Table 1.

Residential Care/Assisted Living Regulations Relevant to End-of-Life Care Delivery

Regulations	Coding based on regulation data governing the license type	Rationale
Third-party services
Allow hospice services	Allow = explicitly allow persons on hospice to be admitted OR explicitly allow residents to use hospice services; Silent = silent on allowing residents to use hospice services AND is either silent on allowing persons on hospice to be admitted OR does not allow persons on hospice to be admitted (2 license types, merged with silent because of small sample size of 635 residents)	Research shows a positive association between utilization of third-party services and retention in RC/ALs.13,28 Third-party services could meet the growing care needs of residents approaching the end of life
Allow private care aide services	Allow = explicitly allows residents to hire private care aides (does not include family care); Silent = silent regarding private care aides (does not include family care)
Allow home health services	Allow = explicitly allows residents to use home health services; Silent = silent pertaining to home health services
Staffing
Require RNs	Require = has a requirement for RNs (e.g., ratio, staffing level, specified responsibilities); Silent = silent regarding RN staffing	Recoded variables based on the distribution of staffing specificity measures developed by Thomas et al.2 The measures were shown to be associated with hospitalization rates. Specifically, increases in DCW specificity were associated with decreased hospitalization rates among RC/AL residents.2 In addition, research in nursing homes consistently shows the positive relationship between residents' outcomes and requirements on increasing staffing levels46,47
Require LPN/LVNs	Require = has a requirement for LPN/LVNs (e.g., ratio, staffing level, specified responsibilities); Silent = silent regarding LPN or LVN staffing
Require minimum ratios/levels for DCWs	Require minimum ratios/levels = specifies staffing ratios or minimum staffing levels for DCWs (i.e., DCWs without certification or licenses, not including certified nurse aides or medication aides); Other requirements or silent = silent pertaining to DCW staffing level OR requires DCWs, but does not specify levels or ratio OR specifies that DCW staffing levels or ratios are “sufficient” to meet acuity of the residents (a majority of the sample (72%) resided in RC/ALs with such regulation)
Medication management
Require regular medication reviews	Require = explicitly requires scheduled reviews of residents' medications; Silent = silent regarding regular medication reviews	Indicator for regular monitoring of medication management practices. This is important given that RC/AL residents take multiple medications on a daily basis,37 likely even more toward the end of life, and half of the medications are distributed by DCWs,42 who do not have formal training in assessing resident health conditions, monitoring potential adverse drug events and drug interactions.20,43 Depending on state regulations, regular medication reviews might cover a variety of topics, such as the type of staffing required for the review, reviewing medication inventory, safe medication storage, accurate dosage and timing for medication administration, etc.19,20,27
Require RN/LPN/LVNs to administer oral medication	Require = explicitly requires RNs OR LPN/LVNs to administer oral medication; Not require = explicitly does not require RNs OR LPN/LVNs to administer oral medication; Silent = silent pertaining to oral medication administration by BOTH RNs AND LPN/LVNs. Note: no license types have conflicting regulations regarding RNs vs. LPN/LVNs (e.g., explicitly requires RN but explicitly does not require LPN/LVN, or vice versa). The license types that do not require RNs to administer oral medication are also the licenses that do not require LPN/LVNs to administer oral medication	Although licensed nursing staff are more qualified to administer medications, having such a regulation in place could create barriers in timely medication administration given the lack of presence of RN/LPN/LVN in some RC/ALs, in addition to the costs for hiring nurses and potential nurse shortage in local markets.50 Permitting DCWs to administer medications may facilitate medication management, although DCWs may not have enough training to ensure safe medication administration.20,43 Note: CNA or medication aides are not included in this category. We did not include the regulation requiring CNAs to administer oral medications due to the low prevalence of this regulation in our sample (8%)
Permit DCWs to assist with oral medication	Permit = explicitly permits DCWs to prepare and help residents take oral medication; Prohibit = explicitly does not permit DCWs to prepare and help residents take oral medication; Silent = silent pertaining to oral medication by DCWs
Require RN/LPN/LVNs to administer injections	Require = explicitly requires RNs OR LPN/LVNs to administer oral medication; Not require = explicitly does not require RNs OR LPN/LVNs to administer oral medication; Silent = silent regarding oral medication administration by BOTH RNs AND LPN/LVNs. Note: Similar to the oral medication regulation, no license types have conflicting regulations regarding RNs VS LPN/LVNs (e.g., explicitly requires RN but explicitly does not require LPN/LVN, or vice versa)
Permit DCWs to administer injections	Permit = explicitly permits DCWs to administer injections; Prohibit = explicitly does not permit DCWs to administer injections; Silent = silent pertaining to injection administration by DCWs

AL, assisted living; CNA, certified nurse aides; DCW, direct care worker; LPN, licensed practical nurse; LVN, licensed vocational nurse; RC, residential care; RN, registered nurse.