Working in Assisted Living and 55-Plus Communities

Why this matters

Senior housing looks like ordinary residential work until you are at the front desk. The resident who called may not own the faucet, the son paying may not be allowed to approve the work, the building may not let you past reception without insurance paperwork, and the door you prop open for a minute may be the one a memory-care resident walks out of. Shops lose these jobs, and occasionally cause real harm, by treating every unit as a house. The fix is knowing which of four kinds of place you are in, because each one answers "who decides, who pays, and who lets you in" differently.

Four kinds of place

The names vary by state and by marketing, so go by what the place actually does, not the sign out front.

A 55-plus community is usually just housing. Under the federal Fair Housing Act, a community may restrict residency by age under the housing-for-older-persons exemption if at least 80 percent of occupied units have at least one occupant aged 55 or older, along with published age policies and age verification. Nothing about that makes it a care setting. The resident is an ordinary homeowner, and the layer that bites you is the HOA's governing documents, which commonly reserve roofs, exterior walls, fences and anything visible from the street to the association and require approval before an exterior change, such as moving a condenser or adding a standby generator.

Assisted living is licensed by the state, not the federal government, and what it is called and what it must provide differ widely: residential care facility, personal care home, adult care home. Skilled nursing facilities sit under federal requirements as well, at 42 CFR Part 483 for facilities in Medicare and Medicaid, which is one reason their vendor rules are the strictest you will meet.

Who owns what, and who pays

In anything above a 55-plus community, a rule of thumb that holds most of the time: if it is part of the building, the operator owns it and usually pays for it; if the resident brought it in, the resident owns it and pays. Plumbing fixtures, in-wall piping, the PTAC unit or heat pump, the electrical panel, the smoke detectors and the door hardware are the building's. A recliner lift chair, a personal refrigerator, a TV mount or a window air conditioner the resident bought are the resident's.

The exceptions are in the resident's agreement with the facility. Some charge residents for damage they cause, some allow residents to hire outside vendors for certain work and forbid it for others, and some forbid outside trades in resident units altogether, with the maintenance team doing everything. The family usually has a copy of the agreement and has rarely read that clause. The maintenance director knows it by heart.

Getting in the door

Expect the front desk of independent living, assisted living, memory care and skilled nursing to want some or all of:

• A certificate of insurance on file, often naming the facility as an additional insured. Your agent can usually issue one within a day; without it, the visit does not happen.
• Sign-in and sign-out, with a visitor badge worn the whole time you are on the property.
• Background check or vendor registration, sometimes through a third-party credentialing service the facility uses for all vendors.
• Health screening or visitor restrictions during an outbreak. Facilities can close to non-essential visitors during a respiratory or stomach-bug outbreak, sometimes for days. Call the morning of the visit.

Inside: the rules that protect residents

These are where a tech can cause harm without meaning to.

• Doors. In memory care, exits are locked or delayed and alarmed so residents who wander cannot leave unnoticed. Never prop an exit door, never hold one open for a resident who wants to follow you out, and never share a door code you were given. If a resident walks toward an exit with you, stop and get staff. A resident lost outside in the cold or the heat is the worst outcome a vendor can contribute to in this setting.
• Fire alarm and detectors. If your work will make dust, heat or smoke near a detector, or needs a detector removed, the facility decides how to handle it, including whether the alarm is placed in test and whether a fire watch is needed while it is. Do not cover, disconnect or remove a detector yourself. In a building of residents who cannot evacuate unaided, the alarm is the evacuation plan.
• Hot water. State licensing rules commonly cap water temperature at resident fixtures, often somewhere in the 110 to 120 F range; the facility knows its own number and logs it. Do not change a water heater setpoint or a mixing valve in a facility without the maintenance director, and read the tap afterwards with them.
• Shutoffs. Water, power or heat off to a wing affects bathing schedules, meals and, for some residents, oxygen concentrators and powered beds. The facility schedules the shutoff; you work to it. See related: Planning a Shutoff in a Home With Medical Equipment.
• Tools and materials. A cart left in a hallway is a fall hazard for a resident with a walker, and an unattended blade, chemical or cord is a hazard for one with dementia. Keep everything with you or behind a closed door.

Residents who cannot authorize work

In memory care, and in some assisted living, a resident may ask you to fix something, offer to pay, or hand you a card. Do not take the job or the money from the resident. Route it to staff, who route it to the family member or legal representative on file. Even where a resident seems entirely clear, you are in a setting where many residents have a guardian or an agent acting under a power of attorney, and you have no way to know which. Whether someone can contract at all is covered in depth elsewhere: see related: Capacity to Contract: The Signs and What to Do, and Working With a Power of Attorney or Guardian.

In independent living and 55-plus communities, residents are generally ordinary customers who decide for themselves, and treating them as anything less is its own insult. See related: Working With Elderly Customers Reference.

Worked example: the faucet and the disposal

A man calls a plumbing shop on a Monday. His mother lives in an assisted-living apartment; her kitchen faucet drips, and he has bought a garbage disposal he wants installed while the plumber is there. He will pay. The office books Tuesday at 10:00 and sends a tech.

At 9:55 on Tuesday the front desk asks for the shop's certificate of insurance. The facility has none on file. The tech calls the office; the office calls the insurance agent, who can issue it by end of day. The visit is off. That is the first failure: the office booked into a facility exactly as it would a house, and the cost was a wasted trip, about an hour and a half of the tech's day counting the drive both ways.

The certificate arrives Tuesday afternoon. Before rebooking, the office calls the maintenance director, which is the call that should have happened Monday. What the call establishes:

• The faucet is a building fixture. The facility's in-house tech will fix the drip at no charge to the resident under her residence agreement. A bill to the son for it would be a bill for work the facility already owes her.
• Disposals are not allowed in resident units in this building, because of the shared kitchen drain stacks. The son's disposal cannot go in, whoever pays.
• The facility does allow outside vendors for resident-owned items, with a certificate on file and sign-in. The mother also has a personal refrigerator whose ice maker line leaks, which the son mentioned in passing on Monday.

The office calls the son back with exactly that. The rebooked Thursday visit is the ice maker line on the resident's own refrigerator: checked in, badged, the maintenance director told it is happening, the refrigerator's own shutoff closed behind the appliance, the line replaced, the connection watched for two minutes and dried with a towel to show any weep, and the director shown the dry fitting before the tech signs out. Invoice to the son, who agreed to pay for it.

Why each call went that way: the faucet was the facility's because it is part of the building, and billing for it would have made the shop the problem in the son's eyes once he learned the facility covers it; the disposal was the facility's decision, not the son's, because it is the facility's drain; the refrigerator was the resident's own property, which is the work an outside shop is there to do.

What changes the answer: had the mother lived in a villa in a 55-plus community, the shop could have installed the disposal the same day on her or her son's say-so, since she owns the house and a disposal is an interior change no HOA reviews. Had the drip been a burst line flooding a hallway, the order flips: the tech closes the nearest shutoff he can reach, tells staff immediately, and the facility takes over from there.

How to check the shop handles this well

Search the job history for the last year's visits to any senior-housing address. For each, check: was a certificate of insurance on file before the first visit; did the office speak to the maintenance director or HOA before booking; and was the invoice addressed to the party who actually owned the item worked on. Count the wasted trips. In most shops the first year of tracking turns up a handful, nearly all on first visits to a building, which is the argument for a one-line "senior housing: call the facility first" rule at booking.

References

• Fair Housing Act housing-for-older-persons exemption, 42 U.S.C. 3607(b), as amended by the Housing for Older Persons Act of 1995
• 42 CFR Part 483, Requirements for long-term care facilities (skilled nursing)
• Your state's assisted-living licensing agency, for resident water-temperature limits and facility rules
• See related: Capacity to Contract: The Signs and What to Do
• See related: Planning a Shutoff in a Home With Medical Equipment