E19 Jonathan Edenbaum ALFs
[00:00:00] Alex: Are there different tiers? Like, I don't know if you guys do this or does anybody do this where like I dunno for $4,000 a month, you got this, but if you paid 5,000 a month, like you get extra dessert and alcohol and I don't know, like, like, are there, are there upsell opportunities in assisted living?
And if so, what do they look like? 
Amy: We're only going to pay attention to your aunt, Sally, if you pay us the extra thousand, the other ones it's total loneliness. We just going to put her in the room


 
welcome back listeners to our third podcast of 2021 mastering Medicare. I'm Dr. Amy Schiffman. I'm here with my co-host Dr. Alex  and we are so excited about today's guest. It's like, it's just [00:01:00] basically like get in line. If you like, knew Amy back when she started a house calls practice, you get to be on the podcast.
So that's basically what this has turned into. So today we have Jonathan Eden Baum, who is both a dear friend and an owner operator. That's what I'll call you an owner operator of a chain of assisted livings in the Maryland DC Virginia area. And I am so excited to have him here now. The great news is I'm going to let him introduce himself, but I also just want to put a plug in that when I did house calls I had nurse practitioners and myself and another doctor who used to staff your assisted livings.
We would go see patients there. So it was always a pleasure to do that. And I'm so excited to have you on the podcast. Welcome. 
Guest: Thank you, Amy. Always a pleasure. My name is Jonathan Eden, BEM, and I'm owner of Eden homes of Potomac. And I've been in the assisted living business for about 30 years.
[00:02:00] So I started when I was two. You 
Amy: such a great plastic surgeon. 
Guest: Oh my God. Absolutely. Yeah. So, you know, we have homes here in Maryland. And I also had run large facilities before that in the Washington DC area and then opened up the smaller assisted livings and here, here in Montgomery 
Amy: County.
That's great. Well, I can't wait to dig in because we are going to talk a little bit about the types of assisted livings that you currently own and operate and sort of the difference between them and larger facilities. But why don't we just start with something super easy, which is. What is an assisted living?
Like what is 
Guest: that? And assisted living is Large or small. You can basically helps people with activities of daily living, such as helping them get dressed, helping making sure they get their medications housekeeping services [00:03:00] meal, getting their meals and most important is stimulating their mind.
So having wonderful activities in the facilities as well. And, and again, they come in many models, you have larger models, which can range from 90 to 200 beds to the smaller boutique models, which usually have between eight and 15 
Amy: or of the small boutique. You are the small boutique variety. That's correct.
That's your current 
Guest: model, right? So it's a nice, yes, 
Amy: just, just so I understand. So when you say boutique, does that mean more expensive or it just means more small? 
Guest: Both. Both. I mean, it means, it means you know, our, our facilities are rape beds, so boutique and it does mean a little bit more high end.
So people who want a little more care not necessarily more care, but higher staffing ratio is what we have as well as, you know, beautiful [00:04:00] homes and people get what they want when they want. 
Amy: So I want to reflect back for just a second, because when I first started doing house calls and someone was like, Oh, you want to start.
Patients that assisted livings. Of course, I thought of these enormous ones that you drive by, you know, John, they look like hotels, whatever it might be. And then one time, I don't even remember how I met you or how this all happened, but I remember you gave me the address and I pulled up and I was like, this is an assisted living.
This is a house in a neighborhood. And how many times have I driven past this house that is masquerading as an assisted living? It was kind of amazing. And one of the things that I don't know, Alex, did I ever take you on a house call? And I was like, this is an assisted living. And you were like, this is a house.
Wait, what, 
Alex: when I was new to the senior world that was definitely a surprise for me. There were houses in my neighborhood that I'd always looked at, like why there's so many cars there. And they tend to be kind of these rambler houses [00:05:00] and they might even have like a little Wheelchair ramp or something like that.
That might be a clue that something interesting like that is going on, but it's a lot more prominent than I ever knew. And, and there are some other names for these, right? I, I is group homes synonymous with small assisted living or no. 
Guest: That, that is sort of the old term. I mean, that is a term, but it's sort of got a negative connotation to it.
So we try not to use that, but it, it, it, the County does license us as a group home. Whereas the state licensed us as an assisted living. 
Amy: Oh, that's interesting. So the County lists you as different than what the state lists you as, as you have between whatever eight and something beds eight 
Guest: or less, right?
Residents? Yes. Her per, per house, I guess. [00:06:00] Yeah. And then they have eight or less is considered the, the smaller homes. And then they have another category from nine to 15, which is a large group home. And the state, the state license, us, all of us has assisted livings. 
Amy: And then you have to abide by all the rules that the County has and then all the rules that the state has.
And then you got to figure that all out and that's okay. Got 
Guest: it. Right. Yeah. 
Alex: So Jonathan, roughly, how many of these houses do you currently own or 
Guest: manage. I currently own two and we are building a third, which is going to open up in March, April. 
Alex: Gotcha. And is there some attempt to centralize these so that they can share resources or do you try to spread them out so that you get different parts of the market or like what's the strategy 
Guest: there?
For, for my company, we do share resources because [00:07:00] we have them close together. But they are separate entities and separate homes. So we would never have like a central kitchen delivering because that's not home. Like, so, you know, it's home like online, right? Oh, like is the 
Amy: key. Yeah. And that's what, and that's sort of the differentiator between some of these more giant facilities and a small group home.
Guest: Right, right. We really try and make it a home-like environment. 
Amy: Do you think that the folks who would want to live in a large assisted living in terms of age, co-morbidities sort of to think of it a little medically or the same as what are going to be looking at a small group home? Are they the same population or do you find that one prefers one more than the other.
Guest: I find that one prefers one more than the other. And I'll tell you if you want to be very social and have a B in a group of a lot of people and, and are fairly independent. [00:08:00] A larger place is a better fit for you. You're not going to be happy in a small home. 
Amy: So that's really interesting now what, and, and some of these smaller group homes, you can have them that they're just both boutique, but they also can be niche.
So like you have a kosher home, do you have two kosher homes? They're putting one kosher home. So you can actually sort of create environments that suit people that. Is even more home-like in some ways than saying to the chef at the three, you know, the 200 person assisted living. Oh yeah. This one needs a kosher meal.
It's all kosher. It's all in the same roof. It's it's all kind of, it's all sort of focused on one little, you know, niche market, basically. 
Guest: That's correct? Yes. And we have a chef in that house and it is strictly kosher. And you know, nobody's allowed to bring in food from outside. And that way the people in the community know that we really are a kosher home and follow all the rules and guidelines.
Got it. 
Amy: Let me ask one question, but I'm going to [00:09:00] lead it into it. And then I think we're going to kind of it's going to expand our conversation a little bit. So for anybody who has been listening to this podcast for a while, you know, we always. Title of it is mastering Medicare. So we kind of have to dive a little bit into who pays for the services that you would receive in an assisted living.
So Jonathan, I will ask them a series of yes or no questions through, I make them true or false. I'll mix it up. A's B's trues falses, multiple choice. So isn't it, isn't it true that assisted livings are not paid for by Medicare? That is true. That is true. So for the listeners out there, who've been following along, you're saying, why is this on mastering Medicare?
And I think, you know, part of what we are trying to accomplish with this podcast is tell you what Medicare does pay for and what Medicare does not pay for. And when I entered into the senior serving world, one of the things that really struck me is everything that Medicare doesn't pay for and why everyone should basically save their shackles.
I always say that, save your shackles, save your shackles, save your shackles. Cause [00:10:00] you're going to need them at the end. I mean, We talked a little bit about we, we, on our last podcast, we focused a little bit about Medicaid and long-term care, but that is a totally different world than the world of assisted living, which is really a private pay world.
Guest: Right. Except for Amy, if you need some services such as OT, PT, and speech or, and medical equipment, if you have Medicare part B, 
Amy: correct. But the room and the board component of assisted living is a private pay endeavor. 
Guest: That's 
Alex: correct. Jonathan, can we talk briefly about the levels of care immediately below and above assisted living?
Like what would be the lower level of care? Would it be independent living or is there something even in between independent living and assisted living and what would be the key. Feet. Like what would be the key triggers where somebody who's living relatively independent and he should start to think about, maybe I should go into [00:11:00] assisted living.
Guest: Sure. Well below assisted living is really independent living. And there are senior buildings that are independent living where they provide meals and housekeeping and, and social activities. Then assisted living is where you start getting help. With your, you know bathing dressing, toileting, right?
Toileting, medic medication management, all of that. And if somebody, you know, comes in and just needs a little bit of help, you know, that's. They just can't manage on their own. And sometimes financially, if you stay an independent and have to bring in outside sources, such as private duty aides, it gets fine.
It gets very expensive. So going into assisted living is actually a lot less expensive than being on your own with help. 
Amy: Right. So we once have done this calculation on this podcast as a matter of fact, and [00:12:00] if you had 24 seven awake care in your home with private duty, it's about $225,000 a year. Did neither of you fell over.
Okay. So if you take, you know, around 20 or 25 bucks and you multiply that times 24 and then multiply that times 365, that's basically what you get. So I think that ultimately we have to sort of think to ourselves that is not what assisted living costs. No, right. Like in general, 
Guest: absolutely not.
Amy: Right. I mean, you're sharing yeah. Resources obviously, but you're not, you know, in any way, shape or form, getting yourself into a position where you know, you have you know, that type of costs. Although there are remarkably people who do, who do have private aides on top of assisted living care. And that is to add one-to-one care, even in a situation where they may have what, four to one care is that sort of like the standard for.
Patients clients, residents or [00:13:00] whatever you want to call to one caregiver, correct? 
Guest: That's that's pretty much the norm. Yes. And is that just 
Alex: like, is there a different rule at nighttime? 
Guest: Overnight. Well, you have to have at least where we are in the state of Maryland Montgomery County, you have to have at least one awake overnight staff person 
Alex: in a, in a home that has eight residents.
That's correct. And then during the daytime that you have to switch to one to 
Guest: four, basically, I think the rags and. Off the top of my head. I think the rags are, are, are one to six, but most places have one to four, one staff person for four residents. We do a little bit higher than that. We have a one to two and a half.
Oh, wow. Oh yeah. That's just where we choose to spend our money. That's important. 
Alex: How do you ensure your staff is awake overnight? 
Guest: That's a good question. We do drop by visits [00:14:00] and make sure that people are awake. We also make phone calls. You can tell if somebody's waking up with a very sleepy, groggy voice and my, my business partner, and I often just do checks and not at the same time and you can't sleep.
I live close by, she lives close by. We just, you know, take turns, getting in our car and just dropping by and. You know, pretending we're doing some paperwork and not letting them know now of course, they're going to know that we're checking on them. Yeah. 
Amy: So, I mean, I think what I reflect on is when, so there's a way of doing a lot of things, right?
Like the, the bigger assisted living model, which are these giant sort of corporations. And then there's sort of this personal touch version of assisted living that you're essentially providing in the form of boutique. Is that about right? That's 
Guest: correct. 
Amy: And so the, the people who lived there, the adult, children of the people who live there tend to know you very well, correct?
Guest: That's right. Yes. Yes. 
Alex: Jonathan, what do you guys [00:15:00] do in terms of keeping in touch with family members? And do you train your staff to send messages to family members? Like, is there any sort of structured program about communication with family or is it kind of ad hoc? It's just 
Guest: like, it all depends upon.
Sure. It all depends upon what the family wants. Some people want a lot of communication, some people. You just want to know if something's up if there's an issue. So we do email, we do text and of course now we're dealing with COVID. So things they're very different. We don't have visit, you know, visitors in the homes anymore.
We do visit outside, but it's kind of cold. And even though we have those outdoor heaters, but I'm telling you then they don't work as well as warm weather. So we do a lot of of phone calls. We do Skype, we do zoom. We [00:16:00] email the families some want to be emailed or texted once a week.
Some, they just pick up the phone and call. So it depends on some, you know, once or once or twice a year, but that's pretty rare. Our, our families are pretty involved. 
Amy: And would you say, so I'm going to kind of dive a little bit into sort of types of. Clients patients, residents, we can call them all those different things.
An optimal client, well, not an optimal client, but a, a client will often have cognitive deficiencies in general that lives in a small group home or in assisted living or it's plus minus 
Guest: I'd say it's plus minus it's mostly plus. So you're correct. They do better in a smaller environment with more individualized care and routine.
And I'd say even a lot of the larger facilities are also have a lot of people with cognitive impairments, as well, as opposed to years ago, you didn't see that as much. 
Amy: Sure. So it's not like you're a memory care [00:17:00] unit. It just, it self-selects itself to people with cognitive impairment because that's sort of like the point at which they could no longer start.
They could no longer keep living by themselves essentially. 
Guest: Right. And whereas a larger place may be overwhelming to them as well. Can I, could I follow 
Alex: up on that, Jonathan? Is it, is it typically a cognitive issue that triggers the, the transition from independent to assisted living more so than an actual physical issue?
Guest: I would say no, I've seen both. 
Alex: Okay. So either one. Okay. 
Guest: Either one. Absolutely. So 
Amy: Again, here's me with my crazy ideas. So one of the things that I had heard, and I honestly can't remember where I heard this from years ago was that one of the main reasons that people move into an assisted living is because of incontinence.
The continents becomes sort of a driving reason why maybe now the spouse can just no longer do it themselves. [00:18:00] I could do it until number twos started being in our bed or whatever it was. It just, that became the triggering factor. Do you see that as a, as a common theme? 
Guest: I'd say yes and no, there's usually.
There's usually some something, some occurrence that has just pushed the person over there, then that pushes the spouse slash caregiver, you know, family, caregiver over the edge where they just can't do it anymore. 
Amy: So but would you say it's often a hospitalization, does a hospitalization often trigger this move or like.
Are people coming in from the hospital, from nursing homes, like this is their first time in assisted living or do you see it mostly as like, Oh, the pie in the sky. I know dad's going to need it someday. I know mom's going to need it someday. And then it's sort of like this nice, smooth, non, non freaked out move.
I mean, having done this for years, I would say most of the moves I saw kind of were coming after [00:19:00] an event. 
Guest: Right. I, yeah, you're correct. There are some that have planned for a long time and say, you know, they, they do their research early on. And they know they pick what place they want their family member to be, or with the family member involved.
So when it's time to move, they're not dealing with a crisis. Oh my gosh, what do I do? So, and there are, there are many also who have come from the hospital and rehabs that just can't go back home or can't go back to a large facility and have to deal with, you know, private one-on-one care. 
Amy: What are, what are the cases that you can't take that would require a nursing home level?
Guest: Good question. Somebody, first of all, we can't do IVs. And so somebody who needs IVs even, you know, on a regular basis, we couldn't handle M a licensure wise. We're not allowed to handle. 
Alex: Is that, is that a general rule for all assisted livings or depends on [00:20:00] their resources. 
Guest: I it's a general rule for all assisted living, certainly in the, in the greater Washington metropolitan area.
Yeah. Cause that really is skilled care. And we also can't do we can't do ventilators, but that's a lot of nursing homes can't do ventilators. Right. There's very few in the area that do. And, and also, I mean, somebody coming, coming in, being admitted, and this is getting a little technical. So for newcomers In terms of a decubitus Ben soar.
If you have a stage there's stages, one through four, if you have a stage three or four, we're not allowed to take them, admit them as a new resident with 
Amy: unless, unless.dot, dot. 
Guest: And this are all on hospice, 
Amy: right? If you're on hospice, you are basically excused from that particular rule. 
Guest: Right. If 
Alex: they require BiPAP or CPAP, is that [00:21:00] generally okay.
Yeah. 
Guest: Interesting. That's that's fine. 
Amy: Dilatory support. Yeah. What's the big deal 
Guest: do you ever, and we even take we'd even, or we even have and are allowed to take people with feeding tubes. So drive is relatively easy. 
Alex: Do either you or the general industry have to decline certain residents because of other issues like personality issues, mental health issues, as something where you think they would not be a great fit.
And how do you assess for those sort of things? 
Guest: Yes, that's a good question. We do. We do not take people who are a danger to themselves or others. And if they have, you know, aggressive outbursts, this is a small group. We, we can't take them off the bat like that. We have said, you know, get a psychiatric evaluation and let's see what's going on.
And then we can re re-examine [00:22:00] and, and, and reassess. Before anybody moves into any of our homes and I, and I know the, all the other facilities, large or small, they do an assessment of their own to make sure that 
Amy: it's done by an RN, correct. These assessments are done by an RN, I guess is a good moment to kind of take a step sideways.
So yeah. Assisted livings are not without medical care intrinsic to their fabric, meaning that there is an RN that is involved with the care in every assisted living. Well I've ever been to. And the cadence of that involvement is determined by the County or the state in which you live. I'm guessing. Because I know in Virginia, it is a little bit different than Maryland, but it's an RN has to evaluate each resident every.
45 days, every 45 days. Yep. There is a change in status within 24 to 72 hours. I can't remember what it is then. RN must see that person. 
Guest: Right. 
Alex: Yeah. I did [00:23:00] not know that. And is that RN an employee of yours and do they physically come to the house and do that assessment or can it be done virtually? Can you talk to me about that?
Guest: Sure, sure. Well, of course we're dealing with different times now. So from what I did this year, as opposed to what I did two years ago, it was very different. First of all my business partner and Colona of the kosher home Terry ship, she's a registered nurse. So, and I, and I, I know that a lot of the facilities here in Maryland, the smaller ones, a lot of them are owned by nurses or nurse practitioners.
But that, and the larger places have nurses full time are registered nurses full-time and LPN as well. So our, our nurse does do assessments. Now we are unfortunately doing them virtually and speaking a lot to the to the family. Now we did, if they're [00:24:00] coming from home, we ha we do go into the home with all of our gear.
And it's usually the nurse that does the assessment. Amy's right. And it's not, it's overwhelming to have a whole group of people go in and assess somebody. So we usually send one person, so, and that's usually the nurse, so they go and assess and they look at you know, all the medical components, the, the social components and mental status and whatnot.
And they also interview, if there's a caregiver, they interview, you know, a caregiver as well as talk to the family. 
Amy: And that person is called a delegating nurse, correct? Like that's the term a delegating nurse. And I don't know why it's called a delegating nurse. I guess you're delegating the responsibilities of the CNAs within that facility to that RN.
Is that right? Is that just CNAs operating under the license of the RN? That is the delegating 
Guest: nurse. That is correct. Oh, interesting. And all the med techs are [00:25:00] also, which are the people who dispense the medication. They're oppor they're dispensing meds under the RNs license. 
Alex: And these assessments are not built to any payer.
Right? This is just part of the. 
Amy: Part of the, part of the Amex visa, MasterCard process. 
Guest: So, yeah, 
Amy: actually, 
Alex: yeah. That's a good question. What what 
Guest: are the forms? Yes. Every facility is different, so some most don't charge to do an assessment. There are some that do Right. So for the majority of them around here do not charge to do an initial assessment to see if they're appropriate for placement.
Are they? 
Alex: Yeah. Are there different tiers? Like, I don't know if you guys do this or does anybody do this where like I dunno for $4,000 a month, you got this, but if you paid 5,000 a month, like you get extra dessert and alcohol and I don't know, [00:26:00] like, like, are there, are there upsell opportunities in assisted living?
And if so, what do they look like? 
Amy: We're only going to pay attention to your aunt, Sally, if you pay us the extra thousand, the other ones it's total loneliness. We just going to put her in the room. Nothing an extra thousand bucks. We'll talk to her. 
Guest: So that, that's kind of a loaded question to answer. So so some facilities do charge by level of care.
So, whether you want, you know, basic care, whether you need more care, you know, it goes up by tier our facilities and majority of them, we have an all inclusive price, no matter how much care or how little care you need, it's all the same price. And if you want extra dessert and the doctor writes an order saying, you can have a cocktail go for it.
So 
Alex: I actually, [00:27:00] it's really interesting topic for me. Can you talk about alcohol use in the elderly and assisted livings course 
Amy: your interests?
Guest: Sure. Is it a problem? 
Alex: Yeah. 
Guest: Talk to me about that. Sure. As, as long as the, as the doctor writes an order saying, it's okay for the person to have, we had one physician write an order that somebody had to have a high ball at five o'clock and that was in there. It wasn't, but I could see you doing it.
So you actually 
Alex: need a doctor's note for that. 
Guest: Yes, we do because of medications. And so, yeah. But you know, and, and certain people might want a glass of wine with dinner. And we had one lady who was 103, who had to have her glass of red wine with dinner and. By golly, if the doctor says it's okay, I'm giving her her wine.
So I might sit down and join her. 
Amy: Exactly. So, all right. So let me, let me just take a step sideways for a second. Cause I wanna, I do want to come [00:28:00] back to like who's an appropriate and like who is inappropriate from a, like a needs to go to a nursing home type thing. Cause nobody needs to go to nursing home anymore.
As far as I'm concerned. Cause assisted livings are the new nursing homes. It's just not paid for by long-term care Medicaid, but. This is what I wanted to get into. So we're going to go through Amy's list of true false, and as it applies to mastering Medicare. So we have somebody who has made a decision that they are going to move into an assisted living.
They have come to terms that it is going to cost somewhere between four and $12,000 per month to live in this particular facility, depending upon where you live the services, blah, blah, blah, blah, blah. Cause we're like. Nationally, you know, assisted livings have a wide, wide sort of birth of what people pay, but once you're in that facility, as you said at the beginning, Jonathan.
They can get access to the same services that they would get if they were living in their home, which means they get part B physical therapy and occupational therapy [00:29:00] absolutely come in to your facilities and any assisted living they can receive, not simultaneously with, but in lieu of part a services, which means skilled nursing.
Stuff, which means somebody comes out of the hospital. Maybe they need a little help with their blood pressure medication management. So a part a agency can come in, like the Bayada is the Medicis is the Potomac, the, you know, whatever, the big name ones I'm like sitting here going, Oh my God, did I name all the big publicly traded ones?
You know, the part eight skilled nursing. Agencies will can also come into an assisted living because you are not a nursing home. So it's not double-dipping into the part a world and hospice can also come in. So you can have the full spectrum of Medicare services lay on top of the care that you are getting in the assisted living.
Guest: True or false. Absolutely true. 
Amy: Okay. So I think that's [00:30:00] really important for our listeners to remember is as we're talking about Medicare, because this is what people always want to know yet. Medicare is not going to pay for your room and your board. They are going to pay for the other services that come in.
Now, when you were in assisted living, your medications are paid for by part D. There is no. There's just not a nursing home. So the same applies as if you were living in your home because Medicare considers an assisted living basically to be your home. From a house calls part B provider, I'll say that there is a separate set of codes that nurse practitioners, physician assistants and medical doctors do have to use when they are seeing patients in an assisted living.
But essentially from the part B. Other services like x-rays labs med, not meds that's part D but x-rays labs DME, physical therapy, and then the party services. It is seen basically as if you are living in your home. [00:31:00] So I think that's really, you know, I just had to plug my plugin for mastering Medicare.
They're like, just understand that it's not skilled. It is not unskilled either, which kind of annoys me, but it is not a skilled location. So what are the kinds of things that you said you can't do? You can do you, yes. Can do feeding tubes. You cannot do IVs. Could somebody do dialysis, home dialysis there?
Could they have a, has that ever been done? Peritoneal dialysis, which you would do in the, in your. Probably not, 
Guest: I don't know. It's never been done. Most of our people go out all of our people that have dialysis go out, go out. Right. Because I think you have to do something with the plumbing as well. 
Amy: I don't really know, 
Guest: actually.
Yeah. I have a family member that does home and they had to. Do redo some dialysis. Yeah. Right. I 
Alex: have a question about the IVs. Sometimes when patients get discharged from the hospital, they need like Ivey antibiotics [00:32:00] for a few days or weeks, and that can eat, you know like if you, if that person were in their private home, there might be a nurse who sent to their house to do that.
So does that happen in assisted living where or like an infusion nurse? Yeah. Not necessarily an infusion nurse that is your employee, but maybe it's part of some other program just to get the patient out of the hospital. Is that something you that can happen in this facility? 
Guest: Well It, it depends on the situation.
It always depends on the situation and what the, what, what happened. Cause we've applied for a waiver before for that, is that an RN would have to sit while the Ivy ran. They could not leave the premises until the Ivy was finished. So just because CNAs and CMTS are not trained to do IVs. Got it. So most like, you know, we've had people that, you know, the best thing [00:33:00] to do is try and get them on to oral antibiotics upon discharge from the hospital.
Alex: Can you talk about romantic relationships between. 
Amy: I'm curious romance, trying to 
Alex: figure out what I can look forward to.
Guest: I mean, we've had some couples, I mean, couples that became couples when they were here. And you know, as, as, as long, if depending how far it goes, as long as they're both competent to make the decision about what they want to do. It's it's perfectly fine with us. And if it's, you know, as long as they do it, you know, preferably behind closed doors.
So it's not infringing on the other residents. Yeah. So absolutely. And you know, our feeling is if it makes them happy, but at the end it's not dangerous. And it's, it's fine. I mean, we've had, we've had couples and usually it's sort of like being sweet and nice and holding hands and [00:34:00] things like that.
But So, of course it's allowed, but to the degree that they are competent to make the decision, right. And then sometimes you also have to deal with families who are a little upset that their mom or dad is with, you know, another person that's not their spouse. Right. So 
Alex: they're random spot checks by any sort of oversight agencies from the County or the state.
Guest: Yes. We just had one yesterday. The state of St. Same, just, yup. They walked in the door at nine o'clock. So the state and the, and the County, the state, the state comes about every two years and the County comes about every year and they basically they don't announce when they're coming, they just show up.
So you need to be ready. What are the types of things that they're ready at all times, because you never know when someone's coming. 
[00:35:00] Alex: W what are the types of things that they're looking for? Like, what would be the top three or four or five issues that they're trying to. See check 
Guest: on. They're checking on the, of course the residents the residents charts, and they're the making sure that all the medical components are taken care of and documentation is there.
They're looking at the physical plant. They're looking at the staff members, they're looking at to make sure that their files are complete and that all the trainings are complete. They're very big on the trainings. And so they should be And and then they, they go around and, you know, make sure that the residents, you know, seem happy and, and whatnot.
But mostly it's a lot of documentation they're looking at looking for. And 
Alex: do they actually talk to the 
Guest: residents when they do? They do? Yes, they do. Yes. And I can usually tell if somebody really can't answer the question. So if an 
[00:36:00] Alex: assisted living does poorly on one of these checks, where is that published?
Where can people see that 
Guest: that is published? I believe in the office of healthcare quality, if you go on their website, at least for the state of Maryland, so you can go on their website and see all the the surveys are, are there and it's public public knowledge, public access. Jonathan, since 
Alex: you've been in the industry so long And I think there is a wide variety of quality in the assisted living world from very high quality to some that are not as high.
If, if I am a lay person looking for a place for mom or grandma, what are some of the things I should be looking for that might be clues that a place is either low or high quality. 
Guest: I would say, you know what? I tell people when they're there, they're looking first of all, your first impression is very important when you walk in the door, you know, if you [00:37:00] see things that are just not up to par, that's something you need to go with your gut.
I also encourage people to, you know, ask questions when they can, you know, of the residents and of the staff. But I also tell people to come and make an unannounced visit. After you've had your visit with your marketing person and you've had your sales pitch come and come and take an unannounced visit.
And if they don't let you in the door, of course, we're talking non COVID times. Sure, sure. But if, if they're not going to let you in the door, that's a red flag right there. I also encourage people to get family references. From people in the facilities that are already there, so they can talk directly with a family member and not staff that are paid and work there.
Right. 
Amy: That's great. That's a lot of transparency. I mean, I reflect on that a lot. I mean, from there's two things that make me feel like it's a day in day out 24 seven operation, which is the state or the County could drop in at any moment. [00:38:00] And. Your future clients basically are judging you on your minute to minute care of their loved one.
It's really an, and if you can't have somebody that would recommend you, then it really becomes a big problem. I mean, you don't really have to always 
Guest: be right. 
Alex: And on that theme, Jonathan, do you guys employ, or do do folks in the industry employ like video cameras inside from monitoring? For safety issues and just staff quality issues.
What are the thoughts on that? 
Guest: We do, we allow cameras to be in the residents' rooms if the family wants, but they need to sign consent. Okay. You know, mainly it's for safety reasons. Not, not that anybody's looking at anything, but it's mostly for S for safety and we have some families that even have a camera that's that they can look at too.
So, and I don't have a problem with it. If, if [00:39:00] you have a problem with it, you gotta wonder if somebody is trying to hide something. So, and our night staff is doing unlike most places. The night staff is doing checks constantly on the residents to make sure they're okay. 
Amy: Let me ask a little funny question here over the past pandemic.
Have you been approached by lots of companies that are interested in interjecting technology that you did not otherwise have into your facilities? Have you been approached by random it companies that are like, Hey, we've got this like, kiosk that we could stick in the first level. And it will allow video calls between you and your, you know, residents and the families, or, you know, or, you know Sort of a or patient monitoring or something.
That's like, Oh, we, we, if you plug it into the back of the TV, we're like a different type of activities, director that's all virtual or, you know, have you been approached by a lot of these types of [00:40:00] companies? 
Guest: We've been approached by a few, but you know, pretty much we are doing it ourselves. So we were already one step ahead.
So but the activities, people, I think, I mean, our staff have all stepped up, but they are missing those outside vendors. So we've been creative. We have one guy who. Well, I know I'm jumping around here, so, but in terms of, you know, having somebody beyond, beyond the deck and open the door so they can still be entertained, but in terms of technology, absolutely I've been approached, but I don't think that they're bringing anything that we don't already have.
That's working. You know, we have a lot of video calls with the families. We set up you know, laptops all over. So we, and we help the residents so they can visit. So Skype and zoom I've become very popular here. And you know, it just, and, and in terms of activities, we've done a lot of, yeah. A lot, you know, [00:41:00] Skyping and S and just been very creative, but yes, we have been approached by many people, and I think it's terrific.
They're thinking outside of the box, 
Amy: Right, but it's just expensive for something that people, so that you have to incur the costs. Then you either make a decision that it's a return on investment to sort of absorb it yourself, or you pass it along to the resident's family. And that's always the, sort of the big question as to how much do you turn people off by saying, Oh, you know, I know we could do it with FaceTime, but like now we're going to pay for this random video service.
And I'm sure there's this whole. Balancing act that you have to do internally as you consider these things. 
Guest: Absolutely. Yeah. It all comes down to what's it going to cost? 
Amy: It's going to cost now, let me ask this question and Alex don't get too excited. Okay. Ready? How many of your residents. Have personal blood pressure, pulse, oximetry, or other devices that are connected back to their physician.
We call that remote physiological monitoring or [00:42:00] remote patient monitoring. Do you have anybody in any of your facilities that currently has anything that is sort of like operated monitored by their 
Guest: physician? We do not. Nobody has that. I mean, we just give them readings, but nothing is going right back to the physician.
Alex: For most of your residents. John, is the doctor coming to the home to see them, or are they leaving the house to get seen in the doctor's office? 
Guest: The doctors are coming in to see them. We've done. It's been on and off with virtual versus in-person. So depending on sort of what's going on with the pandemic, 
Alex: get a new client.
Do you tell the family that, Hey, here's a doctor or two that we tend to work with and we like them because they come here already. Or is that not a thing? 
Guest: No. I mean, we certainly it's, it's much easier for everybody. If the doctor comes to the house, it's mostly for the resident because going out into the community.
So we do push, we do push. [00:43:00] Yeah. We have certain practices that we use. Amy knows who they are.
Alex: Is there since there seems to be such a divide between the mega ALS and the kind of smaller boutique ones like yours is there any sort of formal organization of those who. Own or operate these eight bed or smaller ALS. And do they ever come together to do certain things together? Like, I don't know.
Yeah. Or having to get a bus and take them all to a casino in Atlantic city or so, I don't know. Like, I'm just curious. What's going on, on the business 
Amy: side with these, you mean, you mean the owners? Yeah. 
Guest: Like
Alex: is there an association of owners of these smaller assisted livings and what sort of things do you guys discuss? If there is such a 
Guest: thing, there are, there are groups, but they're not official quote, unquote groups. [00:44:00] There are groups. There are groups of us that get together. And we do it on a regular basis.
There's a certain core group, but there is nothing that is an official group. So, and you know, we talk about regulations. We talked about if anybody's had any fantastic ideas, we bring problems to the table and we discuss it openly. And you know, some people find this solution, that solution. So yeah, it's very helpful and supportive, but there is no official.
Group. Got it. It's under the table, I guess you could say. Yeah. 
Alex: What about the, kind of the real estate aspect of this business? I'm really curious, like, are there any sort of special tax credits or anything because the real estate is being used for this purpose. And w w when you, when you obtained these properties how much work did you need to do in [00:45:00] order to prepare them so that they would be good enough to meet the requirements to be in assisted 
Guest: living?
Very good question. Well, first of all, in terms of zoning, Am I in our County here, Montgomery County, if you have eight or less residents, you're considered residential. So you don't have to get permission from zoning. But you also have to make sure that you're not in a neighborhood with a homeowners association because a lot of times they do not allow multi-family dwellings.
And in terms, so we've done, we've done existing homes that we have renovated. And we, our newest one is from the ground up. So yeah, so I would say, you know, I think an existing home is a little bit more difficult to build to, to get it exactly as you want it. Whereas when you're building from the ground up, you're getting exactly what you want.
But both, both, both models have worked out very nicely. So [00:46:00] I would say from the ground up is, is harder, but it's, it's, it's a better, the end product is better. Amy. 
Alex: Th that, that, that assisted living that we visited that's on seven locks in Bradley. Is, is that w is that one of Jonathan's or no, 
Amy: I think you used to manage that one, but I 
Guest: used to manage those.
Yes. Because they're built from the ground up. Yeah, 
Alex: that one was beautiful. Gorgeous home. Yeah. That's 
Amy: amazing. Is there something about when you read, well, you have to learn what's called not rehab. I guess you have to refurb or whatever, a house that you might find that want to turn into an assisted living.
What is one of the safety features in an assisted living that is the hardest to like retro, whatever it's called 
Guest: retrofit. I would say probably having. You know that they like people on the main floor. So if you're, if you're non-ambulatory. The County and state don't like you on the second floor. [00:47:00] So trying to find a rambler, which is twice, you know, the lot has to be twice as large.
So because you've, you know, you've got to spread out as opposed to going up. So that makes it, I'd say the layout of the house. Now I'm one house that we did buy that has two stories. We put an elevator in. So that can also be costly, but you know, it's hard moving walls, load bearing walls. You have to have a lot big enough to go out.
So cause he's ended up being, you know, big homes, but we try not to stand out. We really try and blend out in the community. So you don't want a big monstrosity on your lot where everybody else is just, you know, middle of the road. 
Amy: Right. Well, I, I think in some ways it's sort of that applies in any neighborhood.
Like we, we had a family just like no tear downs in my whole neighborhood and they put this enormous house on the corner and it stands out. Imagine if that was an assisted living. I mean, like you couldn't [00:48:00] hate those people more probably because now you've got extra traffic and a giant house and all that stuff.
So I guess what is, what keeps you up at night? 
Guest: What keeps me up at night, 
Amy: everything. Now what keeps me up at night as it pertains to owning an assisted living. 
Guest: I would say if I know that a resident is not doing well you know, if they're having some medical issues that keeps me up at night, worrying about them, talking to the staff a lot when I open.
What else worries about me? COVID has certainly, this has been a huge challenge for us. So, and we've managed to, we've done very well, but you know, It can happen in a second. And no, of course, physical plant wise with God forbid the furnace goes out or something like that. I mean, we all have, you know, you got to worry about the physical plant as well, too.
And if [00:49:00] God forbid there's a call out, you know, then we got to scramble to get 
Amy: so staffing laughing, staffing. This is what I hear about a lot of different senior serving industries. It's about staffing because we rely very, very heavily on employees who don't always make a ton of money, just that their industry, they don't make a ton of money.
So how do you as a how do you create sort of a stickiness with your employees to make them want to stay? Even if they're not making a ton of money? I 
Guest: think four, I think, right. I think a lot of that to be in this line of work, to be in this business, you really have to care. And I think a lot of them really care.
So, and they love their residents. We've had we've we have very little staff turnover. We've been very lucky. We have a core group of people and they, we don't advertise for help. They always know people and they find us people. But that, that is, I remember working at the larger facilities and really scrambling.
So [00:50:00] and I'm not saying that I just happened to be lucky, but it could easily go the other way. Right. So, yeah, I just remember. Yeah, no, I just remember when people call out in the larger facilities, going down the list and trying to find somebody to come in and it's a nightmare and you have to be competitive with your rates and you've got to treat your people.
Well. 
Amy: Yeah, let's talk a little bit about in a, we're going to wrap up sort of shortly, but I just have one more question personally, and then Alex, maybe you have something, but. How do you market yourself? And so this is going to sort of expand into sort of like this bigger picture, which is, you know, obviously people are coming to you from nursing homes, from hospitals, from their homes.
You do have a niche of having the kosher home, but then you have one that's not kosher. And how do you sort of tell people when there's an open bed? Are you able to sort of, is there a technology that you use or is this whispering [00:51:00] in some care managers ear? Is this, you've a waitlist, like, tell me a little bit about that.
Guest: Well all of the above, but yeah, I'll tell you a lot of our residents, first of all, where do they come from? A lot of it is word of mouth. We do a lot of advertising, but I would say most people are coming from a referral from S from a friend, from a family member, somebody So we do have a website.
And when we do have an opening, I start, you know, letting all the care managers know that we have an opening. And you know, we all know each other, so everybody knows. If, you know, if I have an opening, they're gonna do their best to if it's a right match to help fill, fill our slot. And, you know, the, the hospitals, it's very difficult because the hospital staff come and go so much and it's, and right now we can't get into the hospitals.
So, or the rehabs. I mean, if there's somebody there that knows you [00:52:00] wonderful. But as, as we all know that the staff changes constantly, the social worker could be there this weekend gone that next week. I 
Amy: do not come to visit you. Correct. I mean, like how would they know to refer to you or refer to this place, refer to that place?
I mean, I've always been sort of like, will have you visited any of these places or you just get, they just give a list. Here's a list. I have a great time, 
Guest: right? Some want to come visit and some do visit. I would say most of them just say, you know, you drop brochures and a basket of goodies and that, you know, they get to know you, but but also we refer to them as well.
If somebody needs rehab, He needs to go into rehab. And when you refer to a certain rehab, they get to know us. So, so, you know, it's a two way street and I also don't refer to a rehab unless I visited it myself. 
Amy: Okay. In that situation would be, somebody was in the hospital, came back and within 30 days they needed to go into rehab.
You would choose that rehab because Medicare will allow, if you've had a 72 hour [00:53:00] stay in a hospital, then discharged within 30 days, you're still eligible to go to a rehab. Even if you opted not to go to rehab. Immediately after that hospitalization is that right? You're kind of implying 
Guest: that, that as well as when they need to they're in the hospital needs to go to rehab.
The family are asking, where do I send my mom? Or, you know, that type of thing. Yes. Got it. So the families, the families listened to us a lot. They, they depend on us. That guy helped guide them. Yep. 
Alex: And when a resident gets hospitalized and let's say their hospitalization is lasting a long time, At what point do you have to make the decision that they're probably not going to come back and now you, you open up the room to somebody else.
And how does that process work? 
Guest: We usually, you know, work with the family to sort of decide If somebody definitely can't come back and needs a higher level of care, such as a skilled nursing facility, then obviously we released the room, but if [00:54:00] somebody is going to be in the hospital for a bit, and the goal is rehab and back here to their home, that's what we try and do.
And we will hold the room, but we do charge while the room, while they're holding the room because all of their possessions were there and whatnot. Right. 
Amy: Okay. One last question. Sorry. Do you guys do respite and how commonly do assisted livings do respite? Which means, you know, They usually live at home, but some event or some future event or unexpected event has caused their caregiver to have to go or to the hospital or go on vacation or whatever, or everybody just needs to break from whatever's going on at their house.
Guest: Yes. Yes. We, we, if we have availability, we certainly do respite. We do require that it be at least, you know, a month respite, because it's a lot of paperwork get out of work to get 
Amy: somebody in the door. Yeah. Right. In order for it to be worth 
Guest: it. Yeah. Yes. And [00:55:00] I'll be honest with you. Sometimes those respites, a good, good deal of the time turn into long-term stays.
Right. Everyone 
Amy: wants to put their toe in the water. They're like, we'll just give you a little 
Guest: try. Yes. I'd say the past, I'd say in the past year I've had like two admissions that happened like that and they did end up staying. Well, and also it gives them a map, gives them an out if they are so guilt-ridden or if they say, Oh, mom will never like it.
So, but also we've had families that take vacations that, you know, the individual can't go. So yeah. Yes, yes. And yes, yes. 
Amy: And yes, Alex, do you have any other questions otherwise we should summarize? 
Alex: No. Are residents allowed to gamble? Oh, my God. It's like, 
Guest: is there a casino night 
Amy: gambling? 
Guest: Okay,
bingo for quarters in terms of going to the casinos, listen, I'm, I, we probably [00:56:00] have had one or two that would have loved to, but most of them don't want to go and 
Alex: he assisted livings have slot machines in them. There shouldn't be like a casino room. I'm like, why not? Why not tell 
Amy: you? I am obsessed with kinetic toys and like, Pinball machines and slot machines.
And I will talk after the podcast about where you can acquire some slot machines. Should do you want them Japanese ones though, but that's fine. 
Alex: This has been really awesome, Jonathan. So great to do a deep dive on, on this topic. I have no further questions, but this was really, really great. I appreciate it.
Amy: Absolutely. So I'm going to just summarize briefly just to make sure that we all kind of recenter ourselves into the mastering Medicare universe, which is assisted livings are basically a private pay long-term care. Answer that is not paid for by Medicare. It is not paid for in most places by Medicaid.
It is. [00:57:00] Giant. It is just primarily just a private pay endeavor. However, because it becomes the patient's home. They can have part a services laid on top and other part B services laid on top part D will pay for their medications. It is staffed by CNAs who are overseen by a delegating nurse, who, depending upon the state that you live in, have to check in on those.
Patients clients residents every 45, 91, sick, whatever it is, number of days. And that there's multiple levels of assisted living that seemed to be in existence. There's a giant ones. And then there's the smaller group homes and some are boutique-y and more expensive and some are just small and small. So I don't know.
I think that kind of summarizes where I wanted to get to. Is there anything else? 
Alex: Oh, yeah. So Jonathan, what is your website for your accompany and any other contact information you've got, you want to share? 
Guest: Oh, sure. Our, our company is Eaton [00:58:00] homes at Potomac and it is www dot Eden homes of Potomac, all one word.com.
And our main office is if anybody wants to contact us by phone is three Oh one. Two nine nine zero zero nine zero. That is 
Alex: a great phone number, 
Guest: phone 
Amy: number that is such a classic.
Alex: Awesome. Okay. That's Eden homes of potomac.com. Thank you so much, Jonathan. Thank you for having us. 
Guest: Thanks. Thank you all. I appreciate it. Bye-bye.