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


The majority felt that the regulatory requirements for oversight in both CBRFs and RCACs were inadequate, and as a result the state was not enforcing regulatory standards.

  • I don't have a good answer to how you keep the bad providers out. More regulations in nursing homes have not solved the problem. The quality of care in Wisconsin is good compared to what we hear about in other states. We need more enforcement of existing regulations. There are very few license revocations.

  • The CBRF licensing guarantees only minimum oversight -- with an annual visit. RCACs don't even get that.

  • Severe under-funding (and more to come with the budget crisis) has led to inadequate oversight of RCACs by the state agencies. At least CBRF residents have the ombudsman program. RCAC residents have nothing. Anecdotally, I hear as many horror stories about bad care in RCACs as in CBRFs, but they have no recourse except the legal system.

  • In an RCAC, which has much less oversight than a CBRF, you can get 28 hours of nursing care compared to a three hour limit in CBRFs. There is a lot less supervision in RCACs. Most CBRFs have a two staff to eight resident ratio. In RCACs -- it's all contracted services -- they have one staff person on duty for 100 folks.

  • In general, the regulatory process needed to be overhauled. But we are concerned about the cost of the licensing process. There are no facilities that would argue against the necessity for regulations as long as the cost is not exorbitant, particularly for small facilities with 4 to 8 beds who can't afford the training costs on top of recruitment costs. We're spending $1200 to get folks into jobs and then they leave in six months.

  • RCACs were created based on a philosophy of de-regulation. The state now realizes that there are enough problems that it needs to visit these facilities more frequently than required in regulation. The state had only one staff person to deal with the oversight of 5000 units. The industry was basically off the hook and got used to this, but then the state got additional staff and started issuing citations.

  • The requirements are excellent and the oversight to assure the requirements are met is abysmal.

  • There should be oversight and regulations should be enforced. There is a system for fining providers, but it's not implemented well. Providers are not fined the full amount. There is inadequate enforcement of existing rules.

  • The state's top regulatory initiative is to shift from a consultation to an enforcement mode in RCAC regulation. The state has identified the need to develop a consistent policy framework for interpreting the RCAC rules as the initial enforcement actions are taken.

    Another state goal is to seek increased program revenue to support a more substantial level of enforcement activity -- increasing the certification fee (currently $350 +$6 per bed per year), extending fees to registered as well as certified facilities, and pursuing Medicaid administration funding for regulatory staff costs.

  • More enforcement of existing regulations is needed. The CBRF industry is a good example of how regulations by themselves don't equate to quality. We don't want to over-regulate. The Ombudsman program is not regulatory. The providers should see this as an advantage. It's better than having crises lead to heavy regulation.

A number of respondents mentioned that when the RCAC regulations were being developed, the industry opposed oversight by the ombudsman program.

  • In some ways Wisconsin is progressive in their standards and some ways not. For example, the Ombudsman Program is not allowed into RCAC's. The rationale was that the state did not want to burden the providers. The law specifically states that the Ombudsman is not permitted to advocate for people in RCACs. Even if an RCAC resident calls the Ombudsman's office, the program is not legally allowed to respond. We are promoting the involvement of the Ombudsman Program in RCACs. However, with the budget crunch, it may not be a priority issue this year.

Several noted that the way in which RCACs are regulated reflects a compromise among the industry, state staff and consumer advocates; but some felt that the industry had the upper hand.

  • We didn't get what we wanted, e.g., like a requirement that all RCACs provide three meals a day. We had to fight for every thing. It was very hard. We did the best we could but the decision not to license RCACs is questionable as is the decision to not allow the ombudsman program in RCACs. Not having enough staff at state level at the outset of the program was a problem -- one person statewide for a new industry. There was little opportunity for adequate consultation.

One respondent noted that after four and a half years of a consultative approach to RCAC regulation, Wisconsin is now citing and fining violators for the first time: three citations have been issued in the last 6 months, and 11 complaints are currently under investigation.

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