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


Many respondents--both providers and consumer advocates--expressed concerns that the licensing category of assisted living was too broad and created problems, both for consumers and for facilities that provide the new model of assisted living.

  • The state's licensure category is too broad. In the battle that occurred before the new law put all types of adult care homes under one term, I was on the side that assisted living in its purest sense should have been for the frail elderly. If the state is going to use it for all adult care homes, then at least we need separate classifications for homes that serve different populations: the frail elderly, the seriously mentally ill (SMI), and the developmentally disabled (DD).

  • There was a push by some providers to call everything assisted living--now we have the same regulations for facilities that have 35 year old seriously mentally ill folks and for frail elderly playing bridge all day. Very generic rules; they don't work. It's a disservice to the general public who don't know what's going on. We get lots of inquiries asking about homes and they are given a list and not told that it's a mixed facility. Providers should be given the choice for different licensure requirements and marketing. Combining everyone into one category is a big disservice. I get calls from families who are looking for assisted living for their mothers, and they go to facilities with SMI and DD folks, and call me crying, saying I can't put my Mom there. Then we have to explain that there are some assisted living facilities that serve only the frail elderly.

  • The public is confused about long term care options. They don't understand the difference between residential care facilities, nursing homes, and assisted living. They also do not understand the difference between skilled and intermediate care, particularly the difference between eligibility requirements and staffing requirements.

  • In North Carolina, assisted living is nothing but a marketing term; a lot of so-called assisted living is just like institutional care. Many adult care homes look just like nursing homes. Most of the rooms are dual occupancy, few have private baths, and none have locked doors, but they can call themselves assisted living just like the $4000 a month Sunrise assisted living facility in Raleigh.

  • Assisted living in North Carolina does not necessarily mean a studio or apartment with a lock on the door. The domiciliary care industry decided that the words assisted living made them more marketable so they repainted their signs. There may be exceptions, but on the whole it's just a new name for an old program.

  • Assisted living should mean privacy plus a la carte service options plus the ability to stay and receive additional services as your care needs increase. You don't get that in adult care homes. The private pay folks get it in high end assisted living.

  • Some people in the state are interested in developing affordable models of assisted living that have private rooms and baths, but it can't be done without the assurance of Medicaid funding for services. With the freeze on the waiver program, it's simply not feasible at this time. If the time comes when we can do, given that North Carolina now uses the term assisted living generically to cover a wide range of facilities of varying levels of care and quality, we would not call it assisted living.

A few respondents raised serious concerns about quality and safety.

  • Regulations are always minimum health and safety. In the county where I worked, there was a home chronically doing terrible things--violating rights--didn't have food. We documented everything--breakfast--no one there--cook gone to get eggs and milk--nothing in larder--they are supposed to have several days supply of food. Even with media attention--change doesn't happen. People who care get burned out.

  • When the state authorized the use of the Medicaid Personal Care option in adult care homes, there were concerns about how the extra money was going to be used. The industry had gotten a 10 percent increase. Advocates felt that the extra money should be used to increase staffing (the regulations at the time only required one staff person per 20 residents and 1 to 50 at night).

    Shortly after, there was a fire in a rest home and 7 men died of smoke inhalation (the staff were in the women's wing). There was no sprinkler system. A Governor's Committee was established to look at the issue. The media found out that the people who died were not ambulatory, and that the regulations really applied to a less impaired population. Consequently, there was an increased focus on this issue. Some members of the Governor's Committee insisted that there be a performance standard that if people couldn't evacuate, the facility had to have a sprinkler system, but it was not enacted. There was also a motion to reduce the number of high level needs folks in these homes, but it wasn't allowed to come up for a vote. A positive result of the Committee's works was that the staffing ratio was reduced from one to 50 to one to 30. But how can one person help 30 people to evacuate in the case of a fire? The new facilities have sprinklers, but a lot of older facilities without them were grandfathered.

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