When Assisted Living Is No Longer Enough: Signs, Options and the Move

Assisted living communities and board and care homes are licensed in California as residential care facilities for the elderly (RCFEs). They are non-medical homes, and the law draws lines around what they may take on. These changes can be signs that a resident is near one of those lines:

• The person needs a nurse around the clock. Health and Safety Code section 1569.72 says no resident may be admitted or retained if the resident requires 24-hour skilled nursing or intermediate care.
• A prohibited health condition develops. Title 22 section 87615 lists stage 3 and 4 pressure injuries, gastrostomy and naso-gastric tubes, tracheostomies, and a staph or other serious infection.
• The person now depends on others to perform all activities of daily living, which is on the same prohibited list.
• The person has become bedridden for longer than a temporary illness and the home does not have the fire clearance the law requires for bedridden residents.
• Behavior has become a threat to the person's own safety or to other residents, and the home's interventions have not been enough.

None of these means a move is certain, and only the doctor can say what your relative needs medically. Two licensed homes can also answer differently, because each decides what its own staff and building can manage. The full allowed, restricted and prohibited list is in health conditions an RCFE may accept.

Title 22 section 87463 requires the home to update the pre-admission appraisal in writing as often as necessary, or once every 12 months, whichever comes first, to note significant changes in condition. The regulation gives examples: physical trauma such as a heart attack or stroke, changes in cognitive function, behavior that may result in harm to self or others, and illness or injury that significantly changes health care or dietary needs.

When there is a significant change, the home must:

1. 1

   Tell the medical professional

   Bring the change to the attention of the appropriate licensed medical professional immediately, or as soon as reasonably possible, and record what was recommended.

2. 2

   Tell the resident and the family

   Communicate with the resident and, if there is one, the resident's representative about the change and the recommendation.

3. 3

   Change the care

   Make corresponding changes in the care and supervision provided, and evaluate whether there are enough direct care staff to support each resident's needs.

4. 4

   Meet

   Arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the representative and the appropriate staff.

Ask for that meeting if it is not offered. It is the place to hear which need the home says it cannot meet. How appraisals work is explained in the assisted living care assessment.

More care does not always mean leaving. The regulations say the limits on who a home may keep are meant to allow residents to age in place in the least restrictive environment when appropriate, and they allow a home to keep a person who receives needed medical care from a visiting nurse.

Ask the home for the new rate in writing before agreeing to a higher care level.

The California Department of Aging describes skilled nursing facilities as providing 24-hour skilled nursing care, as well as related or rehabilitative services, for people whose needs cannot be met at home or in a residential care setting. They are licensed and inspected by the California Department of Public Health, not by the Department of Social Services that licenses RCFEs.

The Department of Aging says the typical resident is a person who is chronically ill or recuperating from an illness or surgery, so a stay may be long or short. The differences in care, cost and who pays are set out in assisted living vs nursing home in California. Ask the doctor or the hospital discharge planner about that kind of move.

There are three routes. The first is voluntary: the resident and family decide to move, and the Resident's Bill of Rights in Health and Safety Code section 1569.269 gives every resident the right to move from a facility.

The second is eviction. Title 22 section 87224 lists, among the reasons a home may evict, that after admission the resident is found to have a need not previously identified, a reappraisal has been done, and the home and the person who performed the reappraisal believe the facility is not appropriate for the resident. That ground requires 30 days' written notice stating the reasons and specific facts. A notice of only three days is possible with the licensing agency's prior written approval, on a finding that the resident's behavior is a threat to the health or safety of the resident or others. A resident who disagrees can ask the Department to investigate, and the notice must explain the right to a court hearing. See California's assisted living eviction rules.

The third is a state order. Under Title 22 section 87637, when a resident has a health condition that cannot be cared for within the limits of the license, requires inpatient care, or is prohibited, the Department must order the home to relocate the resident. The resident is told of the right to request an interdisciplinary team review. The home must write a relocation plan that takes no more than 30 days, consult the resident's physician, and take part in finding an acceptable place with the resident and the responsible person. If the Department finds imminent danger, it can order an immediate move.

These are legal processes. The Long-Term Care Ombudsman or an elder law attorney can explain a resident's options in a particular case.

Hamssa Benrekia is a senior living placement specialist in Torrance with a background in hospice, palliative care and home health. When a home in the South Bay or Harbor area of Los Angeles County says it can no longer meet a resident's needs, she can help the family look for another licensed assisted living community, board and care home or memory care home that may be able to. She does not place people in skilled nursing facilities and does not give medical or legal advice. More topics are in the California Assisted Living Placement Guide. To talk through a situation, contact Hamssa.