Mom is in a ALF but needs more care than they can provide. How do you know it's time for Hospice?

Sounds like you need to place her in a Skilled Nursing Facility.

She doesn't want to take meds, because it will keep her here longer.

Why won't she take meds?

Is she against them on principle? Does she think that someone is trying to poison her?

I'm 65, and I ache all over! If I didn't take some Ibuprofen every morning, I'd be miserable!

What are her physical ailments? She'd only be eligible for hospice if she has something life limiting (although that can be open to interpretation, apparently).

But if she won't take meds, how do you propose that they keep her comfortable?

Your option would be a Nursing Home or Memory Care, there she would get more help.
Hospice does not provide 24/7 hands on care. There will be a Nurse that will come in weekly, A CNA that will come in a few times a week but they will not be there all the time. And a person has to qualify for Hospice. Now she might so it does not hurt to get an evaluation. Even if she does not qualify now it might be a matter of a week, month before she would. If there is anyone on this site that is Pro Hospice it would be me. I loved my Hospice team, I could not have done what I did for my Husband without their help. I feel that far too many people do not take advantage of the services of Hospice so PLEASE call. They will do every thing they can to help keep her comfortable but they do have to work within the guidelines set up by Medicare.
There is always the option of her (or you) hiring an additional aide or companion to assist her. You would have to check with the facility to determine what the "rules" are for that.

Hospice doesn’t really provide much hands-on care in my experience. They will keep her comfortable with meds. And provide aides to come & bathe her as well as provide emotional support to the family. But if she needs more hands-on care, I don’t know that hospice would provide that unless you put her in a hospice facility.