Legislature(1999 - 2000)
05/06/1999 03:05 PM House HES
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* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
HB 16 - LICENSURE OF ASSISTED LIVING FACILITIES Number 0523 CO-CHAIRMAN DYSON announced the next order of business as House Bill No. 16, "An Act transferring to the Department of Health and Social Services the authority to license all assisted living facilities; eliminating the authority of the Department of Administration to license assisted living facilities; and providing for an effective date." Number 0537 REPRESENTATIVE ERIC CROFT, Alaska State Legislature, sponsor, came forward to present HB 16. He said HB 16 started as a simple idea but the issues got complicated in discussion. The simple idea of at separating the people who run the Pioneers' Home in the Department of Administration (DOA) from the licensing function came out of a report of the Long-Term Care Ombudsman regarding issues surrounding the Pioneers' Homes. That is all that HB 16 does, but it got them into a fascinating and long discussion about the role of assisted living facilities in the entire set of care facilities for elder Alaskans; how it evolved out of nursing homes; possibly some of its benefits; some of the growth it has had over the last ten years; how they should license them and how it should be changed; and whether the current licensing structure for assisted living homes is sufficient. Simply removing the potential for conflict of interest between an administrative function and a licensing function brought them into some of those issues. REPRESENTATIVE CROFT referred the committee to a chart in their packets labeled Assisted Living. The chart shows the structures of the Department of Administration and the Department of Health and Social Services (DHSS), and where the people are now who do this function, and where the bill would move them to and some of the issues that have been brought up. Assisted living facilities have grown tremendously in the last five to ten years and have prevented a mushroom growth in nursing home residences. In many ways, the assisted living model has advantages over the traditional nursing home model in terms of cost efficiency and service. It is a different vision of care and probably deserves a different licensing structure, which it has now. The chart shows only the assisted living licensing community. There will be a lot of discussion and work by the department this summer on rewriting the regulations for licensing assisted living facilities. The current situation has 1.5 people in the DOA, Division of Senior Services, Longevity Programs, handling licensing of assisted living facilities and one person in DHSS, Division of Mental Health. Most of the nursing home licensing is done in DHSS, Division of Medical Assistance, Health Facilities Licensing and Certification. The nursing home licensing is not shown on the chart. Number 0869 REPRESENTATIVE CROFT indicated that they are proposing consolidating these two areas into where nursing home licensing is now. The reason he didn't show the nursing home licensing on the chart is because it is a different community, has a different funding source, largely federal funds, and has a fairly large contingent of people. The assisted living licensing group is fairly small, probably adequate for the assisted living facilities they had five or ten years ago, but arguably not now. The original version of HB 16 consolidated the 2.5 people they have doing this function into Health Facilities Licensing, with a nominal low fiscal note to move them. The DHSS said in response to the original HB 16, they feel uncomfortable taking on this entire area of responsibility which has grown like a weed over five to ten years with the current people, some in DOA, some in Division of Mental Health. That is what he put in line 3 of the chart. The DHSS's response is about an $800,000 fiscal note to have the nine people that they feel is sufficient to do this job. Number 0956 CO-CHAIRMAN DYSON asked Representative Croft how many people in the DHSS are doing the licensing of nursing homes. REPRESENTATIVE CROFT answered he didn't know but referred that question to Elmer Lindstrom of DHSS. CO-CHAIRMAN DYSON asked if the DHSS came back and said they would need nine people to do the work that is presently being done by 2.5 people. Number 0988 REPRESENTATIVE CROFT answered yes. It was somewhat of a shock to get an $800,000 fiscal note for something he thought was simply moving 2.5 people. In deference to the DHSS, he doesn't feel that the fiscal note is fictitious or imaginary. The DHSS has been worried about the adequacy of this effort as it grows. CO-CHAIRMAN DYSON asked Representative Croft if the DHSS was using HB 16 as the vehicle for bringing the staffing up to where it should be. Number 1028 REPRESENTATIVE CROFT indicated that the DHSS is asking that if they consolidate it in a new place, that the legislature fund it at the appropriate level. Option four on the Assisted Living chart is the result of several months' work. The DHSS came back and said "Let's see what we can do," in light of the idea that all assisted living homes are not created equal. The licensing of the very largest ones, including the Pioneers' Home, probably has to have an intensity and frequency that is closer to the nursing home model, but slightly different in the amount of medical oversight. The oversight over a small home could be lighter and done in a "leaner and meaner" fashion. That mirrors to some extent the regulatory distinction that they were contemplating as a way to deal with this area. REPRESENTATIVE CROFT mentioned that because nursing home licensing is within Health Facilities Licensing now, there is at least a tendency for them to use the same intensive standard. If they put assisted living in with the nursing home licensing, they might accidentally get that same level, even in the smaller homes, and it might not be needed. It was suggested to distinguish between small and large assisted living homes. That is what he means by less than 16 and greater than 16 on the chart. They could have a different licensing structure for the small homes kept in the DOA and have the big homes licensed under Health Facilities Licensing in DHSS because they can do a lower intensity type of oversight; they don't need as many people as they did before, and they can do it for that much less. There is a range of possible approaches. Representative Croft wanted to bring it to the Health, Education and Social Services (HES) committee because there is growing concern over the state of assisted living facilities, their safety and the adequacy of the state oversight on it. Number 1202 REPRESENTATIVE KEMPLEN commented that he would be interested in seeing some statistics on how many people the state uses to license child care facilities. He wondered what type of administrative procedures were in place to ensure those facilities are "up to speed" in terms of their integrity and safety. Number 1307 ALISON ELGEE, Deputy Commissioner, Department of Administration, came forward to testify in support of the concept of HB 16. She agreed there is a lot of merit to consolidating the functions of assisted living licensing. The assisted living law that they are operating under today is five years old. They have learned a lot since its inception, but it was designed so that the DOA, Division of Senior Services, would license assisted living facilities that were providing care for the seniors throughout the state. The DHSS, Division of Mental Health and Developmental Disabilities would license those assisted living facilities providing service to the mental health and developmentally disabled community. Both departments license under the same set of regulations. MS. ELGEE explained that they have found that as the program has matured and expanded, they are sharing a number of the facilities that house both seniors and mental health consumers. The initial regulations envisioned an assisted living industry that was primarily made up of "mom and pop" operations so the regulations are geared toward the smaller homes. They are finding that they are not sufficient, or necessarily appropriate, for some of the larger homes. This summer the DOA and DHSS will begin to differentiate the licensing standards for the larger homes from their expectations of the smaller homes. There may be areas of the existing assisted living licensing statutes that they would also suggest modifying, and they are just beginning that work now. Number 1421 ELMER LINDSTROM, Special Assistant, Office of the Commissioner, Department of Health and Social Services, came forward to testify. He said currently, the Division of Medical Assistance, Certification and Licensing, certifies and licenses various types of facilities: acute care hospitals, nursing homes and home-health agencies. The licensing function for assisted living is split between the Division of Senior Services, DOA and the Division of Mental Health and Developmental Disabilities, DHSS. The licensing function is just one of the things that those staff do. They are not full time licensing people; they also provide technical assistance to assisted living facilities, some of the business planning, community development and are advocates for building the capacity of the assisted living industry. Assisted living didn't exist five years ago; now there are hundreds of these facilities that have been instrumental in keeping the pressure off the nursing home growth. MR. LINDSTROM referred to the large fiscal note from the DHSS. He said if the desire is to consolidate that licensing within Certification and Licensing, Division of Medical Assistance, they are not simply going to get the same thing at a much higher cost. If the licensing function for assisted living is centralized in Certification and Licensing, and if they were to adopt the fiscal note, they would be getting something very different that will cost more. It will be a more rigorous and different kind of licensure and inspection system. CO-CHAIRMAN DYSON asked if that was appropriate. Number 1556 MR. LINDSTROM answered their conclusion is, getting back to the differentiation between the smaller and larger facilities, it probably is appropriate. The Anchorage Pioneers' Home has 240 beds and while they would not inspect and license to the nursing home standard, nevertheless, that facility resembles the type of institutional care more like a nursing home rather than a "mom and pop" assisted living facility. They do believe it would be appropriate to bring more rigor and yes, it will cost significantly more. The narrative on the fiscal note will give them an idea of the type of rigor that will be brought to this. For facilities having 51 beds or more, which includes all the pioneers' homes, they would be averaging inspections that would last 4.5 days, and it would include a team of three or four staff persons from different disciplines, and that is not the kind of inspection going on today. He suggested that Shelby Larsen on teleconference could answer questions. Number 1663 MS. ELGEE clarified that there are two pioneers' homes that are under 50 beds. They acknowledge that they don't have the resources necessary today to rigorously enforce assisted living licensing the way they would like to. Presently they only do on-site licensing every other year. They agree that the bigger homes need to be visited and licensed on an annual basis, but with the existing level of resources, they cannot provide this now. Number 1701 REPRESENTATIVE GREEN asked whether the additional people would be brought on board or are they available now to review the licensing. MR. LINDSTROM answered that they are requesting a significant number of additional staff. They would for the most part be the same type of staff currently in Certification and Licensing. They would be cross trained with existing staff so they could mix and match on the inspections. Number 1736 REPRESENTATIVE GREEN is concerned that for approximately $1 million that is a lot of staff. He asked for Mr. Lindstrom's view on option 4 on the Assisted Living chart that cuts it in half. They are trying to cut bureaucracy, not add it. MR. LINDSTROM said the scenario described by the sponsor would cut the fiscal note by half. He feels they would have a much improved system. If they are going to do this, the DHSS would like to do it in a way that there will be greater assurance of safety in these facilities and more rigorous inspection of these facilities. They would be buying an improved system of surveillance and licensing for these facilities. REPRESENTATIVE GREEN asked what it is they will be doing that is more rigorous that requires more than what is being done now. Number 1869 MR. LINDSTROM answered that now the inspections are done once every two years. The certification and licensing people feel very strongly that the best and appropriate practice for these larger facilities is to have annual reviews, and that is a significant part of the difference. If they compare the time appropriate for assisted living facilities, it is still 40 or 60 percent of the intensity of the review that they would do for a nursing home. When they compare the standard to what they do under federal standards for nursing homes and acute care hospitals, it is significantly less intense than those inspections. A team of people goes into a hospital or nursing home and will spend a longer period of time than they are showing on assisted living homes. If they contrast it to the standard for acute care and nursing home, it is substantially less than that; the fiscal note is credible. Number 1947 REPRESENTATIVE KEMPLEN asked if there are national standards for assisted living facilities. MS. ELGEE said there has just been some work on the national level to develop assisted living standards, and she asked Kay Burrows to speak to that. Number 1973 KAY BURROWS, Director, Division of Senior Services, Department of Administration, testified via teleconference from Anchorage. She acknowledged that there are very recent standards that have come out in terms of quality. Nationally, assisted living is very new, as is the whole issue of licensing and regulatory standards. The things that have come out nationally did not have specific requirements in terms of regulatory (indisc.). However, it did acknowledge the need for a team of people, particularly in the larger assisted living homes, which is not how they currently do licensing in the division. Currently, they have a person who is qualified as a social worker and occasionally in the more difficult investigations, they will also use a nurse from their Medicaid waiver team. MR. LINDSTROM noted that the licensing and certification for the acute care hospitals and nursing homes are driven by federal standards, and he suggested that Shelby Larsen could speak to that. Number 2028 SHELBY LARSEN, Administrator, Health Facilities Licensing and Certification, Division of Medical Assistance, Department of Health and Social Services, testified via teleconference from Anchorage. He said there are federal regulations for Medicare certification for acute care hospitals and nursing homes and many other provider types which they certify. There are also licensure regulations for nursing homes as well. When they do a survey or inspection of a facility, they look at that facility in relation to both the federal and state requirements. REPRESENTATIVE KEMPLEN asked if the state is seeking to establish standards for assisted living which are not linked to any national standards. MR. LARSEN said he would imagine that the standards developed by a national association would be a guideline in how they would establish standards for assisted living facilities in Alaska. Different states have different concepts about what assisted living is so they would be tailored to the state's needs. Number 2117 REPRESENTATIVE KEMPLEN asked why the department feels there needs to be a linkage with these more rigorous licensing standards for assisted living when there is not agreement for these standards on a national level. He asked if there are documented instances of abuse that are occurring in Alaska's assisted living facilities now that warrant more rigorous licensing requirements. Number 2152 MS. ELGEE noted that the licensing is only the beginning of the activity of the people that are responsible for the licensure of these facilities. A major activity is complaint investigation. The more people in a facility, the more potential for complaint. It is the licensing people who will also do the complaint investigation for the facilities. When they started this process five years ago on the senior services side, they were licensing nobody. Today they license 90 homes throughout the state. This is quite an effort for the 1.5 people that they have dedicated to this. Number 2191 REPRESENTATIVE KEMPLEN said that it seems a case has not been made for this increased oversight of the assisted living facilities unless there is additional information that he is missing. Number 2218 MS. ELGEE said their concern is that the potential is there. They have not had any serious incidents that have resulted in the death of a resident in an assisted living home. They are concerned because of their lack of resources to address the entire licensure effort in a way that would assure them of quality of care and safety of the residents. Number 2243 MS. BURROWS said while they have been fortunate in not having any incidents, they are seeing a significant increase in the number and intensity of investigations. She mentioned a situation in Anchorage where she has had to involve several staff and send them out to some homes on at least four occasions, and they are still dropping in on a daily basis at least once or twice unannounced. They are seeing a need for professional oversight particularly in the larger homes with 16 beds or more. One consideration is to increase the standards for the larger homes, while to continue the current methods for the smaller homes. CO-CHAIRMAN DYSON asked Mr. Larsen if he felt that the organization that does the licensing and inspections should be different than the organization that runs and administrates a service. MR. LARSEN answered yes. He always has concerns when one organization has both program development and quality oversight within the same group. The direction it takes can often be influenced by the priorities that are established by the management. TAPE 99-52, SIDE B Number 2347 MR. LARSEN said if the priorities are established for program development, then they run a risk of not having or not putting enough resources into the quality oversight. From his perspective, it is better to have the programs separated. CO-CHAIRMAN DYSON asked Mr. Larsen if it makes sense to have the inspection and licensing of the variety of services that are provided for seniors in one organization. Number 2310 MR. LARSEN said there could be advantages to that. CO-CHAIRMAN DYSON asked Mr. Larsen if there were any disadvantages to having the senior licensing and inspection and quality control in one organization. Number 2299 MR. LARSEN said the main disadvantages would be if there were a lack of resources. The DHSS based the fiscal note on the assumption that an annual survey would be required. There are 225 assisted living homes, the 90 or so from Senior Services and rest from the Division of Mental Health and Developmental Disabilities. If they were to take that on, they would be looking at a considerable project from their perspective. Now they have 15 nursing homes that they do licensure for, which represents 720 beds, and their fiscal note, including the Medicare/Medicaid and state licensure, was slightly less than the fiscal note for HB 16. There would be an increase in the oversight, but it would still not be at the level of the nursing homes. Number 2225 CO-CHAIRMAN DYSON asked Mr. Larsen if it is too difficult for the inspectors to do highly intensive inspections in some facilities and do lower intensity inspections in others where it is not required. MR. LARSEN indicated that it could sometimes represent a challenge. They have about 16 different provider types that they either license or certify or both, and they all have their own sets of requirements so they are constantly shifting. He pointed out that they don't do the same kind of survey in outpatient physical therapy that they would do in a nursing home or hospital. Another concern is the medical model versus other models. They have had to shift from the medical model to behavioral model. The inspectors have had that experience. Number 2170 CO-CHAIRMAN DYSON asked Mr. Larsen if other states have privatized the licensing and inspection and oversight successfully. MR. LARSEN answered that he is not aware of any states that have privatized. He is only aware of those agencies in state government. Number 2129 REPRESENTATIVE GREEN did some figuring and came up with a figure of $1,300 per person per investigation day and wondered if that seems like too much. MR. LARSEN explained that there are other things to consider that might throw the fiscal note off like time on-site, time off-site in report preparation and communication with the facilities. The outside time was so they could calculate travel. REPRESENTATIVE GREEN wondered if after the initial review, would the following years' inspections require the same degree of review and discussion that could possibly happen in transferring over from DOA to DHSS. He wondered if there was a standard "go by" that would reduce this cost. The committee is extremely sensitive to these kinds of fiscal notes. He wondered if there was a possibility that they could do these reviews with a lot less money. Number 1959 MR. LARSEN said the initial survey that they do on acute care facilities is usually the easiest. The facilities have an idea of what they are supposed to do, they get everything ready, they get started and a year later the state returns, and it is totally changed. The first inspection is the easiest; the subsequent ones are more difficult. Number 1932 MS. BURROWS commented that the assisted living facilities actually see the opposite often times. The smaller homes often get into it with their heart instead of their head. They often have a lot of work to do up-front, and after a couple of years it slows down, and they have a level playing field unless there is a crisis. That is a difference between assisted living and some of the businesses that Mr. Larsen is used to. Number 1861 MS. ELGEE reiterated that they need to remember how new this industry is to the state and the nation. Some of the things they thought would initially work need modification, and that is why they are going to take on the regulatory review project this summer. Number 1834 CO-CHAIRMAN COGHILL said with the Long-Term Health Care Task Force recommendations that have come through this committee this year, they are going to have to sit down and look and see how all the issues interface. They have seen several licensing bills, and it will be important to see if they have connected them right. They want to work with the departments on this. Number 1811 REPRESENTATIVE KEMPLEN commented that he feels it would be premature to accommodate changes before the departments meet this summer to review their regulations. Perhaps it would be more appropriate to request the new staff after the review has been accomplished. He suggested that they have their regulatory review and then if they need legislation, they could come back and deal with this next session. It seems they should keep HB 16 as simple as possible. Number 1658 REPRESENTATIVE BRICE said that in the meetings this fall of the Alaska Caregivers Association, they were developing their own standards to ensure quality care of their clients. He asked what the departments have done in terms of being able to incorporate that idea or concept into the idea in HB 16. MS. ELGEE replied that they have just begun the process of setting up a work plan for the regulatory review they intend to do this summer, and they will be working very closely with industry. MS. BURROWS agreed they have just begun the discussion of what will help them toward looking at regulations this summer and any needed statute and regulatory changes. She expects that will include continuation of a public process with the assisted living home owners on standards and ethics. There is good national work being done. The General Accounting Office (GAO) has just released a federal report on assisted living, and they will be looking at that. They probably will be holding forums on a monthly basis throughout the state as they move towards creating a work plan. MS. BURROWS informed Representative Brice that the care coordinators are working closely with the state because they work closely with the assisted living industry as well. CO-CHAIRMAN COGHILL mentioned to Ms. Burrows that some of the committee members may be interested in attending their meetings. Number 1528 MR. LINDSTROM noted for the record that the child care facility licensing is not part of Mr. Larsen's business or involved in any way with the assisted living licensure. That responsibility currently rests with the Division of Family and Youth Services. There is pending legislation that would transfer that responsibility to the Department of Education as part of the restructuring bill. Number 1481 FRED LAU, Administrator, Homer Senior Citizens, Incorporated, testified via teleconference from Homer. They operate an assisted living facility apartment in Homer. He is encouraged by the discussion. If he had testified at the beginning, he would have testified against HB 16. The issues that have been brought up point out a need for further discussion. The states have different ideas about assisted living, and that is one reason why there are not national standards. Alaska is going to have to develop their own in this particular situation. MR. LAU doesn't agree with splitting the licensing by size of institution. The standards ought to be the same and perhaps have different tiers for size. One of the initial problems they had with this bill has to do with the model that is applied to assisted living. They are concerned that if the licensing is shifted to DHSS that the medical model would be what is applied. If this is the case, the cost of assisted living will go up. Assisted living came about to fill a gap, and it is providing an alternative for seniors, which is a lower cost than long-term care in the state. He agrees that HB 16 needs further discussions and offered to be involved. There are many issues that need to be addressed, and statewide standards is one issue they need to get on right away. CO-CHAIRMAN DYSON asked Mr. Lau if they have an association of providers. MR. LAU answered not now. The meeting they had in Anchorage was their first attempt to get together. They have set up a second meeting and that may be the beginning of forming a group and sitting down and discussing standards and regulations and all of these issues. Number 1293 CO-CHAIRMAN DYSON mentioned that the committee has been talking about work they might do during the interim. He asked Mr. Lau if they did get together and come up with some standards and so on, to let them know. MR. LAU said there are a couple organizations that belong to the assisted living affiliation, the Northwest Alaska group associated with the Assisted Living Federation of America (ALFA). That is an organization that has done some work on standards in other states, particularly in the northwest. REPRESENTATIVE GREEN asked Mr. Lau if there would be a potential to set up a "go by" that could reduce the cost evaluations. MR. LAU said he can't speak to the cost of each one of the divisions. Presently they are under a two-year review, however, they are being reviewed annually even now. He would think once the standards are established, that the cost could be reduced. Number 1151 FRANCIS PURDY, Long-Term Care Ombudsman, testified via teleconference from Anchorage. She spoke from a resident's standpoint. She applauded the committee for wanting to take a look at a change in regulations, but the issue of this legislation is not changing the regulations; it is just enforcing it on a consistent basis. The issue came up because residents are treated differently, based on how the regulations are enforced across the two departments and within the two departments, depending on which assisted living home it is. There is a perception, or an actual conflict of interest, depending on that home's relationship to the other programs within the division. From a resident's perspective, the solution would be to move the licensing to a neutral place where it is not entangled, or appears to be in conflict with other programs. That is the primary reason for supporting this legislation. MS. PURDY told the committee that she is working on a task force nationally to take a look specifically on why the changes are happening in assisted living. Now the movement is to merge assisted living licensing with nursing home licensing at least in the same department since nursing homes are moving away from just a medical model. They are looking at assisted living homes ranging from a total social model to an integrated social/medical model to everything in between. They are starting to see differentiation, not necessarily by type of facility, but by the corporate culture of the facility. The advantage of having assisted living home and nursing home licensing and home health licensing all with the same regulators is that they have the broad knowledge of everything what is needed in home services to what is needed in the most institutionalized form of delivery service, which is the nursing home. Number 0942 REPRESENTATIVE CROFT commented that he originally intended to just solve a perceived conflict of interest. There are a lot of people who fear if they move it into Health Facilities Licensing, the standards will be changed. He never intended to do that. The standards may need to be changed, re-evaluated, and that process can go on without him. He only meant a location change to solve a potential or real conflict of interest. He commented that it does not mean if the licensing functions are consolidated in the same area, that the same standards would have to be applied. REPRESENTATIVE CROFT referred the committee to other groups who support this but were not able to testify today: the Older Persons' Action Group, the Alzheimers' Association, the Alaska Caregivers' Association in North Pole, Marty Margeson (ph) who represents herself and her father who is in the Anchorage Pioneers' Home, and lot of pioneers' home groups. House Bill 16 has support in its general concept. Mainly the opposition comes from an assumption that he means to change the standards of licensing, and he truly does not, though he understands that may be a productive discussion. REPRESENTATIVE CROFT feels there is a problem when they have the same people running the facility saying every year they meet the minimum requirements. It creates a perception that it is not getting as thorough a review as it should. He does feel there is a qualitative and a quantitative difference between the bigger and smaller homes. That gets back into a standards discussion of should they have different licensing criteria for lesser homes. It may then be appropriate to move that licensing in a different area. That is what option four is on the Assisted Living chart. They should be able to consolidate with a small as possible increase in people and give a clear directive that this is not meant to assume that all of the heavy licensing requirements would be applied to assisted living facilities. He cannot seem to get around that with people, but it seems to him that they can consolidate without merging the standards. Number 0692 REPRESENTATIVE BRICE asked Representative Croft if this was part of the Long-Term Care Task Force recommendations. REPRESENTATIVE CROFT answered that this was one of the recommendations of the Long-Term Care Ombudsman. Number 0664 CO-CHAIRMAN DYSON asked Mr. Lindstrom and Ms. Elgee if they thought there were better or more appropriate ways to do this. Number 0623 MS. ELGEE answered that this is a conversation Commissioner Perdue had begun with her about trying to consolidate the licensing function for assisted living. They find that they are licensing under the same set of standards, the same kinds of homes, in some cases they are actually mixing the two populations that they represent in a single facility. Under those circumstances, they don't go in and license twice. As the industry has grown, they have found they will get people shopping for who is going to license. They feel there is real merit in combining the assisted living licensing function in a central location. They were not predisposed in that conversation as to where that might be. They had only begun the conversations. CO-CHAIRMAN DYSON noted that was an excellent and candid answer. He asked Ms. Elgee if she had done it on her own, would she have anticipated a fiscal note like the one given to HB 16. Number 0532 MS. ELGEE answered it was their intent, before they attempted to merge anything, to do the regulation review this summer so they would have a better idea of what they are faced with in terms of licensing expectations for small versus big homes, and then reassess the resource needs of how they would proceed. She felt they had to put something together right now based on what they know. By the end of the process this summer, they may be back supporting option four on the Assisted Living chart, which carries a different cost. At this point, they are not prepared to say that one approach is better than the other, but they will be by the time session begins next year. CO-CHAIRMAN DYSON asked Ms. Elgee if she felt that they are doing an adequate job of licensing and inspecting now. MS. ELGEE answered no. They feel that they are very resource poor in this area. One and a half people are not adequate under the best circumstances. They are presently licensing 90 facilities, and they are interested in being able to expand that. She doesn't know how they will cope with additional licensing responsibility. Frankly, the only reason it works right now is that most of the assisted living industry resides in Anchorage or Fairbanks. Number 0409 CO-CHAIRMAN DYSON asked anybody listening if they know if other jurisdictions have used third parties, or non-governmental organizations to do licensing and inspections. MS. PURDY answered that she queried all the states, and unless something has happened since December, there is no state that has privatized that function. CO-CHAIRMAN DYSON asked if they leave the departments alone and they go off to do this right, what is a reasonable time frame. Number 0330 MS. ELGEE answered that they hope to have this work completed on the regulation review and where they are headed by early fall, but she would not anticipate having brand new regulations in place at that point. They would hope to know what they were going to propose and also at that time have identified any statutory change that they would also want to have reviewed in this process. Number 0287 REPRESENTATIVE GREEN asked whether the assisted living homes are privately or publicly operated. MS. ELGEE replied that the only state-operated assisted living homes are the six pioneers' homes; all the rest are private. REPRESENTATIVE GREEN asked if there is any concept now of how close either the state-operated or privately operated facilities may be to meeting the standards. Number 0189 MS. ELGEE answered at this point she does not anticipate changes in the assisted living regulations that would subsequently result in increased cost to the pioneers' home operations. Because the pioneers' homes go beyond what assisted living regulations require, they really have an operation that is a hybrid of a nursing home environment and an assisted living environment today. They have some documentation that compares the licensing requirements of a nursing home and an assisted living home and shows where the pioneers' homes are in the context of those two licensing standards. REPRESENTATIVE GREEN asked what they are going to gain with the additional reviews. Number 0075 MS. ELGEE answered that nobody is perfect. There is always an opportunity for things to fall through the cracks, go unnoticed if they are not rigorous in the oversight. When they are dealing with vulnerable populations, it is important to be vigilant so they can assure the residents and the families that the residents are receiving quality care. REPRESENTATIVE BRICE mentioned that the Alaska Caregivers' Association in the interior have been working to develop specific standards of care. TAPE 99-53, SIDE A Number 0001 REPRESENTATIVE BRICE commented it would be interesting to find out where in the process the Alaska Caregivers' Association is now because they had some interesting insight. CO-CHAIRMAN DYSON asked Mr. Lindstrom and/or Ms. Elgee if many of the people being cared for are receiving federal or state monies to pay for their costs. Number 0060 MS. ELGEE answered that they have a variety of clients. The pioneers' homes have a rate schedule with the ability to pay. In the private assisted living homes, they will find private-pay clients, where the state has no involvement beyond the actual licensure of the home; they have clients on waivers: the Medicaid waiver for elderly Alaskans and the Medicaid waiver for adults with physical disabilities, who would be eligible for levels of nursing home care, but without an assisted living opportunity, they would most likely be in a nursing home. They also have the general relief clientele who are vulnerable adults who need a protective environment. They sometimes need assisted living services, their needs may not actually be to the level of a nursing home, but they are unable to live independently. CO-CHAIRMAN DYSON asked Ms. Elgee to estimate the percentage of Medicare/Medicaid reimbursement for the clients. Number 0189 MS. ELGEE answered that between the two waivers that they operate, the elderly Alaskan waiver has almost 600 people on it today, and the adult with physical disabilities waiver has just over 200 people out of a total population of 30,000 seniors in the state. CO-CHAIRMAN DYSON asked what the total of seniors are in out-of-home placement. MS. ELGEE couldn't answer that. CO-CHAIRMAN DYSON asked Ms. Elgee if the subsidized programs would allow for part of the rate structure to cover a part of the cost of providing a bed and services, and would it allow for the cost of the licensing and inspections to be a part of that rate. Number 0274 MS. ELGEE answered that they don't see the potential there to fully cover the cost, but Shelby Larsen could expand what he has looked at in terms of the potential for fees. Number 0299 MR. LARSEN answered that the fee collection for the way it is currently done would amount to about $35,000 per year, which is a long ways from covering the cost. CO-CHAIRMAN DYSON asked if the federal laws or regulations preclude them from recapturing the licensing and inspection costs from out of the federal funding stream. Number 0387 MS. BURROWS answered that the current waiver rate allows a portion of the administrative costs of fees be collected, but it doesn't currently allow enough so that it would meet the total cost of this fiscal note. In order to do that, they would be looking at the total population of about 760 or so people on waivers, 40 percent of them currently use assisted living. Whatever 40 percent of that is would be responsible for having sufficient fees to do all the inspections and regulations, and she doesn't think that would be feasible. CO-CHAIRMAN DYSON suggested that the committee continue this hearing until Tuesday. He would like to know if they charge the providers for the cost of the process they go through for licensing and inspection, what would be that figure per institution. He also asked if anyone knows of any jurisdiction that has penalized the care providers for failure to perform and/or rewarded them for excellence in this area of providing for senior care. Number 0577 REPRESENTATIVE KEMPLEN wondered if there is actually a successful model of voluntary self-regulating organizations out there providing social services. Number 0674 MS. BURROWS answered that there are a couple of commissions. The largest one is the Joint Commission on Accreditation of Healthcare Organizations, which has recently included home-health agencies for nursing homes and have been doing hospitals for a long time. That was set up on a private, nonprofit basis a type of review that is more peer review and certainly has that kind of caveat to it and charges big fees. The hospitals spend thousands of dollars on self-surveys done over a period of time. They do not at this time, nor any other to her knowledge, include assisted living, although they have been looking at assisted living. The work done by the Alaska Caregivers' Association did look at the quality piece of peer review that was their beginning attempts to not only set standards but to do their own kind of association peer review. The professional associations have tried to take this on. Number 0772 MS. PURDY said one of the difficulties of having the private organizations monitor is that it is based on the idea that the private sector can regulate what happens. That does not protect the individual resident. One of the problems of the joint commission is that it can recommend that the participating parties no longer be accepted, but that does nothing to the facility's ability to continue to operate. That means the individual residents may not know that there are individual problems, and that there is no limitation about the organization continuing to operate. The result is that the residents are not protected. Number 0840 REPRESENTATIVE CROFT said this bill was originally intended to take care of the risks that come along with self-regulation. The perception or reality of a conflict of interest is what they were trying to fix in government. The Department of Administration running the program and licensing it, to the extent that they try and fix it with business regulating itself, they have gone full circle to the problem again. It is difficult when the same organization both runs and monitors whether they are running sufficiently well. Those two functions probably need a separation. REPRESENTATIVE CROFT loved the idea of seeing if the federal funding stream could pay for some of the monitoring, they hadn't done that; they talked in terms of can the mental health pay for some of the mental health patients. They are not going to do that steadily; they might fund some of the research into redoing the regulations or reforming the system, but they are not going to be supplanting state money in this regard. The legislature could apply fees so that it pays for itself; but right now the assisted living people feel very strongly that they haven't had a raise in rates for a number of years, and what they are getting paid per bed is unconscionably low now. There is a bill in Senate Finance to raise those rates. MR. LINDSTROM said the proposed rates go from $35 to $50 for two fiscal years and then up to $75 in the third fiscal year. Number 0945 REPRESENTATIVE CROFT commented that that bill has about a $1.2 million fiscal note now and a steady state of between $3 million and $4 million later, and it is now stuck in Senate Finance. To tell the providers they aren't going to get a raise, instead they are going to charge the providers for the licensing, might not be well received. If they apply to that all the things they license, including hospitals and nursing homes, they could to some extent subsidize that pressure. The hospitals would want to say something about a great increase in the hospital inspection rate. Some of those ideas are not closed, they just have their own dangers. CO-CHAIRMAN DYSON suggested that the committee consider what they can do to facilitate this process. He encouraged the departments to figure out what needs to be done, the best way to do it, define what should be done, and set a time line for that. MR. LINDSTROM mentioned that they should expect to see a resolution for a continuation of the Long-Term Care Task Force. [HB 16 was held over.]
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