Because of Texas’s mild winters and hot summers, it’s no surprise that so many retirees flock to the state for its beautiful state parks, historical landmarks, outdoor activities, and easy access to cultural attractions. Although Texans have to pay substantially higher property and sales taxes, Texas is one of a few states that don’t collect any income taxes, making it more affordable than many people think. Individuals considering an assisted living community in Texas can use the following information to learn more about available options, the average cost of care, and how the state regulates long-term care facilities.

Assisted Living Facility (ALF) Definitions

The Texas Department of Aging and Disability Services licenses three different types of facilities. The department licenses single-occupancy apartments called assisted living apartments, double-occupancy apartments called residential care apartments, and residential care non-apartments.  

An assisted living facility is an establishment that provides, in one or more facilities, food and shelter to four or more people and provides personal care services, supervision, or direct administration of medications and other services. 

Adult foster care provides a living arrangement for up to three adults who cannot live independently in their homes due to physical, mental, or emotional limitations. The provider and residents must live in the same household and share a common living space. There can be no more than three adults living in the foster home, with the exception of family members.

The department gives three different licenses based on the ability of residents to evacuate the facility. All licenses for assisted living facilities are Type A, except for a facility that markets itself as providing care for persons with Alzheimer’s disease or similar disorders. This type of facility must be certified and have a Type B license. The Type C license is for an adult foster care facility with a fourth bed.

Resident Agreements and Disclosures

All residents must have a written agreement with the facility. This agreement must provide information on the services provided and the cost of those services.

Each assisted living facility must have a written policy regarding its admission criteria, the services they provide, the charges for these services, refund policy, aging in place, the normal staffing patterns over a 24-hour period, residents’ rights, and any other key rules and regulations. This disclosure must be explained and provided to each resident or their representative. If the facility provides services or supplies that Medicare may cover, this must be disclosed to the resident.

Assisted Living Admission and Retention

All residents must be “appropriate for the facility” based on the facility’s license type when they move in. If a resident is no longer deemed appropriate for the facility, they may not be retained. A resident admitted to a Type A ALF must be physically and mentally able to evacuate from the facility unassisted in the event of an emergency and must not require observation while they are sleeping. A resident in a Type B ALF may require assistance from staff to evacuate the facility in case of an emergency.

A facility cannot admit or retain individuals whose needs cannot be met by the facility or through a third-party service provider. The facility is responsible for all care, even those provided by outside resources.

Generally, residents are admitted and retained if they:

•  Exhibit mental or emotional disturbance symptoms but are not deemed a threat to themself or others. 
• Need assistance with mobility, bathing, dressing, or grooming.
• Need reminders to encourage toilet routines
• Need assistance or supervision with self-medication or administration of medications 
• Are incontinent without pressure sores

Type B facilities must provide their Alzheimer’s and dementia residents with activities encouraging self-expression, cognitive awareness, socialization, and physical activity. The activity programs must be planned and structured and must be appropriate for each resident’s abilities. These residents cannot be forced to participate in these activities. Those who do not must be offered the option to participate in a small group or one-on-one activity daily.

Service Planning

Within 14 days of admission, a comprehensive assessment of each resident must be completed. Based on the assessment, the appropriate staff completes an individual service plan which is documented on a form developed by the facility. This 14-day policy is required for all licensing types, including those licensed for Alzheimer’s and dementia care.

A resident can contract with licensed home and community support service agencies or a health care professional to deliver health care services at the facility.

Assisted Living Food and Dietary Provisions

All facilities must provide at least three balanced and nutritious meals each day. Meals must be served at regular times with no more than a 16-hour span between a substantial evening meal and the morning meal. Any therapeutic diet that has been ordered for a resident by their physician must be provided by the facility according to the resident’s service plan.

Assisted Living Staffing Requirements

Each facility must have a manager that is on duty for 40 hours per week and is responsible for managing one facility. Managers of small Type A facilities with at most 16 residents may manage up to four facilities. Managers of the small Type A facilities must be available by telephone when conducting facility business off-site and have a designated employee responsible in the manager’s absence. When residents are present in all facilities, a member of the direct care staff, known as an attendant, must be present in the facility.

There are no minimum staff ratios, but a facility must develop and implement staffing policies to fulfill all of the needs of the residents. The facility must have sufficient staff to

• Maintain order, safety, and cleanliness.
• Assist with resident medications.
• Prepare and serve meals that meet the requirements.
• Assist with laundry.
• Ensure each resident receives the supervision and care required to meet their needs.
• Ensure safe evacuation of the facility in case of emergency.

Night-time staff must be immediately available in small facilities and must be immediately available and awake in larger facilities. Regardless of the number of licensed beds, Type B facility night-time staff must be available and awake.

Type B facilities that provide care for residents with dementia must employ an activity director at least 20 hours a week if the facility has more than 17 residents.

Assisted Living Staff Training Requirements

All assisted living facility staff must receive a four-hour orientation before starting their job responsibilities. This orientation must include reporting abuse and neglect, the confidentiality of resident information, conditions that require notification to the facility manager, resident rights, emergency and evacuation procedures, and any other topic deemed appropriate for that facility.

All facility managers must complete a 24-hour course on the standards of managing an assisted living facility. The course must include information on the standards of assisted living, the characteristics of residents, resident assessment, skills necessary for working with residents, basic management principles, food and nutrition services, and federal laws covering assisted living. The managers must receive 12 hours of continuing education (CE) annually.  These CE hours must include at least two of the following:

• Resident and provider rights and responsibilities.
• Abuse and neglect.
• Confidentiality.
• All topics covered in the initial 24-hour course.

Direct care staff (attendants) must complete 16 hours of on-the-job training on topics related to providing care for residents. These topics include

• Assisting with ADLs.
• Resident health conditions and how they can impact the provision of tasks.
• Safety to prevent injury and accidents.
• Emergency first-aid procedures.
• Actions to take when a resident falls suffers a laceration or experiences a sudden change in physical or mental status.
• Behavior management.
• Fall prevention.

Attendants must complete six hours of annual continuing education. This education must include one hour on fall prevention and one hour on behavior management.  

Facilities that employ licensed or certified staff to assist with or administer medications must provide training that is appropriate for their job responsibilities.

All staff in Type B facilities that provide care for residents with dementia must receive four hours of dementia-specific orientation before starting job responsibilities. Direct care staff must receive 16 hours of on-the-job training and 12 hours of in-service competency training on Alzheimer’s disease. This training must be focused on providing appropriate assistance for residents with Alzheimer’s or some other form of dementia, including preventing aggressive behavior.

Assisted Living Housing Requirements

Private housing units are not required in Texas, but many facilities do provide them. For facilities that do not provide private units, a maximum of four people can share a room, and less than 50% of the beds may be in rooms with more than two residents. There must be one toilet, one sink for every six residents, and one tub or shower for every ten residents. There must be at least one toilet, sink, and bathing unit provided on each sleeping floor that is accessible to residents of that floor.

The Medicaid STAR+PLUS waiver program pays for services in three types of settings: single-occupancy AL apartments, residential care apartments, and residential care non-apartment settings.  

An assisted living apartment is single occupancy and must have a private space with individual living and sleeping quarters, a kitchen, a bathroom, and adequate storage space.  Upon request, double-occupancy apartments may be provided.

Residential care apartments are units with two bedrooms, each with a single occupant, a shared kitchen, and a bathroom. The kitchen must be equipped with a sink, refrigerator, cooking appliance that can be removed or disconnected, and a space for food preparation.

A residential care non-apartment setting has living units that do not meet the definition of an assisted living or a residential care apartment. Most facilities have double-occupancy rooms, while some may have rooms for up to four residents.

What Is Included With Assisted Living Care In Texas?

There are several requirements that each assisted living community must provide for its residents. The facility must offer both general observations and health supervision to assist in identifying each resident’s health condition and ability to function. The facility must assist residents with all ADLs and medication services and assess the need for medication attention or nursing services.

Assisted Living Medical Provisions

Residents who can self-administer medications must have the medications locked in their rooms and must be counseled monthly to determine the resident’s ability to continue medication self-administration.

For residents incapable of independently self-administering medication, facility staff must supervise self-administration. This supervision includes reminders to take medications at the prescribed time, opening containers and packages, replacing lids, pouring prescribed dosages, returning medications to the proper locked areas, obtaining medications from a pharmacy, and listing the medications taken on a resident’s medication profile record.

Staff members who assist in medication administration must be licensed to administer medications, hold a medication aide permit, or be a trained facility employee who an RN has designated.

Health Care Services

In Texas, ALFs must provide care and services in the resident’s care plan. This can include coordinating medical care and appointments. Communities may also deliver health services, with 56% of communities providing skilled nursing. Many have health care specialists and on-site services, with 42% of communities offering dental care. In addition, 60% of ALFs have hospice services.

Mental health issues are a growing consideration for communities, and services to address these concerns are becoming more common. In Texas, 83% of communities conduct depression screenings, and 51% offer mental health counseling. Social work programs are also found in 43% of ALFs. Social workers can provide counseling, conduct assessments, and help ensure residents can access all the resources they need.

Activities of Daily Living (ADLs) Assistance Services

A primary service of assisted living that benefits residents is receiving help with activities of daily living (ADLs). These are fundamental tasks that a person must do regularly to sustain life and general health, including toileting, bathing or showering, dressing, transferring (getting in and out of bed or a chair), ambulating (walking), and eating. Signs that a person may benefit from living in assisted living include increased isolation, loss of mobility, noticeable weight loss or gain, and/or neglecting household chores. 

Residents in Texas’s assisted living facilities often receive help with their ADLs. In Texas, 18% of residents need help with eating. Other commonly used services include bed transfer (30%), toileting (37%), and walking (66%). Caregivers in ALFs help 46% of residents dress and 58% of residents bathe.

Cost Of Assisted Living Care In Texas

The average cost of assisted living care in Texas is $3,998. This cost is $502 lower than the monthly national average of $4,500 per month. The cost of living in Texas is less than the national average by 7.9%, with health care costs less than the national average by 4.8% and housing costs less than the national average by 16.2%.

The level of care a person requires impacts the cost of care, as does where you live. The cost of assisted living ranges from a low of $2,770 in the Texarkana area to a high of $5,600 per month in the Victoria area of Texas.

How Costs Compare In Nearby States

If you live close to one of Texas’s borders, you may find assisted living in a neighboring state is an affordable option. One of Texas’ neighboring states has a higher average monthly cost.  Arizona averages $4,000 a month.  Oklahoma has an average monthly cost of $3,855, Arkansas averages $3,760 and Louisiana averages $3,748 per month.

How to Pay for Assisted Living

Texas Assisted Living Oversight

Texas Health and Human Services oversees the state’s assisted living communities. The Office of the Independent Ombudsman for State-Supported Living Centers ensures it upholds the rights of long-term care residents. The ombudsman advocates for residents and investigates and resolves complaints of neglect or abuse.

Legal Resources

The Texas Legal Services Center provides free legal advice to low-income seniors, including people with limited resources. The center provides legal services in elder law, consumer law, pensions, and benefits.

The Texas State Law Library maintains a list of legal assistance organizations in the state. Those who qualify can receive free or low-cost general legal assistance, including legal advice, legal representation, and legal clinics.