot erase the fact that no matter how comforting we make these surroundings, it is not the same as home. Transitioning to a new lifestyle will be difficult for many. Thus, establishing expectations is a first step in defining and delivering quality care and services and minimizing risk in the long-term care environment.

Because of increased litigation within the industry (some reports indicate that assisted living now surpasses long-term care in the amount of awards), risk management has become a key concern for many assisted living providers. A larger percentage of market share for the assisted living industry means the increased attention of not only state and local authorities, but also the federal government, in addition to plaintiffs' attorneys.

Back in the mid-1990s, assisted living trade organizations proposed best practices and risk-limiting protocols for the industry. The guidelines covered four main areas: services, environment, consumer protections (including resident rights, contracts, and risk negotiation), and management responsibilities. These still serve as the basis for risk-management protocols in the current assisted living environment:

  • Services. Resident screening should occur before move-in. In additional, each resident must undergo assessments for health, psychosocial, and cognitive status. This ensures that the facility is able to meet the resident's needs and serves as a basis for the development of a comprehensive service plan. Information from the resident's physician and documents such as guardianship papers, powers of attorney, living wills, and do-not-resuscitate orders also should be obtained at the time of admission. The service plan should be developed with the help of the resident and/or designated agent. The plan should include the scope, frequency, and duration of services and monitoring, and it must be responsive to the resident's needs and preferences. The plan should be reviewed at routine intervals after move-in and annually thereafter, or as the resident's needs or preferences change.

  • Environment. A safe, homelike environment should be provided for all residents. This environment should support choice, independence, privacy, comfort, and individuality.

  • Consumer protections. Residents should not be physically or chemically restrained, except when expressly ordered by a physician to treat a medical condition. Residents' records should be kept confidential and released only with consent. In addition, providers should ensure residents' choices and the right to autonomy for as long as possible, even if that means taking some risks. Residents should share responsibility for decisions affecting their lives and be fully informed of their rights and responsibilities.

  • Contracts and agreements. Resident contracts should contain all the facility's commitments and actual practices, including the criteria and procedures for admission, on-site transfers, and discharge. Payment information should be comprehensive and include: rate structure and payment provisions for both covered and noncovered services; an explanation of billing, payment, and credit policies; criteria for determining level of service and additional charges; fees and payment arrangements for third-party providers; provisions for payment during absences; and the facility's policy for residents who can no longer pay for services.

  • Shared or negotiated risk. When a resident wants to engage in potentially risky behavior, such as service refusal, a risk agreement should be negotiated, following open discussions with management and family members about the consequences of the resident's choice. If the resident's mental or physical condition changes substantially, the risk agreement should be reviewed. Providers must be careful to avoid using the negotiated risk or shared-risk process as a means of retaining residents who are beyond the scope of care that can be provided in the setting.

  • Staffing. The facility should maintain sufficient qualified staff members capable of meeting scheduled and unscheduled resident needs at all times. The facility should have ongoing training for staff on how to monitor changes in residents' physical, cognitive, and psychosocial conditions. In facilities serving residents with dementia, direct-care staff should receive dementia-specific training each year.

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