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Proposed rules would offer new assisted living protections

Residents of assisted living homes would receive significant new protections under rules proposed Friday by Massachusetts regulators — changes aimed at closing gaps that threatened elders’ safety.

Under the strengthened regulations, assisted living residences would be prohibited from accepting residents so frail they need months of skilled nursing care. The rules also call for expanded training for workers, and require detailed emergency evacuation plans, including enough equipment and medicine if extreme weather threatens.

Many elders who once would have moved to nursing homes when their health declined are instead choosing to remain in assisted living, often because the cost is significantly less than for nursing homes. As a result, the populations in these loosely regulated, apartment-like facilities have been profoundly transformed, with a growing segment of residents who are increasingly frail.


Today, roughly 14,000 people in Massachusetts dwell in about 225 assisted living residences.

Elder advocates have long lobbied state regulators to update the rules governing those residences, saying that guidelines to protect residents have not kept pace and have not been updated since 2006.

Ann Hartstein, secretary of the Executive Office of Elder Affairs, said the changes should enhance residents’ safety. The agency, which is charged with overseeing assisted living residences, worked on the updates for close to a year and a half.

Hartstein said the state wanted to ensure that residents, who generally pay out of pocket, clearly understand the services they will receive and “ensure that residences have the required services to meet their need.”

In many ways, the proposed regulations aim to address the new realities of assisted living, especially the growing ranks of fragile residents.

The rules would prohibit the facilities from accepting residents, or allowing them to remain in the facility, if the patients require more than 90 consecutive days of skilled nursing care. The rules also require annual evacuation drills.

While existing rules require substantial training for staffers, the updated guidelines mandate education in two areas of special concern: recognizing and reporting elder abuse and techniques for managing and calming aggressive behavior, something commonly encountered in caring for patients with dementia. The rules also require more frequent activities for residents in special care units at the facilities, which are becoming increasingly popular for elders with dementia.


Specialists in Alzheimer’s disease had urged such updates, saying that people with dementia fare better when they engage in meaningful activities and have caregivers who understand their complex behaviors.

“It’s definitely moving in the right direction,” said James Wessler, president of the Alzheimer’s Association of Massachusetts and New Hampshire.

Wessler, who had not read the proposed rules Friday but was briefed on them, said his association was also encouraged by updates that would require a nurse to assess whether prospective residents are capable of taking their own medications.

Current regulations allow “self-administered medication management,” with staffers reminding patients to take their medications and documenting whether they take them or refuse. Alzheimer’s specialists had expressed concerns that too many dementia patients have not been getting their medications under the existing relaxed approach.

“To have somebody who is medically qualified and trained to make that assessment, that is an important step forward,” Wessler said.

The proposals stopped short of requiring some measures advocates had sought, including minimum staffing levels for all residences. Instead, the proposal stipulates only that it “shall never be considered sufficient to have less than two staff members in a Special Care Residence,” which typically cater to residents with dementia.


Some attorneys who specialize in elder abuse cases said they believe insufficient training and staffing are at the heart of most of the abuse cases they see.

“Anything is an improvement from what we have, but I don’t think this has teeth,” said David Hoey, a North Reading attorney who specializes in elder abuse law.

“At the end of the day, there still needs to be enforcement and oversight,” Hoey said. “There is too much for the [Executive Office of Elder Affairs] to handle. It doesn’t have enough staff, manpower, money, and supplies to police the assisted living industry right now.”

Many states regulate assisted living residences as health care facilities, but Massachusetts remains among a handful that still consider the facilities more similar to apartment living.

Emily Meyer, president of the Massachusetts Assisted Living Facilities Association, said in an e-mailed statement that her association is reviewing the draft regulations.

The rules will be presented to an advisory council and will be the subject of a public hearing next month. They could go into effect as soon as January.

“While we are concerned about the short time frame for this process, we look forward to providing [the Executive Office of Elder Affairs] with our feedback,” said Meyer, whose group represents most of the state’s facilities.

Elder Affairs has announced a public hearing about its proposed regulations on Dec. 15, from 10 a.m. to noon at 1 Ashburton Place, Fifth Floor, in Boston. The agency is also accepting written comments until 5 p.m. Dec. 17. The proposed regulations are available on the agency’s website, www.mass.gov/elders or by calling 617-222-7562.


Kay Lazar can be reached at Kay.Lazar@globe.com Follow her on Twitter @GlobeKayLazar.