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States nationwide eye assisted living policy.

To many in the assisted living industry, state legislative sessions in the first half of 2004 have seemed fairly uneventful. Perhaps legislators have been reluctant to expand existing programs or enact new initiatives, given that economic recovery in many states has been sluggish at best. Another explanation might be that legislators are anxious to avoid controversial issues in an election year, preferring instead to exit state capitals quickly to begin their reelection campaigns.

Whatever the reason, only a handful of issues relevant to assisted living have dominated debate. The biggest issue, without a doubt, is overhauling regulations.

Sweeping Reform

Several states enacted comprehensive reform of existing regulations, including Colorado, Iowa, Michigan, Montana, and New Hampshire. The West Virginia legislature approved last year's assisted living revisions, and the Pennsylvania Department of Public Welfare is expected to release final rules in the next two months. Wide-ranging legislative reform proposals were also approved by general assemblies in New York and Washington.

ALFA state affiliates in Wisconsin and Oregon continue to participate in ongoing regulatory review efforts. Legislatures in Massachusetts and Louisiana recently approved the creation of state workgroups to recommend changes to current regulations. From coast to coast, lawmakers signaled a willingness to revisit the rules that govern this business.

In a high-profile example of reform, the New York state legislature unanimously passed a measure that will overhaul oversight and beef up enforcement of assisted living communities. The measure, supported by a wide spectrum of industry and consumer groups, includes important protections for residents. In a June letter to Gov. George Pataki, ALFA joined with other leading industry and consumer groups in advocating much-needed assisted living reforms in New York. Many industry observers expect the passage of reform legislation in New York, a bellwether state, to have ramifications nationwide.

Medication Aide Training

After regulatory reform, the main concern in state legislatures has been medication aides: Should the state create this caregiver category? What tasks should medication aides be permitted to perform? How much training should be required? ALFA state affiliates in Alabama, Arkansas, Ohio, and Utah are attempting to implement state programs. Other states--including Maryland, Montana, and Oklahoma--recently have enacted legislation or regulations to implement such programs or make modifications to existing systems.

More than half of the states have established training programs for medication aides or will have programs implemented in the near future, ALFA found in a recent survey of policies and practices in states nationwide. Where programs currently exist, nearly two-thirds of the states require certification. In fact, six states require that medication aides first be certified as nursing assistants.

Providers have sought approval to train medication aides on the premises of assisted living communities, and two-thirds of the states with programs currently allow them to do so. Still, eight of these states also require that on-site instructors receive training in advance. In other words, instructors must participate in state-approved "train the trainer" programs.

The number of training hours required varies dramatically, from four hours in Florida to 140 hours in Texas. Six states do not stipulate the number of hours in classroom and clinical education; however, the trend appears to be moving toward gradually increasing the number of training hours required. Nearly half of the states with programs in place require 20 hours or more of instruction.

Other Issues

Several states reviewed legislation or regulations in response to a crisis within the given state. For example, tragic nursing home fires in Tennessee undoubtedly influenced legislators to require all assisted living properties and homes for the aged to sprinkler their entire facilities. Likewise, power outages created by Hurricane Isabel prompted legislators in Virginia and Maryland to consider bills mandating that assisted living homes have on-site electric generators. New disclosure policies were approved in Oregon regarding firearms following tragedies involving residents.

Several states have enacted new programs or initiated studies to address future issues. For example, severe nursing shortages are prompting Utah officials to test a pilot program involving geriatric managers, licensed practical nurses who will have enhanced nursing rights and responsibilities. Utah and Indiana also are implementing feeding assistant programs in assisted living homes. Florida and Maryland are developing managed care programs for dually eligible (Medicare and Medicaid) long-term care recipients. And in North Carolina the state will review the need to establish separate licensure categories when adult care homes and nursing homes serve different populations, such as the mentally ill.

Across the country ALFA state affiliates played vital roles in the development of effective regulation and legislation of assisted living:

* ALFA's Arizona affiliate was successful in promoting passage of legislation that authorizes the state's Department of Health to sanction business entities that do not comply with state requirements regarding assisted living staff education and training.

* The ALFA affiliate in Indiana has held meetings with state officials on modifying current licensure rules for assisted living managers. A proposal outlining various requirements, including education, experience, and training, has been drafted and stakeholder input is now being sought.

* In Kansas, Medicaid reimbursement rates were not reduced, although the unit payment rate system continues to be a problem. The ALFA affiliate recently participated in hearings held by state officials to discuss the payment system methodology.

* Although proposed Kentucky legislation was not enacted mandating enhanced dementia care training, the ALFA state affiliate continues its work with the Alzheimer's Association on joint projects to improve the education of direct-care staff.

Bottom line? Assisted living industry representatives remain engaged in the development of effective public policy. While statehouses' actions may not have made headlines in recent months, not all was quiet on the state policymaking front. Additional details are available in the complete 2004 Mid-Year Summary of ALFA State Affiliate Legislative/Regulatory Activity at ALFA Online ( in the Members Only section.


Q: If one of our skilled nursing facility's (SNF) Part A residents needs to go to an outside facility for a hearing test, does our facility have to pay for it?

A: To determine the answer, you must look at the CPT code selected by the practitioner who performed the procedure. For example, the practitioner may use code 92506--evaluation of speech, language, voice, communication, auditory processing, and/or aural rehabilitation status. The SNF would pay for this service during a resident's Part A stay, as this code is subject to consolidated billing provisions. To determine whether particular CPT or HCPCS codes are subject to consolidated billing, refer to CMS consolidated billing Web site located at At this Web site, CMS lists each CPT or HCPCS code and notes whether it is subject to or excluded from the consolidated billing provisions.

From Billing Alert for Long-Term Care by Lee Heinbaugh, consultant, PMG, LLC (Cleveland), published by HCPro, Inc. ( Nursing Homes/Long Term Care Management bears no responsibility for the opinions/advice contained herein.

Ann McDermott is a consultant for state government relations with the Assisted Living Federation of America (ALFA). For further information, contact ALFA at (703) 691-8100 or visit To comment, please send e-mail to
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Title Annotation:ASSISTED LIVING review
Author:McDermott, Ann
Publication:Nursing Homes
Geographic Code:1USA
Date:Oct 1, 2004
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