Assisted Living Facilities

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Assisted Living Facilities

Sections within this essay:

Background
Federal Purview
ResidentRights
Funding
State Provisions
Additional Resources
Organizations
American Association of Retired Persons (AARP)
The American Bar Association (Commission on Legal Problems of the Elderly)
The National Citizens' Coalition for Nursing Home Reform

Background

The concept of "assisted living" as a unique program of care or service for elderly/minimally impaired persons has been slow, in the eyes of legislators and practitioners, to distinguish itself from other existing forms of services. The distinction becomes important for purposes of funding and financial assistance from state and federal entities. But more importantly, the distinction becomes important in the eyes of the residents and their families.

Assisted living is often described as a statement of philosophy which differentiates itself from other forms of "residential care" by focusing on a model of living that promotes independence, autonomy, privacy, and dignity for residents in a facility. In other words, the concept relates more to an approach toward care rather than to the actual care received. Moreover, families struggling with the less appealing option of placing their loved ones in traditional "nursing homes" are more soothed by the option of knowing that assisted living strives to maintain the current level of independence enjoyed by residents, but with supervision or support when needed.

In general, the term "assisted living" is used transitionally with that of "board and care" services. However, assisted living statutes and regulations usually contain language referring to "independence," "autonomy," "privacy," etc. Assisted living is also different from other residential programs (e.g., homes for the aged, board and care facilities, residential care facilities, etc.) in that it is more likely to involve apartment-like settings and (if living space is to be shared) choice of apartment mates. Finally, assisted living facility staff will often make arrangements for external entities rather than internal staff members to provide nursing care or health related services to residents. This arrangement makes such services more likely to be reimbursable as "home health care services" under Medicaid or other funding initiatives.

But when assisted living residents need nursing care, the distinction between "assisted living" and other forms of residential care becomes more nebulous. In many states, assisted living facilities may admit or retain residents who meet "level of care" criteria used for admission to nursing facilities. At the same time, many nursing homes divide their beds into wards or designated areas, so as to accommodate varying levels of resident needs. They may have a skilled care area, an intermediate care area, and an "assisted living" area all within the same facility. Generally, such an arrangement is mutually beneficial to facility and patient. It keeps occupancy rates high at the facility and allows residents to move internally from one area of care to another without the need to move to another facility altogether.

Semantics aside, assisted living generally refers to a residential living arrangement in which residential amenities are combined with "as needed" assistance with "activities of daily living" (ADLs) (eating, dressing, bathing, ambulating, toileting, etc.) and personal care. Although only about half of all states actually use the term "assisted living" in their regulations or statutes, a vast majority of states have either reviewed existing legislation or enacted new laws to address the growing demand for assisted living facilities. This action occurred particularly during the years of 1995 through 2000.

Federal Purview

All assisted living facilities accepting state or federal funds must be licensed. For those accepting federal funds, most of the applicable regulations and rules are incorporated into those applicable to nursing homes in general. They include:

The Nursing Home Reform Act is absorbed in a massive piece of legislation known as the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987). The Act imposes more than just minimum standards; it requires that a facility provide each patient with a level of care that enables him or her "to attain or maintain the highest practicable physical, mental and psychosocial wellbeing." Importantly, OBRA 87 makes each state responsible for establishing, monitoring, and enforcing state licensing and federal standards. Under the Act, states must fund, staff, and maintain investigatory and Ombudsman units as well.
The Patient Self Determination Act of 1990 is absorbed in the Omnibus Budget Reconciliation Act of 1990 (OBRA 1990). Applicable to more than just nursing homes, it essentially mandates that facilities provide written information to patients regarding their rights under state law to participate in decisions concerning their medical care. This includes the right to execute advance directives and the right to accept or reject medical or surgical treatments. The facilities must also provide a written policy statement regarding implementation of these rights, and must document in each patient's record whether or not an advance directive has been executed.

ResidentRights

States are required to effect bills of rights for nursing home residents. Generally, the same rights attach to residents in assisted living facilities as those in nursing homes. Most state declarations of rights parallel the federal ones, codified at 42 USC 1395i-3(a) to (h); and 1396r(a) to (h) (1988 supplement to the U.S.C.). They are enumerated in the section addressing nursing homes.

Funding

Public subsidies for elders in residential settings take different courses in different states. Older persons qualifying for low-income subsidies may apply their federal SSI benefits, as well as any state supplemental SSI benefits, toward assisted living charges for room and board. Medicaid generally pays for nursing or medical services provided to qualified individuals. In most states, this is done through Home and Community Based Services (HCBS) (Section 1915(c)) waivers. Waiver programs acknowledge that many individuals at high risk for being institutionalized can be cared for in their own homes or communities, thus preserving their independence and ties to family and community, at no more cost than that of institutional care. Thus, a person eligible for institutional care may "waive" that right and apply the funds toward home care or assisted living arrangements. Waivers are generally granted for three years and may be renewed for five years.

Finally, many states are developing policies that combine SSI with Medicaid benefits to provide one level of care appropriate for the resident. This encourages "aging in place" rather than the stressful alternative of finding another facility should the resident's health decline and he or she needs more than what assisted living can offer.

State Provisions

The following information summarizes state approaches to assisted living arrangements. The absence of certain information in the summary for a particular state (e.g. a mention of minimum staffing ratios or room sizes) is not to be construed as meaning that no requirements exist for that state regarding that element or factor. Rather, the information focuses on some of the important or distinguishing points from state to state.

ALABAMA: See Ala. Code Chapter 420-5-4. Revisions to existing regulations were issued in 1999. The state recognizes three categories of assisted living facilities: congregate (17 or more adults), group (4 to 16 adults), and family (2 to 3 adults). The regulations provide that residents must be "ambulatory adults who do not require acute, continuous, or extensive medical or nursing care and are not in the need of hospital or nursing home care." Staffing ratio requirements are one staff member per six residents, 24 hours a day. Minimum room size is 80 square feet for single or 130 square feet for double occupancy. No public financing is available other than SSI.

ALASKA: See Alaska Stat. 47.33.005 et seq; also Reg. 7 AAC 75.010 et seq. In addition to private facilities, the state operates six Pioneer Homes that provide supportive living services. Alaska's "general relief" program does offer limited financial support in combination with a Medicaid HCBS waiver for certain qualified individuals. Alaska has minimal facility and staff requirements, but requires a written contract between home and resident that covers all conditions, charges, policies, duties and rights, etc. The state continually reviews its regulations.

ARIZONA: Ariz. Adm. Rules, R9-10-701 et seq. The Arizona Long Term Care System (ALTCS) has expanded its Supportive Residential Living Center (SRLC) state-run project, which consolidated adult care homes, support residential living, supervisory care homes, and adult family care into a single "assisted living" category. The state now has three licensed classifications (facilities assisting ten or fewer residents, eleven or more residents, and adult foster care homes with one to six residents). Minimum room size, 80 square feet for bedroom units, 220 square feet for residential units. There are no minimum staffing ratio requirements, but facilities must be able to meet the needs and handle crisis intervention on a 24-hour basis. Minimum one toilet/lavatory per eight residents.

ARKANSAS: Ark. Ann. Code 20-76-201 et seq. requires that tenants be 18 years of age or older and be independently mobile (physically and mentally capable of vacating the facility within three minutes). There are numerous other requirements regarding minimum physical and mental conditions. Single units must have at least 100 square feet; double units must be 80 square feet. There must be a minimum of one toilet/lavatory per six residents. Staffing requirements are scaled for daytime, evening, and night shifts.

CALIFORNIA: Cal. Code of Reg, Title 22; Division 6, Chapter 8 governs "residential care facilities for the elderly (RCFE)," of which the state has approximately 6,000 facilities. In 1995, special legislation was passed to permit RCFEs serving persons with Alzheimer's Disease to develop secure perimeters (exterior doors or perimeter fences, delayed egress doors, etc.) One toilet/sink per six residents. Minimum staffing requirements for facilities with fewer than 100 residents is one person. Medicaid coverage is not available.

COLORADO: Colorado regulates "personal care boarding homes" under Chapter VII, Section 1.1 et seq. Minimum requirements include one toilet/lavatory per six residents, no more than two residents to a room, and a 100 square foot single occupancy room size.

CONNECTICUT: Conn. Gen. Stat.192-490 and Agency Regulation 19-13-D105 address the state's unique approach of permitting "managed residential communities" (MRCs) to offer assisted living services through assisted living services agencies (ALSAs). The state has about 25 licensed ALSAs. Minimum requirements include at least one RN on-call 24 hours a day and one toilet/lavatory per six residents. Medicaid reimbursement is available for assisted living services in elderly housing complexes. Residents may receive temporary nursing services through an external agency.

DELAWARE: Under state law, assisted living agencies (Del. Code Ann, Title 16, Part II, Ch. II, 63.0 et seq) are distinguished from "rest residential homes" (Part II, 59.0 et seq.) in that the latter is intended for those who only need shelter, housekeeping, board, personal surveillance or direction in activities of daily living. Persons with income less than 250 percent of the SSI level are eligible for fee waiver service. In residential homes, there must be one toilet and bathtub or shower for every four residents.

DISTRICT OF COLUMBIA: All community residential facilities are governed by D.C. Code Ann. 32-1301 et seq, 34-3400 et seq., and DC Law 5-48. The DC Housing Code (DCMR) establishes minimum square footage and bathing/toilet requirements. However, no more than four persons may share one sleeping room. Short term nursing care is permitted (72 hours or less).

FLORIDA: Florida law maintains three levels of assisted living: standard, limited nursing services, and "extended congregate care (ECC)," (requiring a higher level of assistance/care). See Fla. Stat. Ann., Ch. 400 Part III and Admin. Code Ch. 58-A-5. The general rule is that facilities serving more than 17 residents must have staff on duty 24 hours a day; fewer than 17 residents requires staff on duty or monitoring mechanisms to ensure the safety of residents. There is a minimum requirement of one bathroom per three residents. There is an optional state supplement to federal SSI and SSDI assistance and a Medicaid home and community based services waiver. RNs must visit ECCs twice a year to monitor residents and review state compliance.

GEORGIA: See Ga. Code Ann. 31-2-4, 31-7-2, and Regulation 290-5-35.07 et seq. "Personal Care Homes" serve any adult over 18 years of age who is ambulatory and does not require continuous medical, nursing, or mental health monitoring or care. The maximum facility size is for 24 residents or less. Bedrooms must have at least 80 square feet of usable floor space per resident. A Medicaid waiver is available. Facilities must have at least one staff person to 15 residents during waking hours, and one to 25 during non-waking hours.

HAWAII: See Hawaii Admin. Rules 11-90 to 11-101. The state distinguishes between "assisted living" facilities (for independent living) and "adult residential care" facilities (Types I and II) whose residents require at least minimal assistance in ADLs. Neither can accept persons who need nursing care, although adult residential care facilities may obtain an "extended care license" to serve residents who meet the nursing home level of care. Assisted living facilities must have a minimum of 220 square feet of living space, while residential care homes only require 90 square feet for single rooms or 70 square feet per occupant of a multiple occupancy room.

IDAHO: See Idaho Code 39-3301 et seq. and Admin. Rule Title 4, Ch. 22-70. The state has one designation of "residential care facility" that is broken down into three categories by level of care: minimum, moderate, or maximum. A state fund is maintained to assist in reimbursement costs for eligible persons. Facilities must have at least one staff person available to residents at all times.

ILLINOIS: Under Illinois law (77 IAC 330 and Title 89, Ch. 1, Subchapter d, Part 146) "shelter care facilities" are licensed for maintenance and personal care but not routine nursing care. "Supportive living facilities" (SLFs) offer 24-hour supervision and assistance and is most consistent in definition with the accepted definition of "assisted living." The state has set up a third option, "community based residential facilities" (CBRFs) intended to provide short or long term needs in order to relieve family caregivers. SLFs require licensed and certified staff.

INDIANA: Indiana law only provides recommendations for assisted living facilities, although it has several laws that impact residential care facilities in general.(See, e.g., 410 IAC 16.2 et seq.). For example, all facilities must have at least one staff member on duty at all times (for facilities with fewer than 100 residents) and an additional staff member for each 50 residents above 100. Medicaid coverage is not available but is being assessed.

IOWA: See Iowa Code Ann 231C and 321 IAC Chapter 27; IAC 661-5.626. Licensed facilities serve at least six residents and may provide health related care in addition to personal care and assistance. Minimum staffing is left up to the facility, but each tenant must sign an occupancy agreement that explains services, charges, etc., and whether or not staff are available 24 hours a day. Each dwelling unit must have 190 square feet of living space. Multiple occupancy quarters must have at least 80 square feet of living space per bed.

KANSAS: Kan. Stat. Ann. 28-39-144 et seq. addresses assisted living facilities (caring for six or more individuals). Health care attendants provide assistance and services up to 12 hours a day. Medicaid waivers are available to elderly persons who meet the nursing home level of care criteria and have income below 300 percent of the federal SSI payment.

KENTUCKY: See 905 KAR 5:080 and 902 KAR 20:036. The state has a voluntary certification program for assisted living facilities. For certification, the maximum number of beds per room is four; there must be one toilet/lavatory for every eight residents, with separate bathrooms for each sex on each floor. No room size requirements. There is no Medicaid funding available.

LOUISIANA: See La. Rev. Stat. Ann 2151 et seq. Assisted living homes refer to facilities that provide room, board, and personal services to two or more residents who reside in individual living units. Personal care homes offer the same but have congregate living settings of two to eight residents. Shelter care homes are larger scale personal care homes with congregate living and dining services. There must be at least one awake staff on duty at night and sufficient staff to cover resident needs during daytime hours. Elderly Medicaid beneficiaries who can no longer live at home may qualify for assistance.

MAINE: See Me. Rev. Stat. Ann. Tit 22. Section 7902. Laws finalized in 1998 provide for Level I residential care facilities (formerly known as adult foster care homes or six bed boarding houses) and Level II residential care facilities for more than six residents. Levels I and II facilities must have 100 square feet for single or 80 square feet for double rooms. Bathrooms must be provided for every six residents, and showers/bathtubs for every 15 residents. Medicaid funds are available for eligible residents. Staffing rules require a ratio of 1:12 residents during day shifts; 1:18 for evening hours, and 1:30 for night shifts.

MARYLAND: Assisted living programs are covered under Md. Code Ann., Title 10.07.14. Facilities may not serve persons who require more than intermit tent nursing care. Medicaid does not reimburse for assisted living beyond the existing Senior Assisted Housing Program. Assisted living programs have three levels of care distinctions for purposes of staffing requirements and services provided.

MASSACHUSETTS: See Mass. Code of Regulations, 651 CMR 12.00. Persons needing 24-hour skilled nursing supervision are not eligible for assisted living facilities. Medicaid's Group Adult Foster Care (GAFC) provides some subsidizing of services for low income residents. The state has created a special SSI living arrangement for assisted living.

MICHIGAN: Michigan distinguishes homes for the aged (supervised personal care facilities under MCL 333.20106) from adult foster care homes (large group homes). Neither type of facility may accept residents who require continuous nursing care. There are staffing ratio requirements for adult foster homes. Medicaid waivers are available if services are delivered by community agencies and not the facility's staff. Toilet/lavatory ratios are one to eight residents.

MINNESOTA: See Minn. Stat. Ann. 144 et seq. and 144A and D. Minnesota covers assisted living through its funded Alternative Care (AC) program and Medicaid waiver programs. The AC program serves persons whose income exceeds Medicaid eligibility but who would spend down to Medicaid levels within six months of admission to a nursing home. There are no unit size requirements for facilities, nor are there minimum staffing requirements.

MISSISSIPPI: See Mississippi Regulations 1201.1 et seq. "Personal care homes" are licensed to provide care to ambulatory residents who are not in need of nursing care. Separate toileting facilities are required for each sex on each floor, with a ratio of one to six residents. Residents may not be required to access one bedroom by entering another. There is a maximum of four beds per room and a minimum of 80 square feet per resident. Medicaid funding is not available for assisted living.

MISSOURI: See Vernon's Ann. Mo. Stat. 198.003 to 198.186, and regulations, title 13, Section 15-10.010 et seq. Missouri law recognizes Type I and Type II residential care facilities (RCFs). Type II involves a higher level of care under the direction of a licensed physician. Both types require that residents be of such mental and physical capability as to be able to negotiate a normal path to safety, using assistive devices or aides when necessary. There is Medicaid reimbursement for personal care services. All licensed facilities must have a minimum of 70 square feet per resident, irrespective of whether in single or shared quarters. State requires one toilet/lavatory for every six residents.

MONTANA: Personal care facilities (PCFs) are governed by Subchapter 9, Section 16.32.902. Adult foster care homes are covered under Chapter 16, Subchapter 1, Section 11.16. Both are eligible for Medicaid HCBS waiver reimbursements. Single dwelling bedrooms must be at least 100 square feet, multi-tenant bedrooms must contain at least 80 square feet per resident. One toilet is required for every four residents. In PCFs, residents are classified as either A or B categories (B involves incontinence, under chemical or physical restraint, ventilator dependent, etc.; facilities may have up to five B residents).

NEBRASKA: Assisted living facilities are covered under NAC Title 174, Chapter 4. In 1998, state legislators approved $40 million in grants or loan guarantees to nursing homes to convert wings or entire facilities to assisted living. This action followed a law passed in 1997 that replaced residential care facilities and domiciliary facilities with the new distinction of assisted living. All facilities must be licensed. Minimum room size of 100 square feet is required for single apartments or dormitory-like rooms; 80 square feet per resident for shared room space. A toilet and sink must adjoin each resident's bedroom. Medicaid waivers are available.

NEVADA: See Nev. Rev. Stat. Ann. 449.017 et seq. and administrative code section 449.156. Residential care facilities may be in the form of an adult group home or an Alzheimer's group home. Single occu-pancy rooms must be at least 80 square feet in size; maximum shared quarters of three residents with at least 60 square feet each. Alzheimer's facilities must have sprinkler systems and 24-hour awake staff, as well as exit doors with alarms or time-delay locks and fenced yards. Residents are assessed as "care category 1" (ambulatory) or "care category 2" (non-ambulatory). Personal care services are Medicaid reimbursable if residents meet SSI eligibility criteria. Facilities with more than 20 residents must have at least one awake staff around the clock, with a second available within ten minutes.

NEW HAMPSHIRE: Supported residential care facilities are covered under Chapter He-P 805; residential care home facilities are covered under Chapter He—804. RCFs are defined as offering services beyond room and board to two or more individuals. No resident may require 24-hour nursing services. A minimum room size of 80 square feet for single residents or 140 square feet for double occupancy is required. Residents must be mobile and able to self-evacuate. Medicaid reimbursement is available.

NEW JERSEY: See N.J. Admin. Code Chapter 8:36. Regulations effective in 1996 created assisted living programs in subsidized housing sites, as well as licensing of "service agencies" to deliver assisted living services to subsidized elderly housing projects. No more than two persons may occupy an assisted living residential unit. There must be at least one awake personal care assistant and one additional staff member available at all times.

NEW MEXICO: Adult residential care is covered under New Mexico's Administrative Code, Title 7, Ch.8, Part 2. The state offers assisted living as a Medicaid waiver service. Private rooms must have at least 100 square feet of useable floor space.

NEW YORK: See NY Social Law 461-1 et seq., as well as NY Comp. Codes R & Regulations, Title 18, Section 485.1 et seq. Assisted living programs are Medicaid-reimbursable and are available in both "adult care homes" and "enriched housing programs" (which offer congregate services but independent housing units). No more than three persons may share independent units.

NORTH CAROLINA: See N.C. Admin Code Title 10, Ch. 42, and N.C. Gen. Stat. 131D-2. In 1995, state law combined former "adult care or domiciliary homes" and multi-unit assisted housing with services, under the new umbrella of "assisted living residences." Adult homes may have up to four residents share bedroom space, with a minimum 80 square feet per bed. Personal care services are reimbursable as state plan services through Medicaid. Staffing requirements vary with facility size.

NORTH DAKOTA: North Dakota funds assisted living programs that require apartment like settings in basic care facilities. While licensing is not required, the public welfare statute contains a clear definition of assisted living that must be met in order to qualify for monetary assistance. Assisted living participants in the state's Service Payments for Elderly and Disabled (SPED) program must have impairments in four ADLs or five IADLs and not be eligible for the Medicaid HCBS waiver. Adult day care and respite care is Medicaid reimbursable. Awake staff must be on duty 24 hours a day in basic care facilities. See Chapter 50-24.5 and Chapter 23-09.3.

OHIO: See ORC. 3721.01 et seq. (residential care facilities) and ORC 3722 et seq (adult care facilities). Most assisted living facilities in Ohio are licensed as residential care facilities. RCF residents may receive up to 120 days of nursing services on a part-time or intermittent basis. Adult care facilities provide fewer services (e.g., no administration of medication or wound care, etc.). RCFs must offer a minimum of 100 square feet for single or 80 square feet per resident in multiple occupancy rooms. Toilets/lavatories are required for every eight residents, including separate toilets for the sexes if there are more than four of a sex on any floor. RCFs require one staff person on site at all times.

OKLAHOMA: Oklahoma has both residential care homes and assisted living centers. See Okla. Stat. Ann. Title 63, 1-819. An assisted living category was legislatively created in 1997, and all such facilities require licensing. No more than two residents may share bedrooms. There is a minimum square footage of 80 for single rooms or 60 square feet per bed in multiple occupancy rooms. Residents cannot have needs greater than intermittent or unscheduled nursing care. Staffing requirements are a minimum of 3/4 hour of personnel per day per resident, based on the average daily census. Limited Medicaid reimbursements are available for certain services.

OREGON: See Or. Admin Reg Division 56: 411-056-0000 and 56: 411-55-000. Assisted living is handled as a program within a physical structure, which may be a "residential care facility." RCFs operate with two categories of residents: Class I residents must be ambulatory and only need assistance with ADLs; Class II residents have higher needs. Payments are available for services to Medicaid recipients residing in assisted living settings who meet the nursing home level of care criteria. Staffing ratios are established in the regulations on a sliding scale according to time of day and number of residents.

PENNSYLVANIA: Personal care homes are governed by PC Title 55, Chapter 2620. Single occupancy rooms must have 80 square feet of floor space; multiple occupancy rooms require 60 square feet per person, with a maximum of four. Residents who are not ambulatory may nonetheless be admitted if they do not require nursing care.

RHODE ISLAND: Regulations R23-17.4 SCF. Regulations use the term "residential care and assisted living facilities," and the state does have Medicaid waiver provisions for certain service arrangements. There are general requirements that resident rooms must have no more than two beds with a minimum floor space of 100 square feet per single or 80 per person double occupancy. No more than eight persons may share toilet/lavatory facilities. Residents must not require medical or nursing care but may require medication administration. A responsible staff member must be on the premises at all times.

SOUTH CAROLINA: See S.C. Regulation R61-84, Community Residential Care Facilities. Minimum bedroom size is 80 square feet for single or 60 square feet per bed for double occupancy, with one toilet/lavatory for every eight residents. Minimum staff requirements are one staff member for every ten residents during daytime hours and one per 44 residents at night. Medicaid waiver reimbursement is available.

SOUTH DAKOTA: Article 44:04 et seq. governs assisted living centers. Medicaid waiver reimbursements are available. All must be seen by a physician at least once a year. For facilities with more than ten residents, one staff person who is awake is required during sleeping hours; if fewer than ten residents, staff may sleep if there are adequate fire alarm systems and staff call systems in place. See S.D. Codified Laws Ann. 34-12-1.

TENNESSEE: The Tennessee Rules of the Dept. of Health, Ch. 1200-8-9 et seq. cover assisted living facilities and homes for the aged. Homes for the aged must have contract agreements with a physician who is available to render care and with a nursing home that will accept residents who must be discharged from the home for the aged because of medical or care needs that surpass those provided by the home.

TEXAS: Texas law provides for "personal care homes" under Tex. Rev. Health and Safety Stat. 247.001 et seq. and Administrative Code Title 25-146.321 et seq. Medicaid waiver reimbursement is available for services provided in personal care facilities licensed by the Texas Dept. of Human Services. There are required staffing ratios of 1 to 16 residents for day shifts, 1 to 20 for evening, and 1 to 40 for night shifts. Room sizes must be a minimum of 80 square feet for single bedrooms and 60 square feet per bed for multiple occupancy rooms (maximum of four persons).

UTAH: Assisted living facilities are covered by Regulation 432-270. Residents must be ambulatory to the extent of being able to evacuate a facility without assistance. Pets are permitted according to local ordinances. Direct care staff members are required on site 24 hours a day. Minimum room size for congregate facilities is 100 square feet for single or 160 square feet for double occupancy. Medicaid waiver reimbursement is available.

VERMONT: Residential care homes are licensed under Regulation Section 7102 Medicaid waiver coverage is available. Residential care homes differ from assisted living residences in that they include more extensive personal care services, whereas assisted living generally provides "supportive services." Under certain criteria, residential care homes may retain persons who need nursing services for 60 days or less.

VIRGINIA: 22 Virginia Administrative Code Section 40-71-10 et seq. covers for adult care residences (ACRs). Medicaid HCBS waivers are available. ACRs may offer single rooms (minimum 100 square feet) or multiple occupancy rooms (80 square feet per resident, with a maximum of four). One toilet/lavatory is required for every seven persons. Staffing ratios are based on resident needs.

WASHINGTON: Medicaid assisted living in covered under the Washington Administrative Code Chapter 388-110. Boarding homes in general are covered under Chapter 246-316. Assisted living services are those contracted with a licensed boarding home to be provided to residents, and Medicaid recipients may be required to move when their needs exceed the level of contracted services.

WEST VIRGINIA: Personal care homes are covered under 64 CSR 14, et seq.; residential care homes (for ambulatory residents) are covered under 64 CSR 65; and residential care communities (congregate fa-cilities/apartment units for ambulatory residents) are covered under Section 16-5N-1 et seq. Awake staff are optional in personal care facilities with ten or fewer residents. Larger facilities must have one awake staff per floor in multi-story buildings (with limited exceptions).

WISCONSIN: In Wisconsin, there are two categories of facilities available. First, there are residential care apartment complexes (RCACs) provide for residents "not more than 28 hours per week" services that are supportive, personal, and nursing care related. Conversely, "community based residential facilities" focus more on care and treatment services above the level of room and board and which serve as primary functions of the facility. Both categories require ambulatory residents. State funding is available for Medicaid recipients who meet the nursing home level of care criteria. See Wis. HFS Chapters 83 and 89.

WYOMING: In Wyoming, assisted living facilities are distinguished from boarding homes by the fact that they provide limited nursing care. Neither type provides habilitative care. Rooms must have at least 120 square feet for single or 80 square feet per person for double occupancy. Toilets/lavatories are required for every ten residents. At least one awake staff is required for all facilities with more than ten residents.