Last year ProPublica and PBS FRONTLINE took a close look at the fast-growing assisted living business, which provides housing and day-to-day help to the elderly and those too ill or disabled to live independently. In the course of that reporting I traveled to 11 states. I spent a day in a facility in rural Oregon. I met with workers in Mississippi. I interviewed medical experts at Johns Hopkins in Baltimore.
Many things about the industry, to which America has entrusted the lives of some 750,000 people, proved to be shocking, not least of all how bad things appeared to be in California. The state's regulatory apparatus, our reporting showed, had deteriorated so drastically that the assisted living industry was actually lobbying the state to police it more aggressively.
A few snapshots:
Employees at a facility in Whittier allowed a resident to develop a ghastly pressure ulcer. Pressure ulcers, or bedsores, are wounds that typically form when a person is left lying in bed for prolonged periods — and this one was so bad that surgeons were planning to clean it up by cutting out rotten flesh that extended all the way down to the bone. A specialist said the ulcer was teeming with "numerous" strains of bacteria, a sign the person had "probably gone a couple of months" without treatment.
At another facility, the staff encouraged seniors with dementia to fight one another and videotaped or photographed the altercations. It was like an Alzheimer's Fight Club.
Then there were the deaths. Many deaths. Many preventable and unnecessary deaths, our reporting determined. The state's own records often made it clear.
Amid this landscape of hurt, it struck many that the California Department of Social Services, which oversees assisted living facilities in the state, seemed to have simply given up. It had adopted one of the loosest inspection schedules in the nation, visiting facilities only once every five years — though, in some cases, its inspectors didn't even hew to that schedule. The department handed out some of the most meager fines in the nation — typically $150 in cases of fatal neglect or abuse — and often didn't bother actually collecting those fines. Inspectors responding to allegations of serious physical abuse or neglect were allowed to wait 10 days before actually opening a probe.
In recent days, Gov. Jerry Brown has signed into law 10 bills aimed at improving conditions in the state's roughly 7,700 assisted living facilities. The new regulations are, to be sure, a major step forward. Facilities will be required to give staffers more training and correct significant problems promptly, generally within 10 days. Perhaps most important: the financial penalties for severe transgressions have been increased dramatically — $15,000 is now the top fine for violations that lead to the death of a resident — giving assisted living operators a real financial incentive to better treat their clients.
Even before Brown approved the new legislation, the social services department had shown some signs that it had been stirred to action. The department sought and received a budget bump of $7.5 million to hire more than 70 new employees. And it enhanced its website, giving the public more information about facilities that have been cited for regulatory violations.
But advocates for the elderly say the regulatory apparatus could still be strengthened in many ways. Most notably, California is sticking with its five-year inspection cycle; 43 other states require more frequent inspections; 19 states mandate inspections at least every 18 months. So far, Governor Brown has only committed to studying the possibility of conducting annual inspections starting in 2018.
There are undoubtedly fiscal concerns about stepping up inspections. Just how great those fiscal implications would be is a matter of debate, however. According to an analysis by the California Department of Finance, moving to an annual schedule would require the state to hire 32 new employees and cost $2.9 million per year — a minute fraction of California's total budget of $156.4 billion. And our reporting has made clear that a decision not to spend that money, now or in the future, comes with its own cost: the increased vulnerability of seniors, many suffering from dementia and other serious health conditions, to cruel or negligent caregivers.