Residential Care and Assisted Living Compendium: 2007. Overview of Policy Developments Since 2004

11/30/2007

In 2007, states reported 38,373 licensed residential care facilities with 974,585 units/beds compared to 36,218 facilities with 935,364 units/beds in 2004; these numbers do not include facilities licensed separately as adult foster/family care or facilities licensed by Departments of Mental Retardation and Other Developmental Disabilities (MR/DD) or Mental Health.2 Compared to 2004, the supply of licensed facilities rose 6 percent and the number of units rose 4 percent. See Figure 1-1 for a comparison of growth rates since 2000.

FIGURE 1-1. Supply Changes

FIGURE 1-1. Supply Changes

Changes in facility supply varied across states. About half reported an increase in the number of licensed facilities and half reported a decline. The supply of the number of licensed facilities rose over 10 percent since 2004 in 11 states (Alaska, 41 percent; Arizona, 29 percent; California, 14 percent; Georgia, 10 percent; Massachusetts, 11 percent; Minnesota, 33 percent; North Dakota, 26 percent; Wisconsin, 46 percent; and Wyoming, 33 percent). Supply declined more than 10 percent since 2004 in five states (Hawaii, 11 percent; Kansas, 12 percent; Nevada, 14 percent; New Mexico, 18 percent; and New York, 14 percent.) The decline in the number of licensed facilities did not always follow the direction in the supply in the number of units which suggests that smaller homes may have closed and a fewer number of larger homes were licensed leading to a decline in the number of facilities and a small increase in the number of units.

The 2007 review of state policy and activity found that regulation of residential care settings continues to evolve. Regulatory changes have tended to address the challenges posed by serving frailer and sicker residents as well as concerns among state licensing staff about inappropriate retention, adequacy of care, and the shortage of trained staff. States revised provisions in several areas, including staffing requirements; training requirements for direct care workers and administrators; criminal background checks; admission and retention criteria; disclosure requirements; and resident agreements.

Twenty-one states revised their regulations between 2004 and 2007, and 12 states reported current activity to revise regulations. Two states revised their residential care regulations to add a service philosophy, and Missouri and Pennsylvania adopted the term assisted living for residential care settings. Forty-three states and the District of Columbia now have a licensing category or statute that uses the term assisted living. Pennsylvania enacted a law creating a new licensing category for assisted living that requires units to have private bathroom, living and bedroom space and food preparation areas.

A few states reported changes in Medicaid coverage since 2004. Indiana and Ohio implemented Medicaid home and community-based services (HCBS) waiver to cover services in assisted living settings. While Alabama and the District of Columbia received approval to cover services in residential care settings under waiver programs, they have not yet implemented them due to lack of funding (Alabama) and promulgation of regulations (District of Columbia). California implemented a new 1915(c) waiver program that covers services in assisted living as a demonstration project. West Virginia withdrew an approved Medicaid HCBS waiver to establish a pilot assisted living program (ALP) in public housing sites in four counties.

The reported number of Medicaid beneficiaries served in residential care settings -- including assisted living but excluding adult foster/family care -- declined modestly from 121,000 in 2004 to about 115,000 in 2007.3 Most of the decline occurred in Medicaid state plan programs in Michigan and Florida.


2. The data were obtained from state agency websites, when available, or reported by state licensing agencies. Partial information was reported for some categories in Delaware, Kentucky, Minnesota, New Jersey, New York, New Mexico and West Virginia. (See Table 2-1 in Section 2 for each state’s information.) While these numbers do not include facilities licensed by state MR/DD agencies, some individuals with MR/DD may be living in facilities licensed as residential care/assisted living.

3. The number of residents receiving Medicaid in residential care settings is slightly underreported because it does not include data from Kansas. Kansas’ reporting system does not differentiate between waiver clients served in their own homes and those served in residential care settings.

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