Private Duty Attendants in Assisted Living

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• Ethel Mitty

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• Sandi Flores

Assisted living is ever evolving, not just in services offered but also in definition. It is not simply the owners and operators who define the care and services that will be provided in the assisted living community (ALC). Stakeholders—regulators, families, and residents—are pushing the limits on resident retention. Residents not only are comfortable with the accoutrements of assisted living but have (re)built their social network within the ALC and would rather remain in place (i.e., age in place) despite the costs. Hence, as resident needs—typified as the older adult with multiple chronic illness and likely increasing support needs—become increasingly complex, solutions are sought to keep the resident in the ALC.

A typical ALC promotes independence and autonomy but is unable to provide adequate supervision to residents with significant personal care and monitoring needs. Residents are in their individual apartments, “behind closed doors.” The most frequently used solution to increasing care and supervision needs is the private duty attendant (PDA). Frequent falls, propensity for wandering or unsafe behaviors, and other heightened care needs prompt a request for a PDA from family or a responsible party who grasps at this solution as a recourse to prevent the resident's relocation to a higher level of care.

Although some ALCs provide PDA services from in-house staff, most rely on outside individuals from agencies or family recruitment efforts. Even though many ALCs appreciate the fact that services provided by the PDAs to residents have a secondary effect of maintaining the ALCs census, having a PDA is not without negative financial impact for the ALC. Some ALCs face revenue challenges as residents turn to the PDA for the provision of some personal care services, decreasing the level of care (LOC) income for the community by virtue of the state's LOC labels and commensurate reimbursement or because the resident or family is not obtaining or purchasing the additional services from the ALC. Some ALCs (or corporations) monitor PDA use as a quality indicator measure; that is, could PDA use be an indicator of lack of satisfaction with care? (Elizabeth Wheatley, Corporate Director of Clinical Operations for Five Star Senior Living, personal communication, May 5, 2009).

PDA use is not a panacea to address resident care needs. Probably the most significant concern is the impact of a PDA on residents' ability for self-care. PDAs are rarely trained in restorative nursing. To justify their salary, it is not unusual to observe the PDA serving the resident—that is, doing everything for the resident, including caregiving that the resident is capable of doing independently. Such acts include fetching items the resident could retrieve himself or herself, dressing the resident, and unnecessary use of a wheelchair for transport.

Few regulations governing the use of PDAs are related to training. The competency of PDAs varies significantly. Many ALCs require PDAs to be obtained or “placed” only from licensed home health agencies that employ certified home health aides. The average cost of a home health aide can be $19 an hour, and more if placed from an agency. To combat cost, families will often attempt to find their own “caregiver.” This person often lacks formal training. Some ALCs require PDAs to attend an orientation where expectations of care and reporting requirements are taught.

Many ALCs require a criminal clearance as well as a health screening on any PDA in the facility. It is common for these costs to be paid by the resident or responsible party. Increasingly, providers are including language in their residency agreements that clarify these requirements. Also included is the right of the community to accept or reject a PDA. This is important because there have been occasions when a resident adores a particular PDA, but the PDA is incompetent, putting the resident at risk. Communities are also advised to maintain a policy on the use of PDAs that addresses requirements regarding worker's compensation insurance, liability coverage, and so forth, for the PDA.

The PDA's “agenda” may differ from that of the ALC; the goals of the care or service plan may not be the same. Rather than immediately reporting change of condition or problems to ALC staff, the PDA will report it to the responsible party (e.g., family member). In doing so, the PDA is attempting to validate his or her importance or indispensability to the resident (and family) and to show, by inference, where the ALC is failing to meet the resident's care and safety needs. Some ALCs require that PDAs report to staff twice on each shift, sharing any resident concerns or care issues. The PDAs are also required to describe residents' meal consumption, any bowel and bladder issues, and any change in general activity level including mentation. (Anne Ellett, MSN, NP-C, SVP Health Services, Silverado Senior Living, personal communication, May 5, 2009).

The fact that a resident has a PDA does not negate the ALC's ultimate responsibility to ensure that resident care is adequate. This includes that the PDA is appropriately supervised. Some ALCs require that all residents attended by a PDA are observed by an ALC staff person every 2hours. (Ron Mead, Vice President of Operations for Senior Resource Group, personal communication, May 5, 2009). Other ALCs require that staff actually observe resident bathing and other activities of daily living performed by the PDA. Most assisted living providers prefer to provide actual care services and utilize PDAs simply in a companionship role.

The PDAs duties are described in the service plan and should clarify what the PDA should or should not do for the resident (to maintain the resident's self-sufficiency). As such, the PDA should be instructed on how to read the service plan and asked to state or “rephrase” in his or her own words how the resident should be cared for, including restorative nursing and maintenance of self-care ability. In a very real sense, this is like delegation. Therefore, in keeping with the professional code of ethics for nursing and scope and standards of practice for assisted living nursing, the nurse is responsible to ascertain that the PDA has the necessary skills and knowledge to do what is expected with regard to the resident's care goals and service plans.

The director of assisted living should provide feedback to the family or responsible party on PDA performance. Typically this is done verbally during routine service planning meetings but may also be accomplished by regular formal written reports. Whatever the method, the director must ensure that resident needs are appropriately met.

As assisted living evolves, administrative and nursing policies will also need to do so. When residents choose to hire PDAs, the role and responsibility of the assisted living nurse is to ensure effective and safe resident care by evaluating the competency and capacity of the PDA to provide care as expected.

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Resources 

1. AARP Public Policy Institute. Valuing the invaluable: a new look at the economic value of family caregiving. 2007. Available at www.thefamilycaregiver.org/pdfs/NewLookattheEconomicValueofFamilyCaregivingIssueBrief.pdf. Cited May 13, 2009.