CALA News & Views | Issue 49 | Top 5

News &Views 5 OPTIONS FOR EXPANDING ACCESS TO ASSISTED LIVING SERVICES TOP 5 CALA 5 WAYS TO ACHIEVE RESIDENT & FAMILY SATISFACTION

5 WAYS TO MAINTAIN COMPLIANCE BEYOND TITLE 22

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Specialists in Innovative Senior Housing Design

Douglas Pancake Architects (DPA) specializes in design for aging and serves the senior living and healthcare industries across the United States. For 30 years, Douglas Pancake has been a leader in the evolution of senior housing design, code development, and advocacy for our elders. The architects at DPA are compassionate and talented individuals, who are focused on creating supportive and meaningful healing environments for the frailest and most vulnerable members of our communities.

19000 MacArthur Blvd., Ste. 500, Irvine, CA 92612 | Phone: (949) 720-3850 info@pancakearchitects.com | www.pancakearchitects.com

TOP 5

IN

THIS ISSUE

Secrets of the CALA Staff & More!

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5 Ways to Maintain Compliance Beyond Title 22 5 Ways to Achieve Resident and Family Satisfaction Top 5 Things Providers Need to Understand Regarding Surrogate Decision Makers 5 Connections to Help with Emergency Preparedness 5 Options for Expanding Access to Assisted Living Services

Everyone loves lists! In this issue of the CALA News & Views, we delve into a diverse array of topics, each presented in a crisp and concise manner as the “Top 5.” Whether

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you're seeking insights on the latest issues, practical tips for everyday challenges or simply a dose of lighthearted fun, we've got you covered. Let’s start with the lighthearted fun and maybe you’ll learn a few things about the CALA staff in the process. I asked the staff five intriguing questions: Pancakes or Waffles? A whopping 83% of the staff prefer pancakes over waffles. Vacation or Staycation? With 86% opting for a vacation over a staycation, I wonder what destinations are topping their travel bucket lists. Dogs or Cats? 71% of the staff have a soft spot for dogs. Italian or Mexican Food? It’s a close call, but Italian cuisine wins by a nose, with 57% of the staff favoring it over Mexican fare. Elephant or Alpaca Ride? 100% of the staff were smart enough to know you can’t ride an alpaca! But, riding an elephant “around town” sounds like an interesting challenge!

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5 Tools and Resources for CALA Members

CALA News & Views – Submission Policy At this time, CALA does not accept unsolicited articles or queries. Many of the articles we publish are written by our regular contributing writers. We appreciate the time and energy people put into making suggestions for our current and future issues. Our organization’s policy, however, prevents us from accepting for review any unsolicited submissions.

Nancy Ball Director of Meetings and Events nancy@CAassistedliving.org Denise Brandt Director of Workforce Development denise@CAassistedliving.org

Selena Coppi Hornback Director of Public Policy selena@CAassistedliving.org Agnes de la Vega Education and Workforce Associate agnes@CAassistedliving.org Heather Harrison Senior Vice President of Public Policy & Public Affairs heather@CAassistedliving.org Katherine McLoskey Director of Operations katherine@CAassistedliving.org Sally Michael President & CEO sally@CAassistedliving.org Haty Pietrasz Director of Creative Design haty@CAassistedliving.org Maddie Robbie Associate Director of Public Policy maddie@CAassistedliving.org Kevin Swartzendruber Director of Marketing & Communications kevin@CAassistedliving.org Jan Trifiro Vice President of Professional Development jan@CAassistedliving.org

CALA STAFF

We hope you enjoy exploring this edition of News & Views with a blend of Top 5 insights and advice! Sally Michael, CALA President & CEO

CALA BOARD OF DIRECTORS

Board Chair Ron Mead, Vice President of Operations Senior Resource Group, LLC Vice Chair David Eskenazy, CEO, Cogir Management USA, Inc. Treasurer Laura Fischer, Chief Operating Officer, Integral Senior Living

Secretary Courtney Siegel, President & CEO, Oakmont Management Group Past Board Chair Danielle Morgan, President, Clearwater Living

DIRECTORS OFFICERS

Michel Augsburger, Chairman & CEO, Chancellor Health Care, Inc Mark Cimino , CEO & Co-Owner, CiminoCare Dave Coluzzi, President & CEO, Carlton Senior Living

Tara Cope, Chief Legal and Administrative Officer, Vi Senior Living Carmel Dolcine-Joseph, Vice President of Wellness, Elder Care Alliance Paula Hertel, Founder, Senior Living Consult Rick Jensen, President & CEO, Northstar Senior Living Michelle Kelly , Senior Vice President, Investments for National Health Investors, Inc Rodger Lederer, Senior Vice President, Marsh Senior Care Practice Douglas Lessard, COO & Executive Vice President, Belmont Village Senior Living Tana McMillon , Regional Vice President of Operations, Silverado Memory Care Nancy Schier Anzelmo, Principal, Alzheimer’s Care Associates Todd Shetter, Chief Operating Officer, ActivCare Living Jay Thomas , Assistant General Counsel, Operations, Atria Senior Living

CALA 455 Capitol Mall, Suite 222 Sacramento, CA 95814 Phone: (916) 448-1900 www.CAassistedliving.org

EX-OFFICIO DIRECTORS Josh Allen, Principal, Allen Flores Consulting Group Joel Goldman, Partner, Hanson Bridgett

Copyright © 2024 California Assisted Living Association. All rights reserved. No part of this publication may be reproduced or transmitted in any form - print, electronic, or otherwise - without written permission from CALA.

TO 5

WAYS

EMPLOYMENT LAWS & PAGA

CAL/OSHA

Beyond MAINTAIN COMPLIANCE TITLE 22

HAZARDOUS WASTE

INFECTION CONTROL

By Selena Coppi Hornback, CALA Director of Public Policy

JANUARY 2010, VOLUME 1 4 CALIFORNIA ASSISTED LIVING ASSOCIATION

Residential Care Facilities for the Elderly (RCFEs) and Continuing Care Retirement Communities (CCRCs) must follow requirements in the Health and Safety Code and in Title 22, but as employers, businesses and medical waste generators, etc. they must also maintain compliance with other laws and regulations that may be less familiar. CALA turned to members with expertise in employment law, Cal/OSHA requirements, hazardous waste requirements and infection control to provide their top tips to help members comply with these additional requirements.

Employment Laws and Private Attorneys General Act (PAGA) This section contributed by Diane Marie O’Malley, Hanson Bridgett LLP

Best practices for preventing or defending PAGA claims are to work closely with your human resources and legal counsel to shore up your wage-and-hour policies and make sure your practices reflect those policies. Some of the more frequent allegations seen in these claims include the following areas:

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Rest and Meal Periods: Make sure that employees are getting rest and meal periods, documenting any statutorily permitted exceptions. Regular Rate of Pay: Make sure you are paying overtime, meal and rest break premiums and sick pay the regular rate of pay, when required. That means checking to assure you are including all non-discretionary income (such as bonuses, shift differential, etc.) earned in a workweek in your calculation of those payments. Reimbursements for Business Related Expenses: Review if employees are using personal devices to communicate about work (such as communicating with supervisors); and, are there policies inappropriately requiring employees to pay for business-related expense such as replacing lost name tags or company-issued uniforms. 2 3

Paycheck Stubs/Wage Statements : Provide itemized wage statements and ensure the statements accurately portray all applicable Labor Code Section 226(a) items. For example, wage statements should depict the correct legal entity name and address of the employer. Remember to review if the wage statement reflects paid sick leave balances. Correct Employee Classification: Regularly audit job duties to determine if your employees classified as “exempt” are, in fact, exempt.

Working Off-the-Clock: Audit to determine if you have any employees engaged in employer directed activities before or after they clock in to work that would be considered “off-the clock” work, such as regularly responding to work related messages after hours, checking for changes in their schedules, preparing or completing paperwork before they clock in or after they clock out; “checking the workspace,” “locking up and securing the premises” after clocking out.

PRACTICE: BONUS BEST

Cal/OSHA

CALA NEWS & VIEWS I ISSUE 49 | MARCH 2024

This section contributed by Scott Bertulis, Marsh Senior Living & LTC Industry Practice, US and Canada Cal/OSHA is a division within California’s Department of Industrial Relations dedicated to protection and improvement of employee health and safety. Here are the top five Cal/OSHA compliance tips, and a bonus tip.

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Maintain a comprehensive Injury and Illness Prevention Plan and make sure you update it annually. See a model IIPP plan on the Cal/OSHA website at https://www.dir.ca.gov/dosh/dosh_ publications/IIPP-Model-high-hazard.doc.

Maintain compliance with the most frequently cited Cal/OSHA standards as follows: Injury and Illness Recordkeeping, Bloodborne Pathogens, Chemical Hazard Communication, COVID-19 Standard and Respiratory Protection.

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Make sure your communities all have active safety committee meetings that meet monthly to review and discuss employee safety and Cal/OSHA compliance. Perform regular walkthrough safety inspections of your communities to ensure that common Cal/OSHA violations are identified and corrected; some examples include: a. Blocked electric panels. b. Blocked or non-compliant emergency eyewash stations (cannot be eyewash bottles and must be able to flush the eyes continuously for 15 minutes). If employees use corrosive cleaning chemicals, then eyewash/emergency showers may be required, based on employee exposure. c. Improper disposal of sharps and/or biohazard waste; make sure sharps containers are not “FULL.” d. Fire extinguishers that are not inspected monthly and/or blocked. 4

5 e. Electrical hazards, such as damaged electrical cords and tools. Make sure your communities contact the home office and/or legal counsel immediately for guidance if there is a Cal/OSHA inspection, serious injury/illness that must be reported to Cal/OSHA or they receive an employee complaint letter from Cal/OSHA.

Senior Living communities must have written workplace violence prevention plans in place by July 1, 2024. Cal/OSHA recently published its model program for workplace violence prevention, along with a “fact sheet” on the new Cal/OSHA requirements to help employers develop their own policies. These resources can be found on Cal/OSHA’s webpage at https://www.dir.ca.gov/dosh/ puborder.asp

BONUS TIP

Hazardous Waste This section contributed by Samir J. Abdelnour, Hanson Bridgett’s Environment, Natural Resources and Land Use practice group CALA members learned more about additional requirements for handling and disposing of hazardous waste during two webinars offered last September. For more information, please visit CALA’s Webinars webpage to access both webinars and handouts, and read on for five tips to help maintain compliance when dealing with hazardous waste.

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Understand the difference between medical waste and hazardous waste If a pharmaceutical waste is classified as “hazardous” under the federal Resource Conservation and Recovery Act (“RCRA”), it must be managed as hazardous waste and cannot be managed as medical waste. This means different rules apply for registration, the types of waste containers that can be used, accumulation time limits and disposal of the wastes. Document your pharmaceutical waste management program Your community should have easily accessible documents that describe how to properly manage medical waste and how to properly manage hazardous waste. These documents should also include lists of commonly encountered pharmaceutical wastes at your facility that fall into each category. Training, training, training! whether each pharmaceutical waste they are handling is a medical waste or a hazardous waste, and the proper procedures for each one. They should also know where at the community they can find documentation and guidelines 2 3 Every employee whose job involves handling pharmaceutical waste should be trained to know

for how to handle each waste, and what to do if they are unsure which category a waste falls into. Good housekeeping matters Make sure waste containers are properly labeled, accumulation time limits are observed and waste management program documentation is readily accessible. When you have all these things in place, it signals to a waste inspector that your facility takes these issues seriously. Work with, not against, your local waste inspector and regulatory agency When an inspector comes to your community, your employees should be trained to be cooperative and respectful. The inspector has a right to be there and do their job. The more they feel like you are working with them to ensure compliance, the more flexibility they will give you to fix issues they identify. Also, when in doubt, reach out and ask for assistance. Your local agency is there to help you maintain compliance, but if they don't think you are making a good effort, they can issue citations and impose fines, or worse, refer you to a prosecutor. 4 5

JANUARY 2010, VOLUME 1 6 CALIFORNIA ASSISTED LIVING ASSOCIATION

Infection Control This section contributed by Josh Allen, Allen Flores Consulting Group

Infection control was heightened during the COVID-19 pandemic, and senior living providers followed state, federal and local public health guidance. The Department of Social Services also released infection control regulations during this time that providers must comply with. Following are five infection control tips to help maintain compliance.

Keep it simple! The basics of infection control are the most effective components. Have clear policies and train your staff on hand hygiene and use of gloves. When to perform hand hygiene? Infection Control regulations include washing with soap and water, using an alcohol-based hand sanitizer or other method recommended by medical or health care professionals. The regulations require hand hygiene must be performed “immediately before and after resident care; before and after handling, preparing or eating foods; before and after assisting with medications; after contact with blood, body fluids or other potentially infectious material, or contaminated surfaces; 1 2 Diane Marie O’Malley is a partner at Hanson Bridgett LLP, in their Labor and Employment Section. Her practice concentrates exclusively on representing employers mainly in the senior living and public transit industries. Scott Bertulis , CSP, ARM, CSPHA, is the Senior Vice President, Risk Control for Marsh Senior Living & LTC Industry Practice , US and Canada. Samir J. Abdelnour is a partner in Hanson Bridgett’s Environment, Natural Resources and Land Use practice group. He advises clients on state and federal hazardous waste management, storage and disposal laws across a variety of industries. Josh Allen, RN, is principal for Allen Flores Consulting Group , which provides clinical management and consulting services to Assisted Living providers throughout the United States, and a CALA board member. 3 4 5

immediately before putting gloves on and immediately after removing gloves; and when hands are visibly soiled.” Update your infection control plan at least once per year, and ensure your staff are aware of it and training is documented. Ensure you have proper biohazard waste procedures in place. This should include proper definition of biohazard waste, appropriate storage containers, and waste removal. Are you compliant with Cal/OSHA fit testing requirements? All staff who are required to wear a respirator at work (such as an N95 when caring for residents with COVID) must have a medical clearance and fit testing.

CALA’s Legal Library, a free resource made available through a partnership with Hanson Bridgett LLP, a CALA premier partner, provides guidance and clarity on many issues that apply to senior living providers. Click here to access the Legal Library for additional resources. LEGAL LIBRARY

Worried About Wages? Setting fair and competitive wages and benefits is critical to employee recruitment and retention, especially in these unprecedented times. CALA’s Compensation Study provides data specifically for Assisted Living, Memory Care and CCRCs in California. Plan now to participate, beginning mid-May. Contact Kevin Swartzendruber with questions. compensation study

CALA NEWS & VIEWS I ISSUE 49 | MARCH 2024

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By Douglas Armstrong, Belmont Village, L.P.

TIPS

for

Managing

DIFFICULT

Difficult conversations are an inevitable and inescapable part of the daily management of an Assisted Living community. Nearly everyone, however, dreads the difficult, challenging conversation, including conversations in which we have to deliver unpleasant news, discuss a delicate subject, or talk about something that needs to change or has gone wrong. The following tips will hopefully help you to understand the need for a difficult conversation, how to prepare for the conversation, how to effectively conduct the conversation to achieve a reasonable and productive outcome, and how to complete a post conversation evaluation. Conversations

JANUARY 2010, VOLUME 1 8 CALIFORNIA ASSISTED LIVING ASSOCIATION

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When Is It Time to Have That Difficult Conversation? We all have heard that inner voice telling us when we need to have a difficult conversation with someone, a conversation that, if it took place, would improve life and operations at the community for ourselves, our residents and their family members and our community staff. So why do we avoid difficult conversations? ● We convince ourselves that talking about the problem will make the problem worse. ● We fear that the cure may be worse than the disease. ● We are not sure where the conversation will end and we fear the consequences/retribution. ● We fear the possibility of "legal liabilities." Remember the saying: "If you don't say it, you'll show it." People pick up on unexpressed feelings or opinions surprisingly well and when they do, the way they perceive you changes without you being able to influence it.

How Do You Prepare for That Difficult Conversation? To prepare for the conversation, you need to be very clear about the issue(s) in dispute, you should ask yourself: ● What exactly is the issue/condition/behavior that is causing the problem? ● What is the impact that the issue/condition/ behavior is having on you, the resident or the community? What do you want to accomplish with this conversation? What is the desired outcome? What items are non-negotiable (because of Title 22 Regulations or company policy, research and know these restrictions). Determine who are the necessary participants for the conversation? Consider percipient knowledge, areas of expertise, effective communication skills and reputation for reasonable and fair decision making.

Where Do You Conduct That Difficult Conversation?

Plan but don't script. It may be helpful to jot down some notes and key points before your conversation, but drafting a script is a waste of time. Rarely will the other participants in the conversation know their lines. 3 2 How Did That Difficult Conversation Go? Reflect and learn from your handling

Choose the right place to have the conversation. Calling people into your office may not be the best strategy. Consider meeting in a private dining room or meeting room where you can sit adjacent to each other without your desk as a barrier.

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How Do You Conduct That Difficult Conversation? STEP #1 ADOPT AN ATTITUDE OF INQUIRY – Be open to hear what the other person has to say before reaching closure in your mind; learn as much as possible about the other person and his/her point of view; slow down and listen. STEP #2 KEEP TO THE TOPIC AT HAND – Focus on the topic of this conversation; do not bring up issues or complaints related to other topics or past events; make sure you understood what the other person has said before you respond. STEP #3 MANAGE THE EMOTIONS – Avoid finger-pointing or blaming, avoid name-calling, yelling, screaming, sarcasm, cursing, insults, or threats (emotional or physical); no interrupting and allow the other person to finish speaking before you respond; allow for possible time-outs. STEP #4 ADVOCACY – What is my primary message? How will I tell my story while maintaining a respectful and non-judgmental position? Ensure that your objective is fair and that you are using a consistent approach. Know what you want to accomplish. STEP #5 PROBLEM SOLVING – Approach the conversation with openness and an interest in problem solving rather than needing to be right or winning a competition. Find ways to be constructive by suggesting other solutions or alternatives. Don't end without clearly expressed action items.

of the difficult conversation. Examine what went well and

what didn't. Think about why you had certain reactions and what you might have said differently. Ask other participants from

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the community to evaluate the conversation. What would help us to avoid doing this again?

CALA NEWS & VIEWS I ISSUE 49 | MARCH 2024

Douglas Armstrong is Senior Vice President of Regulatory Affairs and Quality, Belmont Village, L.P.

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It all starts with having a mission and a culture that is focused on the resident. For our culture to be one of ensuring our residents love where they live, our associates must love where they work. Culture starts with helping our associates feel valued by the organization. If our associates show up every day excited to be at our community, that will be reflected on the service they provide to our residents and families. Focus on resident satisfaction starts with focus on the associates. Our associates need to understand why the work they do is so important. Our associates need to believe that what they do and how they interact with residents and families has a tremendous impact on the life of the resident. Our associates need to know that the company they work for truly believes in its mission statement, that it is not simply something written on a piece of paper collecting dust somewhere. 5 ways to 1

By Sheila Garner, Oakmont Management Group and Brookdale Senior Living (retired); Jen Johnson, Atria Management Company; and Roselynn Muzzy, Integral Senior Living Achieve Resident a

So, every day, take the time at a stand-up meeting to recite the mission statement or talk about why what every associate does is so important. It should not take more than a few minutes of time, but that few minutes can make a tremendous positive difference in how staff interact with residents and families. And where possible, involve associates in stand up. Provide an opportunity for them to share their input/feedback on resident well-being, family feedback and concerns. Associates need to know that what they do matters and that their insights, feedback and input matter.

Each of us knows that effective communication builds trust, and trust builds satisfaction. It is almost impossible to overcommunicate with residents and families. Communication is easy when the subject is positive. The tougher part is being willing to communicate when the subject is not positive. Not everything that we must communicate to our customers and staff is easy, but giving the why and how helps. For example, a long-term executive director is retiring. So how do we go about reassuring residents and families during the transition as well as helping our associates and leaders of the departments transition to new leadership? Typically, residents and family members form bonds with the leaders of the community, from the first time they meet at move in, and through conversations throughout their stay. The staff also form bonds with the leader of the community from all staff meetings and daily interactions in the community. Having a welcome event for the new leader where residents and families can learn about the new leader and meet them helps in the transition and opens the lines of communication, which are so important. It’s the same for associates and directors of the community, having a welcome meeting and learning fun facts about the new executive director helps to create that open path to communication.

2 Sheila Garner is former Senior Vice President of Operations for Oakmont Management Group and Division Vice President at Brookdale Senior Living (retired); Jen Johnson is National Care Director at Atria Management Company ; and Roselynn Muzzy is Regional Vice President of Operations for Integral Senior Living . All three presented on growing resident and family satisfaction at a previous CALA Elevate Conference & Trade Show.

Listening is also a large part of communication. Although we may not be able to have a solution for everything, for a resident, family or staff member, the act of being heard goes a long way. As you listen to a resident or family concern, you may not have a solution at that very moment, but let them know that you will get back to them, and then arrange a date and time to do so. It shows you have heard the concern, that you have listened. And that you are invested in the outcome. Communication is a two-way street; talking and listening, both are equally important with resident, staff and family interactions. Trust is built by consistent messaging. Consistent messaging comes through effective communication. Resident satisfaction increases when associates are informed, trained and know that they are part of an organization that values them and the work they do. Achieving high resident and family satisfaction is a top goal of every Assisted Living community. We take pride in delivering quality services and enriching the lives of our residents and their family members. But achieving that goal of high resident and family satisfaction does not just happen. It takes work and a focus every day on why we do what we do. As insiders in this field who have also had loved ones living in Assisted Living, we would like to share five things to keep in mind when working with residents and families. Here are some insights from experiencing both perspectives. 3 4 5 and Family Satisfaction Staff interactions with residents is one of the more secret ingredients. Most of your staff will interact almost every day with residents. The residents talk to them during care, dining or while their apartment is being cleaned. It is important to understand the dynamic. And it is important for staff to understand that even though they may be busy and need to get on to the next task, they need to have conversation while in the apartment or at the table with the resident. Staff need to understand that it is OK to spend the extra five minutes to engage with the resident. Those few extra minutes can help a resident feel heard and feel like they are a true part of the community. Have fun. That sounds so simple, and yet there are certainly days when nothing seems to be very fun. But our residents deserve to find joy in living each day. We need to think about the activities that will engage our residents. How many times have you seen a resident and staff member enjoying an activity together and both of their faces are exuding joy. Our residents deserve to live in a place they love, and our associates deserve to work in a place they love. Every community has a focus on increasing resident and family satisfaction, as well as associate satisfaction. Satisfaction for all comes when an organization focuses on its culture, effective and transparent communication, has good listening skills, encourages staff interactions with residents and desires to build a community where each day can be filled with fun.

Things Providers Need to Understand Regarding Surrogate Decision Makers TOP By Allan D. Jergesen, Hanson Bridgett LLP

Allan Jergesen is a partner at Hanson Bridgett LLP, where he has practiced for over 40 years. He specializes in health law and in senior housing and long-term care law, representing a variety of providers, including RCFEs. Areas of focus include resident consent issues, privacy questions and relationships between RCFEs and health care providers.

JANUARY 2010, VOLUME 1 12 CALIFORNIA ASSISTED LIVING ASSOCIATION

Assisted Living providers always look first to the resident to make decisions about his or her care and living conditions in a community. In some circumstances, however, providers may need to deal with family members, friends and others who maintain that they have authority to participate in, or even to direct, decisions affecting the resident. Such individuals are seeking recognition as “surrogate decision makers” who can act on the resident’s behalf. However, not everyone who claims this status may have legal authority to do so. In determining legal authority, providers should keep five things in mind.

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There are several types of surrogate decision makers who have formal legal authority to act on a resident’s behalf.

X Surrogate decision makers with formal legal authority over property are: • Agent under power of attorney for property – where principal is competent; this authority ends on the principal’s death. • Agent under durable power of attorney for property – where the principal is unable to manage financial affairs. • Conservator of the estate – where principal has been adjudicated to be unable to manage financial affairs; requires court

document titled “letters of conservatorship” giving conservator jurisdiction over property. X Surrogate decision makers with formal legal authority over health care decisions are:

Depending on the circumstances, other persons can act as a resident’s surrogate decision maker. • Conservator of the person – where principal has been adjudicated to be unable to make health care decisions; requires court document titled “letters of conservatorship” giving conservator jurisdiction over named health and personal decisions. • Agent under an advance health care directive – includes authority not only to make health care decisions, but also to determine where the principal will live and to make other personal decisions such as hiring private care givers, handling mail and arranging recreation and entertainment. 01 02 X The RCFE regulations recognize the role of a resident’s “representative” to assist with routine matters involving the resident, such as participating in the move-in process, establishing a plan of care, and articulating the resident’s preferences with regard to daily activities. This may include the resident's spouse, registered domestic partner, family member or a person designated by the resident. X In addition, the RCFE regulations recognize “health care surrogate decision makers” who can act on behalf of the resident in the absence of a formal appointment by virtue of a relationship with the resident (e.g., the resident's next of kin). 03 It is not necessary to have the original signed version of a surrogate decision maker document. X A copy of the surrogate decision-maker document is sufficient if it is in proper form and includes all of the legally required attachments such as witness declarations for advance health care directives. X In addition, surrogate decision making documents can be signed electronically, using a recognized electronic signature software program.

CALA NEWS & VIEWS I ISSUE 49 | MARCH 2024

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There are rules governing what happens when surrogate decision makers disagree.

X In the event of a conflict, a conservator of the person or agent under an advance health care directive will prevail over other surrogates. X In the event of a conflict between a conservator and an agent under an advance health care directive, the person who received the designation most recently will prevail. X Unless the advance health care directive provides otherwise, the agent designated in that document who is known to the health care provider to be reasonably available and willing to make health care decisions has priority over any other person in making health care decisions for the principal. X Otherwise, the provider may follow instructions of informal surrogate decision maker who appears to be acting in the resident’s best interest.

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There are certain actions that a provider can take if a surrogate decision maker is not acting in the resident’s best interest.

X Report the matter to the long-term care ombudsman or county adult protection agency. X Refuse to comply with the request by agent under power of attorney for health care if the principal objects to the decision. X Consider removal of conservator – conservatee, spouse or domestic partner of conservatee, relative or friend of conservatee or any interested person may petition the court to have the conservator removed. X Consider removal of agent under power of attorney – principal, principal’s spouse, relative, friend or any interested person may file the petition with the court to remove the agent for just cause.

SAVE THE DATE! elevate HYATT REGENCY HOTEL AND SAFE CREDIT UNION CONVENTION CENTER, SACRAMENTO JUNE 3-5 2024 CALA SPRING CONFERENCE & TRADE SHOW

JANUARY 2010, VOLUME 1 14 CALIFORNIA ASSISTED LIVING ASSOCIATION

It’s our business to know your business. Let our senior housing attorneys help you navigate the challenging business and regulatory issues that arise in today’s complex and competitive market.

CALA NEWS & VIEWS I ISSUE 49 | MARCH 2024

Joel Goldman JGoldman@hansonbridgett.com

HANSONBRIDGETT.COM

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to Help with emergency Connections 5 Preparedness Residential Care Facilities for the Elderly (RCFEs) and Continuing Care Retirement Communities (CCRCs) are required to follow specific emergency preparedness requirements that can be found in Health and Safety Code 1569.695. CALA was instrumental in shaping strong, effective and proven practices to prepare for and respond to emergencies. In addition to the many resources available to members on the CALA Emergency Preparedness webpages, consider the following top five connections to help strengthen your emergency preparedness planning. By Selena Coppi Hornback, CALA Director of Public Policy

Many CALA members already engage with their local police officers and sheriff’s deputies, fire department personnel and EMSA paramedics and other emergency services providers. Establishing relationships with these key emergency personnel is beneficial in helping them know that they have older adults in their jurisdictions and allows providers to help educate them on how best to interact with and serve older adults and those with cognitive impairment. CALA members have benefited from these relationships in numerous ways including by receiving emergency preparedness training at the community or receiving guidance on individual emergency preparedness plans and being included in areawide emergency preparedness drills and planning. Over the years, CALA members have found various ways to establish these beneficial relationships. Many members have simply invited emergency responders into their communities for tours as a first step. During various times of the year like Veterans Day, Independence Day, and on 9/11, members have thanked and celebrated first responders by inviting them to a breakfast or lunch, bringing breakfast or other goodies to them, or bringing them care packages. These are just a few of the ways CALA members have creatively fostered relationships with local emergency responders.

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Local Law Enforcement

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Fire Department

Emergency Medical Services Authority 3

local hospital 4

It’s inevitable that residents will visit the hospital at some point while living in your community. One way to foster a good relationship between your local hospital staff and administrators, your staff and residents is to visit your local hospital(s) on an outing. One CALA member, Eskaton Village Placerville , was recently invited to bring residents to eat at the newly renovated hospital cafeteria. The hospital and Eskaton recognized the opportunity in having residents visit during a non-emergency to become familiar with the hospital and to help remove fear of the hospital. The hospital also got the chance to highlight their delicious chef-inspired menu.

CALA Associate Members Provide Valuable Resources CALA’s Associate members provide valuable resources and services to senior living providers. Go to the Find Products & Services link under the Associate Members tab to view the various types of products and services associate members provide.

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Vendors or outside resources for your emergency plan

up local and out-of-area (back-up) transportation with wheelchair lifts can be beneficial, as well as considering alternate types of transportation like school buses and paratransit. Installed generators need fuel and it’s important to foster relationships with fuel suppliers who understand the importance of the work you do, the older adults you serve, and the need for quick service during emergencies. If you plan to rent a generator, maintaining relationships with your supplier to ensure quick access if needed is also important. Other important relationships during times of emergencies are food and water suppliers, pharmacies and doctors. Whether communities evacuate their buildings or not, they will need speedy access to maintain these supplies and residents will need access to medications.

Emergency preparedness plans require providers to cultivate relationships with various groups to ensure they have transportation resources available if they need to evacuate their building, they have at least two designated locations they can evacuate to if needed, they have a permanent generator or can access emergency power during a power outage, and they are capable of being self-reliant for 72-hours. Providers have worked with sister communities and other CALA members to share transportation during emergency situations, and they have served as locations they can evacuate to during emergencies. Some providers have also thought outside the box regarding transportation and check in regularly with those vendors to maintain that relationship. Providing a credit card to keep on file may result in your community receiving priority for the transportation. Setting

5 Options for Expanding Access to Assisted Living Services By Selena Coppi Hornback, CALA Director of Public Policy

JANUARY 2010, VOLUME 1 18 CALIFORNIA ASSISTED LIVING ASSOCIATION

CALA Associate

As more adults enter retirement age, it is becoming increasingly clear that more options for care and services are needed to meet the needs of this growing aging population. Providers are looking at options for addressing and expanding access to older adults in various economic situations. This article looks at five public options that provide some assistance to help meet the needs of older adults. 1 being, allowing residents to age in place while receiving essential services.

PACE covers all the care and services that both Medicare and Medi-Cal provide. This includes doctor visits, hospital stays, prescription drugs, transportation, home care and much more. PACE cannot pay for rent or room and board but can pay for housing tenancy supports such as home modifications, pest eradication, and other items that help maintain safe and stable housing. PACE participants work closely with a dedicated healthcare team. This team collaborates on health goals, ensuring seamless coordination of medical, social and behavioral services. For an Assisted Living community, this team would maintain close collaboration with community staff to address identified issues that could impact the well-being of the resident. Many PACE services are provided at the PACE center which encompasses an adult day health center and a clinic. These centers provide a safe and engaging environment where participants can socialize, receive medical care and participate in activities. Assisted Living residents can attend these centers during the day, enhancing their quality of life. Assisted Living residents can access in-home services. These services allow residents to maintain their independence while receiving necessary support. To enroll in PACE, the individual must be at least 55 years old, live within the service area of a PACE program, require a nursing home-level of care (as certified by the state), and be able to live safely in the community with PACE support. Residents can work with local PACE programs to get started. They can find nearby PACE plans by visiting the CalPACE website.

Options for Veterans CalVet Veterans Homes operate throughout California with seven homes providing Assisted Living services, and four of the seven homes also providing Memory Care services. The homes vary in the number of residents they serve and the size of the campus, but all CalVet homes serve California’s veterans and their eligible spouses and domestic partners. Veterans pay a specified percentage of their income as member fees to live in a CalVet home, and a lack of income will not make a veteran ineligible for admission. Another program for veterans through the federal Veterans Affairs department is Aid & Attendance (A&A). Veterans that receive A&A are required to pay the entire amount to CalVet as part of their member fees. All residents retain a set minimum amount regardless of their fees, like how residents on SSI/SSP retain a personal and incidental needs allowance. The A&A is a federal monthly benefit that qualified veterans and their surviving spouses can receive to help with the cost of care when they require assistance with certain activities of daily living (ADLs). Through the A&A, an increased monthly pension amount to pay for the cost of care for ADLs can be used to pay for Assisted Living in any community and not just a CalVet home. For more information on A&A, please visit CALA’s Toolkits & Brochures webpage under Member Resources to download the brochure.

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CALA NEWS & VIEWS I ISSUE 49 | MARCH 2024

Program of All-Inclusive Care for the Elderly (PACE) This section contributed by Karli Holkko, California PACE Association The Program of All-Inclusive Care for the Elderly (PACE) is a comprehensive healthcare program designed to support medically complex, individuals aged 55 and older who wish to continue living in their homes and communities rather than moving to nursing homes or other institutions. For individuals residing in an Assisted Living community, PACE bridges any gaps to fully support residents’, physical, emotional and social well

Medi-Cal Programs The Assisted Living Waiver (ALW) began as a pilot program in three counties. It is currently available in 15 counties and helps transition older adults out of nursing facilities or keeps them from having to go into a nursing facility when they can be safely cared for in an Assisted Living community. Residents pay for their room and board with their Supplemental Security Income/State Supplementary Payment (SSI/SSP) Non Medical Out of Home Care (NMOHC) Payment and the state Department of Health Care Services (DHCS) pays the Assisted

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JANUARY 2010, VOLUME 1 20 CALIFORNIA ASSISTED LIVING ASSOCIATION Supplemental Security Income/ State Supplementary Payment (SSI/SSP) SSI/SSP is a program funded by the federal government and the state for people who are 65 and older or blind or disabled. Other eligibility requirements include income and resources, and the individual cannot be living in an institution, among others. Some Assisted Living providers provide care and services specifically to individuals on SSI/SSP, however, the rates are extremely low making it challenging for providers to operate accepting residents receiving SSI/SSP. Residents that are also enrolled in the ALW or other state program have additional funds for care and services paid to the Assisted Living provider. negotiations rather than artificially set rates by the state that do not address geographical variation or rising minimum wages. CALA staff are working to educate managed care health plans about the benefits of Assisted Living and help facilitate conversations between CALA members and interested health plans. There are also companies working to bring the two parties together and serve as the Medi-Cal provider and subcontract with the Assisted Living provider, which minimizes the complexities for the Assisted Living provider. Learn more about which health plans are offering Nursing Facility Transition/ Diversion and in which counties by clicking here, and click here for a Medi-Cal Community Supports Explainer. 4 Living community a daily rate for care and services. Assisted Living providers must become a Medi-Cal provider to participate in the program. The ALW was recently approved by the federal government for another five years. DHCS has stated their intent to transition ALW residents into the CalAIM Community Supports program and to discontinue the ALW program once all current residents have transitioned. This plan will likely take several years and may not be completed during the new five-year waiver period. CALA will continue to be involved in these stakeholder conversations and keep members updated. Learn more about the ALW and signing up to become a provider here. California Advancing and Innovating Medi-Cal (CalAIM) is an effort by the state to provide whole person care for Medi-Cal beneficiaries. Like the ALW, CalAIM Community Supports allows for individuals to transition from a nursing facility into an Assisted Living community or divert someone who would otherwise have to go into a nursing facility into an Assisted Living community. As with the ALW, residents pay for their room and board with their SSI/SSP NMOHC payment, but providers negotiate directly with managed care health plans for payment for care and services instead of the state paying the Assisted Living provider. This program holds a lot of promise for expanding access to Assisted Living services to Medi-Cal beneficiaries beyond the 15 counties in the ALW to the entire state and could lead to adequate reimbursement rates for providers through independent

Community Care Expansion (CCE) In recent years, the state saw several closures of adult and senior care communities serving residents that receive SSI/SSP due to low reimbursement rates. The CCE is a program within the Department of Social Services with the goal of creating additional beds to serve this population while preserving communities at risk of closure to help prevent homelessness for residents on SSI/SSP. According to the CCE website, funds are used to help these adult and senior care programs remain open and expand access to individuals also at risk of homelessness by supporting “acquisition, construction and rehabilitation” of those communities. The expansion component has made $570 million available to accomplish these goals. The state closed the application portal for capital grants on June 1, 2023 and is still working through some of the applications received. As of March 6, 2024, the CCE Capital Grants data dashboard shows that 55 expansion awards totaling $464.06 million have been granted resulting in an anticipated 2,465 beds. Another component of the program provides funds to help make critical repairs or upgrades that are needed to these communities so they can remain in operation and serving these individuals receiving SSI/SSP and at risk of homelessness. These funds are awarded to approved counties who will then work with providers in need of these funds. A list of county leads for participating counties can be accessed here. Thirty-four counties are participating in the preservation component of the program, which has made $249 million available to achieve the program’s stated goals.

Share your Experience with CALA

If your company or community has participated in any of these programs, let us know about your experience. Was the enrollment or application process difficult to navigate? What has your experience been like working with the payor? If your company or community has not participated in any of these programs but is interested in learning more, please let us know. Email Selena Coppi Hornback to share your experiences or learn more about these programs.

Karli Holkko is Director of Government Affairs for the California PACE Association, CalPACE. CalPACE works to support, safeguard and promote the Program of All-Inclusive Care for the Elderly (PACE) model of care through education and advocacy.

TOOLS AND RESOURCES for CALA members TOP 5 Staying ahead in Assisted Living demands constant access to cutting-edge resources and tools. CALA recognizes this imperative and is committed to furnishing its members with innovative solutions to navigate our unique challenges. Here, we unveil five hidden gems within CALA’s toolkit. 1 Consumers can find you with our interactive mapping tool: CALA’s latest interactive map of member communities transforms the way consumers visualize and navigate community locations. With a user friendly interface, potential residents and family members can effortlessly zoom in or out, scroll and access detailed information about individual communities. This tool also offers routing and direction maps, streamlining the process of planning visits or assessing proximity between communities. By harnessing Google map data, consumers can identify nearby CALA member communities within specified distances or drive times. INTERACTIVE MAPPING TOOL

By Kevin Swartzendruber, CALA Director of Marketing and Communications