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


Respondents in every state acknowledged that regulations were necessary, if for no other reason than to "keep the bad providers out." But many felt that some prescriptive regulations at best did not guarantee good care and at worst impeded it. A few stated that regulations "got in the way of quality of life."

Several noted that licensing and regulatory provisions are too rigid and need to be more person-centered and outcome-based, though one respondent noted that outcome-based provisions would be better included in Medicaid provider contracts than in licensing and regulatory provisions.

Regulations related to assuring a nutritious diet were most frequently cited as too rigid. Several noted that facilities are required to serve nutritious meals based on the food pyramid, but these meals may not provide the type of food that people like to eat. Some suggested an outcome-based alternative: to simply determine if the residents were maintaining an appropriate weight and were happy with the meals provided.

Inflexible, prescriptive non-person-centered rules were viewed as particularly problematic when caring for persons with dementia. For example, one respondent noted that North Carolina has a rule that there must be a minimum of ten hours between breakfast and dinner, but a resident with dementia wanted to sleep late, have breakfast at 10 AM, and dinner at 5:30 PM. Unless a facility followed this schedule, the resident became agitated; nonetheless, the facility was cited for not adhering to the ten hour rule.

Several providers in Oregon expressed concern that the state had started with a resident-centered model but that the regulations were becoming more prescriptive and more costly for providers to meet. One noted that the state prohibits bed rails because they are considered restraints, but some residents have used bed rails at home and want to continue doing so when they move to an ALF because it makes them feel safer at night. One felt that a potential consequence of more regulations is that ALF providers will admit more private pay residents to help meet the cost of the new regulations, resulting in Medicaid clients having fewer choices and ending up in double occupancy residential care facilities. On the other hand, several respondents felt that more regulation was needed because the nursing needs of the average resident have increased.

Another complaint related to licensing and regulatory provisions that were perceived to increase cost but not quality. For example, Florida prohibits stock supplies of over-the-counter medications for multiple residents and requires all non-prescription drugs to be labeled with a resident's name. One provider noted that this rule prevents providers from giving a resident an aspirin for a headache from a stock bottle. On the other hand, several respondents had major concerns about medication administration by unlicensed, untrained, and unqualified personnel, and felt that additional regulations might be needed to prevent medication errors.

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