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


The rules require ALFs to be located, designed, equipped, and maintained to promote a residential, non-medical environment, and provide for the safe care and supervision of all residents.

  • ECC facilities must provide rooms or apartments with lockable doors unless the resident's safety would be jeopardized. Residents not in private units must have a choice of roommates. Those that offer rooms rather than apartments must have bathrooms shared by no more than four residents. Private rooms must offer 80 square feet and shared rooms 60 square feet per resident.

  • Non-ECC facilities licensed after October 1, 1999, shall have a maximum bathroom occupancy of two persons. A toilet and sink must be provided for every six residents, and one bath tub or shower for every eight residents.

  • Facilities licensed prior to October 1999 may allow four people to share a bedroom.

Medicaid sets a maximum of two persons per room for waiver clients. One respondent noted that the maximum was strictly enforced and that facilities with more than two residents sharing a room could not participate in the program. When drafting rules for the waiver, discussions about privacy were contentious and advocates were unsuccessful in their attempts to make single occupancy a requirement of the waiver program. However, many providers do offer private rooms to waiver clients as their standard practice.

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