The Virginia Assisted Living Association (VALA) represents licensed assisted living communities of varying organizational structures and resident capacities throughout Virginia. We thank the Virginia Department for Aging and Rehabilitative Services (DARS) for considering areas of improvement to the Auxiliary Grants (AG) Program to more effectively serve current and potential residents of assisted living facilities (ALF). 

The Auxiliary Grant Program serves some of Virginia’s most vulnerable older adults and individuals with disabilities. While Virginia has made important investments in the program, significant barriers continue to limit provider participation and reduce access to assisted living services for individuals who rely on the Auxiliary Grant. Increasing provider participation should be the primary objective of these regulatory revisions because expanded participation directly increases housing and care options for low-income Virginians. 

Over the years, the biggest challenges expressed by assisted living facilities in accepting the Auxiliary Grant is the significantly insufficient rate to cover the basic cost of care for a resident, the extra requirements imposed on an ALF to accept AG residents, and the delay in payment or consultations from some of the local departments to serve the AG recipients. 

Below are some improvement recommendations and highlighted concerns of the regulations for the Auxiliary Grants Program (22VAC30-80):

• 22VAC30-80-10. Definitions. 
  • “Assisted living facility” or “ALF” means, as defined in § 63.2-100 of the Code of Virginia, any congregate…
    • Recommend matching the definition in the ALF regulations, 22VAC40-73
  • “Personal needs allowance” means a portion of the AG payment that is reserved for paying for meeting the individual’s personal needs.
    • The current personal needs allowance is not sufficient to “meet” anyone’s needs, as inflation continues to increase so does the cost of any personal expenses. 
  • “Residential living care” is not listed anywhere else within 22VAC30-80; therefore the definition is not needed. 
  • “Qualified assessor” – DARS should evaluate whether the current requirement limiting assessments to state-funded qualified assessors remains necessary and whether additional trained assessors could be authorized to conduct assessments and reassessments for AG recipients. Many ALFs employs staff who are trained and qualified to complete assessments and expanding the pool of eligible assessors could reduce administrative costs on the state and local departments, improve timeliness, and increase access to services.       
    
    Providers have reported delays in obtaining assessments due to scheduling challenges and limited assessor availability. In some cases, applicants have been unavailable at the time of a scheduled assessment because they were hospitalized or otherwise temporarily absent, resulting in further delays in evaluations, eligibility determinations, admissions, and payments. Allowing appropriately trained assessors to conduct these evaluations could help ensure more timely access to housing and care while reducing administrative burdens on both providers and the Commonwealth.
• 22VAC30-80-15. Residency Requirement. 
  • What is the state’s reasoning for the 90 days? Could it be changed to a lesser timeframe, such as 60 days? 
  • B. Exception to the 90-day residency requirement – Recommend allowing in-laws, and someone identified as the Power of Attorney or legal guardian be also included in exception allowance. As it is more beneficial to the residents if they can reside near the individuals helping making decisions on their behalf.
  • C. Virginia locality of residence. – We have heard of concerns from providers that some localities experiencing staffing shortages rely on other localities to meet the needs, which can cause additional delays in approvals and assessments resulting in lengthy delays for placements. These delays create unnecessary hardships for individuals in need of services as well as their current caretakers if they have any.
• 22VAC30-80-20. Assessment.
  • DARS should establish performance expectations for completion of UAIs and reassessments. Delays in assessments can postpone admission, interrupt services, and delay Auxiliary Grant payments. Consider establishing target completion timeframes and allowing qualified trained ALF staff to conduct assessments when an state Qualified Assessor is unavailable. 
  • C. ALFs are prohibited from charging a security deposit. – Allowing the acceptance of a security deposit could encourage more ALFs to accept challenging residents with behavioral issues if they know they have the security deposit to help offset any potential damages to buildings or equipment should the resident become aggressive. Allowing for a limited security deposit, such as $500, would be helpful. 
• 22VAC30-80-30. Basic services in an assisted living facility
  • The language listed is very duplicative to the ALF regulations 22VAC40-73 in 600, 610, 620, 630, etc. By having the language word-for-word, this creates potential conflicts as regulations are independently changed by each agency. Recommend to only refer to the required services and to list the ALF regulations such as 22VAC40-73-600. 
  • A. c. “Basic and bedtime snacks” – ALF regulations do not distinguish a difference between basic and bedtime snacks.
  • 1. d. Clean bed linens and towers as needed by the individual and at least one a week. – This is already required in 22VAC40-73-780
  • 2. c. Provision of personal toiletries including toilet paper. – This is already required in 22VAC40-73-9258
• 22VAC30-80-40. Personal Needs Allowance.
  • A. …The personal needs allowance is provided expected to help cover the cost of the following items and services:
    • The current personal needs allowance is not sufficient to “meet” anyone’s needs, as inflation continues to increase so does the cost of any personal expenses. 
  • A. 6. – Does “long distance telephone calls” need to be included today? 
  • A. 7. Personal telephone, television, or radio, or other streaming/subscription service;
  • A. 9. Other items and services agreed upon by both parties except those required in this chapter listed in subsection B of this section. 
  • B. 4. Provider laundry charges in excess of $10 per month. – with today’s costs for laundry supplies and staffing, this rate is too low.
• 22VAC30-80-45. Conditions of participation in the program.
  • A. 2. d.  ALFs are prohibited from charging a security deposit. – By allowing the acceptance of a security deposit could encourage more ALFs to accept challenging residents with behavioral issues if they know they have the security deposit to help offset any potential damages to buildings or equipment should the individual become aggressive.
  • A. 2. e. Accept the established rate as payment in full for services required to be rendered. – the resident may choose additional services or supplies beyond the minimum services, which could incur an additional charge through the third party payments.
  • A. 2. h. VDSS is considering proposed regulations on discharge notices which may be create differences from 22VAC30-110-40.
  • E. Third-party payments shall not be used to pay for a private room in an ALF or AFC home. – Families should be permitted to supplement AG funding for private accommodations when available and when desired by the resident. Allowing third-party payments for room upgrades would not increase state expenditures and could increase placement options for AG recipients.  
  • It is not uncommon for family members or other third parties to express a willingness to contribute financially toward the cost of care and services for AG recipients. The regulations should allow voluntary third-party payments for services, accommodations, or amenities beyond those covered by the Auxiliary Grant. Allowing these supplemental payments could increase placement opportunities, enhance resident choice, and help ensure that individuals can access the level of car and accommodations that best meet their needs without increasing state expenditures. 
• 22VAC30-80-50. Establishment of rate. 
  • The rate should be comparable to the average rate of assisted living care for companion accommodations. 
  • DARS should evaluate implementation of a tiered reimbursement methodology that recognizes varying resident care needs. Residents requiring extensive assistance with activities of daily living, medication administration, behavioral support, or specialized supervision for residents with cognitive impairments create significantly different staffing and operational costs than residents requiring minimal assistance. With the current compensation, basic human care needs cannot be met in most ALFs. 
  • The approved rate by the Virginia General Assembly should not be reduced by the individual’s income. It should be paid in full as allocated to supplement the income. 
  • ALFs have shared the process for approval can take up to 90 days to get approved. Local departments should be required to process AG applications, reassessments, and payment authorizations within specified timeframes. Delays in local processing can result in extended hospital stays, homelessness, caregiver burnout, and financial hardship for participating ALFs. Delays can result in the ability of the individual’s care needs to be met causing potential health issues and care concerns. 
  • It is recommended that DARS provide a report of an annual review to the Virginia General Assembly of the established rates compared to inflation, wages, housing costs, and care needs. DARS could create a stakeholder advisory group that includes AG recipients, family members, ALF providers, and disability advocates to consider more appropriate rates for the Virginia General Assembly to consider. 

Virginia’s current Auxiliary Grant rate and administrative requirements continue to discourage provider participation, reducing housing and care options for low-income older adults and individuals with disabilities. By improving reimbursement, streamlining assessments and eligibility determinations, reducing administrative burdens, and increasing flexibility for providers and families, DARS can strengthen the AG program and expand access to safe, licensed assisted living services throughout the Commonwealth. 

In addition to reviewing the AG program regulations, we recommend that DARS review and enhance its reporting process to provide more current and accurate information regarding ALF participation and admission availability for AG recipients. Virginia’s published list of assisted living facilities that participate in the Auxiliary Grant program is intended to help individuals and their families identify available placement options. However, individuals report that it is often difficult to locate ALFs that are accepting new AG admissions. Upon contacting the ALFs, families frequently discover that openings are unavailable or that the facility is not currently accepting additional AG residents. 

We thank the DARS for considering these recommendations and concerns of the Auxiliary Grant Programs. Please let us know if you have any questions regarding these comments.