Doctor taking nasal swab of senior patient for COVID-19 testing.

Accreditation supports a balanced response to COVID-19 in senior living

Residents and staff in senior living have been hit particularly hard by the COVID-19 virus. For months now, news stories and public reports have highlighted the rapid spread of COVID-19 and high fatality rate in nursing homes, which provide care to seniors with significant medical needs, but assisted living programs have many of the same risk factors, including shared living spaces, congregate dining, and residents with multiple chronic health issues that predispose them to a more serious form of COVID-19. An investigation opened by Senators Elizabeth Warren and Edward Markey and the House Oversight Committee found that:

  • Rates of coronavirus infection in assisted living facilities are more than five times the national average.
  • Hospitalization and fatality rates are dangerously high for assisted living residents with COVID-19.
  • Assisted living facilities are not reporting COVID-19 cases and fatalities directly to the federal government. As a result, there is no comprehensive information on COVID-19 occurrence and fatality rates.
  • Inadequate sick leave policies for employees put assisted living facility workers and residents at risk.
  • Lack of testing and inadequate testing protocols in assisted living facilities place workers and residents at risk of COVID-19 outbreak.
  • Widespread shortages of personal protective equipment (PPE) impose significant hardship on assisted living providers.

Where regulatory oversight is varied by state and inconsistent, the CARF standards can position assisted living providers to prepare for and respond to a pandemic using an approach that:

  1. Promotes the health and safety of residents and staff.
  2. Fosters a culture of transparency.
  3. Focuses on individual needs.
  4. Implements continuous quality improvement.

CARF-accredited providers are accustomed to this transparent and person-centered approach to care. CARF spoke with Vice President of Operations Ron Mead of Senior Resource Group (SRG), which operates 33 senior housing communities, including independent and assisted living. SRG started the CARF accreditation process in 2003 when it operated 8 campuses mainly on the West Coast. SRG now has communities throughout Arizona, California, Oregon, Washington, Georgia, Florida, and Texas, for a total of 33 campuses. Like all providers, SRG has been challenged by the pandemic, especially given the varied severity of outbreak and regulatory response by each state.


Mead said each community must adhere to the regulations set forth by the state in which it operates, “and going through the CARF process has certainly helped,” when it comes to setting infection control policies and procedures. “Although we never anticipated the scale of the pandemic, we felt well prepared for infection control and didn’t need to reinvent the wheel.” In February, a policy review was under way, and by early March, SRG went full speed ahead with implementing infection control and other emergency procedures. To protect staff and residents, SRG implemented the use of Accushield®, a kiosk that checks each visitor’s temperature and asks the CDC-recommended questions to screen for COVID-19. In addition, SRG went forward with streamlining its sanitation practices by contracting a single vendor for infection prevention. Masks are also required.

Left up to each state, SRG leadership also felt testing for COVID-19 was inadequate and proceeded with contracting outside labs within its service areas. SRG nursing staff has been trained to swab for COVID-19, and with labs now operating around the clock, results are returned more quickly. In addition, new residents are dual-tested, prior to move in and three days later, in the instance a case developed in the interim.

Communication and transparency

The CARF standards foster a culture of transparency and require an organization to implement written procedures for reporting critical incidents to CARF and all external authorities. In addition to complying with legal and regulatory requirements, CARF-accredited organization must communicate emergent and ongoing issues with staff. Throughout this pandemic, timely and transparent communication with residents and their families, staff, and regulators has been paramount. SRG communicates updates on its response to COVID-19 via the homepage of its website, At the community level, the frequency of connecting with both residents and their families has increased significantly, a feature SRG plans to continue in this “new normal.”

In a company update, CEO Michael Grust said, “We remain in the midst of this challenge committed to the rigorous precautions, contact tracing and the ongoing testing that are part of our community life today. And yet, mindful of striking a balance between needed precautions and engaging lifestyle opportunities that allow our residents to thrive.”

Person-centered approach

In senior housing, an outbreak of the flu or norovirus is not uncommon, so procedures were already in place for isolating residents and scaling back activities. Nonessential visitors could no longer be permitted. SRG has needed to balance the risk of infection spread with the risk of deteriorating emotional well-being due to resident isolation and loss of support. The organization purchased a number of iPad mobile devices and provided training on the use of Zoom Cloud Meetings, so residents could visit with family and friends online. For others, “drive-by” or balcony visits were possible. Rites of passage like the graduation of a staff member and the 104th birthday of a resident were still celebrated but at a distance. More recently, when it has become safe to do so, visitors are able to schedule an outdoor visit with their loved one.

Congregate dining in assisted living contributes largely to residents’ social opportunities, which is a factor for many when choosing a community. Typically, SRG communities operate full-service dining rooms and buffet-style meals for special occasions, which have always been well received. Buffet service has now ceased, and dining room services operate at a limited capacity. Meals are now cooked to order and delivered to each resident’s room. Despite limitations placed on dining, SRG continues to meet residents’ unique needs and tastes (quite literally), a cornerstone of the person-centered approach to care recommended in the CARF standards.

Continuous quality improvement

The CARF standards require an adequate workforce to deliver care, and CARF’s person-centered approach extends to staff as well. With much of the global workforce in aging services stretched thin and overworked, SRG prepared for the stress to its own staff early on. To cover absences, some SRG staff members were redirected. For example, drivers who would ordinarily take residents to appointments or off-site activities and some dining staff were trained in sanitation practices. Leadership implemented the SRG Strong initiative, a sick-leave policy, which allocated an additional 80 hours of paid sick time to any employee missing work for a COVID-related reason. All employees were also given an increased rate of pay for the months of April through June. Mead said, “Some call it “hazard pay;’ we call it ‘hero pay.’”

Living the CARF standards, always focusing on the persons served, and the forethought of hard-working SRG executives have positioned SRG’s communities to serve residents safely during this unprecedented pandemic. CARF’s comprehensive standards go beyond state regulations to guide assisted living providers in their response to a pandemic and mitigate risk to residents and staff. CARF has more than 20 years of experience in developing and maintaining up-to-date international consensus standards in the area of assisted living, having published the first standards manual for assisted living in January 2000.