When Assisted Living Isn't Enough

If there is one point of education that we find ourselves making over and over again in the assisted living space, it’s this: there are certain conditions that, if present, mean that an RCFE (assisted living) is legally not allowed to accept the resident, or keep them after the condition develops. If your loved one develops one of these, the facility can't just shrug and keep providing the same routine level of services. They're supposed to move that person up to a higher level of care or make arrangements to ensure the care needs are met.

In our firm, we have all heard stories where families were told by assisted living staff that "we can manage the changing condition here" more times than we can count. Sometimes that's true. If a condition is recognized, a plan is put in place, and if appropriately licensed and credentialed staff are brought in to provide care, some conditions can be managed, particularly acute illness or temporary conditions. But often the condition will be chronic, progressive and deteriorating, and assisted living level of care isn’t enough. Knowing the rules on restricted and prohibited conditions can mean the difference between someone getting the care they need and neglect.

What an assisted living facility cannot handle

California state law generally prohibits an RCFE from accepting or retaining a resident who:

• Has a primary diagnosis of a mental disorder and a need for care for a mental health disorder unrelated to dementia

• Depends on others for all activities of daily living

• Has a Stage III or Stage IV pressure sores

• Requires gastrostomy or nasogastric tube (G-tube or feeding tube) care

• Has a tracheostomy and is ventilator dependent

• Staph infection or other active, serious communicable disease

• Requires 24-hour skilled nursing care on a chronic, ongoing basis.

California restricts an RCFE from accepting or retaining certain residents as well. RCFEs are permitted to accept or retain residents with certain restricted health conditions if there is a plan in place and coordination with appropriately skilled professionals (like an RN or LVN).

Restricted Health Conditions include:

• Administration of oxygen.

• Catheter care (indwelling urinary catheters).

• Colostomy and ileostomy care.

• Contractures.

• Diabetes.

• Injections (e.g., insulin).

• Enemas, suppositories, and/or fecal impaction removal.

• Intermittent Positive Pressure Breathing (IPPB) Machine use.

• Stage 1 and 2 pressure injuries (healing wounds)

Read these lists again if your loved one is currently in an RCFE. If any of these conditions are present, it's worth a direct conversation with the facility about their plan to meet your loved one’s needs. Ask who is qualified to provide needed care relating to one or more of these conditions? What does that look like day to day? What level of “nursing” (RN/LVN) oversight will there be? Has the physician been informed and signed off on my loved one staying here? Have they seen the plan and do they agree it is adequate? Vague reassurance is not enough. You need specifics.

Why these rules on “prohibited” and “restricted” conditions exist for assisted living facilities

An RCFE is, first and foremost, a housing arrangement, not a hospital, not a nursing facility. The staff aren't required to have medical training the way a skilled nursing facility's staff are. So the law draws a line: past a certain point of medical or nursing need, an assisted living setting simply isn't equipped to care for the resident. In that case, the facility has to convene meetings with the family and involve the resident’s physician to make a plan to bring in needed resources, or to arrange a transfer to a higher level of care, rather than try to stretch its staff past what they're trained or licensed to do.

That line exists to protect your loved one. It also gets ignored more than it should, usually because moving a resident out of a facility means lost revenue, not because it's actually in your loved one's best interest to stay.

What to do if you think it's time for a transfer

Start with a team meeting with facility staff and the responsible doctor. Ask directly whether your loved one's current needs still fall within what the facility is licensed to provide. Get the answer in writing if you can. If the facility resists or gives you the runaround, that's information too.

You don't need to already have proof that something's gone wrong to start asking these questions. You just need to be informed about the limitations on care in an RCFE / Assisted Living environment to be sure the facility is licensed, staffed, equipped and trained to take care of your loved one.

If you're not sure whether your loved one's current facility is still the right fit, we're happy to talk it through, no obligation, just answers.