Volume 2 | Issue 1 | March 2020
This issue of our #FullDisclosure covers how the State and assisted living facilities treat one of the most fundamental things of life: food. From how the current policies regulate food budgets, nutritional content, and how they stack up against other benchmarks - it's all here.

If you know someone who could benefit from the information in this newsletter, we hope you will share it with them.
There's Food, Then There's Nutrition. 
by Chris Murphy, MS
As Rebecca Ruiz discusses in the two following articles, the food budgets approved by the state licensing office (California’s Community Care Licensing Division or CCLD) for residential care facilities for the elderly (RCFEs) strain our credulity as we try to imagine how an 85-year-old woman, having multiple chronic diseases, living in an assisted living facility, can receive high-quality nutrition on $4.98 a day (at $150 per resident, per month (PR/PM). 

Meeting the increased nutritional needs of frail elders on low food budgets pervasive in RCFEs increases the concern of malnutrition and dehydration among a facility’s population.  Some studies suggest that malnutrition among the skilled nursing and assisted living populations is as high as 60%. [1]   Poor nutrition adversely impacts seniors by making chronic health conditions worse, reducing resistance, and may even contribute to falls. [2]

According to the U.S. Bureau of Labor Statistics April 2019 report , the average older adult living independently spends about $3,300/year on food ($9.20/day or about $300/month). Yet in “Assisted Living Food Budgets – Breaking the Bank?” Rebecca reports that CCLD recommends, but does not require, a food budget of $200 (PR/PM).  In fact, many LIC 401s we review cite a food budget of only $150 PR/PM .

Assuming the average small 6-bed RCFE charges a modest $4,000 per month per resident, their monthly revenue will be $24,000.  Considering a monthly food budget of $1,200 ($200 PR/PM x 6), represents about 5% of the facility's revenue, one must concede that's a big disparity between what Mom would be spending on food at home, compared with what she’s likely getting in an assisted living facility. 

There are no requirements for food or nutritional monitoring by CCLD in either the Health and Safety Code 1569, or Title 22 regulations for RCFEs. The state neither collects data assessing food quality, nor does it randomly review the nutritional components of food served in the facilities reporting $150 PR/PM. Facilities licensed for 50 or more residents are required by Title 22, Section 87555 to have regular consultations with a nutritionist, dietitian, or home economist if the full-time person responsible for food service is not one of those trained professionals. Since nearly 80% of California’s licensed facilities are 1-6 bed facilities, the requirement for a qualified nutritional expert does not apply. Section 87555 also requires that served food should meet federal standards for nutrition, but this is just another empty requirement the state has, without the expertise, personnel or funds to assess.

In view of the Governor’s Master Plan for Aging, stakeholders and policymakers are tasked to create a robust plan for assuring individuals in any long-term care setting in California receive sufficient nutritional technical support and education to assure the residents are receiving optimal nutrition to support their health.

Between CCLD-accepted $150 PP/PM monthly food budgets, no nutritional expertise, and no way to assure that federal standards for nutrition are being met, the Master Plan for Aging, Long-Term Care subcommittee has a tall order to fill. 

[ 1] Ennis, B., Saffel-Shrier, S and Verson H. (2001). Diagnosing malnutrition in the elderly.  Nurse Practitioner , 26(3): 52-58. 
[2] Esquivel, M. (2018) Nutritional assessment and intervention to prevent and treat malnutrition for fall risk reduction in elderly populations. American Journal of Lifestyle Medicine, 12(2): 107-112.
Assisted Living Food Budgets - Breaking the Bank?
by Rebecca Ruiz, Data Analyst
Let’s crunch some numbers on what you get out of RCFE food budgets. Starting with the absolute bare minimum: USDA Thrifty food plan standards. At $164 a month for the average 71 year old adult, the USDA Thrifty food plan assumes all food being homemade and is the lowest an older American can spend on foodstuffs and still be nutritionally satisfactory. Spending any less may place seniors at risk for malnutrition.

Deep within CCLD's website, there is a recommendation for food spending, which is $200 PR/PM. This $200 value seems to be an arbitrary amount that has not been adjusted for inflation in who knows how long. The document does state that a “reasonable amount” must be reported on the application’s LIC401 , (the document that describes a facility’s monthly expenses). But let’s say that $200 per resident per month is our new gold standard. It breaks down to $6.67 per day or $2.22 per meal. 

Assisted living facilities seem to have taken this recommendation and really run with it.  Having looked at 278 LIC401 documents from our Public Document Warehouse, CARR’s findings are that, 

  • 36% of residents live in facilities that reported over $200 of food per resident, per month. 
  • 12% of residents live in facilities that reported exactly $200 of food per resident, per month.
  • 52% of residents live in facilities that reported less than $200 of food per resident, per month.

This means that 1 in 2 seniors are living in RCFEs where food spending doesn’t meet CCLD's recommendations. Yet CCLD continues to approve for licensure the facilities that report as little as $66 PR/PM in 2013. That’s less than getting a cup of coffee every day! Facilities are estimating spending less money on food than if the senior lived at home and got the maximum SNAP benefit ( $194 ). Amazingly, if a senior meets SNAP qualifications but lives in assisted living, they cannot apply for or receive benefits. 

Assisted living already breaks the bank for so many people, so you should be getting your money’s worth. In places that advertise resort-like or home-like environments shouldn’t the food you are eating reflect that too?
You are What You Eat
by Rebecca Ruiz, Data Analyst
When you move into assisted living, you give up certain personal freedoms to be cared for in a home-like setting. Based on CARR’s data, why would you agree to be fed at the bare minimum ($150 to $200 per resident per month) if you pay on average, based on a survey of San Diego, $4,500 a month? What kind of food and nutrition can you expect on less than $3 a meal ? Is the food going to meet your nutritional needs?  Is there even enough room in the budget for occasional sweets, cultural foods, or food preferences?

Assuming you lived at home and spent only 10% of your $4,500 RCFE rent on food, you would have a $450 food budget to purchase whatever types of food you preferred. At $15 a day, that’s more than twice what many facilities spend. You can buy whatever types of food you want to meet your personal tastes and nutritional needs. 

Think about how much food is a major part of your life. Food can be a comfort, a way to remember your childhood, a way to connect with your culture. We need food to survive, but it should be something to look forward to and enjoy.  And it should be high quality and nutritionally dense.  

Next time you are checking out a new facility for yourself or a loved one, keep these tips in mind:

  • Take the time to eat a meal at the facility to assess for yourself the quality of the meal and the dining environment.
  • Talk about meal planning with the administrator to find out if residents participate in food selection.
  • Ask what accommodations can be made for individual or cultural preferences (they have to accommodate for medically necessary food restrictions).
  • Ask if a mini-fridge is allowed in private rooms or if staff will store resident’s personal food in the main fridge.
  • And, don’t be shy about asking for seconds.  

If the proverb “You are what you eat,” is true, then you’ll definitely want to keep a watchful eye on the quality and quantity of food served in the assisted living facility.  You’ll want to see high quality food prepared in a manner to preserve nutrients, seasoned to your personal and cultural preferences, and in sufficient quantity to satisfy your or your loved one’s appetite. Bon appetit. 
Public records don't harvest themselves
CARR's annual intern program with SDSU costs us about $3,000. And it's because we have an exceptional intern program that CARR has been able to amass about 40,000 public documents on assisted living facilities in California. We are able to collect and understand what's in the public records in ways nobody else in California can.

But - it costs money. $3,000 a year in fact.

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Your contribution will help us continue to promote transparency for California's licensed assisted living facilities. Work like this newsletter would have never been possible without a resource like our public document warehouse.

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