Passed during the 2017 General Assembly session, Senate Joint Resolution 266 (Senator Dance) instructed the Joint Commission on Health Care (JCHC) to study the current staff-to-resident ratio requirements for assisted living facilities and special care units. The resolution was passed by indefinitely in Senate Rules committee with the understanding that JCHC would conduct the study.

The JCHC study included site visits to five ALFs in the Central Virginia region which entailed tours of the facilities and interviews with ALF operators, staff members and residents. In addition, input was solicited and received from advocates, industry groups, and employees of several state agencies that are responsible for various ALF licensing, oversight, and payment issues. Lastly, a literature review provided information regarding staffing ratio policies in other states, ALF labor adequacy, salary information, staff turnover rates, and information on the projected cost of ALF care.The literature review revealed that very few states require specific staffing ratios; rather, they have rules that are similar to those in Virginia that require a sufficient number of staff members in order to safely operate the facility(*2). ALF operators, industry groups and state agency staff expressed the view that implementing specific staff-to-resident ratios would be very difficult, due to the variety of facility configurations, the differing and frequently changing mix of resident level-of-need in each facility, and the commitment to provide personcentered care, which may result in the need for different staff levels at various times of day (e.g., many residents need assistance bathing and prefer to bathe before breakfast). In addition, both the literature review and ALF operator interviews revealed that there is high turnover of direct care staff(*3). ALF operators reported that after training staff at their expense, staff frequently leave the facility after a few months to work in home-based care.

Persons meeting low income and other eligibility requirements may qualify for funding to pay for ALF stays from the Auxiliary Grant (AG), (which provides state and local funds that contribute to ALF costs). The AG rate is set by the Virginia Legislature, and the current rate covers approximately one-third to one-half of the cost of providing ALF care. Over the last several years, a number of ALFs serving persons who receive the AG have closed or reduced the number of beds allocated to AG recipients. ALF operators expressed concern that increasing labor requirements would be costly and could result in increasing the rates to private-pay residents and/or reducing the number of AG recipients they are able to serve, as they are unable to adjust charges to AG recipients. In February 2018, a new, wide-ranging regulation package updating the rules for ALFs took effect, and operators, industry groups and state agency staff expressed the preference for allowing time to implement the new rules before deciding whether or not to set specific staffing ratios. Also, ALFs are required by the Department of Social Services (DSS) to use a staffing tool when setting staff levels. DSS monitors their use of the tool during inspections. Currently, DSS, in conjunction with facility operators, is developing a new tool that can be used by ALFs to better determine their staffing needs. The new tool will be pilot-tested and should be completed in 2018. Another issue that was highlighted during talks with industry groups and state agency staff was the fact that the DSS does not have the information technology capability to generate standard reports on ALF inspection results. Creating monitoring reports is currently a manual process, requiring data drawn from several different systems, is time consuming and relies upon institutional knowledge and outside industry groups who gather information from their member facilities. JCHC members were presented with four policy options. At the November 2017 JCHC Decision Matrix meeting, members voted to proceed with policy option three: to introduce a budget amendment to raise Auxiliary Grant rates (amount to be determined), and policy option four: by letter of the JCHC Chair, request that the Secretary of Health and Human Resources direct the DSS to field a Request for Information (RFI) for enhancing data reporting capabilities.
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(*2) The National Center for Assisted Living, Assisted Living 2016 State Regulatory Review; October 2016.
(*3) The National Center of Assisted Living 2013 Survey