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


Many felt that insufficient regulations inevitably lead to problems and if the media picks up on it and reports the problems, then the pendulum swings the other way with a demand for regulation to address the problems, such as a need to assure a higher quality of staff in CBRFs and RCACs.

  • We have a lot of concerns. We have a list of homes in the community and social workers give information about what's available. We get feedback from families about quality and some issues are pretty serious. For example, a resident left the facility and the staff did not know they were missing for eight hours; families go to the facility and can't find the staff; the staff are not trained properly; and the staff did not know who to call in an emergency.

  • With regards to quality the major problem faced by all states is staffing. There is a lack of trained staff to work in both nursing homes and assisted living. There are major problems recruiting and retaining which leads to poor quality. The turnover rate is phenomenal - about 100 percent. Pay is low and benefits are non-existent. The State has to do more regarding the pay scale and the quality of the work environment. There have been some promising quality initiatives in nursing homes to improve the work environment. McDonalds and Lands End are competitors for staff - they pay $8-10 an hour plus benefits.

On respondent stated that there were major concerns about quality, based on a six-month investigative report by a major newspaper, which reviewed 460 assisted living facilities (CBRFs and RCACs) and found numerous citations for violations over the past 4 years relating to untrained staff, medication errors, not calling the doctor when a resident got sick, leaving residents alone, and abuse. Other respondents felt that there are always a few bad providers, which get the media's attention, but that most providers do their best to provide good care.

  • In my 21 years experience in the field, I can say that those providers who are in the business to provide good services do wonderful things. Those doing a lousy job are always complaining about too little money. I always tell the industry, this is not a place to expect to make huge amounts of money.

A number felt that the major causes of poor quality were inadequately trained staff, a lack of training requirements and competency testing, and lack of enforcement of existing training requirements.

One provider related the inadequacies of staff, in part, to the increased needs of the typical resident.

  • The original concept for RCACs was good -- folks who were pretty independent and needed protective oversight and less care than CBRFs -- could be cared for in a supervised apartment setting. But what's happened is that once the first layer of higher functioning people are placed then you get people with higher and higher needs, the same as in CBRFs.

    And I agree with the state that the industry is taking care of people who are too highly impaired. But there is also a push to get people out of nursing homes. The original concept of CBRFs was also to take care of the mildly impaired. But if they are caring for some very impaired residents, obviously more training is needed. I understand the state's perspective. But the state needs to understand that the extra training costs more.

View full report


"med4rcs.pdf" (pdf, 3.73Mb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®