Under the Radar: States Vary in Regulating and Reporting COVID-19 in Assisted Living Facilities

State Regulation of Assisted Living Facilities and COVID-19

To examine how states are regulating assisted living facilities in response to the COVID-19 pandemic, we collected and analyzed state-issued guidance for ALFs for each of the 50 states and District of Columbia. This information was posted in a variety of online locations across states: some regulatory guidance pertaining to long-term care facilities was posted on state-run websites dedicated to COVID-19-specific information and resources; some was posted on state Department of Health websites, some was stored on Governors’ websites, and some was posted on the websites of other state regulatory agencies, such as the Department of Human Services. State regulatory information was collected via Google keyword searches as well as targeted searches of government websites as listed above.

Regulatory information pertaining to ALFs was also conveyed in a variety of formats, including executive orders or press releases issued by state Governors’ offices, orders or guidance issued by state Public Health departments or other state regulatory agency (such as the Department of Human Services), or information or guidance appearing on state-run websites housing COVID-19-related information.

State regulatory information pertaining to ALFs was initially collected on a rolling basis via online search as detailed above between March 26 and April 20, 2020, and subsequently updated between May 29 and June 1, 2020, and is current as of June 1. Although best efforts were made, due to the wide variation in online location, presentation, and formatting of regulatory information pertaining to ALFs between states, it is possible that the research team inadvertently neglected to include some information, or was not aware of an update to information already collected. In some states, the regulatory guidance was directed to “long-term care” settings generally, in which case it was assumed to apply to ALFs.

State Reporting of COVID-19 Data for Assisted Living Facilities

To collect data on COVID-19 cases and deaths in ALFs, we reviewed public reporting of COVID-19 surveillance data displayed on applicable state-run websites in all states, and collected numbers of cases and deaths for ALFs in states where this data is reported separately from cases and deaths in LTC facilities generally, in order to exclude nursing facilities from our analysis. Not all states report cases and/or deaths in LTC facilities, and some only report this data for nursing homes. State data on COVID-19 cases and deaths was collected between June 5 and June 8, 2020, and is current as of June 8.

We included COVID-19 case and death data for states (n=11) that reported for ALFs specifically, as well as other states (n=5) that report ALF data separately from nursing facilities, but do so within a larger category that includes ALFs along with other non-nursing home facility types. The facility categories used by states reporting for ALFs under a broader classification are: Residential Care Facilities for the Elderly, Residential Care Facilities, Community Residential Care Facilities, Adult Residential Facilities, and Adult Care Facilities. We include these congregate facilities because assisted living facilities represent a large share of their total residents in many states. We intentionally exclude states reporting in broader categories that include nursing facilities because these numbers are reported to CMS separately and our goal is to understand the impact of COVID-19 in assisted living facilities to the extent this is possible with current data limitations.

Notably, not all states report data for both cases and deaths; some report only cases and others report only deaths. Not all states report for staff and residents; some report cases and/or deaths for residents only, and some states (n=2) report aggregate cases for residents and staff. Most states in our analysis (n=12) report cumulative case and death data, however four states (Florida, Mississippi, Utah, and North Dakota) report only active cases. States differ slightly in how many cases constitute a facility “outbreak” which triggers reporting – some states report data for facilities with just one active case, others begin reporting when two or greater cases are reported by facilities. States also differ in whether they report suspected COVID-19 cases and deaths, in addition to confirmed cases – some only report cases confirmed via diagnostic test. For the purpose of this analysis, we have included both suspected and confirmed COVID-19 cases and deaths reported. Additionally, four states (Massachusetts, Rhode Island, Utah, and California) report ranges of cases and/or deaths, versus specific counts. For these states, we used the median of the reported range, or 5 in the case of “5 or above” reported, and 31 for “greater than 30.”