Using Medicaid to Cover Services for Elderly Persons in Residential Care Settings: State Policy Maker and Stakeholder Views in Six States. Licensing and Regulatory Requirements


Respondents had conflicting views about licensing and regulatory requirements. Many expressed concerns that the combination of ECC licensing and Medicaid waiver funding is moving some assisted living facilities more towards a medical model.

  • ECCs should be regulated because they are providing nursing services. The only difference between nursing homes and ALFs is that nursing homes are an entitlement program. But many people served in both settings have the same needs.

  • Really sick people are being served in Extended Congregate Care ALFs, but you can find nursing home residents having a drink in a bar. Some nursing home residents have cars, one man was running his business from the nursing home.

  • ECC ALFs do not want to become mini nursing homes, we want to be part of home and community services. But in most peoples' eyes we are considered institutions; we need to get out of our 400 chapter, and into the 430 chapter.20

  • My biggest concerns about all these studies is that they will lead to additional requirements. We need to be aware of the diversity of ALFs in Florida. Prescriptive regulations do not help anyone. We need to be creative and respond to needs. Making facilities take more impaired people isn't a good idea either.

One had very strong recommendations about licensing and regulation.

  • We should abolish specialty licenses, that is, limited nursing services, limited mental health, and extended congregate care. ALFs are the residents' home and we should apply the same approach that is used when relatives can no longer provide proper care in the home, i.e., acquire more services through alternate resources. The individual should have a choice and the caregiver should have a choice. Delivery of care should be based upon the agreed tenets of shared risk or negotiated risk.

    By moving ALFs out of Chapter 400 (Public Health, Nursing Homes and Related Health Care Facilities) and into Chapter 430 (Social Services, the Department of Elder Affairs), there would be more sharing of resources and consumers could be offered a greater selection of programs. I also suggest amending Chapter 430 to allow the governor to appoint an additional member to the Department of Elderly Affairs Advisory Council from the Florida Assisted Living Association. This would allow the assisted living industry to represent this continuum within the department's structure.

Several expressed concerns about specific licensing and regulatory requirements that were considered unnecessary and in some cases, added unnecessarily to costs.

  • We are in the people profession and we are being controlled by the politicians. You cannot legislate heart and caring, only criminal intent. How do you keep a homelike environment with all these signs on the walls?

  • Regulations should not get in the way of quality of life; they should address health and safety issues but not constrain the facility's ability to meet residents' preferences.

  • Rigid nutrition regulations are one of the industry's pet peeves. Facilities are required to prepare meals based on the pyramids, but nutritious meals may not provide the food that people like to eat.

  • I had a diabetic on medicine, she was in her 80s. The inspector wanted to know why she was eating chocolate cake. The question is, "Whose choice is it, the frail elder who requires services, the provider of the service, or the Government who is paying for the service?"

  • The rules state that a stock supply of over-the-counter medications for multiple resident use is not permitted in any facility and non-prescription drugs, when centrally stored, must be labeled with the resident's name. In practice, this means that I cannot give a resident an aspirin for a headache from a stock bottle.

One noted that regulations were always needed to deal with bad providers, and said that the best regulations can do is to require the key indicators of health and safety and then "get out of the way" and let providers deliver care. Another noted that the ombudsman program used to take a problem solving approach, but recently have adopted an adversarial approach.

A number expressed concerns about the proliferation of unlicensed (i.e., illegal) facilities.

  • There are many unlicensed board and care homes providing services for private pay. It is an underground network; you can see them all around the neighborhood; they are family businesses, Filipino and Hispanic, which provide services to members of their communities.

  • There are board and care homes, unlicensed, that are not supposed to provide personal care services. But they do and try to get away with it. Residents with incomes higher than SSI will pay for services. But OSS and Medicaid won't pay for anyone in a facility that is not licensed.

20. Florida Statutes, Chapter 400 is the "institutional" chapter and covers nursing homes, adult day care centers, adult family care homes, and assisted living facilities. Chapter 430 covers the community based services, such as Community Care for the Elderly, Home Care for the Elderly, Alzheimer's clinics, Respite for elders, and others.

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