Worse quality at for‐profit assisted living facilities in non‐urban Minnesota

Assisted living facilities (ALFs) have grown as an alternative to the highly regulated skilled nursing facility industry, with 30,600 nationally.1 Due to the lack of federal regulation and wide variation in state regulation,2, 3 there is a lot unknown about the quality of care in this setting. Past research in Florida and Oregon find for-profit, large and rural ALFs are cited more often.4-6 Passed in 2019 and implemented in 2021, Minnesota established regulatory standards governing ALFs statewide. Surveyors visit facilities to assess compliance with licensure which can lead to a citation every two years. In Minnesota, older residents are more common in non-urban areas with 32% of urban residents aged 50 years or older, compared to 38% of large town residents, 41% of small town residents and 44% of rural Minnesotans.7 This report focuses on non-urban ALFs where there is a disproportionate number of older adults. The purpose of this study is to examine the results of licensure surveys of ALFs in non-urban Minnesota. We used results from licensure surveys conducted from August 2021 to July 2023. Provider data (capacity, location, and ownership) was from Minnesota Department of Health. We defined non-urban using Rural Urban Commuting Areas (RUCA) codes which classify census tracts based on population size, density, and daily commuting. Following past work, we group RUCA types by large town (RUCA 4–6), small town (7–9), and rural (10).7 We examined fines and the number of citations as outcomes. Note the actual fine amounts were either $500 or $3000. We described the sample using frequencies, means, and proportions. We conducted one-factor analysis of variance to compare outcomes by RUCA type and t-tests to compare outcomes by profit status. We examined common citation types by RUCA-type. We mapped the average number of citations by zip code. We assumed a two-sided null hypothesis at the 0.05-level to be statistically significant. There were 292 ALFs in non-urban Minnesota with a licensure survey between August 2021 and July 2023 (Table 1). Most ALFs were in in large towns (42%), 30% in small towns and 28% in rural areas. Majority of ALFs were for-profit owned (60%), 67% in small towns and 51% in rural areas. The average number of citations by zip code ranged from 1 citation to 42 (Supplemental Figure 1). Citations and fines did not statistically significantly vary by RUCA type. In large towns, ALFs had on average 14.7 citations with $1723 in fines. In small towns, ALFs had on average 16.3 citations resulting in $1821 in fines. In rural areas, ALFs had on average 13.9 citations with $1963 in fines. For-profit ALFs had on average 16.6 citations resulting in $2700 in fines compared to all other facilities that had an average of 12 citations resulting in $1250 in fines. The most common citation was related to meals, with 79% of facilities in large towns, 78% of facilities in small towns, and 79% in rural areas having such citation (Figure 1). The state requires that ALFs must offer at least three nutritious meals daily with snacks available seven days per week, according to the recommended dietary allowances in the United States Department of Agriculture guidelines, including seasonal fresh fruit and fresh vegetables. The second most common citation was related to fire protection concerning safety and evaluation plans including training everyone on those plans: 67% of facilities in large towns, 71% in small towns, and 61% in rural areas received such citation. In the first two years of ALF licensure in Minnesota, all non-urban facilities surveyed received a citation. There were no statistically significant differences in citations or fines by geography type, but there were higher citations and fines among for-profit facilities. The most common types of citations were related to meals and fire protection. Similar to past research on assisted living4-6 and nursing homes8 we found for-profit facilities had worse quality. Policymakers should question whether this ownership type is in the best interest of its residents. Rural residents who want to age in place should be reassured that there are no quality differences between large towns, small towns and more rural areas. Consumers should ask questions regarding meals and fire safety when visiting potential ALFs. Although survey results are publicly posted, they are not yet in a consumer-friendly format. Minnesota is set to launch a report card for assisted living in Fall of 2023. A limitation and strength of this study is that we focus on non-urban ALFs. By limiting our sample we have a smaller sample size, but a more appropriate comparison.9 These are facilities located in areas with limited consumer choice, smaller workforce pools, and less resources overall. Although this study focuses on a single state, the data are from the last two years allowing for a more accurate assessment of the current state of quality. Dr. Loomer takes full responsibility for the concept and design, acquisition of data, analysis, and interpretation of data, and preparation of manuscript. The author declares no conflict of interest. There are no sponsors for this paper. Supplemental Figure 1. Average citations per zip code in non-urban Minnesota. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.