State Variations in Regulatory Stringency for Assisted Living Communities: Potential Implications for Service Supply, Cost, and Quality
Authors: Temkin‐Greener H. , Mao Y. , Ladwig S. , McGarry B. , Li Y. 
Published: August 2020

Research ObjectiveOver 30 000 Assisted Living (AL) communities in the US now serve 1 million older Americans. AL growth has occurred largely without federal oversight and with variable state regulatory efforts. Research on AL regulations has been scant, largely descriptive, and mostly focused on dementia‐care. This study aimed to (a) assess/compare states’ approaches to regulating AL communities across multiple policy domains and (b) identify state‐level factors associated with regulation stringency.Study DesignPrimary data source was each state’s AL regulations published on state websites. Additional data, for example, the 2019 National Center for Assisted Living (NCAL) Regulatory Review, were used to augmented/check the accuracy of our coding of policies. Several secondary sources were employed to derive state covariates.We focused on 4 policy domains, which regulate residents’ admission and retention (9 items), medication management (4 items), staffing/training (8 items), and dementia care (9 items). We used codes developed in prior research and developed new codes inductively. Each domain was coded independently by two researchers, and differences were reconciled. For each domain, we summed all items and created a standardized state‐level stringency measure as: (X‐mean)/SD. For each state, the standardized values were added to create an overall stringency score. Psychometric properties of the individual and overall stringency measures were tested using factor analysis and Cronbach α.Descriptive statistics, mapping, and OLS regression analyses were employed to examine 5 measures of stringency (overall and 4 domains). Based on literature reviews, we identified 5 state‐level independent variables: AL average monthly cost; number of AL beds/1000 people age 75+; % aged Medicaid beneficiaries using AL; Medicaid spending on AL services; and % nursing homes (NH) with 4‐5 star quality on deficiencies.Population StudiedDescriptive analyses included data on 50 states and DC, while 47 states were included in OLS regressions.Principal FindingsOverall, 10 states had high (>1SD) and 5 states had low (<1SD) stringency. While only 1/3 of states with high overall stringency exhibited similar levels of stringency across all domains, 2/3 of states with low stringency remained consistently low. State variations were highest in regulations for medication management (18 states scored high and 13 low), and lowest for staffing/training (8 high and 7 low). Regression results showed statistically significant (P < 0.05) negative associations between AL cost and AL beds/1000 for all domains except staffing/training. NH quality on deficiencies and Medicaid AL spending were positively associated with staffing/training regulation stringency.ConclusionsWhile many states have implemented some AL regulatory measures, substantial variations across states exist. For example, in states with higher Medicaid AL spending, regulation on AL staffing/training is stronger. AL investors may react to overall state regulatory environment as lower AL bed supplies are found in states with stronger regulations. High stringency may influence AL providers to maintain lower case‐mix acuity among residents, which may be more congruent with the ALs’ ability to provide services, and in turn results in lower monthly costs.Implications for Policy or PracticeState variations in AL regulations may influence service supply and cost as well as resident case‐mix and care quality. A more in‐depth understanding of these relationships is needed.Primary Funding SourceAgency for Healthcare Research and Quality.