Casey Demands Three of the Largest Assisted Living Facility Owners Answer Concerns About Workforce, Cost, and Quality of Care

In letters to CEOs of largest facility owners, Casey pushes for information about high costs, worker shortages, and safety of residents

Letters follow disturbing reporting about widespread care, cost, and workforce issues at American assisted living facilities

Casey will hold Aging Committee hearing addressing these concerns on January 25

Casey: “I have an interest in ensuring that older adults and people with disabilities are receiving high-quality care, have access to proper housing, and receive good value for their hard-earned dollars”

Washington, D.C. - Today, U.S. Senator Bob Casey (D-PA), Chairman of the U.S. Senate Special Committee on Aging, sent letters to the CEOs of three of the largest corporate owners of American assisted living facilities—Atria Senior Living, Brookdale Senior Living, and Sunrise Senior Living. The letters address significant concerns about workforce shortages and expensive and inadequate care in assisted living facilities raised by recent reporting in the Washington Post and New York Times. In the letters, Chairman Casey requests a series of information from the companies about these concerns.

“The Senate Special Committee on Aging has jurisdiction over the problems older adults face, including matters of maintaining older adults’ health, their ability to secure proper housing, and their ability to obtain care or assistance when needed. Since its formation in the 1960s, the Committee has frequently used its authority to examine private companies when concerns arise about potential health and safety, as well as financial risks posed to older adults. As Chairman, I have an interest in ensuring that older adults and people with disabilities are receiving high-quality care, have access to proper housing, and receive good value for their hard-earned dollars,” wrote Chairman Casey.

In addition to sending the letters, Chairman Casey will hold an Aging Committee hearing on January 25^th entitled “Assisted Living Facilities: Understanding Long-Term Care Options for Older Adults,” where the challenges faced by assisted living facility residents will be examined in further detail.

Read the full text of the letters HERE or sample letter below:

Lucinda M. Baier

CEO of Brookdale Senior Living

111 Westwood Place, Suite 400

Brentwood, Tennessee 37027

Dear Ms. Baier:

As the Nation continues to age, older adults and their families face growing challenges finding care that is reliable, affordable, and safe. Throughout my time in Congress, I have worked to improve the transparency, quality, and safety in the long-term care sector, advocating for expanded access to home and community-based services, improved oversight of nursing homes, and stronger support for the health care workforce. With an estimated one million older adults and adults with disabilities residing in assisted living facilities, it is critical to ensure they and their families can access accurate and timely information about services provided, the costs of assisted living services, and the quality of care. As one of our Nation’s largest providers of care in assisted living facilities, I request information to better understand your company’s offerings for older adults and people with disabilities.

Assisted living facilities, including residences that are referred to as “memory care” settings, are state-regulated residences that provide housing, meals, and other services, that are meant to enable people to live independently. Residents of these facilities have access to varying levels of assistance with activities of daily living such as bathing, mobility, and other personal care needs, as well as sometimes with more complex needs such as financial and medication management. While initially intended as a social model for older adult residents needing a low level of support, people living in assisted living facility today are older, require more care, and have a similar level of acuity to nursing home residents. In addition, nationally, approximately 40 percent of assisted living facility residents have been diagnosed with Alzheimer’s disease and related dementias. As a result, assisted living facilities are home to residents with a wide range of care needs, which may require different levels of care over time.

A recent series in the New York Times highlighted the challenges residents and their families face due to the costs of assisted living care. The series demonstrated the difficulties of obtaining adequate long-term care, gaps in coverage of private long-term care insurance, the structure of costs for assisted living, and additional fees charged by assisting living facilities. The national median cost for assisted living services is $4,500 per month, or $54,000 annually. On top of base expenses, residents may incur additional costs for meals, medication assistance, personal safety alarms, or assistance from an aide for tasks as routine as taking blood pressure readings—amounting to thousands of dollars in additional expenses every month. These additional fees make it difficult for individuals and their families to accurately determine monthly and annual costs and can put care out of reach of many families. One analysis showed 80 percent of older adults with modest assets would be unable to afford four years in an assisted living community. 

Despite these high costs, residents in assisted living facilities have been put in harm’s way, leading to avoidable injuries and death. The Washington Post recently revealed that more than 2,000 people have wandered away or been left unattended outside of their assisted living facilities since 2018, resulting in at least 98 deaths, including seven in my home state of Pennsylvania. The Post also identified multiple instances of staff ignoring warnings, such as door alarms and automated texts triggered when residents leave assisted living facilities. In one case, staff at an Iowa facility ignored multiple alerts while a resident with Alzheimer’s wandered away and was left outside for more than eight hours in freezing conditions. The Post further found that staff in facilities skipped hourly or nightly resident checks; incorrectly administered life-saving medications; slept on the job; and falsified records.

Most states require facilities to report missing residents and preventable deaths, however that data is difficult to find, compare, and aggregate on a national level. While the Post found that state regulators have cited facilities more than 200 times for failing to properly report missing residents since 2018, this figure likely undercounts the frequency of these incidents. Without any sort of national database or tracking, the real number of residents who have gone missing is unknown.

As in the rest of the long-term care industry, staffing shortages in assisted living facilities are a significant challenge. In a 2022 national survey of 120 facilities by the National Center for Assisted Living, 63 percent of respondents reported moderate or high staffing shortages, and 98 percent said they asked staff to work extra shifts to make up for staffing shortages. The Post further found that 43 percent of assisted living workers, excluding new hires, left their jobs in 2022. As a result of these shortages, one direct care worker may be responsible for 20 or more residents.

The Senate Special Committee on Aging has jurisdiction over the problems older adults face, including matters of maintaining old adults’ health, their ability to secure proper housing, and their ability to obtain care or assistance when needed. Since its formation in the 1960s, the Committee has frequently used its authority to examine private companies when concerns arise about potential health and safety, as well as financial risks posed to older adults. As Chairman, I have an interest in ensuring that older adults and people with disabilities are receiving high-quality care, have access to proper housing, and receive good value for their hard-earned dollars. Given the continuing concerns regarding high costs, worker shortages, and the adequacy of care I request that you provide the following information and documents no later than February 5, 2024.

1. Published reports have raised concerns about the costs and hidden fees that put a financial strain on assisted living facility residents and their families.

1. How does your company communicate available services at its facilities—and their associated costs— to prospective residents, current residents, their family members, and other responsible parties?

2. Please provide the minimum, maximum and median base rate that your company charges at its facilities in each state.

3. Please provide a schedule of services, and their costs, for all services offered to residents, but not included in the base rate.

4. Please provide the average revenue per occupied unit for each of the last seven years, and an explanation of the material factors that accounted for year-over-year changes.

2. The Post’s reporting highlighted the difficulty that residents and their families experience obtaining accurate and transparent information about safety and quality concerns at assisted living facilities.

1. For each of the last five years, please provide data regarding the number of residents who have wandered away, and the number of residents who have been injured due to being left unattended, at any facility owned or operated by your company, a subsidiary, a joint venture, or other related third parties.

2. How does your company ensure that residents and families can easily review complaints and any citations issued to facilities owned by your company, its subsidiaries, joint ventures, and any related third parties?

3. What are the policies and procedures for informing current residents and their families about accidents such as falls, injuries, elopements, violent interactions with other residents, etc.? How does your company audit its facilities and staff to ensure that these reporting standards are being met? Please provide the most recent companywide audit that has been conducted.

3. The insufficient long-term care workforce is having a negative effect on the quality of care residents receive, as well as resident safety.

1. Researchers have found that assisted living facility residents experience fewer hospitalizations in states that mandate specific staffing ratios. What, if any, staffing requirements does your company have in place for facilities it owns or operates, or is owned and operated by a subsidiary, joint venture or related third party? To the extent your company maintains internal staffing ratio targets, please provide them. Please also answer the following questions about internal staffing ratios:

1. 1. 1. How do staffing ratios vary between weekdays and weekends, and between days and nights?

2. 2. 2. How do staffing guidelines vary between the different states you operate in?

3. 3. 3. What percentage of your facilities are meeting these staffing standards?

2. Inadequate pay for direct care workers has long raised concerns with the ability of long-term care facilities to attract and retain a sufficient workforce. Please provide a schedule of job titles and pay bands for every employee position at your company and its subsidiaries.

Thank you for your attention to this important issue. If you or your staff has questions, please contact Peter Gartrell, Chief Investigator for Chairman Casey at (202) 224-5364.

Sincerely,

Chairman Bob Casey

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