ANNAPOLIS – Dennis Byrne said he prefers the family setting of a small residential home rather than a large 100-bed facility for his 86-year-old aunt suffering from Alzheimer’s disease.
She stays in a five-bed assisted living place in Howard County where the owner is trained to assist with her Alzheimer’s and where she is sometimes allowed to cook her delicious bread pudding.
“I love it,” said Byrne, a founder of the Small Assisted Living Alliance. “It’s a wonderful place.”
Maryland is flooded with these smaller assisted-living facilities. Of the nearly 2,000 assisted-living homes in Maryland, about 800 homes, or 40 percent, have fewer than four beds, according to data from the Office of Health Care Quality, an agency of the Department of Health and Mental Hygiene.
Many blame a change in definition that took effect six years ago for the proliferation of small, assisted-living places in Maryland.
The growing number of smaller homes has the state at a loss to inspect them with a declining number of regulators. The state is asking the General Assembly to lessen its regulatory responsibility for the smaller homes and redefine assisted-living places in the state.
Byrne said it seemed like the department is taking the easy way out.
“It’s a lot easier to visit 40 large facilities than to visit 1,100 small facilities,” he said.
Carol Benner, director of the Office of Health Care Quality, said Maryland’s definition of assisted living is one of the broadest in the nation. New Jersey, with almost three times Maryland’s population, has only one-10th the number of assisted-living programs.
Assisted living is defined as a residential or facility-based program that provides housing, supervision, personal assistance and health-related services for individuals who are unable to perform the activities of daily living — bathing, dressing, feeding, housekeeping and providing medications — while allowing them to live as independently as possible.
The facilities bridge the gap between independent living and living in nursing homes.
In the early 1990s, there were 12 to 15 programs for the elderly in the state administered by three executive departments and each program had separate rules and standards.
In 1996, the state passed a law, implemented in 1999, that consolidated all assisted-living places into one program under the oversight of the Department of Health and Mental Hygiene and had all providers comply with the same regulations.
The nation experienced a significant growth in assisted-living programs during this time because of the growth in the aging population and the need for affordable care for senior living. The state was aware of 800 programs before the changes were implemented; by 2004, there were more than 2,000.
“I think it’s kind of a double-edged sword,” said Cass Naugle, executive director of the Greater Maryland chapter of the Alzheimer’s Association.
“It provides a less-expensive form of residential care for people who cannot afford the larger assisted-living facilities. But, the state does not have the resources to monitor the quality of the care.”
State law requires at least one survey, or inspection, per year in each of Maryland’s assisted-living places. In fiscal 2004, the Office of Health Care Quality was only able to accomplish 428 annual surveys, according to a report to the Senate Budget and Taxation Committee and the House Appropriations Committee.
Benner said she disagrees with the “one-size-fit-all” law. Small assisted-living programs are over-regulated and larger programs are under-regulated, she said. Surveyors have to spend more time doing technical assistance to help providers get into compliance than in surveying homes, Benner said.
“There’s no way that we can survey 2,000 places a year,” said Benner. “There’s no way.”
Budget cuts have caused a shortage of surveyors. The office is required to have 40 surveyors, but there are only 17, according to the overview.
“It almost sets up a regulatory structure that is unworkable,” Benner said.
Her department requested a bill during this year’s Maryland General Assembly to change assisted-living-home definitions. Homes in a private residence with fewer than four beds would be known as adult-care homes, under the proposal, and surveys would be required only periodically or based on complaints.
Smaller homes of up to nine beds, with providers that operate a chain of such homes for non-adults, would be called residential care homes. They will continue to be surveyed annually.
Only places with 10 or more beds would be called assisted living under the proposal, and they would still also be required to be surveyed annually.
The bill passed the House, but did not get out of the Senate before the session ended. The department is expected to request the bill again next session.
“I strongly believe that they should not change the definition,” said Susan Shubin, supervising attorney of Legal Aid Bureau of Maryland, which represents assisted-living residents.
Studies have indicated that 65 percent of assisted-living residents have dementia-related or Alzheimer’s disease and residents are frequently on at least six medications, she said.
“When you are talking about this type of population, what type of regulations shouldn’t be enforced?”
Marian Grenway, the owner of a five-bed assisted living facility in Howard County, said she doesn’t mind having the same regulations as those with 80 beds.
“People don’t want to put their parents somewhere where there is no accountability.”
She is required to take training classes on CPR, medication management, Alzheimer’s, dementia, infection control, elderly abuse and more.
The state should continue the monitor places with four beds or fewer, she said.
“It gives credibility to the small assisted living places,” Grenway said. “It’s a marketing tool.”
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