Historically, the physical character of a substantial portion of residential care was quite institutional -- as permitted by state regulation -- with 2-4 persons sharing a bedroom, and as many as 8-10 residents sharing toilet and bathing facilities. The new assisted living model of residential care became popular with older people in large part because it offers what traditional board and care facilities generally do not: privacy and the concomitant opportunity to have greater control over daily activities such as bathing, eating, and sleeping. Another reason for its popularity is that ALFs built in the 1990s have more attractive and comfortable physical environments than do board and care facilities, many of which were built in the 1960s and 1970s.
Consequently, single occupancy apartments or rooms dominate the assisted living private-pay market. A survey of non-profit facilities conducted in 1997 by the Association of Homes and Services for the Aging found that 76 percent of the units in free-standing facilities and 89 percent of units in multi-level facilities were private (studio, one, or two-bedroom units).10 A similar survey by the Assisted Living Federation of America found that 87.4 percent of units in its member facilities were studio, one, or two-bedroom units and only 12.6 percent were semi-private (shared by two unrelated persons).11 In a national survey of ALFs in the late 1990s, Hawes, et al. found that 73 percent of the units were private, 25 percent of the units were semi-private, and 2 percent were “ward-type” rooms that housed three or more unrelated persons.12
A 1998 survey of ALFs by the National Investment Conference (NIC) found that 17 percent of the residents shared a unit. Of these, 52 percent said that they shared their unit for economic reasons, 30.4 percent for companionship, and 14.9 percent because a private unit was not available. Just under 65 percent of those who shared a unit were satisfied with the arrangement and 35.7 percent preferred a single unit.13
Nationally, consumer demand, the availability of subsidized units, and the extent of competition are more likely than regulatory policy to determine whether studio or apartment-style living units are available for private-pay residents. However, for Medicaid eligible residents, state regulatory policy and Medicaid policy determine the types of units available. For example, Medicaid contracting requirements in Washington require participating facilities to provide private apartments shared only by choice.
Due to the popularity of assisted living, many providers of all types of residential care settings market themselves as assisted living, whether or not they give private rooms to all residents. Some board and care homes that want to be licensed as assisted living may have an interest in opposing rules requiring apartment-style units and single occupancy. On the other hand, advocates of assisted living as a unique model of care oppose the use of the term assisted living by facilities that do not offer private rooms or units to all residents. Consequently, occupancy requirements have become a contentious issue.
States have taken a number of approaches to setting occupancy requirements. Some states have simply amended their statutes to rename board and care homes as assisted living and continue to permit dual occupancy. Others have allowed dual occupancy standards in grandfathered buildings but require new buildings to offer single occupancy units. Some states maintain separate licensing categories, allowing dual occupancy in some settings and requiring single occupancy in others. Several states have multiple licensing categories and the two-person limit may apply to only one of the categories.
Thirty-five states have rules that allow two unrelated people to share a unit or bedroom. Ten states have licensing categories that allow four people to share a room; three states allow three people to share units. A few states to do not specify how many people may share a bedroom.
States that have developed a multiple-setting assisted living model vary the requirements by the setting. For example, New York allows sharing for board and care facilities participating in the Medicaid program but requires apartments in the “enriched housing category,” which includes purpose-built residences and subsidized housing. Additional examples of states’ requirements follow.
Florida licenses two types of assisted living, one which allows up to four people to share a bedroom, and extended congregate care (ECC), which requires private apartments or private rooms shared only by a resident’s choice.
New Mexico’s assisted living waiver provides services in two types of adult residential facilities offering “home-like” environments, which offer both units with 220 square feet of living and kitchen space (plus bathroom), and single or semi-private rooms in adult residential care facilities. Rooms and units may be shared only by choice.
Texas covers assisted living services through Medicaid to residents in three settings: assisted living apartments (single occupancy); residential care apartments (double occupancy allowed); and residential care non-apartments (double occupancy rooms).
Four people may share a room under what would have been described prior to the use of the term “assisted living” as board and care licensing rules in Delaware, Georgia, Indiana, Iowa, Michigan, Mississippi, Missouri, Nebraska, Pennsylvania, Rhode Island, South Carolina, and Virginia. Shared toilet facilities and bathing facilities are the rule among states with board and care regulations. State rules that allow bedrooms to be shared by 2-4 residents require bathrooms and lavatories for every 6-10 residents.
While a state’s policy sets the parameters for what may be offered and provided, the actual practice may be narrower. Shared units may be allowed, but the market may produce very few or no facilities that offer shared units. Further, facilities constructed prior to the development of the assisted living model may offer shared units while most, if not all, newly constructed buildings have predominantly or solely private units.
Ruth Gulyas. The Not-for-Profit Assisted Living Industry: 1997 Profile. American Association of Homes and Services for the Aging. Washington, DC. 1997. Also, 2000 Overview of the Assisted Living Industry. The Assisted Living Federation of America and Coopers and Lybrand. Washington, DC. 2000.
Ronald K. Tinsely, Robert G. Kramer, et al. Overview of the Assisted Living Industry. Assisted Living Federation of America. Fairfax, VA. 2000.
Hawes et al., op. cit.
National Survey of Assisted Living Residents: Who Is The Customer? NIC and the Assisted Living Federation of America. Washington, DC. 1998.
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