Level of Care Provided

Assisted Living facilities are designed to serve a very different population than skilled nursing facilities.  The goal in AL is to give residents independence, often in an apartment-like setting, while helping with activities of daily living (ADLs).  SNFs aim to provide comprehensive medical care, including rehabilitation and 24/7 skilled nursing care.

AL providers screen residents upon admission to evaluate their medical status.  This includes the resident’s medical history, diet and nutrition, toileting, psychosocial well-being, decision-making capacity, and medication management.  Based on this evaluation, a Resident Agreement is signed, outlining the costs, scope of care, and expectations if the level of care exceeds what the AL can provide.  SNFs also screen incoming patients, and the care they provide is guided by federal regulations.

Payment Models and Regulatory Oversight

Assisted Living Facilities (AL) are regulated at the state level, and standards vary widely among states, with some states offering licensure for different levels of care.  Payment is direct from the resident, or private pay, just as in renting an apartment.  There are some situations where Medicaid pays for certain services, but not for room and board.

Skilled Nursing Facilities (SNFs) operate under federal oversight through the Centers for Medicare & Medicaid Services (CMS).  They must meet uniform standards under the Skilled Nursing Facility Quality Reporting Program (QRP).  A component of the QRP is the Minimum Data Set (MDS 3.0) Resident Assessment Instrument (RAI), and the data collected from SNFs is publicly reported through Care Compare.  Some states have stricter SNF laws and regulations than the federal rules.

Legal Landscape

The presenters noted that despite the differences in AL and SNFs, the claims being brought against ALs often mirror those faced by SNFs.  Common allegations include:

• Failure to prevent falls
• Inadequate wound care
• Delayed diagnosis of infections
• Failure to recognize and respond to changes in condition

As AL residents desire to “age in place,” providers are accommodating residents with more complex medical needs.  This shift demands rigorous review and modifications to resident agreements and proactive communication with families.  Administrators must ensure complete and quality documentation of care transitions and evolving expectations to mitigate liability.

Best Practices in Documentation

Strong medical record documentation is one of the most powerful tools facilities have in the defense of claims and litigation.  In both assisted living and skilled nursing facilities, it can make the difference between a dismissed claim and a costly lawsuit.  Specifically, thorough documentation is critical to demonstrate:

• Timelines of care delivery and interactions
• Compliance with service plans (AL) or CMS regulations (SNF)
• Staff interactions and clinical decision-making
• Preventive measures (e.g., fall protocols, wound care)
• Justification for changes in care level

For ALs that coordinate with external providers such as hospice or home health agencies, integrating third-party documentation into the resident’s chart is essential.

At Excelas, we bring decades of expertise in medical record review to help clients

• assess and improve documentation quality
• provide targeted staff training
• prepare for audits and regulatory reviews
• strengthen risk management programs
• evaluate the merits of a claim/case
• prepare and develop defense strategies

Our experienced medical analysts review medical and other pertinent records and develop a range of powerful reports to support decision-making.  Our most frequently requested reports include:

• Care Calendar – an interactive calendar to visualize the date and time of all interactions with a resident.
• Turning and Repositioning Chart – a simple, visual layout to demonstrate the consistency of care given to a resident.
• Medical Chronology – a customizable report of the resident’s care which can be easily sorted by topic, record type, or provider of care.
• Case Summary – a high-level summary of the medical history, including an opinion by our medical-legal analysts on whether the records support or refute the allegations and comments on any additional areas for investigation
• All reports include hyperlinks to the page(s) in the medical record where the care is documented.

Contact Excelas today to schedule a demonstration of our software, analytic tools, and reports to learn how we can strengthen your legal defense in AL and SNF cases.