Regulatory Issues in Assisted Living


There are over 30,000 assisted living communities in the United States which provide residents with assistance in activities of daily living, housekeeping, meals, medication management,  and wellness programs.  Some also provide Alzheimer’s/dementia care.  While assisted living facilities do not provide 24-hour skilled nursing services, they do typically coordinate with other care providers, which requires integration of medical record documentation.

Licensing and certification requirements for assisted living facilities are established by each state.  Medicare does not cover assisted living services, but Medicaid may cover some services for eligible residents.  LaShuan Bethea, Executive Director of the National Center for Assisted Living (NCAL), provided an overview of recent assisted living regulatory changes at the DRI Senior Living and Long-Term Care Litigation Seminar.  NCAL publishes an annual Assisted Living State Regulatory Review which summarizes selected state requirements.  Highlights of the report include the following:

Assisted Living:

  • 33 States updated assisted living licensing regulations between 2020 and 2022
    • The updated Assisted Living regulations included requirements for Infection Prevention and Control, staffing (e.g., minimum training), admission and retention, medication management, and dementia care.
  • 46 states and the District of Columbia require a consumer disclosure, agreement, and/or bill of rights for residents.
  • All 50 states and D.C. require a form of resident assessment and, at minimum, activities of daily living for residents.
  • 49 states and D.C. allow and have provisions around providing medication management to residents.
  • 45 states and D.C. have minimum educational and/or training requirements for assisted living administrators/directors.

Dementia care:

According to the Alzheimer’s Association, 7.2 million Americans 65 and older will be living with Alzheimer’s dementia by 2025, a 7% increase from 2023.  This does not include individuals with other causes of dementia including, but not limited to, cerebrovascular disease, frontotemporal degeneration, Lewy body disease, and Parkinson’s disease.  The National Center for Health Statistics 2020 National Post-acute and Long-term Care Study reveals that over 42% of residential care community residents and over 45% of individuals in long-term care hospitals and nursing homes have a diagnosis of dementia.  The NCAL reports that:

  • More than one in five assisted living providers have a secure dementia care unit or only serve adults with dementia.
  • 20 states have specialized dementia assisted living licenses or endorsements. These requirements include:
    • Clinical and medical assessments
    • Written disclosure statements
    • Minimum staffing
    • Egress control

Each state has specific dementia education and training requirements.  These requirements typically include training on understanding disease process and symptoms, person-centered behavioral interventions, and communications techniques.  Assisted living communities can demonstrate the quality of care they provide through various certifications beyond licensing, including through The Joint Commission which offers Assisted Living Community Accreditation and Memory Care Certification for Assisted Living Communities.

Risk Management

Ms. Bethea closed her remarks with risk management considerations in assisted living communities, where a major focus is fall prevention.  This is supported in CNA’s 2022 Aging Services Claim Report which shows assisted living resident falls account for 54.8% of claims, and dementia is a factor in almost 73% of assisted living fall related claims.  Among the report’s recommendations to mitigate risk are pre-admission screening, documentation, transfer to higher level of care, care/service plan compliance, and expectation management.

Excelas supports our clients in preparing for and responding to state surveys through data abstraction, audits of medical and related records, and record production support.  Audits can reveal gaps in documentation, documentation support for claim submissions, and compliance with regulatory requirements.  Excelas’ experienced legal nurse analysts can evaluate your community’s compliance with certification/licensing requirements, risk management guidelines, and provide recommendations for documentation improvement.

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