4 comments
Absolutely not! As somebody that currently works within a healthcare system that is financially supporting bills to “lobby” or buy through legislation (which they were successful in doing, here in VA) that will compromise quality care and puts OUR health and safety at risk. You don’t get a “cheap option” when it comes to providing healthcare services to people! And why would it ever be ok to isolate, limit, control, and dictate prevention services? And now they are going to compromise the prevention team? Even though we are 100% adamantly opposed to this? Why is prevention not being heard, seen, and utilized as the first line of defense in preventing disease and costly treatment needs? Which will simultaneously improve the health and wellbeing of a population that is in desperate need of access to QUALITY healthcare services by HIGHLY QUALIFIED professionals, that meet the standards of the already existing, yet overlooked and shunned prevention-focused team we have. There is a shortage of quality places for us to work.. since prevention is under the thumb of the restorative team, for some unknown reason! I would love for someone, anyone to answer me why that is? And even if these options met those standards (which they don’t) no one deserves to have to work within this broken and worn out system they keep recycling! And with little investment into the system, they will run these options off, before long too. And watch out with that foreign trained workforce.. there are some facing some SERIOUS sentences from basically using them as “cheap labor”… YIKES!
I appreciate the opportunity to address how current assisted living regulations disproportionately burden assisted living facilities, particularly those serving Auxiliary Grant (AG) recipients. JLARC’s own findings confirm what small providers have experienced for years: the regulatory framework has evolved into a medically intensive model that is fundamentally misaligned with the original intent, purpose, and capacity of residential?level care homes.
Adult Care Residences were established to support individuals transitioning from institutions under the Olmstead Act. Our role was never medical treatment; it was maintenance, support, and community integration for individuals with mental health needs and disabilities. However, beginning in 2005, the industry shifted. Larger, medically oriented facilities entered the DSS system to benefit from lighter regulations compared to nursing homes, and in doing so, reshaped the regulatory landscape. Residential?level providers were swept into a medical model that does not reflect our mission, our training, or our funding.
Despite these intensified requirements, AG reimbursement has not kept pace with inflation, cost of living, or market value, as JLARC clearly stated. Today, small AG?serving facilities receive less than $80 per day to care for residents—. We are capped, restricted, and expected to absorb every new regulatory cost without any corresponding increase in funding.
This imbalance is economically and financially infeasible. It undermines our ability to:
To preserve residential?level care and prevent the collapse of small AG facilities, several regulations must be amended or separated so that AG?serving beds are classified as Residential Care Only, not grouped with nursing?home?like facilities that receive Medicaid, private pay, reverse mortgages, and other financial supports.
Below are the specific regulations requiring amendment and considerations
One of the most critical issues we must confront is the need for a formal reclassification of Residential?Only Care Facilities and a separate licensing track under the Division of Licensing — or, at minimum, a substantial and enforceable increase in Auxiliary Grant funding. Without one of these two structural changes, small AG?serving homes cannot survive.
This is not just a mismatch — it is a structural failure.
Regulations Requiring Amendment
1. 2VAC40?73?45 — Liability Insurance
The newly mandated liability insurance tiers — ranging from $250,000 to $1,000,000 — were imposed without any funding mechanism, despite JLARC’s findings that Auxiliary Grant reimbursement is already far below market value. Small AG facilities operating on less than $80 per day cannot absorb these massive insurance increases. These requirements were built for medical?model facilities, not for residential?care homes whose purpose and risk profile are entirely different.
The core issue is this: Medical?model regulations are being applied to residential?care facilities, and insurers are responding by classifying us as medical providers — even though we are not funded, staffed, or licensed to operate as such.
This regulatory shift has intensified our liability exposure in dangerous ways:
These regulations force small AG facilities to operate outside the scope of our intended purpose, which is residential care — not medical treatment. They create a semi?quasi nursing environment that we were never designed to function in and never funded to sustain.
For these reasons, all regulations that impose medical oversight on residential?care facilities must be amended or revoked. This is not optional — it is necessary to:
Liability requirements must be scaled to residential?level risk, not medical?model expectations. Without these changes, small AG facilities will continue to be regulated out of existence.
2. 22VAC40?73?80 — Management of Resident Funds
The regulation prohibits charging AG residents for account administration. However, when a resident has a representative payee who charges a fee, the facility is forced to absorb that cost. This is fiscally unfair and economically harmful. Amendment requested: The department of social service must adjust for clients fees to be paid, just as they do for conservators and guardians.
3. 22VAC40?73?490 — Health Care Oversight
Requiring a licensed health care professional to conduct on?site oversight every six months is a medical?model requirement inappropriate for residential?level care. Residents already receive oversight from physicians, therapists, and insurance care coordinators. Amendment requested: Revoke this requirement for residential?only facilities.
4. 22VAC40?73?620 — Oversight of Special Diets
Dietitians oversight every six months is a medical?nutrition requirement that belongs under Medicaid, not AG housing. Amendment requested: Exempt residential?only facilities unless the resident’s insurance or Medicaid covers the service.
5. 22VAC40?73?670 — Qualifications and Supervision of Staff Administering Medications
This regulation requires staff administering medications to be licensed or registered with the Virginia Board of Nursing, or to complete the full 68?hour medication aide course with clinicals. While this may be appropriate for medically intensive facilities, it is not appropriate for residential?only Auxiliary Grant homes, and it is not aligned with the original purpose of Adult Care Residences.
Other AG?serving industries do NOT require 68 hours of training to hand out medication.
Group homes, sponsored residential homes, and other community?based programs serving AG recipients routinely administer medications with far less training, often relying on:
these programs are not required to complete 68 hours of coursework, clinical rotations, or Board of Nursing registration — yet they serve the same population and operate under the same AG funding constraints.
Technology has dramatically reduced medication?administration errors.
Modern computerized systems — including eMARs, pharmacy?linked medication logs, barcode scanning, and automated refill alerts — have transformed medication administration. These systems:
Technology itself has become the safeguard. The regulation has not kept up with the reality.
training costs have skyrocketed — creating an impossible burden for small AG facilities.
Medication aide classes that once cost $100 now cost:
This is for a single 68?hour course, not including:
For small AG facilities operating on less than $80/day per resident, these costs are devastating. We cannot compete with larger facilities that pay higher wages and can absorb training costs. We cannot recruit or retain staff when the entry barrier is so high. And we cannot sustain operations when every regulatory change increases our liability and our expenses.
This regulation forces residential?care facilities into a medical?model environment.
Requiring Board?registered medication aids implies:
This regulation must be amended or revoked for residential?only facilities.
Reduce liability insurance costs
Prevent misclassification as medical providers
Increase the pool of available staff
Reduce training expenses
Restore the original purpose of AG?serving homes
Protect small facilities from closure
6. 22VAC40?73?690 — Medication Review
Annual medication reviews by licensed health care professionals are redundant. Modern electronic systems already allow pharmacists and physicians to review medications directly. Amendment requested: Remove or modify this requirement for residential?only facilities.
Unfortunately, Small AG?serving Adult Care Residences are being regulated out of existence. The current framework forces us to operate outside our intended scope while receiving a fraction of the funding available to medical?model facilities. Without regulatory relief and proper classification, Virginia risks losing the very residential homes that support Olmstead compliance and provide stable, community?based housing for vulnerable adults.
I respectfully and urgently request that these amendments be taking seriously and take immediate action to amend these regulations and establish a Residential?Only classification for Auxiliary Grant beds. This change is not simply a matter of administrative preference — it is a matter of fairness, sustainability, and survival for the small residential?care facilities that serve Virginia’s most vulnerable citizens.
The Auxiliary Grant was never designed for medical?model environments. It was created to support individuals living at home, where no medical regulations exist. It is also used in supportive housing programs, where regulations are minimal, flexible, and aligned with community?based living. Yet DSS places small AG?serving residential facilities under the maximum level of regulation, while paying us the least amount of funding.
This is an impossible contradiction.
We are being held to the highest regulatory burden with the lowest financial support. We are being treated like medical facilities without medical funding. We are being regulated like nursing homes without Medicaid reimbursement. We are being forced into a medical model that does not match our mission, our training, or our purpose.
For the sake of the residents who depend on us — individuals with mental disabilities, individuals transitioning from institutions, individuals who need community?based living — we must be removed from the medical?model regulatory structure. We must be recognized as Residential?Only facilities, with regulations that reflect our actual scope and purpose.
Without this change, small AG facilities will continue to close. And when they close, residents lose their homes, their stability, and their place in the community. Virginia loses the very system that makes Olmstead compliance possible.
I ask you to act now — not later — to protect the future of residential?care homes and the people who rely on them. Establish a Residential?Only classification for AG beds, amend the medical?model regulations, and restore fairness to the system that has become unbalanced, unsustainable, and unjust.
Thank you for your time and consideration.
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.
Commonwealth Senior Living appreciates the chance to take part in this review. We operate 26 assisted living communities across Virginia, and we offer the following comments in a spirit of partnership with the Department, drawn from our experience serving residents and families throughout the Commonwealth.
These Standards matter, and we support keeping them in place; they help ensure residents are safe and well cared for. We also see this review as a good opportunity to refine a number of provisions so they better fit how communities operate today. Our recommendations are offered in that constructive spirit.
We recommend the following amendments and clarifications.
1. 22VAC40-73-10 (Definitions), "Health care provider."
Recommendation: Revise the definition of "health care provider" so that it tracks the definition in the Code of Virginia and includes any individual licensed to provide a specific health care service within their scope of practice, allowing the Standards to keep pace as the Commonwealth adds credentialed professions.
2. 22VAC40-73-120 (Staff orientation and initial training).
Recommendation: Confirm and clarify that a new team member may work under the sight supervision of a trained direct care staff person or the administrator while orientation is being completed, which allows greater flexibility in scheduling orientation and training.
3. 22VAC40-73-140 (Administrator qualifications).
Recommendation: Collaborate with the Virginia Board of Long-Term Care Administrators to reduce barriers to licensure as an administrator.
4. 22VAC40-73-140 (Administrator qualifications), subsection D.2.
Recommendation: Add a qualification pathway (v): "have at least three years of health care experience, to include at least one year in a managerial or supervisory role, in a health care setting within the five years prior to application," to match the requirements to participate in the AIT program under the Board of Long-Term Care Administrators.
5. 22VAC40-73-150 (Administrator provisions and responsibilities), coverage and notification timelines.
The requirement in subsection B to "immediately" employ a new administrator or appoint a qualified acting administrator uses an undefined term that is operationally impossible to satisfy, since recruiting or credentialing a qualified administrator cannot occur instantaneously. The separate notification provisions in B.1 and B.2 are also duplicative.
Recommendation: Replace "immediately" in subsection B with a defined, reasonable period, and consolidate the notification requirements of B.1 and B.2 into a single written notice to the regional licensing office (and, where applicable, the Virginia Board of Long-Term Care Administrators) within 14 days of an administrator change.
6. 22VAC40-73-150 and 22VAC40-73-170, on-site hours requirement.
The requirement that the administrator be on site 40 hours per week does not account for vacation, off-site education, mentoring, or other legitimate responsibilities, and contributes to administrator burnout and turnover in a workforce already under strain. State workforce data indicate that the large majority of assisted living facility administrators already work 40 or more hours per week.
Recommendation: Reduce the minimum on-site requirement from 40 hours to 30 hours per week, a generally recognized full-time threshold, which would allow the administrator to be off site for training and mentoring while remaining on call, with a corresponding adjustment to the required day and night shift coverage hours.
7. 22VAC40-73-150 (Administrator provisions and responsibilities), acting administrator timelines (subsections B.5-6, B.7, and B.9).
The window during which a facility may operate under an acting administrator (150 days, or 90 days if the acting administrator has not applied for licensure) is difficult to meet. The AIT program alone requires 640 hours, which at 40 hours per week is roughly 16 weeks, or about 112 days, before accounting for state processing and examination scheduling. Separately, the restriction in B.9 barring a facility from operating under an acting administrator more than twice in any two-year period significantly hinders an industry with high rates of retirement and turnover.
Recommendation: Extend the acting administrator window, and the single limited extension available under B.7, to reflect the realistic AIT and examination timeline, and eliminate the two-times-in-two-years restriction in B.9 and the corresponding provision in the Code.
8. 22VAC40-73-200 (Direct care staff qualifications and certification).
There is confusion over which certifications are acceptable, and DMAS has not approved personal care aide (PCA) training in over ten years, leaving communities unsure how to evaluate the adequacy of other organizations' direct care training programs.
Recommendation: Clearly specify which certifications satisfy the standard, establish a current approval standard for direct care training, and provide a means to verify the adequacy of third party training programs.
9. 22VAC40-73-260 (First aid and CPR).
Recommendation: Update the standard to match the current first aid and CPR standards effective July 1, 2026, expand the list of acceptable training providers, and tie currency to the certification's listed expiration date, or two years where none is listed.
10. 22VAC40-73-320 (Physical examination and report), hospital admissions.
Completing the required physical examination is often difficult when a prospective resident is in the hospital, as hospital physicians frequently decline to complete the assisted living admission forms and much of the required information already exists in the hospital's electronic medical record. This delays or prevents timely, appropriate discharges to assisted living.
Recommendation: Allow the facility to rely on the hospital's notes, history, and electronic medical record, with electronically signed orders, to satisfy the admission physical when the required information is present, focusing on whether the facility has the information needed to safely admit the resident rather than on the specific form or format.
11. 22VAC40-73-320 (Physical examination and report), serious cognitive impairment screening.
The physician questions on serious cognitive impairment, where the physician circles "yes" or "no," are written unclearly. Because these are the two questions that determine whether a resident requires a secured unit, the lack of clarity causes significant confusion and repeated back and forth at a point that directly affects resident placement and safety.
Recommendation: Reword these questions for clarity so the determination is unambiguous.
12. 22VAC40-73-330 (Mental health screening).
By its terms, this provision applies only where behaviors within the previous six months indicate mental illness or a related condition, yet some inspectors interpret it, through 22VAC40-73-310 B.4, to require a screening for all residents. It also does not specify who is qualified to complete the screening.
Recommendation: Clarify that the screening applies only to residents meeting the behavioral criteria, not to all admissions, and specify who is qualified to complete it.
13. 22VAC40-73-360 (Emergency placement).
Recommendation: Clarify that public and private pay individuals may be equally supported and placed, and that an independent physician (including a physician assistant or nurse practitioner) or an adult protective services worker may document and approve the placement.
14. 22VAC40-73-380 (Resident personal and social information).
Recommendation: Limit required information to that which is vital to the resident's health, safety, and well-being (for example, birthplace is not necessary), and combine overlapping subitems.
15. 22VAC40-73-400 (Monthly statement of charges and payments).
Recommendation: Expressly permit electronic records and electronic delivery of the monthly statement, consistent with the many facilities that maintain records electronically.
16. 22VAC40-73-420.A (Acceptance back in facility).
Subsection A requires a facility to establish procedures ensuring that a resident detained under a temporary detention order is considered for acceptance back into the facility, while A.2 requires the facility to determine whether it can meet the resident's needs. As written, the mandatory acceptance language in A is in tension with the needs determination in A.2.
Recommendation: Revise subsection A so that a resident's return remains subject to the facility's determination under A.2 that it can safely meet the resident's needs, resolving the internal inconsistency.
17. 22VAC40-73-490 (Health care oversight).
The requirement that the licensed health care professional providing oversight have two years of experience in specified settings is not relevant to whether the professional is qualified, and unnecessarily limits the pool of professionals available to provide oversight.
Recommendation: Base eligibility on current, active licensure rather than the two-year experience requirement, and review the section as a whole to align it with current healthcare practice.
18. 22VAC40-73-510 (Mental health services coordination and support).
The provision is unclear and contains redundant language. Portions duplicate the facility's existing obligation under other sections to meet residents' needs, which can confuse assisted living professionals.
Recommendation: Review and reword the section to remove redundancy and improve clarity.
19. 22VAC40-73-520 (Activity and recreational requirements).
Recommendation: Revise the section to remove redundancy with the program of care requirements in 22VAC40-73-30, remove outdated language, and avoid overly specific or non-measurable requirements that create hardship for smaller communities or turn on inspector subjectivity.
20. 22VAC40-73-680 (Administration of medications).
When a PRN medication is documented on the MAR with specific parameters and a signed prescriber order, the additional separate paper order in the chart is redundant and creates duplicative work for both the prescriber and the community.
Recommendation: Eliminate the duplicate documentation requirement where the PRN is already recorded on the MAR with parameters and a signed order.
21. 22VAC40-73-760 (Living room or multipurpose room).
Recommendation: Simplify the section and remove outdated references, such as radio and current newspaper, that no longer reflect how residents access information and entertainment.
22. 22VAC40-73-1130 (Staffing).
The fixed staffing count, one additional direct care staff member for every 10 residents or portion thereof, does not account for the actual acuity or needs of the residents served, and strains facilities' ability to care for residents given the limited direct care workforce.
Recommendation: Replace the fixed count with the standard already used in 22VAC40-73-280, staff "adequate in knowledge, skills, and abilities and sufficient in numbers to provide services," so that staffing is based on the actual needs of the residents rather than a fixed ratio, applied consistently across assisted living and memory care.
We appreciate your consideration of these recommendations, and please reach out if it would help to discuss any of them further. Commonwealth Senior Living cares about getting these Standards right, because clear and workable rules are part of keeping residents safe and well served. We are glad to be a resource to the Department as this review continues.