The Virginia Assisted Living Association (VALA) represents licensed assisted living communities throughout Virginia of varying organizational structures and resident capacities. We thank Governor Youngkin and the Board of Long-Term Care Administrators for considering reducing regulations not mandated by federal or state statute and reducing regulations that are overly burdensome on business operations.

Below are our initial comments regarding the Board’s proposed amendments to the Regulations Governing the Practice of Assisted Living Facility Administrators.

• 18VAC95-30-40 – Required Fees – VALA supports the establishment of a new licensure category of “Inactive License”; however, we recommend a lower fee to be assigned to this category, as the individual would not be utilizing this license to earn income. Also, the fee for late renewal of an inactive license should not exceed that of the preceptor late renewal fee.

• 18VAC95-30-70-C-2 – Continuing education requirements – VALA supports the removal of the requirement to have a signature on documentation of continuing education, as many certificates are issued electronically.

• 18VAC95-30-80-A – Late renewal – “A person who fails to renew his a license or preceptor registration by the expiration date shall may, within one year of the initial expiration date:”    
  VALA supports flexibility of the regulation by utilizing the word may instead of shall.

• 18VAC95-30-91 – Inactive Licensure – VALA supports the establishment of a new licensure category of “Inactive License”; however, the requirement of “providing proof of completion of the number of continuing competency hours required for the period in which the license has been inactive is being reactivated, not to exceed three years” is excessive and may substantially discourage individuals from returning to full licensure status. For example, having to complete three years of CEUs would equate to 60 hours, which is a significant burden to someone reentering the profession while maintaining additional employment to financially maintain their families. VALA recommends the following reinstatement requirement:  
  “Providing proof of completion of 30 hours of approved continuing education of which at least two hours shall relate to regulatory updates and compliance.”

• 18VAC95-30-130-C – Application Package – VALA has received concerns about delays in the processing of applications by several Boards within the Department of Health Professions. With that, VALA is concerned that removing the exception for delayed school transcripts, employer verifications, examination scores, as well verifications from other state boards will cause delays in processing applications while awaiting those items.

• 18VAC95-30-200 – Interruption or termination of program – VALA supports the removal of the requirement to obtain a new preceptor within 60 days.

Below are VALA’s recommendations for additional regulatory changes to be made further promoting the efficiency of the application process and oversight of the Regulations Governing the Practice of Assisted Living Facility Administrators by reducing barriers for initial or continued licensure of an Assisted Living Facility Administrator.

• 18VAC95-30-10-B – Definitions –“"National eExamination" means a test used by the board to determine the competence of candidates for licensure as administered by NAB or any other examination approved by the board.”      
  Regulations should provide broader terminology. VALA recommends allowing flexibility in examination options.             
  
  
• 18VAC95-30-100-A-1 – Educational and Training requirements for initial licensure – After a detailed comparison of Virginia’s educational and training requirements to other states, VALA often hears from interested AITs and employers that the number of hours required create significant barriers to licensure. With the significant workforce shortages that currently exist VALA recommends a reduction in the number of training hours required to make Virginia more competitive and receptive to new licensees. Removing the outliers of the least and greatest number of hours required in other states resulted in an average of 180-hours training requirement. Below are proposed changes to Virginia initial licensure requirements.    
   

“e. Hold a master's or a baccalaureate or higher degree in health care-related field or a comparable field that meets the requirements of subsection B of this section with no internship or practicum and 320 240 hours in an ALF AIT program; 
f. Hold a master's or a baccalaureate or higher degree in an unrelated field and 480 320 hours in an ALF AIT program; or          
Certificate program.    
…have completed not less that a 320 240 hour internship or practicum …      
Degree and practical experience.       
…have completed not less that a 320 240 hour internship or practicum…”      

• 18VAC95-30-100-A-1 – Educational and Training requirements for initial licensure – Virginia’s requirements for initial licensure do not authorize someone without managerial or supervisory experience to be trained to become an assisted living administrator. Managerial experience may sufficiently be achieved in a training program; therefore, VALA recommends creating an additional pathway to licensure that does not require college credits nor managerial/supervisory experience. Below is proposed language to add an additional pathway to initial licensure.
  “h. Have at least five years of health care experience, to include at three years in a long-term care setting within the ten years prior to application and 640 hours in an ALF AIT program. For purposes of this qualification, these definitions shall apply: (i) "health care experience" means full-time equivalency experience in providing care to residents or patients in a health care setting; (ii) "health care setting" means a licensed home health organization, licensed hospice program, licensed hospital, licensed nursing home, licensed assisted living facility, licensed adult day program, or licensed mental health or developmental services facility.”

• 18VAC95-30-110 – Examination requirement for initial licensure – Virginia’s requirements for passage of the NAB exam creates a barrier to licensure and satisfactory practice as it does not test the applicant’s knowledge of applicable regulations that would be required for compliance of an assisted living facility administrator. Virginia’s use of a national exam also encourages portability of licensure to other states instead of encouraging administrators to remain in and practice in Virginia. ALF AITs train on meeting compliance with applicable regulations, which are primarily state based yet are required to take a test on national practices that can conflict with state regulations; this is not a reasonable expectation. Several professions offer licensee candidates the option of a state or national based examination. VALA recommends Virginia to offer a licensure option of a national exam OR a state-based exam to be decided on by the applicant as to whether they seek portability options with their licensure. VALA would be willing to help create the state-based exam and would welcome collaboration with higher education institutions as has been done in other states to create state-based exams. In order to authorize the future creation and utilization of a state-based exam, VALA recommends the changes below to the regulations.
  “To be licensed under 18VAC95-30-95 or 18VAC95-30-100, an applicant shall provide evidence of a passing grade on one of the national credentialing examinations for administrators of assisted living facilities approved by the board.          
  1. NAB National Core Knowledge Exam for Long Term Care Administrators and the National Residential Care/Assisted Living Administrators Line of Service Examination
  2. Virginia Assisted Living Administrator Examination”

• 18VAC95-30-120-B-4 – Qualifications for licensure by endorsement or credentials – VALA recommends removing the word “national.” Regulations should provide broader terminology. VALA recommends flexibility in examination options.

• 18VAC95-30-140-A-2 – Training qualifications – It is difficult for many interested AITs to find a registered preceptor. VALA recommends eliminating “Obtain a registered preceptor to provide training.” from the requirement to be approved as an ALF AIT. Setting a window of time for obtaining a preceptor would be more reasonable, such as within 60 days of approval.

• 18VAC95-30-170-B-4 – Training facilities – The elimination of smaller ALFs from eligible training facilities has created significant discrimination and workforce barriers for small ALFs. This restriction is not required in nursing homes, which have higher acuity requirements and stricter regulations. VALA recommends allowing smaller ALFs to serve as training facilities. VALA encourages Virginia to thoroughly analyze and reconsider the impact this prohibition has created on small businesses, as approximately 26% of all licensed ALFs have a capacity of 20 or fewer residents. The following statement is the proposed regulatory change to eliminate the inequitable prohibition:
  “4. An assisted living facility with a licensed resident capacity of fewer than 20 residents.”
  
  

• 18VAC95-30-180-B-2 – Preceptors – The requirement of preceptor applicants to “be employed full time as an administrator… or be a regional administrator with on-site supervisory responsibilities” excludes many qualified ALFAs from becoming preceptors. Especially with the COVID-19 pandemic, many administrators temporarily left the profession or changed positions within the industry, and some became consultants. Below is the proposed regulatory change to allow for contracted administrators to become preceptors.
  “2. Be employed full time as an administrator in a training facility for a minimum of two of the past four years immediately prior to registration, have a written agreement with a training facility that authorizes on-site supervisory responsibilities, or be a regional administrator with on-site supervisory responsibilities for a training facility.”

• 18VAC95-30-180-C – Preceptors – VALA recommends allowing preceptors to supervise up to three trainees at any one time.

Again, we thank the Board for considering additional options to reduce the Regulations Governing the Practice of Assisted Living Administrators.

Would we consider adding reciprocity as well and maintaining the endorsement option for the VA ALF license

Good afternoon Sir/Madam,

I hope all is well with everyone as we all try to achieve work and life balance. I am appalled by the direction the ALF industry is going mainly because of the changes in the regulations that affects small businesses like mine and those who would like to start a small ALF with the right heart and concern for our Aging population. It is now obvious that the new burdensome regulations for the benefit of big corporations. It is no longer about the “welfare of the Elderly and the overwhelmed families with little to no resources”. The burdensome new regulations also affect small Assisted Living Facilities like mine by prohibiting people from going to us and instead, clients are left no choice but to go to big facilities and corporations. Also new individuals with the right heart, motivations and good intentions are not allowed to start small ALFs because the burdensome new regulations. Are these new regulations influenced by lobbyists? Just an honest curiosity. The following are actual new regulations and existing situations that is prevalent across the state. For example:

1) New regulations only allows Registered Nurses and Doctors (abridged) to start new ALF. And even if they are Registered Nurses, Nurse Practitioners or Doctors, they “must have a prior 5 years experience operating one Assisted Living. So how can one good hearted competent Licensed Medical Professional Start a new facility when they are required to have a previous experience ? 

By this new regulation alone, people cannot go to small facility where Staffing ratio is great, instead the families are forced to bring their Aging loved ones to big facilities where daytime Staffing is one (1) CNA per 8-13 Residents during daytime and at Night Shift one (1) CNA per 30 Residents. If one CNA calls in sick, one CNA would take care of 60 Residents. This is not fictional as I had been a Nursing Supervisor for one of those big Corporations for 7 years whose Staffing grid is done by men in dress shirts and ties and nice suits seating behind a desk who has bo idea of the bedside situation.

I have seen too many Licensed Medical Professionals denied a “commercial loan” because of that new Regulation.

2)This 2nd changes is directly related to the above. Despite their credentials, they are also mandated to be trained and licensed ALF Administrators. They have no problems taking the exams but the trainings ranges from 6 months to 2 years as there is no set Regulations and curriculum for that. That is like taking a Master’s Program! That means the practicing Registered Nurse, Nurse Practitioner, Medical Doctor has to drop their careers, put their lives on hold  just to be trained as Assisted Living Administrators so that they can operate a 5-8 Residents small facility. This Administrator requirement is also adapted by “all” banks offering commercial loans.

3) The places they asked to train them would not train them because after being trained, they were told to work for the facilities they were trained. The big corporations said they would not invest their time in them if they would not work for them.

4) There are highly qualified and experienced Trainors for would be Administrators but they are not allowed to train them because the trainors work or owned only an 8 bed facility. Dept of Health Professions said the Trainors can oly train if they own, work in a 20 or more bed capacity as the new Regulations stated. Why do the would be Administrators be mandated to be trained in a 20 or more bed facility if they would be starting a small business with 1-8 Residents?  Some Virginia counties only allow 8 Residents based on a 5 acre well and septic lot.

5) The new Regulations mandate 2 Staff for 3 Residents. How can a small business afford to pay 2 Staff every shift for 3 shifts every day when the small business owner has only 3 Residents. Yes, the incidence of “Falls” had decreased but “Falls” still happen despite that vigilance.

There is still more, but my time is up as it is now 4 minutes to 5pm and today is the last day for comments. Thank you for the opportunity to make commebts. Thank you for your time.

Respectfully,

Charity

Reducing these regulatory barriers would encourage the growth of smaller Residential Assisted Living (RAL) facilities, which are critically needed in Virginia. The current restrictions disproportionately affect small businesses and hinder the availability of diverse housing options for seniors. Many seniors and their families prefer smaller, more intimate living environments that provide a sense of familiarity and community while also being more affordable and comfortable during the transition to assisted living.

I agree with all of VALA's recommendations, especially with examination for initial licensure to be limited to ONE of NAB CORE Exam OR Virginia Assisted Living Administrator Examination and smaller RAL's to participate as training facilities.  

The prohibition against smaller ALFs serving as training facilities further exacerbates workforce shortages by limiting opportunities for aspiring administrators and healthcare professionals to gain practical experience. Virginia is losing experienced healthcare workers, the senior population, and small business entrepreneurs to neighboring states like Maryland, which do not impose these restrictive and unnecessary regulations.

These proposed changes would not only foster a more diverse and inclusive market for senior care but also strengthen Virginia’s ability to retain talented professionals and support small businesses in this essential sector.

Good evening, I thought the deadline for public comments ended at 5 pm until I saw 11:59pm. I would like to continue on the Regulations that for 3 Residents we must have 2 Staff in all shifts. As I’ve mentioned earlier, it helps lower the incidence of Falls but does not eliminate Falls. Somehow in the Older folks lives it is bound to happen despite the vigilance. It is also not cost effective. In my case, nobody wants to work for me less than  $20 per hour. For 2 Staff I pay $980 a day. With a current census of 3 Residents paying only $10 per hour, how can I make a profit after paying “mortgage, utilities, building and grounds maintenance, car note, utility, bills, house insurance, liability insurance”. How come the Regulation is not applied to big corporations/facilities who still has the Staffing Ratio of 1 CNA to 8-13 Residents during daytime and Night Shift 1 CNA per 30 Residents. And if 1 Night Shift CNA calls in sick, it would be 1 CNA per 60 Residents.

I need clarification on the Regulation “Medication Review by a Licensed Medical Professional”. How come we Registered Nurses are not allowed to do that when in fact it is in our scope of practice. We do that all the time in many ways such as when when we do Medication reconciliation for admits from hospitals and other facilities and when adverse medication reactions happen and when desired therapeutic effect is achieved. For smaller facilities like hours, doctors don’t come every month to renew orders because we do not have Medicaid beds. Physicians do that every month when they renew orders for the next months MARs at big facilities that has Medicare and Medicaid beds. Our Residents meds are only reviewed by Physicians when they go for checkups every 6 months. Every time I send a copy of the Regulations to the Primary Care Physician, they make changes on the meds per our promptings and advocacy but they still do not label them as “30 days, 60!days or 90 days medication review”. Dept of Health Professions also send memos to Private Practices/Primary Care Physicians so that Patients under their care who reaides in Assisted Living Facilities would be compliant.

Liability insurance: I disagree with the directives that we have to tell new Admit clients, their POA and families that we have a liability insurance and to tell them that they would get paid $500, 000 per occurrence should they decide to sue us. That is such a set-up because that happened to me. Luckily, upon investigation by Dept of Health Professions, it was established that the frivolous claims of the family is untrue. But imagine all the stress we went through with the threat of losing our professional and business licenses. We had to provide all 2 years documentation and the claims they said happened over 2 years ago. That just showed that the 2 years statue of limitations does not protect us at all. We also had to provided proof of Nursing trainings and CEUs for 32 years of our progessional practice. Yes 32 years of documentations had to be dug up because the Resident’s family wanted the $500,000 per occurrence that I told them.

We dedicated our lives to taking care of the vulnerable Older Adults but the changes in regulations are making us re-think of our purpose in life and changing of profession and make us quit. I’ve been trying to sell for over 2 years now but the interested people who want to continue the ALF business are not granted “commercial loans” because the Banks applied the current Assisted Living Standards/Regulations to their criteria/requirements which include those mentioned in my earlier comments today which I would repeat: 

New regulations only allow a Nurse or a Doctor to start a small ALF business. I had RNs, Nurse Practitioners and Physicians who want to buy my ALF but they were not granted commercial loan because they are required to have prior 5 years prior experience operating a facility. Well hello! How can they start when they are required to have a prior 5 years experience? 

They are also now required to have a Licensed ALF Administrator or become one, but the trainings are 6 months to 2 years because there is no set in stone curriculum. That means they have to give up their careers, put their lives on hold and do a term that is like going for a Masters Program or an Associate degree. The same Administrator regulation is adapted also by the Lenders. I that for sure as there were instances that I was asked by these prospective buyers to go with them to the banks as an assurance.

Lastly, no facility would tarin them as Administratos if they don’t work for them after their training. They go for training because theybwant to be a small ALF business owners. 

There are qualified, experiencwd trainors who were Admins, Suoervisors of 180 bed facility before butvare not allowed tobyrain would be Administratirs now because they are in a 8 bed facility. Why train in 20 bed or morw facility when they are just going to operate a 12 bed facility? The trainirs certainly know the ins and outs of a 20 bed or more facility because of they used to work there.

Thank you for listening. I hope there would be more favorable changes that would nit just help small businesses so thatvthey won’t quit like I do and sobrgat also new good hearted people can start/go in the industry because there are still good hearted people who are concerned