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Infection Prevention and Control Standards in Assisted Living Facilities: Are Residents' Needs Being Met?

Published:November 18, 2013DOI:https://doi.org/10.1016/j.jamda.2013.09.011

      Abstract

      Background

      Assisted living facilities (ALFs) provide housing and care to persons unable to live independently, and who often have increasing medical needs. Disease outbreaks illustrate challenges of maintaining adequate resident protections in these facilities.

      Objectives

      Describe current state laws on assisted living admissions criteria, medical oversight, medication administration, vaccination requirements, and standards for infection control training.

      Methods

      We abstracted laws and regulations governing assisted living facilities for the 50 states using a structured abstraction tool. Selected characteristics were compared according to the time period in which the regulation took effect. Selected state health departments were queried regarding outbreaks identified in assisted living facilities.

      Results

      Of the 50 states, 84% specify health-based admissions criteria to assisted living facilities; 60% require licensed health care professionals to oversee medical care; 88% specifically allow subcontracting with outside entities to provide routine medical services onsite; 64% address medication administration by assisted living facility staff; 54% specify requirements for some form of initial infection control training for all staff; 50% require reporting of disease outbreaks to the health department; 18% specify requirements to offer or require vaccines to staff; 30% specify requirements to offer or require vaccines to residents. Twelve states identified approximately 1600 outbreaks from 2010 to 2013, with influenza or norovirus infections predominating.

      Conclusions

      There is wide variation in how assisted living facilities are regulated in the United States. States may wish to consider regulatory changes that ensure safe health care delivery, and minimize risks of infections, outbreaks of disease, and other forms of harm among assisted living residents.

      Keywords

      The capacity of US assisted living facilities (ALFs) stands at nearly 1 million beds.
      • Mollica R.
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      Residential Care and Assisted Living Compendium.
      Use of these facilities is expected to grow in response to an aging population and a shift in long term custodial care from nursing homes to assisted living.
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      Trends in Residential Long-Term Care: Use of Nursing Homes and Assisted Living and Characteristics of Facilities and Residents.
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      Assisted living expansion and the market for nursing home care.
      Although a precise definition of ALFs is lacking,
      • Zimmerman S.
      • Sloane P.D.
      Definition and classification of assisted living.
      these institutions typically provide housing and care to persons unable to live independently and provide support for activities of daily living (eg, toileting, dressing, cooking). The typical ALF does not provide the level of care that is provided at a nursing home or acute care hospital. Nonetheless, a large volume of health care is routinely delivered at ALFs, using a variety of approaches, including contracts with home health agencies and facility-based personnel, such as medication aides, nurses, and others.
      • Spillman B.C.
      • Liu K.
      • McGilliard C.
      Trends in Residential Long-Term Care: Use of Nursing Homes and Assisted Living and Characteristics of Facilities and Residents.

      Reimbursement and Research Department: American Health Care Association. The state long-term health care sector: Characteristics, utilization, and government funding. 2011. Available at: http://www.ahcancal.org/research_data/trends_statistics/Documents/ST_rpt_STStats2011_20110906_FINAL_web.pdf. Accessed August 10, 2012.

      • Stachel A.G.
      • Bornschlegel K.
      • Balter S.
      Characteristics, services, and infection control practices of New York City assisted living facilities, 2010.
      • Mitty E.
      • Resnick B.
      • Allen J.
      • et al.
      Nursing delegation and medication administration in assisted living.

      American Assisted Living Nurses Association. Scope and standards of assisted living nursing practice for registered nurses. Available at: http://www.alnursing.org/alnursecert/SCOPE_AND_STANDARDS_FINAL2_09_19_06.pdf2006 Accessed July 17, 2013.

      A growing proportion of ALF residents requires assistance with daily management of complex medication regimens or regular monitoring of chronic medical conditions, such as diabetes and dementia.
      • McNabney M.K.
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      • Lyketsos C.G.
      • et al.
      The spectrum of medical illness and medication use among residents of assisted living facilities in central Maryland.
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      • Steele C.D.
      • et al.
      The Maryland Assisted Living Study: Prevalence, recognition, and treatment of dementia and other psychiatric disorders in the assisted living population of central Maryland.
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      • et al.
      Residents living in residential care facilities: United States, 2010. NCHS data brief.
      The challenge of ensuring that ALF residents' medical needs are met with practices that prevent infection transmission and other adverse events has many dimensions and is illustrated by a number of recent infectious disease outbreaks. For example, between 2008 and 2012, 13 outbreaks of hepatitis B virus infections occurred in ALFs.

      Centers for Disease Control and Prevention. Healthcare-associated hepatitis B and C outbreaks reported to the Centers for Disease Control and Prevention (CDC) in 2008–2012. Available at: http://www.cdc.gov/hepatitis/Outbreaks/HealthcareHepOutbreakTable.htm. Accessed July 12, 2013.

      Almost all of these outbreaks were linked to assisted monitoring of blood glucose among residents with diabetes.
      • Klonoff D.C.
      • Perz J.F.
      Assisted monitoring of blood glucose: Special safety needs for a new paradigm in testing glucose.
      Unsafe diabetes care practices that were frequently identified by public health investigators included using the same fingerstick devices for multiple residents (ie, not using single-use, auto-disabling devices) and sharing blood-contaminated glucose meters between residents.
      • Counard C.A.
      • Perz J.F.
      • Linchangco P.C.
      • et al.
      Acute hepatitis B outbreaks related to fingerstick blood glucose monitoring in two assisted living facilities.
      Centers for Disease Control Prevention
      Multiple outbreaks of hepatitis B virus infection related to assisted monitoring of blood glucose among residents of assisted living facilities—Virginia, 2009–2011.
      Centers for Disease Control and Prevention
      Notes from the field: Deaths from acute hepatitis B virus infection associated with assisted blood glucose monitoring in an assisted-living facility—North Carolina, August-October 2010.
      • Schaffzin J.K.
      • Southwick K.L.
      • Clement E.J.
      • et al.
      Transmission of hepatitis B virus associated with assisted monitoring of blood glucose at an assisted living facility in New York State.
      • Bender T.J.
      • Wise M.E.
      • Utah O.
      • et al.
      Outbreak of hepatitis B virus infections associated with assisted monitoring of blood glucose in an assisted living facility—Virginia, 2010.
      Centers for Disease Control and Prevention
      Notes from the field: Transmission of HBV among assisted-living–facility residents—Virginia, 2012.
      Outbreaks of respiratory and gastrointestinal illnesses have also been reported, highlighting the importance of infection prevention measures in ALFs, such as hand hygiene practices among residents and staff, appropriate environmental cleaning procedures, and appropriate use of employee personal protective equipment.
      Centers for Disease Control and Prevention
      Notes from the field: Outbreak of severe respiratory illness in an assisted-living facility—Colorado, 2012.
      Centers for Disease Control and Prevention
      Norovirus activity—United States, 2006–2007.
      Centers for Disease Control and Prevention
      Notes from the field: Outbreaks of rotavirus gastroenteritis among elderly adults in two retirement communities—Illinois, 2011.
      In addition, surveys of ALFs have identified shortcomings with respect to infection control procedures and policies, such as failing to implement or comply with the Occupational Safety and Health Administration's Bloodborne Pathogen Standard and not requiring staff with direct patient care responsibilities to have infection control training.
      • Patel A.S.
      • White-Comstock M.B.
      • Woolard C.D.
      • et al.
      Infection control practices in assisted living facilities: a response to hepatitis B virus infection outbreaks.
      • Thompson N.D.
      • Barry V.
      • Alelis K.
      • et al.
      Evaluation of the potential for bloodborne pathogen transmission associated with diabetes care practices in nursing homes and assisted living facilities, Pinellas County.
      Resident caregiver annual turnover rates in ALFs can be as high as 38%,

      National Center for Assisted Living. Findings of the NCAL 2010 Assisted Living Staff Vacancy, Retention and Turnover Survey. 2010. Available at: http://www.ahcancal.org/ncal/resources/documents/2010%20vrt%20report-final.pdf. Accessed March 20, 2013.

      posing an additional challenge to maintaining infection control training among ALF staff.
      Regulatory oversight of ALFs is largely a state responsibility.

      Carlson EM. Critical issues in assisted living: Who's in, who's out, and who's providing the care - state summaries. In: National Senior Citizens Law Center, ed. 2005.

      Senate Committee on Aging. Ensuring quality and oversight in assisted living: Hearing before the Senate Committee on Aging, United States Senate. Serial No. 112–10, 112th Congress [1–148]. Available at: http://www.ahcancal.org/ncal/resources/Pages/AssistedLivingRegulations.aspx. Accessed March 20, 2013.

      Several reviews of ALF regulations and policies have been published previously

      Carlson EM. Critical issues in assisted living: Who's in, who's out, and who's providing the care - state summaries. In: National Senior Citizens Law Center, ed. 2005.

      • Hawes C.
      • Phillips C.D.
      • Rose M.
      • et al.
      A national survey of assisted living facilities.
      • Mitty E.
      Medication management in assisted living: A national survey of policies and practices.

      National Center for Assisted Living. Assisted living state regulatory review 2012. Available at: http://www.ahcancal.org/ncal/resources/Documents/Final%2012%20Reg%20Review.pdf. Accessed March 20, 2013.

      National Center for Assisted Living. Assisted living state regulatory review 2013. Available at: http://www.ahcancal.org/ncal/resources/Pages/AssistedLivingRegulations.aspx. Accessed March 20, 2013.

      ; however, none of these focused specifically on infection prevention and control. We reviewed licensing requirements and regulations in the 50 states, with the aim of describing current state laws surrounding ALF admissions criteria and restrictions related to ALF medical conditions of the resident, the types of personnel who can provide assistance with medical care and administer medication in ALFs, standards for infection control training and education for ALF staff, and vaccination requirements for residents and staff.

      Methods

      We identified ALF regulations and licensing requirements through the Assisted Living Federation of America Web site, which maintains links to current state regulations.

      Assisted Living Federation of America. Assisted living regulations and licensing. Available at: http://www.alfa.org/alfa/State_Regulations_and_Licensing_Informat.asp. Accessed August 10, 2012.

      We developed a structured abstraction tool to collect data on ALF admissions criteria, types of personnel who can provide medical care and administer medication, infection control training and education requirements for ALF staff, and vaccination requirements for ALF residents and staff. After piloting and refining the tool, we abstracted ALF regulations and licensing requirements data for all 50 states. Three individuals performed data abstraction from November 2011 to May 2012; a sample of states was abstracted by all abstractors to ensure inter-rater reliability. Data were entered into Excel (Microsoft Corp, Redmond, WA) and exported into SAS version 9.3 (SAS Institute Inc, Cary, NC) to calculate frequencies of selected characteristics and requirements. We also compared selected characteristics according to the time period in which the regulation took effect (1998–2007 vs 2008–2012), using Fisher's exact tests.
      To better illustrate the scope and magnitude of outbreak activity, we queried a convenience sample of state health departments, requesting summary data regarding the numbers and types of outbreaks in ALFs. We requested information spanning the period from January 2010 through June 2013. We requested that states limit their summary data to licensed ALFs only. In several documented instances, we accepted data from states in which the outbreak surveillance system grouped ALFs with other types of long term care facilities.

      Results

      Overall, state regulations governing ALF operations varied with respect to the types of agencies that license and regulate ALFs, the terminology used to describe these facilities, and whether states have multiple ALF licensing levels. Departments of Health, Public Health, or Community Health conduct facility licensing in 72% of states, whereas 28% of states license ALFs through other types of state agencies (Table 1). The terms used to describe ALFs also varied by state; “assisted living facility” was the most commonly used term (88%), but others included “community residential facility” and “residential care facility.” Fifteen states (30%) have multiple licensing levels, which generally correspond to resident characteristics or admission and exclusion policies. For example, licensing categories in Wisconsin are based on the number of residents and their ambulatory status, whereas New York has multiple licensure levels of adult care homes with additional licensure levels for homes providing dementia services.
      Table 1Descriptive Characteristics of State Regulations Describing Licensure and Operation of Assisted Living Facilities (ALFs), United States, 2012
      Characteristicsn = 50 (%)
      ALF licensing agency
       Department of Health, Public Health, or Community Health36 (72)
       Other state agency/department14 (28)
      Year legislation took effect
       1998–200716 (32)
       2008–201234 (68)
      Multiple ALF licensing levels
       No35 (70)
       Yes15 (30)
      Terminology used to describe the facilities:
       Assisted living facility44 (88)
       Community residential facility2 (4)
       Residential care facility2 (4)
       Other2 (4)
      Residents are excluded from admission to licensed ALFs based on criteria specified in state regulation, with some states requiring residents to complete a physical assessment before admission. The most common ALF admission restrictions specified in state regulations were for persons who require continuous nursing care (68%), are chronically bedridden (50%), have a communicable disease (eg, tuberculosis) that requires isolation (42%), or have advanced stage pressure sores or ulcers (40%) (Table 2). Additional admission restrictions mentioned in regulations included incontinence, the need for restraints, and having a tracheostomy. In some state regulations, such as in Texas and Rhode Island, each facility is specifically permitted to establish its own admissions restrictions.
      Table 2Assisted Living Facility (ALF) Resident Admissions Restrictions Specified in State Regulations, United States, 2012
      Condition Preventing Admissionn = 50 (%)
      Requirement for continuous nursing care34 (68)
      Being chronically bedridden25 (50)
      Having a communicable disease requiring isolation and/or reporting
      Including but not limited to tuberculosis, smallpox, and hepatitis A.
      21 (42)
      Having advanced stage III or IV pressure sores or ulcers20 (40)
      Mental impairment or cognitive decline17 (34)
      Feeding tube dependence13 (26)
      Intravenous therapy dependence11 (22)
      Ventilator dependence10 (20)
      Other30 (60)
      Any of the above42 (84)
      Including but not limited to tuberculosis, smallpox, and hepatitis A.
      Most state ALF regulations (60%) required a licensed health care professional to oversee medical care and 10% of state regulations (Connecticut, Indiana, Minnesota, Utah, Wyoming) required a licensed health care professional to be on-site 24 hours a day (Table 3). In addition, most regulations (88%) specifically allowed ALFs (or their residents) to subcontract with home health agencies (HHAs) or private aides to provide routine medical care on-site.
      Table 3Assisted Living Facility (ALF) Health Care Staffing, Infection Control, and Training Requirements Specified in State Regulations, by Time Period in Which the Legislation Took Effect, United States, 2012
      Characteristics1998–20121998–20072008–2012P Value
      n = 50 (%)n = 16 (%)n = 34 (%)
      Staff Requirements
       Licensed health care professional oversees medical care30 (60)10 (63)20 (59).80
       Licensed health care professional is on-site 24 hours a day5 (10)3 (19)2 (6).31
       Licensed health care professional oversees infection control3 (6)0 (0)3 (9).54
       All staff are required to receive infection control training
      States could select more than one.
      :
      On hiring7 (14)2 (13)5 (15)1.00
      Within a specified time period from hiring12 (24)4 (25)8 (24)1.00
      Annually7 (14)1 (6)6 (18).41
      Other infection control training requirements3 (6)2 (13)1 (3).24
      Any of the above infection control training requirements mentioned27 (54)9 (56)18 (53).83
       Subcontracting home health agencies or aides is permitted if
      States could select more than one.
      :
      Patient arranges hiring of aides independently21 (42)6 (38)15 (44).66
      ALF coordinates hiring of aides for individual residents25 (50)10 (63)15 (44).23
      ALF subcontracts with agency for all residents4 (8)1 (6)3 (9)1.00
      Other specified criteria4 (8)0 (0)4 (12).29
      Any of the above subcontracting options permitted44 (88)14 (88)30 (88)1.00
      Infection Control and Prevention
       Facility inspection includes infection control assessment8 (16)4 (25)4 (12).25
       Specific requirement to report cases of communicable disease25 (50)4 (25)21 (62).02
       Specific infection control measures referenced in the regulation:
      Personal protective equipment11 (22)3 (19)8 (24)1.00
      Hand hygiene18 (36)6 (38)12 (35).88
      Safe injection practices5 (10)0 (0)5 (15).16
      Other infection control practice
      Including but not limited to aseptic techniques, compliance with rules regarding special waste, immunization.
      5 (10)1 (6)4 (12)1.00
      Any of the above infection control measures referenced23 (46)7 (44)16 (47).83
       Infection control guidelines/standards referenced
      States could select more than one.
      :
      Centers for Disease Control and Prevention13 (26)1 (6)12 (35).04
      Occupational Safety and Health Administration
      Bloodborne Pathogens Standard, 29 CFR 1910.1030.
      5 (10)1 (6)4 (12)1.00
      General infection prevention standard(s)
      Regulation includes general infection control language using terminology pertaining to “standard of care,” “scientifically accepted,” or “professional standards.”
      8 (16)1 (6)7 (21).41
      Any of the above22 (44)3 (19)19 (56).02
       Specific reference to Standard or Universal Precautions:
      Standard Precautions9 (18)0 (0)9 (26).04
      Universal Precautions16 (32)6 (38)10 (29).57
      Either of the above24 (48)6 (38)18 (53).31
       Specific requirement for written infection control plan18 (36)5 (31)13 (38).63
      States could select more than one.
      Including but not limited to aseptic techniques, compliance with rules regarding special waste, immunization.
      Bloodborne Pathogens Standard, 29 CFR 1910.1030.
      § Regulation includes general infection control language using terminology pertaining to “standard of care,” “scientifically accepted,” or “professional standards.”
      Approximately one-half of state regulations (54%) included requirements for some form of mandatory staff training on infection control (Table 3). Of these states, 19 (70%) required facilities to train staff either on hire (7 states) or within a specified time period (12 states; average time limit to complete training = 23 days). Few states (14% overall) required annual infection control training for all staff. New Hampshire trains staff members annually on transmission, prevention, and containment of infections. Other state regulations were not as specific about mandatory staff training requirements. Only 6% of state regulations (New Hampshire, New Jersey, Virginia) required a licensed health care professional to oversee infection control activities.
      Additional requirements pertaining to infection control and prevention activities were also specified in state regulations (Table 3). For example, half of state regulations specified that ALFs were required to report communicable diseases to the health department; the proportion of state regulations that specified this type of requirement increased significantly between 1998 and 2007 and between 2008 and 2012 (25% vs 62%, P = .02). However, fewer than half (36%) of state regulations required that ALFs develop a written infection control plan and only 16% specified that facility inspections should include an assessment of infection control activities, policies, or practices. Nearly half (46%) of state regulations mentioned specific aspects of infection control practice (eg, hand hygiene). A similar proportion (44%) cited either specific federal guidelines/requirements or general adherence to “standards of care,” “scientifically accepted practices,” or “professional standards.” Of note, there was evidence of increasing reference to Centers for Disease Control and Prevention (CDC) guidelines and Standard Precautions in state ALF regulations. Although some states, such as Georgia, Indiana, and North Carolina, mentioned the use of fingerstick devices by staff on residents, none addressed critical infection control issues around this activity, such as policies around appropriate use of disposable single-use devices and cleaning and disinfecting of blood glucose meters.
      Medication administration was addressed in 64% of state regulations (Table 4); 91% (29/32) of these specified that ALF staff members are permitted to administer oral medications. Injection of intramuscular or subcutaneous medications was specifically addressed in 19 (38%) state regulations, with 5 states restricting this activity to registered nurses. Injection or infusion of parenteral medications was addressed in only 3 state regulations (Indiana, New Mexico, and South Carolina). Of note, one state (Mississippi) required that all medication types (oral, intravenous, parenteral, intramuscular, or subcutaneous) be administered by registered nurses only.
      Table 4Assisted Living Facility (ALF) Medication Administration and Vaccination Requirements Specified in State Regulations, by Time Period in Which the Legislation Took Effect, United States, 2012
      Characteristics1998–20121998–20072008–2012P Value
      n = 50 (%)n = 16 (%)n = 34 (%)
      Medication administration
       Medication administration addressed by regulation
       Oral medication administration allowed29 (58)9 (56)20 (59).86
       Intramuscular (IM) or subcutaneous (subQ)19 (38)6 (38)13 (38).96
      Staff allowed to administer IM/subQ injections:
       Registered nurses5 (26)1 (17)4 (31)1.00
       Not specific on who can administer IM/subQ injections
      Including self.
      14 (68)5 (83)9 (62).60
       Intravenous/parenteral (IV) addressed by regulation3 (6)1 (6)2 (6)1.00
      Staff allowed to administer IV medications:
       Registered nurses1 (33)0 (0)1 (50)1.00
       Not specific on who can administer IV medications2 (67)1 (100)1 (50)1.00
      Vaccinations
       Offered or required for staff
      States could select more than one.
      :
      Influenza4 (8)0 (0)4 (12).29
      Other vaccinations
      Including but not limited to measles, mumps, rubella; varicella; and other vaccinations that are in accordance with Centers for Disease Control and Prevention guidelines.
      5 (10)0 (0)5 (15).16
      Any of the above vaccinations offered or required for staff9 (18)0 (0)9 (26).04
       Offered or required for residents
      States could select more than one.
      :
      Influenza12 (24)2 (13)10 (29).29
      Pneumococcal11 (22)2 (13)9 (26).47
      Other vaccinations
      Including but not limited to measles, mumps, rubella; varicella; and other vaccinations that are in accordance with Centers for Disease Control and Prevention guidelines.
      2 (4)0 (0)2 (6)1.00
      Any of the above vaccinations offered or required for residents15 (30)2 (13)13 (38).10
      Including self.
      States could select more than one.
      Including but not limited to measles, mumps, rubella; varicella; and other vaccinations that are in accordance with Centers for Disease Control and Prevention guidelines.
      The numbers of state regulations requiring vaccination or requiring that vaccines be offered to ALF staff (9 states, 18%) or residents (15 states, 30%) was low. States that issued ALF regulations from 2008 to 2012 were more likely to specify staff vaccination requirements than states that issued ALF regulations before 2008 (26% vs 0%, P = .04). Regulations in Alabama required that facilities adhere to published health care personnel vaccination guidelines. Regulations in Wisconsin required that facilities adhere to published vaccination guidelines for residents. Neither of these state regulations mentioned specific vaccines. The remaining state regulations that included vaccination requirements were primarily focused on respiratory infections (ie, influenza and pneumococcal disease).
      Twelve state health departments provided summary data regarding the numbers of outbreaks that were identified in ALFs between January 2010 and June 2013 for one or more of the targeted categories (respiratory, gastrointestinal, and other; Table 5). Reporting requirements, definitions, and methods used to track outbreaks varied. Most of the 12 states had outbreak tracking systems that could distinguish ALFs, whereas 3 (Arizona, Ohio, and Michigan) aggregated ALFs with related forms of long term care for one or more outbreak category. For example, in Michigan, although the tally of gastrointestinal outbreaks was specific to ALFs, respiratory outbreaks included events affecting adult foster care and nursing facilities. In total, the states reported 355 respiratory and 1180 gastrointestinal illness outbreaks; the predominant pathogens in these categories, respectively, were influenza and norovirus. Eight states reported data summarizing 116 additional outbreaks (eg, conjunctivitis, scabies). These data must be interpreted cautiously given the variability in ALF licensing categories and outbreak-reporting requirements across states; comparisons between states are invalid.
      Table 5Summary of Outbreaks in Assisted Living Facilities (ALF) Identified by Selected State Health Departments, 2010–2013
      StateRespiratory Illness OutbreaksGastrointestinal Illness OutbreaksOther Outbreaks
      No.Example Pathogens
      Listed pathogens are not exhaustive and do not represent the total outbreak experience; many outbreaks were explained as “unknown origin.”
      No.Example Pathogens
      Listed pathogens are not exhaustive and do not represent the total outbreak experience; many outbreaks were explained as “unknown origin.”
      No.Example Pathogens
      Listed pathogens are not exhaustive and do not represent the total outbreak experience; many outbreaks were explained as “unknown origin.”
      AZ
      Includes standalone assisted living facilities (ALFs) and combination ALFs/skilled nursing facilities.
      21Influenza, Influenza-like illness151Norovirus40Conjunctivitis, Scabies
      CA
      January 1, 2010–December 31, 2012.
      ,
      Includes retirement/ALF, group homes, and rehabilitation.
      7Influenza75Norovirus36Conjunctivitis, Hand foot and mouth disease, Pediculosis, Scabies
      CO25Influenza, Streptococcus pneumoniaeNANot availableNANA
      ID7Human metapneumovirus, Influenza21Norovirus1Scabies
      MD49Haemophilus influenzae, Human metapneumovirus, Influenza, Legionella pneumophila, Parainfluenza161Norovirus, Rotavirus, Sapovirus10Methicillin-resistant Staphylococcus aureus (MRSA), Scabies
      MI
      Includes retirement/ALF, long term care/skilled nursing facilities, and adult foster care.
      129Influenza, Human metapneumovirus, Legionella pneumophila, Parainfluenza, Respiratory syncytial virus (RSV)102NorovirusNANA
      NC
      January 2011–June 30, 2013.
      20Influenza, Rhinovirus110Norovirus9Invasive Group A Streptococcus, Scabies
      OH
      Includes standalone assisted living facilities (ALFs) and combination ALFs/skilled nursing facilities.
      18Influenza, Legionella pneumophila85Escherichia coli O157, Norovirus, Rotavirus, Salmonella Typhimurium5Scabies
      OR19Influenza, RSV123Norovirus, SapovirusNANA
      TNNANA13NorovirusNANA
      TX
      August 2011–June 30, 2013.
      4Influenza24NorovirusNANA
      VA56Haemophilus influenzae, Human herpesvirus 1, Influenza, Human metapneumovirus, RSV, Rhinovirus315Clostridium difficile, Norovirus, Rotavirus15Hepatitis B virus, Pediculosis, Scabies, Streptococcus pyogenes
      Listed pathogens are not exhaustive and do not represent the total outbreak experience; many outbreaks were explained as “unknown origin.”
      Includes standalone assisted living facilities (ALFs) and combination ALFs/skilled nursing facilities.
      January 1, 2010–December 31, 2012.
      § Includes retirement/ALF, group homes, and rehabilitation.
      Includes retirement/ALF, long term care/skilled nursing facilities, and adult foster care.
      January 2011–June 30, 2013.
      ∗∗ August 2011–June 30, 2013.

      Discussion

      ALFs fill an important role in the long term care continuum. They provide housing and care for many persons who require assistance with activities of daily living, including management of their increasingly complex medical needs. Our analysis demonstrates that there is substantial variability in regulation of ALFs from state to state with regard to health-based admissions criteria, provisions for directly providing or otherwise arranging medical care, and related infection prevention and control requirements. Although ALFs operate under a variety of different housing and care models,
      • Zimmerman S.
      • Sloane P.D.
      Definition and classification of assisted living.
      • Mitty E.
      • Resnick B.
      • Allen J.
      • et al.
      Nursing delegation and medication administration in assisted living.

      Carlson EM. Critical issues in assisted living: Who's in, who's out, and who's providing the care - state summaries. In: National Senior Citizens Law Center, ed. 2005.

      Senate Committee on Aging. Ensuring quality and oversight in assisted living: Hearing before the Senate Committee on Aging, United States Senate. Serial No. 112–10, 112th Congress [1–148]. Available at: http://www.ahcancal.org/ncal/resources/Pages/AssistedLivingRegulations.aspx. Accessed March 20, 2013.

      • Hawes C.
      • Phillips C.D.
      • Rose M.
      • et al.
      A national survey of assisted living facilities.
      • Kane R.L.
      • Mach Jr., J.R.
      Improving health care for assisted living residents.
      few are considered to operate strictly under a traditional medical model. In most states, ALFs are not regulated by the same entities and in the same manner as nursing homes and other health care facilities. Although the primary mission of ALFs remains the provision of housing and support to maximize the independence and overall well-being of its residents, gaps in the regulation of these facilities are emerging. As ALFs evolve to accommodate residents with more chronic medical needs, ranging from dementia to diabetes and cancer, oversight of ALFs should be updated and improved.
      Prevention of health care–associated infections in residents of ALFs presents challenges based on many factors, including the health of the ALF resident, and the education and training of staff attending to an ALF resident's needs. Our review found that many state ALF regulations do not explicitly restrict admission of persons who are chronically bedridden or who require continuous nursing care. A closely related issue is that of involuntary discharge requirements that may be triggered when a resident's needs increase to the point that they exceed the capabilities of an ALF.

      Carlson EM. Critical issues in assisted living: Who's in, who's out, and who's providing the care - state summaries. In: National Senior Citizens Law Center, ed. 2005.

      • Hawes C.
      • Phillips C.D.
      • Rose M.
      • et al.
      A national survey of assisted living facilities.

      Frontline, Propublica. Life and death in assisted living. 2013. Available at: http://www.pbs.org/wgbh/pages/frontline/life-and-death-in-assisted-living/. Accessed August 12, 2013.

      Although flexible admission and discharge criteria are arguably one of the strengths of the ALF model, we recommend that states pursue a more proscriptive approach to expressly outline the levels of on-site care that are appropriate for an ALF setting under different sets of conditions and staffing arrangements, with clear references to state nurse practice standards and related delegation authorities (Table 6).

      Carlson EM. Critical issues in assisted living: Who's in, who's out, and who's providing the care - state summaries. In: National Senior Citizens Law Center, ed. 2005.

      Distinguishing multiple licensing levels is one approach to achieving this goal, but fewer than one-third of states currently follow this model; this proportion is similar to that reported in 2005.

      Carlson EM. Critical issues in assisted living: Who's in, who's out, and who's providing the care - state summaries. In: National Senior Citizens Law Center, ed. 2005.

      Another approach is to add more specificity to regulatory language pertaining to arrangements with home health agencies and aides, which may be practical given our observation that nearly 90% of state regulations currently address this issue in some form.
      Table 6Policy Options to Address Identified Infection Control Gaps in Assisted Living Facility (ALF) Regulations
      Policy options
      1. State regulations should specify levels of on-site care that are appropriate for an ALF setting under different sets of conditions and staffing arrangements, with clear references to state nurse practice standards and related delegation authorities
      2. State regulations should
       (a) specify adherence to the CDC Standard Precautions guideline
      Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Am J Infect Control 2007;35:S65–S164.
      or otherwise outline basic infection control activities to protect ALF residents from preventable illness
       (b) require facilities to implement an infection control plan, preferably under the direction of a licensed healthcare professional, with staff training upon hire and at least annually thereafter
       (c) include assessment of infection control practices as part of facility inspections
      3. State regulations should prescribe infection control training for ALF and Home Health Agency staff who may assist with the medical care of a resident. For example, states should develop policies and standards surrounding assisted monitoring of blood glucose.
      4. States may also wish to consider strengthening ALF regulations regarding staff sick leave and immunization policies
      Centers for Disease Control and Prevention. Immunization of Health care Personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2011;60(No. RR-7):1–45.
      and outbreak reporting
      Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Am J Infect Control 2007;35:S65–S164.
      Centers for Disease Control and Prevention. Immunization of Health care Personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2011;60(No. RR-7):1–45.
      State ALF regulations inconsistently included requirements for basic aspects of infection prevention and control, with no clear minimum standards outlined across all states. A set of federal guidelines that address basic infection control procedures is set forth under CDC's Standard Precautions,
      • Siegel J.D.
      • Rhinehart E.
      • Jackson M.
      • et al.
      2007 Guideline for isolation precautions: Preventing transmission of infectious agents in health care settings.
      and these evidence-based activities are considered standard in health care delivery settings. Yet, less than a quarter of states specifically mention Standard Precautions in their ALF regulations. Of note, the American Assisted Living Nurses Association includes, as part of its Scope of Practice for an assisted living nurse specialty certification, the “assurance of safe practice for all staff through ongoing assessment of the environment, and adherence to infection control practices and immunization guidelines.”

      American Assisted Living Nurses Association. Scope and standards of assisted living nursing practice for registered nurses. Available at: http://www.alnursing.org/alnursecert/SCOPE_AND_STANDARDS_FINAL2_09_19_06.pdf2006 Accessed July 17, 2013.

      Only approximately one-third of state regulations specifically required ALFs to have an infection control plan. We recommend that, going forward, state regulations should (1) specify adherence to Standard Precautions or otherwise outline basic infection control activities to protect ALF residents from preventable illness; (2) require facilities to implement an infection control plan, preferably under the direction of a licensed health care professional, with staff training on hire and at least annually thereafter; and (3) include assessment of infection control practices as part of facility inspections (Table 6). Our review also identified that offering or requiring immunization of ALF staff and residents offers much room for improvement and opportunity to better align with nursing home requirements.
      Centers for Disease Control and Prevention
      Immunization of health-care personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP).

      Centers for Medicare and Medicaid Services. Pub. 100–07: State operations provider certification transmittal 55. Revisions to appendix PP: Interpretive guidelines for long-term care facilities, tag F441. December 2, 2009. Available at: http://www.cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r55soma.pdf. Accessed March 20, 2013.

      Outbreaks demonstrate the importance of aligning appropriate health care services that follow clear infection control policies with resident needs. Assistance with monitoring of blood glucose levels is one predictable need, as 1 in 6 ALF residents has diabetes.
      • Caffrey C.
      • Sengupta M.
      • Park-Lee E.
      • et al.
      Residents living in residential care facilities: United States, 2010. NCHS data brief.
      A series of recent outbreaks suggest that ALFs struggle with provision of this service in a safe manner.
      • Counard C.A.
      • Perz J.F.
      • Linchangco P.C.
      • et al.
      Acute hepatitis B outbreaks related to fingerstick blood glucose monitoring in two assisted living facilities.
      Centers for Disease Control Prevention
      Multiple outbreaks of hepatitis B virus infection related to assisted monitoring of blood glucose among residents of assisted living facilities—Virginia, 2009–2011.
      Centers for Disease Control and Prevention
      Notes from the field: Deaths from acute hepatitis B virus infection associated with assisted blood glucose monitoring in an assisted-living facility—North Carolina, August-October 2010.
      • Schaffzin J.K.
      • Southwick K.L.
      • Clement E.J.
      • et al.
      Transmission of hepatitis B virus associated with assisted monitoring of blood glucose at an assisted living facility in New York State.
      • Bender T.J.
      • Wise M.E.
      • Utah O.
      • et al.
      Outbreak of hepatitis B virus infections associated with assisted monitoring of blood glucose in an assisted living facility—Virginia, 2010.
      Centers for Disease Control and Prevention
      Notes from the field: Transmission of HBV among assisted-living–facility residents—Virginia, 2012.
      In 2010, for example, failures of ALF staff to adhere to safe practices during assisted monitoring of blood glucose (eg, sharing of reusable fingerstick devices approved for single-patient use only) resulted in 2 notable hepatitis B outbreaks.
      Centers for Disease Control and Prevention
      Notes from the field: Deaths from acute hepatitis B virus infection associated with assisted blood glucose monitoring in an assisted-living facility—North Carolina, August-October 2010.
      • Bender T.J.
      • Wise M.E.
      • Utah O.
      • et al.
      Outbreak of hepatitis B virus infections associated with assisted monitoring of blood glucose in an assisted living facility—Virginia, 2010.
      One occurred in a Virginia ALF that primarily housed residents with neuropsychiatric disorders; 12 diabetic residents became infected.
      • Bender T.J.
      • Wise M.E.
      • Utah O.
      • et al.
      Outbreak of hepatitis B virus infections associated with assisted monitoring of blood glucose in an assisted living facility—Virginia, 2010.
      The other outbreak occurred in a North Carolina ALF and resulted in 8 acute cases: all were hospitalized and 6 patients died of complications of hepatitis.
      Centers for Disease Control and Prevention
      Notes from the field: Deaths from acute hepatitis B virus infection associated with assisted blood glucose monitoring in an assisted-living facility—North Carolina, August-October 2010.
      In 2012, inadequate staff knowledge of the importance of using existing sick-leave policies when ill, coupled with a lack of written infection control policies, contributed to severe respiratory infections and deaths in a Colorado ALF that specialized in the care of elderly persons with dementia and memory loss.
      Centers for Disease Control and Prevention
      Notes from the field: Outbreak of severe respiratory illness in an assisted-living facility—Colorado, 2012.
      In addition to these published outbreak examples, information we collected from state health departments demonstrated that there is a substantial burden of ALF outbreak activity, particularly related to respiratory and gastrointestinal infections. Prevention and control of communicable diseases in residential facilities, such as ALFs, depends on limiting introduction of infectious agents (eg, health care personnel vaccination and sick-leave policies), as well as strategies to limit spread (eg, basic infection control and reserve capacity to meet temporary increases in demands for services, such as toileting and bathing). Clear outbreak-reporting requirements, coupled with appropriate levels of public health epidemiologic and laboratory resources, could benefit ALF communities by enabling health departments to more effectively identify and investigate outbreaks, identify causative agents, and assist with implementation of control activities.
      Preventing the spread of communicable diseases in ALFs depends in large part on a competent and well-trained workforce. We recommend that state regulations prescribe infection control training for ALF staff who may assist residents with their medical and personal care needs (Table 6). For example, infection control training for ALF staff who routinely assist with blood glucose monitoring would reduce risks of transmission of bloodborne pathogens that has been demonstrated with this task. Certain states have begun providing training and programs to assist with and promote these types of trainings. For example, Virginia, which has a robust ALF outbreak reporting requirement, first developed educational materials for blood glucose monitoring following outbreaks in the mid-2000s and recently created and distributed infection control toolkits through their state Healthcare Associated Infections program.
      Centers for Disease Control Prevention
      Multiple outbreaks of hepatitis B virus infection related to assisted monitoring of blood glucose among residents of assisted living facilities—Virginia, 2009–2011.
      • Patel A.S.
      • White-Comstock M.B.
      • Woolard C.D.
      • et al.
      Infection control practices in assisted living facilities: a response to hepatitis B virus infection outbreaks.
      Additional resources outlining appropriate infection control training for ALF staff include an infection control pocket guide from the nonprofit Center for Excellence in Assisted Living that outlines specific infection control knowledge needs for ALF staff.

      Senate Committee on Aging. Ensuring quality and oversight in assisted living: Hearing before the Senate Committee on Aging, United States Senate. Serial No. 112–10, 112th Congress [1–148]. Available at: http://www.ahcancal.org/ncal/resources/Pages/AssistedLivingRegulations.aspx. Accessed March 20, 2013.

      Center for Excellence in Assisted Living. Infection control pocket guide for assisted living workers and home care aides. Available at, http://www.theceal.org/. Accessed March 20, 2013.

      Moving beyond training, states may also wish to consider strengthening ALF regulations around staff sick-leave policies for ALF staff directly involved in resident care to reduce risks of spread of respiratory illness between infected staff and residents, as well as strengthening immunization policies for both residents and staff to ensure protection against illness in the ALF residential environment.
      Although state regulations provide one mechanism for establishing infection control requirements in ALFs, there are other existing federal mechanisms that can also help ensure safe care in these settings. In our analysis, nearly all state regulations allowed provision of care in ALFs by a third party, typically through a contract with a home health agency (HHA). Many HHAs are licensed at the state level and also receive reimbursement from or are certified by the Centers for Medicare and Medicaid Services. As a result, there may be opportunities to strengthen education and training requirements for HHA staff, including specific infection control issues in ALFs.

      Centers for Medicare and Medicaid Services. Survey and certification: Guidance to laws and regulations: Home health agencies. Available at: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/HHAs.html. Accessed March 20, 2013.

      Additionally, some ALF residents with complex medical needs may be eligible for participation in a Program of All-Inclusive Care for the Elderly (PACE) program.
      • Kane R.L.
      • Mach Jr., J.R.
      Improving health care for assisted living residents.

      National PACE Association. State resources. Available at: http://www.npaonline.org/website/article.asp?id=731&title=State_Resources. Accessed July 17, 2013.

      These programs provide comprehensive long-term services and support to Medicaid and Medicare enrollees who meet state eligibility requirements for care in nursing homes, with a focus on keeping enrollees healthy and living in community settings, including ALFs. Although PACE programs may not serve all categories of assisted living residents or be available in all 50 states,

      National PACE Association. State resources. Available at: http://www.npaonline.org/website/article.asp?id=731&title=State_Resources. Accessed July 17, 2013.

      these programs may provide an additional opportunity, where available, to stipulate infection control requirements that would improve the safety of care received by ALF residents.
      This review was subject to several limitations. Although regulations set requirements for ALFs to be licensed, we did not collect any data on policies or practices at individual ALFs. As such, we were unable to describe how frequently facilities either failed to meet or exceeded the requirements prescribed by state regulations. In addition, many states have unlicensed ALFs that are not subject to regulation by the state because of their small size or other facility characteristics. The lack of consistent reporting requirements and surveillance data for outbreaks of infectious disease in ALFs presents an ongoing challenge. Requested outbreak data were available from a limited number of states.
      In summary, there is wide variation in how ALFs are regulated in the United States. Regulations that address the importance of infection control and prevention in ALFs can help ensure the safety of residents who live in these settings. Although some states have recently passed laws to ensure safe delivery of health care in these settings, few state regulations specify requirements for infection control training or oversight. Further, as the number of ALF residents increases nationally, there is a growing need to establish standards and measure compliance related to health care delivery and communal living to minimize the risk of infections, outbreaks of disease, and other forms of harm among ALF residents.

      Acknowledgments

      We gratefully acknowledge the state and local health departments who shared summary data regarding outbreaks in ALFs in their respective states: Jessica Rigler, Arizona; Michael Tormey, California (LA County); Wendy Bamberg, Sarah Janelle, and Lisa Miller, Colorado; Kathryn Turner, Idaho; Emily Luckman, Maryland; Jennifer Beggs and Susan Bohm, Michigan; Zach Moore, North Carolina; Cathy Zuercher, Ohio; Zintars Beldavs, Oregon; Marion Kainer, Tennessee; Neil Pascoe, Texas; and Andrea Alvarez, Virginia.

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