Sponsor
This work was supported by the National Institute on Aging (grant 7RF1AG082308-02) and the 2026 Johns Hopkins School of Nursing Discovery & Innovation Fund.
Published In
Journal of the American Medical Directors Association
Document Type
Pre-Print
Publication Date
10-2026
Subjects
Life care communities -- United States -- Management
Abstract
Objectives
To characterize assisted living (AL) direct care worker (DCW) training requirements across the United States and how these regulations have changed over time. Specifically, we examine state-level profiles of training regulations, including duration, frequency, content, source of materials, evaluation, and changes in regulatory coverage.
Design
Cross-sectional and longitudinal descriptive study using state policy data and AL directories from 2019, 2021, and 2023.
Setting and Participants
All US states' AL training–related regulations; all ALs and AL beds governed by those regulations.
Methods
We used a mixed-methods approach with an explanatory sequential design (QUAN → qual), first conducting health services regulatory analysis followed by qualitative content analysis.
Results
In 2023, 43 states (90% of ALs, nationally) required DCW training, 29 states required annual training frequency, 28 states specified training hours (median 10 hours), 28 required dementia-specific content, and 29 required training to cover at least 5 topics when onboarding. Common training topics included resident rights, emergency response, infection control, and personal care; dementia-specific training topics included Alzheimer's disease, behavior, communication, and dignity of residents, with only 2 states requiring training that addressed DCWs' well-being. Ten states mandated use of professionally designed courses, and 5 states required DCWs to complete an exam. From 2019 to 2023, 6 states made changes to the scope of dementia-specific training.
Conclusions and Implications
While most states mandate DCW training and over half require annual frequency, duration, and cover 5 topic areas, few states specify sources of training materials or require competency checks. Lack of specificity in training requirements requires AL operators to determine what constitutes adequate training for DCWs to be successful. To better prepare the AL workforce for growing resident complexity, policymakers should consider promoting specific training requirements that ensure both onboarding and continuous education for DCWs, particularly around dementia care and workforce well-being.
Rights
© Copyright the author(s) 2026
Locate the Document
DOI
10.1016/j.jamda.2026.106445
Persistent Identifier
https://archives.pdx.edu/ds/psu/45159
Citation Details
Published as: Carder, P. P., Smith, P. L., Yakusheva, F. O., Beeber, F. A., Jutkowitz, P. E., & Thomas, B. K. S. (2026). A Profile of Assisted Living Direct Care Workforce Training Requirements Across the United States. Journal of the American Medical Directors Association, 27(10), 106445.
Supplement
Description
This is the author’s version of a work that was accepted for publication. Changes resulting from the publishing process, such as peer review, editing, corrections, structural formatting, and other quality control mechanisms may not be reflected in this document. Changes may have been made to this work since it was submitted for publication. A definitive version was subsequently published as: Carder, P. P., Smith, P. L., Yakusheva, F. O., Beeber, F. A., Jutkowitz, P. E., & Thomas, B. K. S. (2026). A Profile of Assisted Living Direct Care Workforce Training Requirements Across the United States. Journal of the American Medical Directors Association, 27(10), 106445.