Last summer, the Legislature voted to create a new assisted living category in Pennsylvania, and next summer, the first such housing settings will be licensed.
Now is the hazy part in between, with the Department of Public Welfare unveiling regulations that some provider groups contend are too costly and some consumer representatives criticize as inadequate to ensure safe, quality care.
The new rules, published in Saturday's Pennsylvania Bulletin, the state's official record of regulations, would give the 1,471 personal care homes in the state the chance to shift to the assisted living category. None will be required to do so.
State officials' assumptions are that several hundred of the larger facilities will opt to switch and new homes will be built specifically to offer assisted living -- a category already existing in many states.
The advantage for operators: "Assisted living" is a modern marketing term in the long-term care industry describing facilities that are more homey and less medical than nursing homes. The new category will give operators a chance to keep residents longer when their health declines and to receive increased government funding for their care.
The disadvantage: Licensing fees and potential remodeling costs, along with other requirements more extensive than those for personal care homes, may convince some providers it's not worth their while to change.
Consumers, meanwhile, are guaranteed some amenities that don't necessarily come in personal care homes, like private bedrooms with lockable doors and their own bathrooms and kitchenettes. They would have more ability to "age in place," a popular term for countering the dread that many adults feel at spending their final years in nursing homes.
Welfare department officials gathered representatives of more than 20 interested groups for meetings from October to April to discuss what requirements assisted living facilities should face, over and above those for personal care homes. The meetings generated no consensus, but state officials said they provided the middle ground sought between provider and consumer viewpoints.
"It's taken Pennsylvania 12 years [since legislative proposals on the issue began] to get to where we are today," said Michael Hall, the Rendell administration's deputy secretary of long-term living. "This isn't the kind of thing where everybody's going to be able to reach complete agreement on all the issues."
That is, in fact, the one point of agreement for many in the process: They don't agree with the rules the state has produced to cover the burgeoning industry, one likely to become far larger in the decades ahead as baby boomers become frailer.
"I don't believe they understand the financial concerns and some of the costs homes will incur to become assisted living residences," said Daneen Reese, executive director of the Pennsylvania Assisted Living Association, representing about 250 homes.
Alissa Halperin, director of the Pennsylvania Assisted Living Consumer Alliance, a coalition of advocacy groups in the aging and disability community, objected, saying that the regulations "don't go far enough to ensure adequate care is provided in safe surroundings. ... These regulations just do not cover all the critical bases."
Disagreement centers on something as basic as square footage of individual residence units. The state has deemed 175 square feet proper for existing personal care homes and 250 feet the minimum for newly constructed facilities.
Ms. Reese said the 175-foot requirement would exclude many existing homes, which would find it cost-prohibitive to remodel. Ms. Halperin said the living space would be too small to be safe and comfortable for people in wheelchairs.
Among other concerns from providers: Licensing fees would be far higher than for personal care homes; kitchens shouldn't be required for people who frequently prefer communal meals; no provisions are made for facilities that want to have some units for personal care and some for assisted living; and excessive supervision of licensed practical nurses by registered nurses is required.
Among other objections for consumers: A care plan for new residents would only be required after they've moved in instead of up front; training of direct-care workers in first aid and cardiopulmonary resuscitation is lacking; minimum staffing levels would be no greater than those for personal care homes; and resident rights to challenge discharges or choose their own health care providers are inadequate.
Mr. Hall said the state expects criticisms from both sides, as they lobby to steer possible rules revisions closer to their viewpoints.
He said many of the regulations -- including training of staff in handling people with cognitive impairments and a requirement that a nurse be on call 24 hours a day -- represent clear, noncontroversial improvements over personal care homes.
At least one key group, Pennsylvania AARP, which lobbied for the assisted living legislation, is largely supportive of the welfare department's efforts.
"It's not perfect [for consumers], but there has to be a balance in that we want providers to be able to provide this service," said AARP advocacy manager Ray Landis.
The rules, as written, may be too costly for providers to recover their expenses with reasonable rates and government reimbursements, said Ron Barth, president of PANPHA, an organization representing nonprofit homes. Without changes, he said, they could undermine the state's goal in creating the category because so few facilities may exist as options.
Their decisions about entering assisted living will hinge, he said, not just on the regulations but on a future funding plan the state has to reach with the federal government. The Centers for Medicare & Medicaid Services would have to approve waivers to help the state pay for care of low-income assisted living residents, and set a limit on how many such reimbursement slots will be allowed.
The government does far less at present to pay for costs of personal home care than for nursing homes. A combined state-federal rate of $1,076 monthly is paid for Supplemental Security Income residents, who make up about one-fifth of the 50,000-plus personal care home residents in the state. Industry advocates say that rate is nowhere near the true cost of care, and that for assisted living, it will need to triple.
The cost details will be handled separately from the state regulations, which are to undergo a public comment process and review this fall by legislative committees and the Independent Regulatory Review Commission before they become final. The first reclassified facilities are to be licensed to accept residents starting in July.
