Thank you for the opportunity to offer comments in response to the periodic review of Virginia’s assisted living facility standards and regulations. I am offering comments on behalf of the Office of the State Long-Term Care Ombudsman and the long-term care recipients for whom we advocate. In keeping with our mandate and commitment to help protect the health, safety, welfare, and rights of long-term care recipients, we value this opportunity to provide input that supports our work with partner agencies, policy makers, and other stakeholders to promote quality long-term care. 

As a part of this periodic regulatory review of assisted living standards and regulations, we urge DSS to examine the potential value of creating a more precise and nimble, multi-tiered licensing structure that strengthens resident protections while enabling a continuum of service options through differentiated levels of licensure. In a tiered structure, for example, licensure to provide care for individuals with higher, more complex care needs would come with additional requirements. The most important benefit of such a tiered system is that it provides better protection and transparency for consumers, while not creating barriers for providers that can offer quality residential care to individuals with minimal assistance needs. Creation of multiple, clearly defined licensing levels helps ensure alignment of resident care needs with a provider’s capacity/ resources and promotes transparency to support informed decision-making by consumers.

Discussion:

A multi-tiered regulatory framework would better ensure alignment of provider capacities/ resources with more differentiated levels of resident needs both at the time of admission and over the course of a resident’s stay. A structure with distinct licensure standards applicable to different tiers of licensure would better ensure adequate care support for individuals with more complex care needs, while reserving avenues for operators willing and able to provide good care for ‘assisted living appropriate’ residents with more limited needs.

A more articulated licensing framework would also more safely and effectively address the needs and preferences of the growing number of Virginians who wish to have options to continue living/aging in the least restrictive environment as they face challenges associated with aging and/or disability. A tiered framework would more readily enable consumers to make informed decisions (among settings/services) in their long-term care planning, knowing that the care setting they select can safely support their potentially increasing care needs.

Such a framework with ‘graduated’ standards aligned with residents’ care needs would also  support the preference expressed by most consumers who wish to ‘age in place’ within reasonable parameters. As importantly, It would help address the ‘trap’ into which too many consumers can fall once they have moved into an assisted living community – as some facilities rapidly layer on additional fees for services to address ‘higher needs’ said to be outside the realm of the ‘standard’ care support. Greater transparency is needed to help protect assisted living residents who find themselves ‘over the barrel’ and facing additional costs that may not have been budgeted for and may or may not be legitimate. In other words, in some ways an ‘unauthorized tiered system’ already exists, but too often at the unexpected expense of the resident/family caught off guard. Tiered licensure would better protect consumers/residents.

Virginia has the foundation in place – having already created supplemental standards for providers serving a distinct population – those determined to need care in a ‘secure’ unit (often as a result of ‘wandering’ or other challenging behaviors or cognitive impairments linked to dementia and/or other mental health challenges). The current licensing structure does not go far enough, however. Aside from the enhanced requirements that apply to providers caring for this very limited segment of the assisted living population for whom a secure unit may be appropriate, standards for the rest of the assisted living landscape are essentially ‘one size fits all.’ Virginians needing assisted living care would be well served by better defined levels of care associated with distinct levels of licensure.

It is important to note as well that the creation of a tiered system does not ‘open the floodgates’ in the sense of allowing assisted living facilities to admit just any residents, including those that may truly require nursing home care or another more specialized care setting. Instead, DSS can specifically ensure enforcement of appropriate limits/criteria that currently serve as guardrails against unsafe admission or retention of residents, while allowing individuals to more safely age in place in appropriately equipped settings – perhaps delaying or avoiding transitioning to a more restrictive, less homelike setting prematurely or unnecessarily. This is a win-win modification for residents, families, providers, and regulators alike.

Thank you for the opportunity to share these recommendations.