Reduced State Licensing Staff Prompts Providers to Explore Alternatives

Many state regulatory departments are dealing with cutbacks in licensing staff, and assisted living communities in those states can face difficulty getting licensed or surveyed in a timely and consistent manner. The lack of adequate staffing is preventing some communities from opening their doors or being allowed to provide certain services.

In New York and Texas, for example, it can take months for a surveyor to inspect an assisted living community in order for it to receive the necessary licensing to open and operate. In response, the two states are seeking to introduce or implement legislation allowing them to use third-party accreditation services in lieu or alongside state licensing.

This process depends on cooperation between regulatory agencies and the local private sector, and the state Assisted Living Federation of America (ALFA) chapters are currently working to reach agreements between Texas’ and New York’s regulatory agencies, and third-party accreditor the Commission on Accreditation of Rehabilitation Facilities (CARF), which has an aging services division.


Under this model, assisted living communities in these states would voluntarily agree to pay CARF for its accreditation services, the costs of which vary depending on the type of accreditation being sought.

There are several levels of accreditation providers can choose from, including three-year, one-year, provisional, preliminary, and non-accreditation.

It usually takes nine to 12 months for providers to prepare for a survey, allowing them to self-evaluate their services against CARF standards. Once providers are in conformance, they can move to the next step of filling out the Intent to Survey, which must be submitted at least three months before the provider is requesting a survey.


ALFA member communities would not be required to become accredited under the proposed plan, but those that did could enjoy the benefits of regular reviews with no lapses between surveys, says Ginger Lynch Landy, director of the NY ALFA chapter.

Proactive Industry

“Our industry is extremely proactive, and quality assurance is very important to ALFA members,” she says. “We feel it’s in everyone’s interest not to let there be a lapse between surveys. If we have accreditation, we know the accrediting agency has done its due diligence to make sure the community is up to code.”

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It can take months—even years—for New York assisted living communities to obtain licensing, primarily because the state doesn’t have enough staff to review the number of applications it gets, says Landy. However, NY ALFA has worked with the DOH in the past to streamline the licensing process and is hopeful that can happen again.

A few years ago, the state implemented third-party architectural reviews to verify that assisted living communities meet the standards of licensure in that category, after NY ALFA identified this as a hold-up in the licensing process on the state’s end from not having enough architectural staff.

Now, the association is hoping that CARF accreditation can be used in lieu of state licensing, as new development is taking longer than it should, Landy says, and existing buildings that want to become assisted living certified and already have senior residents can’t offer the full range of aging in place services prior to obtaining licensing.

A side-by-side comparison of CARF standards for accreditation and New York State regulatory standards are “very compatible,” Landy says.

“For the most part, New York State’s regulations match up well with CARF’s standards,” says Michelle O’Connor, a legislative assistant at NY ALFA who is working with CARF, adding that they haven’t identified any “major differences.”

That’s where there’s been some trouble in Texas, as differing licensure requirements are holding up approval for implementing third-party accreditation from the Department of Aging and Disability Services (DADS), the state agency that oversees and regulates assisted living.

Seven states, including Texas, have legislation allowing assisted living communities to substitute CARF accreditation for state licensing, but in Texas that legislation has yet to be implemented because of those different requirements.

Life Safety

The main issue is that CARF’s accreditation policies and procedures don’t incorporate life safety certification and therefore don’t match state requirements, says ALFA Texas Executive Director Gail Harmon. “Life safety” encompasses building codes for security measures such as fire alarms, smoke detectors, fire exits, sprinkler systems, and appropriate evacuation routes.

For CARF accreditation to be implemented and approved by DADS, it must include life safety, and CARF is willing to develop one in hopes of a partnership. However, because of the time and money commitment it would take on their part to develop such a module, CARF is hesitant to proceed unless it can be sure of its acceptance by DADS, according to Harmon.

If an agreement is reached, all DADS would have to do is sign off on CARF’s certification that the building is up to code with state standards, she says, and accredited assisted living communities would not have to wait for state surveyors.

The Texas ALFA chapter is currently talking to some key players at DADS as the ALFA chapter tries to ascertain the department’s willingness to accept CARF compliance, but Harmon says their primary focus is getting the two parties into one room to hammer out an agreement.

The outlook is split: Harmon expressed a fifty-fifty chance of success based on current talks.

“It looks doable,” she says, “[but] when you get down to the trenches and sort out the nuts and bolts of it, if there is opposition that’s where we will hit it.”

Legislative sessions recently began in New York, and the state ALFA chapter has plans to introduce a bill to get accreditation approved in lieu of certain regulatory reviews.

The timeline for the legislation is a “big unknown,” says Landy. “We [will] move swiftly to get the bill introduced and sponsors to support it, but it’s hard to tell how they’ll react to it or if there will be opposition.”

The DOH is unlikely to get enough staffing to handle the volume of applications for assisted living licensing, but Landy says the industry is ready to step up. “Let us, the private sector, take some responsibility,” she says.

Written by Jason Oliva and Alyssa Gerace

This article is sponsored by the Assisted Living Federation of America (ALFA) as part of its efforts to advance excellence and explore topics impacting the future of senior living. For more information about ALFA, visit