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Accreditation of Continuing Care Residential Communities Revisited:
What Does It Mean?

By Lillian L. Hyatt, M.S.W. and a Resident of a CCRC

Excerpted from the Fall 2008 The CANHR Advocate newsletter

“Accreditation” purports to be a way that consumers can learn whether or not a Continuing Care Residential Community (CCRC) adheres to the highest standard of long term care for the elderly. This accreditation is attested to by a handsome bronze plaque in the CCRC’s lobby. What does it actually mean?

In 1966, the Commission on Accreditation of Rehabilitation Facilities (CARF) was founded. This independent, not-for-profit body offered accreditation in adult day services, assisted living, behavioral health and medical rehabilitation. (The use of the word “Commission” in that organization’s title could make a consumer believe that this private not-for-profit association was an agency of either the state or federal government. It definitely was not.) In 1985 the Continuing Care Accreditation Commission (CCAC) was founded by “a group of visionary” continuing care providers. On January 31st 2003, CARF bought CACC for “a few million dollars” and they merged to create a new entity called CARF-CACC. The reason given for this merger was that it would appear strange that the continuing care communities were evaluating themselves through a body which they created.

According to CARF-CACC, accreditation is a process that demonstrates that a provider has met standards for the quality of its services and how it could improve them as established by CARF-CACC. This judgment was to be used as a guide for potential residents in choosing a facility. However, unlike information derived from other surveys and evaluations, none of the data collected by CARF-CACC on Continuing Care Residential Communities is available as public information. On August 20, 2008, I called the Administrator of Operations of CARF-CACC and was told there were no plans to release this information to the public. She explained that since the CCRC was willing voluntarily to complete the complicated and time consuming process of an evaluation, no public information beyond the “Accreditation” would be made available to the public. However, information gathered in the surveys concerning the other types of facilities evaluated by CARF-CACC is open to the public. Inspections and surveys made by state and federal agencies are also open to public inspection.

This fact makes clear that consumers seeking access to accurate up-to-date information from this accrediting organization would not have access to any information about a CCRC that could help them to make a more intelligent and informed decision about the best place to spend their last and most vulnerable years.

The process of accreditation begins with a self-evaluation by committees of residents led by administrators. The residents chosen for these committees are selected by administrators. That committee’s report is then reviewed by administration committees. With this process, I was told it is possible to say that minority reports are not necessary since negative opinions would be “taken care of” before the report is passed on to a CARF-CACC evaluation team.

The next step in the evaluation process is the on-site arrival of a team appointed by CARF-CACC to review the self evaluation. The review begins with a survey of the facility and services it offers. Extensive interviews are held with residents concerning their experiences and opinions. The residents interviewed are chosen by the administration based on a questionnaire distributed beforehand. Before leaving, the team presents a rough summary of its findings to a town meeting of the residents. (In my CCRC, this presentation was preceeded by the admonition that no questions could be asked about the presentation.) The team then leaves to prepare its final report.

This process is not cheap. However, since the cost of marketing an empty unit is about $20,000, accreditation as a marketing tool is considered quite valuable by administrators. The actual costs, up front, are $6,000 for the team evaluation, plus transportation, hotel and per diem expenses. In addition, the annual self-evaluation submission costs $4,000 a year for being read. There is no annual on-site inspection. Residents are generally unaware of these costs- which are paid for out of residents’ monthly care fees.

Designed to convince the applicant that the CCRC is a quality facility, the applicant is not informed that, after the first year, there is only a self-assessment prepared by the CCRC staff. There are no provisions for probation or removal of accreditation even if a CCRC receives a poor rating for their Skilled Nursing Facility from state or federal inspectors during the accreditation period. Everything is dependent on the self-assessment by the CCRC of its own services. Information given to the team of the condition of the building – e.g., the functioning of the elevators- is only revealed by the CCRC administration if it chooses to do so. Information about the costs of renovations or repairs is also given on a voluntary basis.

Financial institutions, including rating agencies and banks, value the due diligence of accreditation and assurance for the stability of a CCRC’s finances. While much information concerning a CCRC’s financial condition can be gleaned from reports submitted to the state and federal governments, information regarding outstanding lawsuits and settlement costs of disputes with residents are never exposed to the team again except on a voluntary basis. New applicants are never apprised of the true financial condition of a CCRC: the services of an accountant to evaluate the financial stability of the CCRC are crucial rather than only viewing the bronze plaque in the CCRC’s lobby.

In actual practice CCRC residents who do participate in the accreditation survey are those who agree to take on a heavy work load. In one CCRC, many residents who had participated in an earlier survey refused to serve again because they felt it was too time consuming. Other residents felt that it had been a chaotic process. Some residents who had filled out the initial questionnaire were screened out and never asked to give their input about services because they had rated them as poor. For these reasons the accreditation granted may be of doubtful value. A more useful tool would be “The Nursing Home Watch List” available from the California Advocates for Nursing Home Reform.

(Ms. Hyatt is a resident of a CCRC and AARP Policy Specialist on CCRCs)