Understanding State Requirements for Assisted Living Facilities: What You Need to Know

Assisted living is a welcome solution for seniors who need some level of support to live their best lives but do not require round-the-clock care offered in skilled nursing facilities. Offering the perfect blend of independence, support, and safety, assisted living provides person-centered care for daily tasks like bathing, medication, and meals. And it’s all provided within a vibrant, home-like community designed to boost socialization while enhancing well-being – and life.

To ensure quality and safety for residents, each state has rigorous regulations and requirements for assisted living. When searching for a community, it’s crucial to understand the regulatory landscape. Here’s what you should know:

Mandatory State Licensing

All assisted living communities must be licensed by their state. States are required to establish and enforce licensing and certification requirements for communities and requirements for assisted living administrators or executive directors. Licensing agencies are typically the state health department or Department of Aging.

After a community is licensed, regular inspections are conducted, often without notice. If a violation is reported, inspections become more frequent, and the state may impose penalties or even revoke the facility’s license if serious issues are not promptly resolved.

Are Nursing Homes and Assisted Living Communities Regulated the Same Way?

Because nursing homes provide medical care and skilled nursing services reimbursed through Medicare and/or Medicaid, they are subject to federal oversight through the Centers for Medicare & Medicaid Services (CMS). Assisted living communities offer supportive services and do not care for individuals who require continuous medical care. It is regulated at the state level, with licensure requirements determined by the state.

Federal vs State Regulations

While some federal regulations apply to assisted living communities (e.g., Department of Labor Fair Labor Standards Act, OSHA, etc.), state-level regulation of assisted living services and operations ensures an efficient, comprehensive licensure system because the state can more effectively coordinate its full range of housing and service programs available to seniors. Different state philosophies regarding the role of assisted living enable provider innovation and the piloting of new models of housing plus services that respond to local consumer demands.

Imposing a ‘one size fits all’ federal approach is not the answer to quality care. What works exceedingly well in improving care and meeting consumer expectations is ongoing collaborative efforts among the various stakeholder groups in shaping responsible regulations.

Medicaid-Certified Assisted Living Communities

The 2014 CMS Home and Community-Based Services (HCBS) Settings Rule established standards for Medicaid-funded settings, including some assisted living communities, to ensure they are home-like and promote resident autonomy. Key requirements include providing privacy, dignity, and control over daily life, as well as facilitating choices regarding services and living arrangements. States are required to develop plans to comply with these standards.

State-Specific Regulations for Assisted Living

Regulations define what services assisted living communities can and cannot provide. Each state has its own distinct assisted living regulations. This means the services and care provided, compliance standards, and enforcement methods can vary from state to state. What qualifies as “assisted living” may also vary from state to state, with each potentially having its own terminology, definitions and requirements.

Assisted Living Regulations: What States Commonly Require

While assisted living facility requirements vary by state, most states have regulations addressing:

• Quality of care standards: Basic requirements for assisted living resident care and wellbeing.
• Services: States define what services communities can and cannot provide.
• Staffing requirements and training: States typically set minimum staffing levels and ratios, as well as training and qualification requirements for staff.
• Admission and retention criteria: Regulations specify what types of residents can be admitted and retained based on their care needs.
• Medication management policies: Rules around medication administration and storage.
• Physical plant and safety requirements: Building codes, fire safety standards, etc.
• Emergency preparedness plans: Requirements for disaster and emergency planning.
• Resident rights and protections: Regulations to protect residents’ rights, privacy, and dignity.
• Compliance: States conduct regular inspections to ensure compliance with regulations and are required to maintain records of inspections, violations, and corrective actions.
• Disclosure: Many states require facilities to disclose information about services, pricing, and policies to prospective residents.
• Reporting: Rules for reporting incidents, complaints, and changes in resident condition.
• Food service and nutrition standards: Requirements for meal provision and dietary needs.

Many states have additional licensing and regulatory categories for assisted living communities. State-specific regulations can generally be accessed through the State Department of Aging.

Updates to State Regulations for Assisted Living Reflect Evolving Care Needs

Many states regularly review and update their assisted living regulations to address emerging needs, changing resident populations, and evolving best practices. Over the past five years, on average, 19 states per year have reported changes to key licensure and/or regulatory requirements for assisted living.

Additionally, industry provider organizations, including ASHA, Argentum, the NCAL, and LeadingAge, work with the National Association of State Regulatory Administrators (NARA) on a Quality in Assisted Living Collaborative (QALC) to develop model guidelines in key areas, such as infection control and prevention, dementia care training, and emergency preparedness.

Dementia Regulations

One in five assisted living providers has a unit, wing, or floor designated for dementia, and most states reference dementia in their regulations. The states listed below have dementia-specific requirements, either included in their state law or in regulations.

• Alabama
• Arizona
• Arkansas
• California
• Colorado
• Delaware
• Florida
• Georgia
• Idaho
• Illinois
• Indiana
• Iowa
• Kansas
• Kentucky
• Louisiana
• Maine
• Maryland
• Massachusetts
• Missouri
• Montana
• Nebraska
• Nevada
• New Hampshire
• New Jersey
• New Mexico
• New York
• North Carolina
• North Dakota
• Oklahoma
• Oregon
• Pennsylvania
• Rhode Island
• South Carolina
• Tennessee
• Texas
• Utah
• Vermont
• Virginia
• Washington
• West Virginia
• Wisconsin
• Wyoming

Need More?

For more information on state requirements for assisted living facilities, contact your state’s licensing agency. Each state has a department responsible for assisted living facility requirements, typically the Department of Health, Department of Social Services, or Department of Aging. Reach out to the appropriate agency in your state.

You can visit the state agency’s website. Many states provide searchable online databases or resources with information on assisted living regulations.

You can also contact your state’s Long-Term Care Ombudsman office for assistance in understanding the regulations.

Keep in mind that regulations are updated periodically, so make sure you’re looking at the most current information.

To get the specific regulations for your state, you’ll need to identify and contact the relevant state agency directly. They can provide you with the most up-to-date and accurate information on assisted living regulations in your area.

Where You Live Matters

Where You Live Matters is powered by the American Seniors Housing Association (ASHA), a respected voice in the senior housing industry. ASHA primarily focuses on legislative and regulatory advocacy, research, and educational opportunities and networking for senior living executives, so they can better understand the needs of older adults across the country.