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


Very few felt that licensing and regulatory requirements posed a major obstacle to affordable assisted living in Oregon.

There were varying views on whether the licensing requirements and regulations assured quality. Most acknowledged that quality problems had been a major issue in the program's early years.

  • The state did a poor job in the eighties and has been catching up ever since. The quality now is good--certainly compared to states like Texas and North Carolina. The state of Washington does the best on quality assurance because they looked at Oregon's mistakes and learned from them and did it right. They bring everyone into the quality assurance system--case workers and surveyors. They also have new training rules but their budget crisis may slow down implementation.

Some thought the regulations were good overall but felt some fine tuning was needed.

  • The RCF rules are outdated and are being updated by the state--they will be more like the assisted living rules when completed. Many changes will be to administrative requirements, e.g., the need for signatures on specific forms. Others will address major issues such as staffing requirements.

  • The assisted living regulations are good. The last revision minimized the aging in place requirements and the rules now recognize that individual facilities may have limits on what services they can provide. The state sets the minimum and facilities are permitted to have different ceilings. A small facility may have only one staff person for 8 clients and be unable to do two person transfers.

A few thought that there were ongoing quality issues and that a lot more work on quality needs to be done in all three types of residential care.

  • There's nothing about Oregon's model that provides better care. What it provides is a wonderful environment that is conducive to a better quality of life. Our track record regarding care is no better than anywhere else--we have individual providers with problems like everywhere else.

A number had complaints about the regulations and varying views on enforcement.

  • I think Oregon has a good regulatory structure. What's lacking is consistent enforcement.

  • There is enforcement about silly things like storage and sign placement--things which don't equate to good care. New staffing regulations may also not be related to better care. Nursing homes are over regulated and that hasn't equaled good care.

  • Increasing the choices tenants have and letting care be directed by the client are good things but new regulations are making it more difficult. They give more responsibility and liability to the provider. For example, there is a prohibition on restraints and bed rails are considered restraints, but some residents may want bed rails because they've had them at home and it makes them feel safer.

  • I'm very concerned that given the high cost of new prescriptive regulations, Medicaid clients will end up in double occupancy RCFs and assisted living will be only for the private pay market. With the current cut-backs, most providers have stopped taking Medicaid clients until they see what's going to happen.

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