Can Assisted Living Care for a Feeding Tube or Swallowing Problems in California?

MedlinePlus, the National Library of Medicine's health site, describes a swallowing disorder, also called dysphagia, as difficulty or pain when swallowing. It is more common in older adults and often comes from another condition, such as Parkinson's disease or a stroke. MedlinePlus says treatment with a speech-language pathologist can help, that changing the diet or the position of the head while eating may help, and that in very serious cases people may need feeding tubes.

Two kinds of tube matter for California care homes. A gastrostomy tube, or G-tube, is a feeding tube placed through the skin and the stomach wall, directly into the stomach. A naso-gastric tube, or NG tube, carries food and medicine to the stomach through the nose.

Whether a tube is right for your relative is a decision for the person, the family and the doctor. This page covers only what it means for where the person can live.

Assisted living communities and board and care homes, licensed in California as residential care facilities for the elderly (RCFEs), are non-medical homes. Title 22, section 87615, lists the health conditions a resident may not have. A person with one of them shall not be admitted to or retained in an RCFE. Gastrostomy tubes and naso-gastric tubes are both on the list, alongside stage 3 and 4 pressure injuries and a few others described in health conditions assisted living can accept.

The section says its list is "including, but not limited to" the named conditions. A tube it does not name, such as one placed into the small intestine, is not automatically allowed. Ask the home to check with its licensing office before you rely on a yes.

The prohibition is about the setting, not the person. An RCFE is licensed for care and supervision, and state law bars it from keeping anyone who requires 24-hour skilled nursing care.

There are two routes, and both depend on the home:

1. 1

   A written exception request

   Under section 87616, a home may ask the Department of Social Services for an exception for a resident with a prohibited condition. The request must include current medical reports, the prognosis and expected duration of the condition, the home's plan for meeting the resident's health needs, and its plan for limiting the effect on other residents. The home applies, not the family, and the department decides.

2. 2

   A hospice care plan

   A home that holds a hospice care waiver does not need a separate exception for a resident who is terminally ill and receiving hospice, as long as the hospice care plan specifically addresses the treatment of the prohibited condition. Section 87633 adds that facility staff who are not appropriately skilled professionals shall not perform any procedure the law reserves for such a professional. See hospice in assisted living.

Even with an exception or hospice, a home may say no. Whichever route applies, ask who will do the feedings, the flushing and the care of the tube site, and how often a nurse will be in the home. Health and Safety Code section 1569.39 requires a home that accepts or keeps a resident with a prohibited condition to assist the resident with accessing home health or hospice services, so that the resident receives the medical care the physician prescribed.

Yes. Swallowing difficulty is not on the prohibited list, and it is not one of the restricted conditions either. Several ordinary rules cover it:

• Before admission, the home's appraisal must look at eating, including the need for adaptive devices or assistance from another person, and at dietary limitations.
• Personal assistance with eating, as the appraisal shows the resident needs, is one of the basic services an RCFE must provide.
• Modified diets prescribed by a resident's physician as a medical necessity shall be provided.
• Meals are served in a dining area, and tray service must be provided in case of temporary need.
• A home that accepts a resident is responsible for meeting the needs identified in the appraisal, directly or through outside resources.

The limit is at the far end. Section 87615 also prohibits a resident who depends on others to perform all activities of daily living. Needing help to eat does not meet that test alone, but it is part of the picture a home and a doctor look at when a person's needs grow. Our guide on when assisted living is not enough covers that decision.

The diet rule is tied to a physician's prescription. If a doctor or speech-language pathologist recommends soft, minced or pureed food, or thickened drinks, ask the doctor to put it in a written diet order and give the home a copy before move-in. The regulations do not list which diets a home must be able to prepare, so the practical question is whether this kitchen can do it at every meal. Our guide to special diets in assisted living goes into more detail.

Swallowing therapy can come to the home. Medicare lists speech-language pathology services among the home health services it covers for people who meet its conditions, which include being homebound. Ask the doctor whether a swallowing evaluation makes sense and whether the results should be shared with the home's staff.

Timing matters most with tubes. If a hospital or rehab team raises a feeding tube, call the home before the procedure and ask whether it could take your parent back. A home that cannot get an exception, and has no hospice plan to rely on, may not legally keep a resident with a G-tube or NG tube. Ask:

• Have you had a resident with a feeding tube, and under an exception or a hospice plan?
• Do you hold a hospice care waiver?
• Who helps residents who eat slowly or need to be fed, and how many staff are in the dining room?
• Can your kitchen prepare the texture the doctor ordered at every meal and snack?
• What do staff do if a resident coughs or chokes during a meal, and whom do they call?
• At what point would you say my father needs more care than you can give?

Hamssa Benrekia is a senior living placement specialist in Torrance with a background in hospice, palliative care and home health. She can help a family in the South Bay and Harbor area look for a licensed board and care home or assisted living community that says it can manage a parent's eating and swallowing needs, and she goes on the tours with you. She does not place people in skilled nursing facilities, and she does not decide what a home may accept. To talk it through, contact Hamssa, or start with the California Assisted Living Placement Guide.