Caregiver-training issue causes split in state's long-term-care community

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A huge disagreement that could taint relationships in the long-term-care community for some time has erupted over state legislation on caregiver training in boarding homes.

Boarding homes in Washington serve more than 22,000 residents and include what's commonly called "assisted living," one of the fastest-growing types of long-term care. Assisted living typically offers a range of personal-care services in a setting that's less restrictive than a nursing home.

The bill, initiated by the care-provider industry and sponsored by House Reps. Eileen Cody, Jeanne Edwards, Shay Schaul-Berke and Mary Skinner, originally would have significantly diluted key aspects of a law passed two years ago that set higher standards for what workers must know before caring for the elderly and disabled in such facilities. That law was due to go into effect March 1.

The move to change the statute has surprised and upset consumer advocates and the state long-term-care ombudsman, who called it a last-minute attempt to save money and avoid regulation.

The industry insists it supports strong basic training but has no way to pay for the special instruction the law requires for workers. The bill also sought to delay the implementation date.

After hearing both sides, the House revised the bill, delaying the start-up date for training in boarding homes to Sept. 1, mainly because the Department of Social and Health Services is behind on revising the curriculum.

But lawmakers preserved the most significant training provisions. That means, for the first time, direct-care workers in private-pay boarding homes — not just in homes that accept Medicaid clients — would receive more standardized basic training. They would learn about such things as the normal aging process, common chronic diseases, infection control and personal care.

Also, for the first time, when appropriate, caregivers in all boarding homes would receive special training on how to work with residents who are mentally retarded or have illnesses such as Alzheimer's or depression.

Dementia and, in particular, depression are fairly common in the long-term-care population.

So providers are "looking at multiple new training requirements. That's why they're so upset about the cost," says Dotti Wilke, training-program manager with the state's Aging and Adult Services agency.

Caregivers also would have to pass competency tests to prove they understand the material.

The bill now goes to the Senate, where the battle between providers and advocates promises to continue. Providers still want training that's more affordable and rules that give them more latitude.

The rift has prompted the state's long-term-care ombudsman to drop membership in the Long Term Care Alliance, a statewide consortium of about 20 providers and consumer advocates. The alliance worked successfully for an increase in caregivers' wages last session.

"How can you cooperate with people when you don't trust your relationship with them?" asks ombudsman Kary Hyre, whose job is to be a watchdog and advocate for the well-being of residents in all kinds of long-term care. "We've learned a lesson by this."

Now the ombudsman easily can take positions in opposition to the alliance positions, Hyre says. His resignation from the alliance also eliminates any implication that the ombudsman agrees with everything alliance members might support.

Resident advocates and some in the provider industry were saddened by the decision.

"It sort of shocks me. I think it's critical that he be part of that alliance. My hope would be that it would be a very temporary situation," said Gene Forrester, vice president of the Washington Senior Citizens Lobby.

The disagreement comes at a time when the assisted-living industry nationwide is under scrutiny for sometimes harming residents through such things as medication errors, inadequate monitoring and insufficiently trained staff.

Assisted living emerged two decades ago as a compromise between totally independent living and skilled nursing care. About 800,000 people nationwide now live in such facilities, which typically offer meals in a central dining room, social activities and help with personal care such as bathing, dressing and dispensing medication.

They operate without federal regulation. The amount of state oversight varies. Even within the industry there's debate about the essential components of assisted living.

In recent years, the frailty of residents in assisted-living facilities has increased.

"We're putting people who are fairly untrained in with a vulnerable population, and it's a recipe for problems," says Karen Love, chairwoman of the board of directors for The Consumer Consortium on Assisted Living in Washington, D.C.

The consortium participates in a national task force of more than 60 groups charged with finding ways to improve the quality of assisted-living care. The task force must give its recommendations to the U.S. Senate Special Committee on Aging next year.

Washington already is considered way ahead of most states in quality and standards for assisted living, Love says.

In the 1990s, the state long-term-care ombudsman produced scathing reports about inadequate state oversight and poor quality of care in boarding homes and adult family homes. As a result, responsibility for boarding homes was moved to DSHS from the Department of Health.

Next came creation of a long-term-care task force, more reports by DSHS, the Health Department and the state Nursing Commission and community forums that examined caregiver-training standards.

These collaborative efforts, which included advice from the boarding-home industry and consumer advocates, led to the 2000 legislation.

Consumer advocates explain that's why they now feel betrayed.

"It's like you've wasted your time all along trying to work together. Then somebody can come in and say 'Oops, we want to do something different,' " says Donna Patrick with the Washington State Developmental Disabilities Council. "This shouldn't be happening."

The industry also is dismayed about the split.

"It's really important that strong advocates understand the reality of implementing quality care in any setting. Whenever groups are polarized like this, it's very difficult to have that kind of conversation," says Karen Tynes, CEO of the Washington Association of Housing and Services for the Aging.

"If the ability to communicate goes away, then the ability to reach resolution goes away. And then the consumer always loses."

Marsha King can be reached at 206-464-2232 or