Assisted Living Checklist

Assisted Living Checklist

Choosing the right facility

Most elderly seniors don't need continuous skilled nursing care. But, many do need help with various activities of daily living, including bathing and dressing — sometimes even reminders to eat. These people, including many seniors with early-stage Alzheimers disease, can benefit substantially from assisted living facilities, many of which are part of continuing care retirement communities.

Assisted living facilities vary greatly in their services and philosophy of care. Thus, it is important to find the right facility for your loved one. It will have a profound impact on their dignity, quality of life and sense of well-being.

Assisted living facilities vary widely in size, from a few residents to hundreds. They typically offer private rooms or small apartments, common areas for socializing and recreation, planned activities, 24-hour staffing and controlled access.

Most assisted living facilities offer personalized care and support services, including meals served in a common dining area or taken to a resident's room, shuttles for errands and appointments, housekeeping, help with medication management and emergency call monitoring. Assisted living facilities also offer some resident supervision.

Step One: Determine what you can afford

Many seniors who need help with their activities of daily living will never have to go to nursing homes — if they can afford assisted living. Unfortunately, Medicare pays nothing for assisted living, and Medicaid pays very little. Instead, virtually all expenses are paid out-of-pocket by residents and/or their families.

The good news is assisted living is not as expensive as it first seems. Instead, to an extent that varies from one person to another, it simply involves a shift of expenses from one living arrangement to another.

After a person's capabilities decline to the point where they need assistance, their move into a facility is usually permanent. When their former home is sold, most of the expenses associated with it can then be used to help pay facility-based expenses. And, the money from the sale of their home can be used, for example, to purchase a CD or annuity that pays monthly interest to boost income.

Also, since a facility's fees usually include all meals, no groceries are needed, thereby freeing up even more money. To help you evaluate your loved one's financial situation, we've included a worksheet, Assisted Living Expenses— Finding the Money.

The worksheet assumes no assets are spent down — that they'll remain intact with the interest/dividends they produce used to supplement your loved one's income. But, if your loved one is short on funds, some or all of their assets will have to be spent down. That is, the principal value will have to be converted into a stream of monthly income payments.

However, several factors need to be kept in mind ...

Your loved one's income needs will increase from month-to-month due to inflation. The cost of long-term care has been increasing 4.5% per year, faster than inflation in general.

You need to decide how many years the income should last (the longer the period, the lower the income). Some people might use remaining life expectancy in a retirement calculator to estimate monthly payouts, but that would be a mistake. By definition, life expectancy is an average for all people; therefore, half of us will live longer than our life expectancy. Instead, you want to be as certain as possible, without overdoing it, that your loved one won't outlive their income. To accomplish that, we recommend you select a payout period based on a 90% probability that they won't. The following pull-down menus, based on the current age of your loved one, show our recommended payout periods for ages 65 through 90.

Men	Women
age 65 = 27.6 years age 66 = 26.7 years age 67 = 25.7 years age 68 = 24.8 years age 69 = 24.0 years age 70 = 23.1 years age 71 = 22.2 years age 72 = 21.4 years age 73 = 20.5 years age 74 = 19.7 years age 75 = 18.9 years age 76 = 18.1 years age 77 = 17.3 years age 78 = 16.5 years age 79 = 15.7 years age 80 = 15.0 years age 81 = 14.2 years age 82 = 13.6 years age 83 = 12.9 years age 84 = 12.2 years age 85 = 11.6 years age 86 = 11.0 years age 87 = 10.4 years age 88 = 9.9 years age 89 = 9.4 years age 90 = 8.9 years	age 65 = 30.5 years age 66 = 29.6 years age 67 = 28.6 years age 68 = 27.7 years age 69 = 26.8 years age 70 = 25.8 years age 71 = 24.9 years age 72 = 24.0 years age 73 = 23.1 years age 74 = 22.2 years age 75 = 21.3 years age 76 = 20.5 years age 77 = 19.6 years age 78 = 18.7 years age 79 = 17.9 years age 80 = 17.1 years age 81 = 16.3 years age 82 = 15.5 years age 83 = 14.7 years age 84 = 14.0 years age 85 = 13.3 years age 86 = 12.6 years age 87 = 11.9 years age 88 = 11.3 years age 89 = 10.7 years age 90 = 10.1 years
Work with a trusted financial advisor to assist you in converting each financial asset into a stream of monthly payments.
Step Two: Select a general location

Once you've determined how much your loved one can afford to pay for assisted living, select the city or region where their facility should be. Go to our page Living Arrangements, including Assisted Living. There you will find a variety of Web sites to help you find assisted living facilities in the area that meets your criteria. (Many assisted living facilities are part of retirement communities that offer a wide variety of living arrangements from completely independent living to 24-hour skilled nursing care.)

Include your loved one in the selection process. After all, it is their future home you are selecting. The goal of assisted living is to allow the person to retain as much independence as circumstances permit. And, it is your role as a caregiver to help them maintain as much control over their lives as feasible, not take it away; this includes allowing them to make their own decisions whenever possible. And, be prepared to accept the fact that your loved one may have strong preferences about where they want to live even though their choice may not be the one you would prefer.

Step Three: Determine your loved one's needs The types of care available varies widely from one assisted living facility to another. To be certain that a facility can provide the care necessary for your loved one, first determine what your loved one's needs truly are (they may be different than you think). We've included 3 excellent checklists in our section, Getting started — What kind of help does your loved one need? When you compare assisted living facilities, some factors matter more than others. No perfect facility exists. Finding one that meets your needs is Goal Number 1. But don't underestimate Goal Number 2, that is, getting the facility to accept your loved one. When you tour a facility and interview its staff, be thorough, clear and professional. Show them that you're part of the solution and will work closely with them to achieve the best care possible for the new member of their community. Be ready to: Explain the type of care your loved one needs. Ask the facility to describe how it will meet those needs, for example, assistance with dressing, taking medications, incontinence, or general supervision. An assisted living facility should provide enough care and support to meet your loved one's needs while encouraging and allowing them to remain as independent as possible. And, don't forget that your loved one may need more care as time passes; ask questions that don't apply now, but may in the future. Visit several facilities; services and fees will vary greatly. Our checklist will help you compare facilities and organize your impressions of different homes. To help you find the right assisted living facility for your loved one, you could use the ElderCarelinkservice which has established a nationwide network of carefully screened facilities. ElderCarelinkprovides this referral service free of charge. Within minutes of completing their brief Needs Survey, you will receive a detailed email report listing assisted living facilities in your area that match your specific requirements. Last year, over 100,000 families utilized this service in their search for high-quality senior care. Click here to use the ElderCarelink service. Step Four: Go Make an appointment for a tour. Ask to see more than the public areas. Visit several residents' rooms. Ask if both you and your loved one can join the residents for lunch or dinner. And, if possible, stroll through the facility on your own. This will allow you to experience it without an official interpretation. Talk to the residents; ask them what they like most — and what they feel could be improved. Take a deep breath and clear your mind. You're ready. (Take a blank checklist with you for each visit.) Name of facility: _________________________________________________ Address:_______________________________________________________ Phone number: _________________________________________________ Date(s) of visit: _________________________________________________ Contact: ________________________________ Phone: ________________ General rating on a scale of 1 (poor) to 5 (excellent) Circle one: 1 - 2 - 3 - 4 - 5 -- Personal and Health Care -- Not all states require assisted living facilities to write a plan of care for each resident. If your state does not require it, it would be wise to request a care plan for your loved one. This assures that the staff has evaluated the resident's condition and developed written guidelines that promote communication and consistency. Care plans begin with a comprehensive assessment of the resident, including level of function and social, emotional, mental and medical condition. The plan should focus on maximizing independence and functioning at the highest level possible. The assisted living facility should revise the plan every three months or whenever the resident's condition changes. In addition to the following questions, ask the facility to specifically describe how it will meet your loved one's known care needs, e.g., incontinence, mental health, supervision or dementia. If you hope to avoid having to move your loved one again, take into consideration the fact that they may need more care in the future. Personal Care Needs How will the facility determine if it is the appropriate facility for my loved one's needs, or if another type of facility would be more appropriate? How will the facility evaluate my loved one's needs? Who will do the assessment? What are his or her qualifications? How often are reassessments done? How does the facility help residents maintain their ability to care for themselves, especially toileting, dressing, and eating? How does the facility accommodate residents with changing needs - what if they need more physical assistance, become confused or incontinent? For patients who develop confusion, how does the facility help determine whether it is due to problems with medications or because of the onset of Alzheimer's or dementia? How often does a staff member check on a resident's whereabouts and well-being? If a resident's behavior changes and becomes verbally or physically abusive, what steps will the facility take? Health Care Needs Assisted living facilities do not actually provide medical care. But, in your absence, the facility you select should manage your loved one's medical care. This includes notifying you of material changes in your loved one's condition, and assisting or supervising your senior with their medications. This is especially important if the facility encourages aging in place. This philosophy allows residents to remain in the facility as they become more infirm, and to receive more care as needed, in many cases until they need 24-hour-a-day care or supervision. Consequently, it is important to evaluate the facility's capacity to manage a broad range of health care needs even if your loved one is relatively healthy now. The Plan of Care Does the facility prepare a written plan describing how it will care for my loved one? If yes, how often will it be revised? — every three months? — after every change in condition? What professionals/staff are involved in the development and implementation of the plan? How will my loved one, my family and I be involved? What involvement does a confused resident have? What if I don't agree with the plan of care? Does the plan focus on maintaining independence? Does it cover every aspect of a resident's life — physical, psychological, social and medical? How often does the staff consult the plan? Providing the Required Care How will the facility monitor my loved one's health? Is there a nurse on staff? What are the nurse's hours and responsibilities? Who is responsible when the nurse is not on duty? If a nurse is not on staff, are there regularly scheduled visits by a nurse or another health care professional? Does the nurse or other health care professional see each resident regularly? or only when the resident doesn't feel well? If a resident doesn't feel well, how quickly and to what extent will they receive medical attention? Will the staff set up medical appointments for my loved one? What health care services are available at the facility: physical therapy? wound care? hospice care? social services? etc.? Under what circumstances does the facility call the family? — the resident's doctor? Emergencies Who decides when to call 911? Are there written policies about how that decision is made? What kind of emergencies are the staff expected to handle and how are they trained for them? Medications The licenses of many assisted living facilities limit their nursing staff to only supervising residents when they take medications; no “hands-on” assistance is allowed. Residents keep their medications in their own rooms. This can lead to serious mistakes, e.g., forgetting to take their medications; forgetting that they had already taken them and taking another dose, etc. Mistakes with medications is often cited as one of the primary reasons seniors have to be taken to hospital emergency rooms. Other facilities allow their nursing staff to handle all aspects of a resident's medication needs, including refills, selecting the appropriate medications to take, and physically helping seniors take their medications. These facilities generally keep all residents' medications in a central location away from the rooms of residents. Are there any limitations on how the staff will handle your loved one's medications? What safeguards are in place to ensure that your loved one gets the appropriate medications on time and in the correct dosage? How are prescriptions filled? Must a resident use the facility pharmacy? What are the costs? Who gives out medications? If not a nurse, how are staff trained and supervised? Who reviews medication procedures and how frequently? Health Care Transportation How does the facility handle transportation to medical appointments? Are there any limitations? Is the transportation wheelchair accessible? What are the fees for using the facility's transportation? Staff What is the training/certification of the people who care for residents? What are the trainer's qualifications? Are background checks performed on all staff members? Who does it, how and when? What is the staff-to-resident ratio? In general, facilities that offer care for Alzheimer's or other forms of dementia should have a ratio of about 1-to-4. On the other hand, if most residents are lucid and need minimal assistance, the ratio could be much higher without endangering the safety of the residents. Is the staff trained to deal with aggressive residents? Wanderers? Is the staff visible? How long are staff shifts? How is staff members' morale? Observe their demeanor and their interactions with each other and with the residents. Do staff members know residents' names? Do staff and residents greet each other in passing? How does the staff respond to your questions? Trouble signs: Are they rushed, uncomfortable, angry? If either the resident or staff members are not native English speakers, can they communicate effectively with each other? What is the procedure for notifying families of any changes in routine or medical condition? Ask to meet these staff members if they are not part of your official tour: 1. Manager of facility and/or on-site administrator How long have they been with the facility? How can they be reached? 2. Activity director Full-time or part-time? Are they creative and innovative? Do they offer programs that would appeal to your senior? What do they do to encourage shy seniors to participate in their activities? 3. Social workers What are their hours? What services do they offer residents and families? 4. Aides How many are on duty during the day? At night? 5. Volunteers How often do they come? Are they from the community? If so, this might indicate that the facility welcomes observers and values outside interaction with its residents. Are they screened? -- Daily Life in the Facility -- When looking at a facility's activities, consider your loved one's preferences. Some people enjoy group activities such as bingo, word games, card games, crafts, etc., even discussions of current events. Others prefer to enjoy their activities privately — they aren't generally "joiners," preferring instead to read a book, watch TV or go for walks. And others may prefer cultural or community events such as museums, theaters and concerts. With this in mind ... Look at activity schedules. Are they varied? Are your loved one's interests reflected? Are activities planned with residents' involvement in mind? Are they designed to be fulfilling, that is, something residents look forward to — or are they designed primarily to keep residents busy? Who develops and supervises recreational activities? What is their background? Do residents have any input into the activities offered? Are residents involved in the community outside the facility? If so, how? What staff members are included? Are field trips available? Is it okay for a resident to go to an event by himself/herself or with a friend. If yes, what are the rules? Is transportation available by the facility or must the resident arrange it himself/herself? Are there recreational facilities such as game rooms on site? Does the facility offer opportunities to exercise? Are the exercise facilities pleasant to be in, and the equipment easily accessible and in good condition? Are there organized exercise programs, or are residents left to themselves to exercise if and when the whim strikes them? Can residents take walks outside? Are there protected/enclosed walking areas for residents with dementia? Are residents encouraged to be as independent as possible? Ask residents and staff, and make your own observations. Are residents allowed to have pets in their living quarters if they are able to care for them? If yes, what are the rules? How does the facility meet the religious/spiritual needs of residents? Does it provide transportation to nearby churches and synagogues? Or, are worship programs conducted in the facility itself? Is there a resident and family council? How often does it meet? Has the council taken any action recently? Resident Services Are the following services available? If yes, note whether they are included in the basic fee or cost extra: Beauty parlor or barber Bed linens/light housekeeping Laundry Transportation for shopping/errands/non-medical appointments -- Meals -- Before selecting an assisted living facility, join the residents for a meal or two. How does the food taste? Are residents offered a choice of foods at each meal? How often does the menu change? Or, do residents get bored with the “same old food all the time?” TIP: Residents often resent the fact that they have reached the point where they can no longer take care of themselves and have to live in an assisted living facility. This can lead to a negative attitude which sometimes manifests itself as complaints about their meals, even though they are very good, nutritious and varied. So, despite what some residents may say, we suggest that you keep an open mind until you have eaten one or more meals at the facility. At what times are meals served? Is the meal schedule flexible? If your loved one has special dietary needs, how will they be accommodated? Does a nutritionist or dietitian review meals and special diets? If yes, how often? What happens if your loved one is late, misses a meal, or refuses a meal? Is the answer different if a resident is confused? Can your loved one ask to have a tray delivered to their room? Is there an additional charge? If a resident doesn't like a meal, what are the alternatives? Is the dining area pleasant? Is the food attractive and nutritious? Is the food culturally familiar? If necessary, will the staff go to a resident's room to remind them of meal times? Does the staff help residents get to the dining room if needed? Does the staff help residents eat if needed? Are snacks available at any time? What kind? -- Other Residents -- If your senior is mentally alert, try to find a facility with similar residents. Living with residents suffering from dementia will not offer a good quality of life for someone who is frail but mentally alert. Likewise, it can also be disturbing for a confused resident to be placed with primarily lucid residents. Do other residents appear happy and relaxed? Are they well-groomed? Are their clothes clean? Are they dressed appropriately for the time of day and room temperature? Are they interacting with each other or just sitting around not doing much? Do they isolate themselves in their rooms? Or, are they parked in wheelchairs in front of the nurses' station at times other than just before meals? Talk to residents about the facility: What do they like best? What do they like least? What is daily life like at the facility? Are most residents at the same level of mental function as your loved one? If not, are residents kept mainly with others at similar levels of mental function and cognitive awareness? Does the facility accept residents who: Have Alzheimer's/dementia? Wander? Use a wheelchair? Use a walker? Smoke? -- The Assisted Living Facility -- Bedroom/Living Space Is there an emergency call button near each bed? Or, do residents wear pendant or wrist call buttons? If so, do the pendant or wrist call buttons work outside of their room? If there is a separate living/sitting room, does it also have a call button? Is there a call button in the bathroom? How often are call buttons checked to see if they are working correctly? Is the bedroom/living space big enough? Is it well-lighted? Does it have a window? Is it clean and pleasant? How often is it cleaned? Can residents bring in their own furniture and personal belongings? What measures are in place to prevent personal property from being stolen? Is there a private bathroom? Are there grab bars in the shower? next to the toilet? Is the bathroom wheelchair-accessible? Are the living quarters private or shared? if shared: How many roommates would there be? How are roommate(s) selected? by matching their needs and personalities? or based only on which beds are available? What's the policy if roommates have problems getting along with each other? What if one roommate has habits or mannerisms that upset another roommate, e.g., staying up late at night, yelling, going through personal possessions of others, keeping a TV’s sound too loud, etc.? What does the facility do if problems such as those in the previous question arise? What's the policy on choosing or switching roommates? Can you and the senior meet the prospective roommate(s) in advance? Are separate rooms available for private visits? Location Is the facility in a safe area? Is it convenient to: Your loved one's doctors and dentist? Hospitals and other medical facilities? Family and friends? Places of worship? Shopping? Exterior Is the building’s exterior well-maintained? Is there a nice outdoor area? Are residents encouraged to use it? Is it accessible to wheelchairs, with plenty of benches and shade? TIP: Don't judge a facility based solely on its looks. However, a poorly-maintained facility may indicate a lack of adequate funds and potentially inadequate care of residents. Interior Is there is a smell of urine? Even a mild urine odor is not normal for an assisted living facility. Be especially leery if the smell is strong. And, be equally concerned if a powerful room deodorizer is being used to mask an unpleasant odor. That could mean the facility is trying to obscure an unclean area rather than clean it. Is the temperature comfortable? Is the noise level acceptable? Do you see personal, home-like touches? Is it well-lighted? Does it have good natural light? Building Safety Are the facility's doors locked? When? How does a resident or family member get into the home when doors are locked? Are exit doors alarmed? Are there safety locks on the windows? Would your loved one be able to get out in an emergency? What procedures are in place to assist residents who may need help evacuating the facility? If it is a multi-story facility, what safety arrangements are in place to help people in wheelchairs evacuate the building? Are the emergency exits clearly marked and accessible? Are evacuation instructions posted that residents can read? Does the facility hold fire drills? Are stairway doors kept closed to prevent potential spread of fire? Do halls and public bathrooms have grab bars? Are there wheelchair ramps? Are hallways, doorways, bathrooms and common areas wide enough to accommodate people in wheelchairs? Is the floor covering made of a nonskid material? Is the building generally clear of clutter? What safety measures are in place to protect residents from wandering away? Do exit doors have alarms in case a wanderer tries to leave? Are exit doors unlocked from the inside? Locked doors prevent wanderers from leaving the building, but they also create a potential hazard. Ask for paperwork showing that the facility has been inspected and meets federal and state codes for fires and other disasters. State Health Inspections Most states license assisted living facilities and perform periodic health inspections. Ask to see the latest inspection reports (some states require that the facilities have a copy easily accessible for anyone who wants to see it). If the facility doesn't have a copy, the state's health department should. If you have questions, ask a staff member to go over it with you. Does the facility post a valid license? Does the facility have a written description of a resident's rights and responsibilities? -- The Legal Contract -- A legal contract must be signed in order to be admitted into an assisted living facility. That contract obligates your loved one, and/or you as his or her representative, to potentially pay very large amounts of money for their care. Before signing it, we encourage you to review a copy of the contract with an attorney who specializes in elder law. In addition to the more specific discussion points below, keep in mind that assisted living facilities have rules designed to protect residents from harm while, at the same time, encouraging them to remain as independent as possible. The delicate balance of protection versus independence varies from one facility to another. It is often described in a negotiated risk agreement which may be part of the overall contract, or a separate document. Ask each facility if they use any form of negotiated risk agreement. If they do, have them explain what it would mean with regard to your loved one. Will you be comfortable with that level of risk? (Remember, when a facility explains how it handles negotiated risk, its actual conduct is governed not by what they say aloud, but instead by what is written in their agreement. Fees and other Costs What is the facility's base monthly fee for your loved one? What services are provided for that fee? What additional services are available, and what are their costs? Extras such as laundry, room delivery of meals and incontinence supplies can be costly. Is an initial payment required? If yes, is any of it refundable? Can any of the fees/charges be changed? Under what circumstances? Who will be notified? How much advance warning will be given? If your loved one has to temporarily leave the facility in case of hospitalization, recovery in a skilled nursing facility, etc., how long will the assisted living facility hold his or her living quarters? What fees/charges would apply during your loved one's absence? What happens if funds run out? Is there any financial assistance? Other Legal Provisions Answers to these questions will help you clarify a facility's ability to care for people with health and behavior conditions that are more difficult to manage. It will also help you determine if you have recourse if you are asked to leave. What behaviors, conditions, or other circumstances are reasons for discharge? Is there an internal appeal process? What is it? How many days notice is given and to whom? How does the facility assist you if they proceed with discharge? What are the eviction procedures? Does the facility offer a separate insurance policy that covers theft or damage to a resident's property, or is theft or damage to a resident's property covered under the facility's own insurance policy, or will a resident's property be uninsured (the latter situation is usually the case)? What happens if there is a spill or accident that destroys property - your loved one's or the facility's? Who is responsible for cleaning/repairing, payment or replacement? TIP: Be wary of any clauses that exempt the facility from liability for injury or lost possessions. Once again, you may want to have an elderlaw attorney to review the contract. -- Second Opinions -- Try these sources: Hospital discharge planners Nonprofit organizations specializing in your circumstances Friends who have faced similar situations Private geriatric care managers Volunteers from the community -- Final Notes and Comments -- Comments: ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ What I liked most about this assisted living facility: ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ What I liked least: ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Overall impressions: ______________________________________________________________ ______________________________________________________________