Legislature(2005 - 2006)CAPITOL 106


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03:35:59 PM Start
03:37:06 PM HB193
05:11:47 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
Heard & Held
+ Overview of School Cost Differential TELECONFERENCED
<Overview Canceled>
+ Bills Previously Heard/Scheduled TELECONFERENCED
HB 193-LICENSING MEDICAL OR CARE FACILITIES                                                                                   
CHAIR  WILSON announced  that  the first  order  of business  was                                                               
HOUSE  BILL   NO.  193  "An   Act  relating  to   the  licensing,                                                               
regulation,   enforcement,  and   appeal  rights   of  ambulatory                                                               
surgical centers,  assisted living homes, child  care facilities,                                                               
child  placement  agencies,  foster  homes,  free-standing  birth                                                               
centers,  home health  agencies, hospices  or agencies  providing                                                               
hospice  services, hospitals,  intermediate  care facilities  for                                                               
the  mentally  retarded,  maternity  homes,  nursing  facilities,                                                               
residential  child   care  facilities,   residential  psychiatric                                                               
treatment  centers,   and  rural  health  clinics;   relating  to                                                               
criminal history requirements, and  a registry, regarding certain                                                               
licenses,  certifications, approvals,  and authorizations  by the                                                               
Department  of  Health  and Social  Services;  making  conforming                                                               
amendments; and providing for an effective date."                                                                               
3:37:06 PM                                                                                                                    
REPRESENTATIVE  CISSNA moved  to adopt  the committee  substitute                                                               
(CS)  for HB  193, Version  24-GH1016\F, Mischel,  4/19/05, as  a                                                               
work draft.   There being no objection, Version F  was before the                                                               
RICHARD  MANDSAGER, M.D.,  Director, Division  of Public  Health,                                                               
Department  of Health  and Social  Services, explained  the added                                                               
change  on page  8  of CSHB  193, following  line  16, where  the                                                               
Department  of  Health  and  Social  Services  is  added  as  the                                                               
administrative  hearing  entity  for   hearings  related  to  the                                                               
centralized registry.   He  explained that on  page 14,  line 21,                                                               
the  word "volunteer"  is added;  volunteers are  subject to  the                                                               
registry  when they  have an  ongoing, unsupervised  relationship                                                               
with a  client.   He pointed out  that on page  14, line  23, the                                                               
word "decisions"  was added.   On page  14, line 27,  he related,                                                               
there is  the addition of  defined medical assistant's  fraud, so                                                               
an entity, provider, or employee  that commits medical assistance                                                               
fraud is included in the registry.                                                                                              
REPRESENTATIVE  CISSNA  inquired  as  to how  the  registry  will                                                               
function with  the high turnover  rates that are  associated with                                                               
human service workers.                                                                                                          
DR.  MANDSAGER  rephrased  Representative Cissna's  question,  "I                                                               
think  what you  are  asking is:   ...'If  they  change jobs  ...                                                               
annually,  for a  while, for  some reason  or another,  how often                                                               
does this whole process have to be gone through?'"                                                                              
3:41:54 PM                                                                                                                    
STACIE KRALY, Senior Assistant  Attorney, Human Services Section,                                                               
Department  of   Law,  said  that  she   envisions  a  regulatory                                                               
provision or waiver such that  the same background check could be                                                               
used when the timeframe between jobs is relatively short.                                                                       
DR.  MANDSAGER  explained  that  on  page  15,  line  12,  a  new                                                               
subsection was  added to  ensure that  reporting occurs  if there                                                               
have been any episodes within the past 10 years.                                                                                
CHAIR WILSON asked for an example.                                                                                              
MS. KRALY said:                                                                                                                 
     the  concept  for  this  provision   was  ...  for  the                                                                    
     centralized  registry ...  an individual  who had  been                                                                    
     ... terminated from employment 20  years ago, we wanted                                                                    
     ...  a  time sensitive  period  with  respect to  these                                                                    
     findings that  would allow for a  good, current picture                                                                    
     of an individual ... if  we're going to go back further                                                                    
     than 10  years we felt  that, like, under  the criminal                                                                    
     registry ...  there's a  discretionary and  a mandatory                                                                    
     bar,  depending on  how old  the offense  is.   We felt                                                                    
     that 10 years was an  appropriate time to look at these                                                                    
     sort of civil abuse issues  to determine whether or not                                                                    
     they should be included on the registry.                                                                                   
MS. KRALY further explained :                                                                                                   
     The  premise of  the ["24  hours"] is  that as  soon as                                                                    
     there is  an allegation  of harm  or a  termination ...                                                                    
     the department  [would] be advised  of that.   The name                                                                    
     doesn't   go  on   the  registry   until  all   of  the                                                                    
     adjudicatory due process provisions  have been met, but                                                                    
     that we would be provided  immediate notice ... we just                                                                    
     wanted things  to get  moving quickly  to afford  a due                                                                    
     process as quickly as possible.                                                                                            
DR. MANDSAGER mentioned  that page 15, line  23, establishes that                                                               
information in the  registry is confidential.   He explained that                                                               
there  is  the  opportunity  to create  access  to  the  registry                                                               
through using a  password, so that the process  is electronic and                                                               
does not require staff.                                                                                                         
DR.  MANDSAGER said  that there  is a  clarification of  immunity                                                               
protections on page 15, line  28, following [Subsection (i)] such                                                               
that  one making  a  report  is not  subject  to  liability.   He                                                               
     Page 16,  line 18,  defines the phrase  "entity," which                                                                    
     is used  in this bill  ....  There's one  other element                                                                    
     in  here  that was  suggested  by  the Municipality  of                                                                    
     Anchorage, in  the Senate hearing  last week,  and it's                                                                    
     on page  23, line 19  ... this  was a concern  that the                                                                    
     bill  was not  explicit as  current  law is  that if  a                                                                    
     municipality with  "home rule" powers wants  to take on                                                                    
     child care licensing authorities  it would be clarified                                                                    
     that they can  do that ....  This makes  clear that the                                                                    
     powers in current statute are continued into this.                                                                         
DR.  MANDSAGER  said  that Anchorage  licenses  approximately  50                                                               
percent of  the child care entities  in the state.   He explained                                                               
that  the  aforementioned  amendment entitles  municipalities  to                                                               
this power of licensing.                                                                                                        
3:47:01 PM                                                                                                                    
REPRESENTATIVE KOHRING  inquired as to the  possibility of moving                                                               
HB 193  out of  the House Health,  Education and  Social Services                                                               
Standing Committee.                                                                                                             
CHAIR WILSON  stated that she has  not read the entire  bill, and                                                               
would like to do so before moving it out of committee.                                                                          
REPRESENTATIVE CISSNA  began discussion  of Amendment  1, labeled                                                               
24-GH1016\G.2, Mischel, 4/19/05, which  [she offered on behalf of                                                               
herself  and   Representative  Anderson].     Amendment   1  read                                                               
[original punctuation provided]:                                                                                                
     Page 1, line 9, following "Services;":                                                                                   
          Insert "relating to public assistance for health                                                                    
     facilities and assisted living  homes, to rates charged                                                                  
     by an  assisted living  home, and  to the  liability of                                                                  
     recipients of  home or community-based services  to pay                                                                  
     for those  services; relating to expansion  of optional                                                                  
     Medicaid  coverage and  to medical  assistance coverage                                                                  
     for companion services"                                                                                                  
     Page 15, following line 29:                                                                                                
          Insert new bill sections to read:                                                                                     
        "* Sec. 20.  AS 47.07.070(a) is amended to read:                                                                    
          (a)  Except as provided under (d) - (f) of this                                                                   
     section,  the [THE]  department  shall, by  regulation,                                                                
     set rates  of payment for health  facilities under this                                                                    
     chapter  and  AS 47.25.120  - 47.25.300  in  accordance                                                                    
     with 42  U.S.C. 1396  (Title XIX, Social  Security Act,                                                                    
     Medical   Assistance)   and   this  section.   A   rate                                                                    
     established  under  this  section  takes  effect  under                                                                    
     AS 44.62 (Administrative  Procedure Act) but  not until                                                                    
     approved   in   writing   by  the   commissioner.   The                                                                    
     commissioner  may  delegate  the performance  of  these                                                                    
        * Sec.  21.  AS 47.07.070  is amended by  adding new                                                                  
     subsections to read:                                                                                                       
          (d)  For residential support living services                                                                          
     provided   to   an   eligible  recipient   of   medical                                                                    
     assistance living  in an assisted living  home licensed                                                                    
     under  AS 47.33, the  minimum daily  reimbursement rate                                                                    
     to  the  assisted  living  home   for  room  and  board                                                                    
     expenses is $28.                                                                                                           
          (e)  The department may not establish a maximum                                                                       
     daily rate  for room and  board expenses charged  by an                                                                    
     assisted living home.                                                                                                      
          (f)  A calculation of the rate for administrative                                                                     
     and  general   costs  for  a  provider,   including  an                                                                    
     assisted living  home, shall be determined  in the same                                                                    
     way as a calculation  of the administrative and general                                                                    
     cost rate  for a Pioneers'  Home.  In  this subsection,                                                                    
     "administrative   and   general  costs"   means   those                                                                    
     expenses that are common to  the overall operation of a                                                                    
     provider  providing  home  and  community-based  waiver                                                                    
     services  and that  are not  directly assignable  to or                                                                    
     borne by a specific program  or recipient of a home and                                                                    
     community-based service.                                                                                                   
        * Sec. 22.  AS 47.07.030(c) is amended to read:                                                                       
          (c)  Notwithstanding (b) of this section, the                                                                         
     department shall  [MAY] offer  a service for  which the                                                                
     department  has  received  a waiver  from  the  federal                                                                    
     government if the  department was authorized, directed,                                                                    
     or requested  to apply for  the waiver  by law or  by a                                                                    
     concurrent or  joint resolution of the  legislature and                                                                
     the  service  will  result  in   cost  savings  to  the                                                                
     department by allowing an  eligible recipient who would                                                                
     otherwise require institutional care to live at home.                                                                  
        * Sec. 23.  AS 47.07.030  is amended by adding a new                                                                  
     subsection to read:                                                                                                        
          (e)  The department shall apply for a waiver                                                                          
     under (c) of this  section and offer companion services                                                                    
     in a recipient's  home to an eligible  recipient to the                                                                    
     extent that  the companion  services are  necessary and                                                                    
     will result in cost savings  to the department over the                                                                    
     provision  of  institutional  care for  the  recipient.                                                                    
     Companion   services   may   be  covered   under   this                                                                    
     subsection  for nighttime  care.   In this  subsection,                                                                    
     "companion    services"    means    nonmedical    care,                                                                    
     supervision,   and   socialization    provided   to   a                                                                    
     functionally  impaired  adult   in  accordance  with  a                                                                    
     therapeutic goal in the recipient's plan of care."                                                                         
     Renumber the following bill sections accordingly.                                                                          
     Page 39, following line 31:                                                                                                
          Insert a new bill section to read:                                                                                    
        "* Sec. 52.  AS 47.07.070(c) is repealed."                                                                          
     Renumber the following bill sections accordingly.                                                                          
     Page 40, following line 9:                                                                                                 
          Insert a new bill section to read:                                                                                    
        "*  Sec. 56.   The  uncodified law  of the  State of                                                                
     Alaska is amended by adding a new section to read:                                                                         
          REGULATIONS ANNULLED.  7 AAC 43.1058(j) and 7 AAC                                                                     
     43.1058(k)(1)(B) are annulled."                                                                                            
     Renumber the following bill sections accordingly.                                                                          
     Page 45, following line 3:                                                                                                 
     Insert a new bill section to read:                                                                                         
        "*  Sec. 64.   The  uncodified law  of the  State of                                                                
     Alaska is amended by adding a new section to read:                                                                         
          RETROACTIVITY.  Sections 20 and 21 of this Act                                                                        
     are retroactive to June 26, 2004."                                                                                         
     Renumber the following bill sections accordingly.                                                                          
     Page 45, line 4:                                                                                                           
          Delete "Sections 51, 54, and 56"                                                                                      
          Insert "Sections 20, 21, 57, 60, 62, and 64"                                                                          
     Conform all  internal bill  section references  on page                                                                    
     40, lines 13,  15, 16, 18, 19, 21, and  24; on page 41,                                                                    
     lines 3, 14,   and 21 -  23; on page 42, lines  3 - 15,                                                                    
     20, 26,  and 29; on  page 43, lines  8, 9, 11,  13, 14,                                                                    
     19, 22, 24, and 28; page  44, lines 24, 25, and 28; and                                                                    
     on page 45, lines 3 - 10.                                                                                                  
REPRESENTATIVE CISSNA explained that  the Amendment 1 would apply                                                               
to the  rates charged and to  the liability of the  recipients of                                                               
the home  as well as providing  community-based services, at-home                                                               
health  care, and  companion services  if it  is a  cost savings.                                                               
She  opined  that  this  could   provide  an  incentive  for  the                                                               
department to  look into cost  savings related to  keeping people                                                               
in their homes.                                                                                                                 
3:50:52 PM                                                                                                                    
DR. MANDSAGER  notified the  committee of a  change added  on the                                                               
companion bill  to HB 193  in the  Senate that allows,  "a person                                                               
that is coming to pick-up or  visit a child-care facility to have                                                               
an unloaded  firearm in a locked  or covered case ....   Since we                                                               
haven't  provided  amendment language,  I  am  proposing that  we                                                               
would provide  that to  the next committee  after it  leaves here                                                               
....   I suppose we  could bring it here  too, just so  the bills                                                               
stay the same, as much as possible on both sides."                                                                              
CHAIR WILSON  stated the  she would  like to  take Representative                                                               
Cissna's amendment  and divide  it into  sections, and  adopt the                                                               
amendment section by section.                                                                                                   
3:53:56 PM                                                                                                                    
REPRESENTATIVE  ANDERSON offered  that Representative  Cissna had                                                               
moved Amendment 1,  and thus with an objection  Amendment 1 could                                                               
be discussed  section by section.   He said this  would eliminate                                                               
the creation of multiple amendments.                                                                                            
CHAIR WILSON objected  and stated that Amendment 1  will be dealt                                                               
with  as she  originally suggested.    She referred  to page  15,                                                               
following  line 29  and highlighted  the  new sections,  Sections                                                               
The committee took an at-ease from 3:56:47 to 4:00:52.                                                                          
4:01:07 PM                                                                                                                    
AMY  ONEY,   Co-Owner/Operator,  Mama's  Assisted   Living  Home,                                                               
explained that last  year, the Division of Senior  Services put a                                                               
cap on  the room and board  rates that the assisted  living homes                                                               
could collect from their residents.   The cap was set at $18.54 a                                                               
day,  she  related.    She emphasized  that  her  program  cannot                                                               
provide service for that amount of money.  She continued:                                                                       
     So, what this amendment has  done:  ... it's rolled the                                                                    
     clock back to  go back into those  ... regulations that                                                                    
     were passed  last year,  and it's given  us $28  a day,                                                                    
     minimum -  which is  what we  had before  - and  it has                                                                    
     taken their  ability to  put a  maximum rate  on there.                                                                    
     ...   If  they had  more income  than that,  that still                                                                    
     qualified for the Medicaid waiver,  they kept the $100,                                                                    
     and we  were able to  collect room and board  above the                                                                    
     $28, if those people had those resources.                                                                                  
MS.  ONEY,  in   response  to  a  question   from  Chair  Wilson,                                                               
     We actually  provide the service, so  what would happen                                                                    
     is, every  month when people get  their ... entitlement                                                                    
     checks, they  are entitled to keep  $100 and, depending                                                                    
     on  the  contract  that  the  home  created  with  that                                                                    
     resident, they were allowed to  keep a minimum of $100.                                                                    
     The  home could  charge  whatever room  and board  rate                                                                    
     they  needed   to  survive,   and  that   resident  was                                                                    
     guaranteed at  least $100 to  live on for the  room and                                                                    
     board side.                                                                                                                
     ... Our waiver  reimbursements do not cover  any of the                                                                    
     food  expense;  they  don't  cover   our  rent.    They                                                                    
     delegate certain percentages out -  ... I think it's 22                                                                    
     percent of  our wages  have to paid  by room  and board                                                                    
     money.  Our utilities, our  home maintenance - any kind                                                                    
     of  ... expenses  that we  didn't put  into our  budget                                                                    
     that   wouldn't   have   been   covered   by   Medicaid                                                                    
     reimbursement - we have to  cover out of room and board                                                                    
     monies.   And by them putting  on a cap for  $18.54 per                                                                    
     day on what we're allowed  to collect per resident, per                                                                    
     day, if they have any more  money than that, we have to                                                                    
     pay it  back to the  state now.   We have to  short our                                                                    
     Medicaid  reimbursements  by  whatever  amount  they're                                                                    
     above  the  minimum, so  that  every  single person  in                                                                    
     assisted living right now is  supposedly supposed to be                                                                    
     paying ... a total of $564  a month.  And that's all we                                                                    
     get  per resident,  per  month to  pay  these room  and                                                                    
     board expenses.                                                                                                            
MS. ONEY detailed the room  and board expenses for her operation.                                                               
In  response to  a question  from  Chair Wilson,  she listed  the                                                               
amount of  money each of the  four homes she and  her husband run                                                               
are  losing  per month  since  the  cap  was incurred:    $2,400,                                                               
$2,000, $1,670, and $2,888.                                                                                                     
4:07:05 PM                                                                                                                    
MS. ONEY, in response to  a question from Representative Gardner,                                                               
said the  home that is  losing $2,888  has five residents  in it.                                                               
She said  each home's expense requirements  differ depending upon                                                               
property values, expenses, utilities, and resident needs.                                                                       
REPRESENTATIVE GARDNER proffered:                                                                                               
     I think I  have the number worked out,  which is $5584.                                                                    
     And I think  it probably is fair to  say the difference                                                                    
     in  cost between  you running  your  home and  somebody                                                                    
     running a private  home for 5 people is  that they have                                                                    
     to   provide    staff   for   them,   as    well,   and                                                                    
     transportation.   ...  That's  calculated:   ... $18.56                                                                    
     times 5  people, is $92  a day  for 5 people,  times 30                                                                    
     days in the  month, the cost would be  $2,784, and then                                                                    
     she's losing  $2800.  So,  in round numbers,  the cost,                                                                    
     then, for  running that  home is  $5584, for  5 people,                                                                    
     which is  ... $1100  a month.   So,  if you  think, for                                                                    
     those kinds of services, for  $1100 a month, that's not                                                                    
     an outrageous amount of money.                                                                                             
MS. ONEY related  that because of the budget, as  a result of the                                                               
Medicaid waiver,  she has  to pay  her staff  much less  than the                                                               
staff of the Pioneer Home is paid.                                                                                              
4:09:55 PM                                                                                                                    
REPRESENTATIVE MCGUIRE  suggested that Ms. Oney  could go through                                                               
the costs  associated with  the operation  of an  assisted living                                                               
MS. ONEY  explained that her  homes serve a  population including                                                               
elderly with dementia and disabled  adults.  She pointed out that                                                               
her homes  provide 24-hour care,  including three meals  per day,                                                               
plus snacks.                                                                                                                    
MS.  ONEY stated  that  room and  board  expenses, with  Medicaid                                                               
waiver clients, are  separated out from services.   She explained                                                               
that  when  she goes  to  the  Medicaid  waiver people  with  her                                                               
budget,  they  tell  her  what  they will  cover  for  service  -                                                               
providing  physical hands-on  care, versus  the time  spent doing                                                               
laundry, cleaning, rooms, and food preparation.  She continued:                                                                 
     So, what  they do  is they take  a random  analysis and                                                                    
     say, "Okay,  we're going  to pay  ... 78  percent under                                                                    
     the cost  of care of  your wages,  or any of  your wage                                                                    
     expense ...."   But since you get room  and board money                                                                    
     from the  residents, you have  to pay them out  of this                                                                    
     other coffer over here; you  have to provide 22 percent                                                                    
     of  those employee  wages  out of  the  room and  board                                                                    
     expenses.  And when you  have a 24-hour staff ... [paid                                                                    
     at] $11 an hour, you can  imagine that, out of $18.64 a                                                                    
     day, it  takes, I think,  two clients just to  pay your                                                                    
     22 percent  [for] your staff just  to be in the  home -                                                                    
     and that's only  if you have one person on  staff.  But                                                                    
     a couple homes, including two  of mine, have two people                                                                    
     on  during the  day,  so  that significantly  increases                                                                    
     that  amount  of that  22  percent  of your  employment                                                                    
MS. ONEY  said Medicaid considers the  layout of the home.   They                                                               
do  not  pay the  percentage  of  rent for  bedrooms,  bathrooms,                                                               
kitchens, or laundry facilities.   She explained, "So, if ... you                                                               
have  a   five-bedroom  facility,   you'll  lose  more   of  your                                                               
reimbursement, because  more of  your floor plan  is taken  up by                                                               
bedroom  space."   She indicated  that the  amount that  Medicaid                                                               
does  not cover  for those  areas is  35 percent;  therefore that                                                               
money must  come out of  room and board  monies.  She  noted that                                                               
food expenses in  the average home is $1,000 a  month.  She said,                                                               
"So, you  can see, if  you're spending two person's  allowance on                                                               
your food  allowance and over  two people on your  wages, there's                                                               
no money  left over to  make up  these other expenses  that we're                                                               
supposed to cover."  For those  who have owner occupied homes, in                                                               
which  the owners  live on  the premises,  Medicaid excludes  the                                                               
personal space  before doing  the allocations.   For  example, if                                                               
there is a  1,000 square foot home and 200  square feet belong to                                                               
the  owner,   then  Medicaid's  calculations  would   be  on  the                                                               
remaining 800 feet.                                                                                                             
CHAIR WILSON inquired as to Ms.  Oney's opinion as to whether the                                                               
aforementioned calculation is fair.                                                                                             
MS. ONEY related:                                                                                                               
     I don't think  it's correct in basing it  on the square                                                                    
     foot ... because most of the  care we do takes place in                                                                    
     their own personal bedrooms.   So, to exclude that from                                                                    
     personal care space,  just in order to  shift the funds                                                                    
     over and  make us pay  that, the allocation  formula is                                                                    
     off, because  the care is being  provided, the Medicaid                                                                    
     portions of  our contracts with those  people are being                                                                    
     provided in  the bedroom.  They're  also being provided                                                                    
     in  the kitchen,  when  we do  special  diets based  on                                                                    
     their medical needs,  and ... when we have  to cater to                                                                    
     each one  - even  if it's the  littlest things  as they                                                                    
     have no  teeth and they  can't chew harder foods  - the                                                                    
     extra  time preparation  is actually  caring for  them,                                                                    
     not necessarily just feeding them ....                                                                                     
MS. ONEY, after hearing Chair Wilson's question repeated, said                                                                  
she thinks it's fair to exclude personal space.  She continued                                                                  
as follows:                                                                                                                     
     What  this actually  addresses is  the  balance of  our                                                                    
     budget that's  allocated by the  personal space  of the                                                                    
     residents.    And so,  when  we  have, say,  a  $10,000                                                                    
     budget  a month  ...,  and  they say  half  of that  is                                                                    
     personal  space and  room and  board cost,  we have  to                                                                    
     come  up  with -  from  the  resident's contribution  -                                                                    
     $5000  a month  to meet  our $10,000  budget.   And so,                                                                    
     what this ... amendment does,  is it prevents them from                                                                    
     limiting that.   Because even if you ...  make the $564                                                                    
     a month that they capped it  at, [and] you round it off                                                                    
     to   $500,   you're   looking  at   the   maximum   ...                                                                    
     contribution to  the homes on  the room and  board side                                                                    
     of ... a  5 bed home, you're looking at  $2500.  That's                                                                    
     what they've  limited us to  collect.  They  prevent us                                                                    
     from  going to  the homes.   If  we want  to provide  a                                                                    
     better quality home  and we wanted to  ask the families                                                                    
     for help, they  have prevented us from doing  that.  We                                                                    
     cannot go to  the families to have  them participate in                                                                    
     increasing  the level  of care  of  ... the  residents.                                                                    
     They have maximized  what we can do, and  they've put a                                                                    
     maximum on  it at an  amount that doesn't work.   We're                                                                    
     sustaining  these  losses  that we've  sustained  since                                                                    
     last year,  just so  that we could  be here  before you                                                                    
     this year.   We've  been working  with [Representatives                                                                    
     McGuire,  Anderson, and  Cissna]  ...  on these  issues                                                                    
     ever since  the regulations passed last  year, and they                                                                    
     [assured] us,  "Hang on  there ...."   So, this  is our                                                                    
     hanging  on, saying,  "We've  done it  for  a year,  we                                                                    
     can't do it  for another year; we  can't continue these                                                                    
     losses."    By  having  us operate  at  a  home,  we're                                                                    
     personally  supplementing the  [Division of  Senior and                                                                    
     Disabilities  Services]  DSDS   budget,  because  these                                                                    
     people are still receiving the  level of care that they                                                                    
     would without it, because we're  meeting our contract -                                                                    
     but  we're doing  it at  a  loss.   So, we're  actually                                                                    
     subsidizing the budget is what it's coming down to.                                                                        
4:20:12 PM                                                                                                                    
CHAIR  WILSON commented  that she  agrees with  much of  what Ms.                                                               
Oney has  said, but  she asked  what is to  prevent abuse  of the                                                               
system by  personal care attendants.   She mentioned  an increase                                                               
of $70 million in two years.                                                                                                    
MS. ONEY responded:                                                                                                             
     The state funds are being  monitored when we put in our                                                                    
     "cost of care" budgets.   The room and board funds that                                                                    
     we were  meeting on our  own through  the contributions                                                                    
     of each  resident ... [are]  limited, because  a person                                                                    
     can only  qualify for the  waiver program if  they make                                                                    
     under a certain amount each  month.  And the department                                                                    
     will be  the first to  testify [that] it  doesn't apply                                                                    
     to  everybody.   Maybe 30  percent earn  more than  the                                                                    
     minimums   that  they're   talking  about.     But   by                                                                    
     preventing the homes from, say,  taking two people that                                                                    
     earn  less  each  month  - the  minimums  -  and  maybe                                                                    
     they'll  share  a smaller  room  or  maybe ...  they'll                                                                    
     receive the  same level of  care, but ...  they'll have                                                                    
     different  aspects to  their living  arrangements than,                                                                    
     say, someone who had $1,400  a month coming in for room                                                                    
     and  board that  might get  a private  room with  a ...                                                                    
     view, ...  so that they're receiving  something for the                                                                    
     extra money they're contributing  to us, but we're able                                                                    
     to meet these expenses.                                                                                                    
     By  not allowing  us to  take in  those people  that do                                                                    
     come in with $1,400 or  even $1,000 a month, and making                                                                    
     us pay  that difference  now into  the state  - because                                                                    
     say they made  $1,000 and, again for  round number, the                                                                    
     cap was at $500 -   we're paying $500 back to the state                                                                    
     now.  Instead of letting us  use that $500 to feed them                                                                    
     and meet  these expenses,  it's getting  reimbursed for                                                                    
     the amount  of Medicaid  waiver funds that  we receive.                                                                    
     So, they are reducing the  state's expenses, but at the                                                                    
     expense of  our homes.   Because we still have  to feed                                                                    
     these people.  ...   This new regulation set here comes                                                                    
     in and  tells us how  to clean  our homes and  how many                                                                    
     times we have to wash  a towel.  They're monitoring the                                                                    
     things  we  do  by  room  and board,  and  we  have  to                                                                    
     regulate - we  have to show and document  the things we                                                                    
     do  - but  they're  making it  impossible  to meet  the                                                                    
     expenses of  doing that.   In fact,  they're increasing                                                                    
     our  expenses ...  in  about five  weeks  with the  new                                                                    
     regulations  they're putting  on  the table  now.   So,                                                                    
     we're not  asking for anything  different than  the way                                                                    
     it was  last year; ...  we're just asking them  to roll                                                                    
     back that maximum  amount.  ...  We're  being forced to                                                                    
     compromise  our  level of  care  that  we can  give  to                                                                    
4:23:57 PM                                                                                                                    
CHAIR  WILSON  expressed  concern  that  people  could  be  taken                                                               
advantage of  as a  result of  what they are  able to  afford for                                                               
living  expenses.   She added  that it  would be  unfair to  have                                                               
people with more available money receive better care services.                                                                  
MS.  ONEY restated  that the  cap  mandates $18.54  per day,  per                                                               
resident, for room and board.                                                                                                   
CHAIR WILSON recalled  that Ms. Oney had previously  said that if                                                               
a resident had an extra $1000  each month, that she would want to                                                               
keep that money to use towards living expenses.                                                                                 
MS.  ONEY explained  that the  previously mentioned  $1,000 would                                                               
not  be  extra   money.    She  said  the  home   is  on  a  cost                                                               
reimbursement program  and there is no  room in the budget  for a                                                               
profit.   She said, "If we  don't match exactly what  we put out,                                                               
we write  them a check  back."  She said  the home needs  to have                                                               
the ability to have  a buffer of money, so that  it can take care                                                               
of unexpected expenses,  such as when the  washing machine breaks                                                               
down.   She added  that a  person with extra  money would  not be                                                               
taken advantage of because he/she always  has the choice to go to                                                               
another home.                                                                                                                   
[Although   the   chair   called   an   at-ease   for   technical                                                               
difficulties, the recording actually continued.]                                                                                
REPRESENTATIVE  ANDERSON   offered  information   concerning  the                                                               
history of  the issues  in discussion  related to  regulations of                                                               
assisted  living homes.   He  related that  assisted living  home                                                               
owners   have  been   voicing  their   concerns  about   the  new                                                               
regulations of  the department and the  department has maintained                                                               
its opinions  and has not  attempted to accommodate  their needs.                                                               
He stated that  the legislature has the option to  hear the needs                                                               
of assisted  living home owners  and address their  needs through                                                               
CHAIR WILSON stated  that the House Health,  Education and Social                                                               
Services Standing Committee would hear public testimony.                                                                        
4:32:23 PM                                                                                                                    
MS. ONEY, in response to  a question from Representative Gardner,                                                               
said that she  knows of at least four assisted  living homes that                                                               
have closed  as a result of  the [$18.54] cap, but  surmised that                                                               
the actual number is higher.                                                                                                    
4:34:56 PM                                                                                                                    
JUDY JACHIM testified, "We cannot  continue to operate at the way                                                               
things have  been."   She related  that she  supports legislation                                                               
that  would   make  wages  offered   in  assisted   living  homes                                                               
comparable to  wages offered  in pioneers' homes.   She  said she                                                               
has found it difficult to  follow the administrative changes that                                                               
have been made in the  last year without anyone consulting [those                                                               
running assisted  living homes].   In response  to a  request for                                                               
clarification from  Chair Wilson, she emphasized  that things are                                                               
not better than they were.                                                                                                      
CANDY CARROLL stated  her support of Amendment 1,  which she said                                                               
would help  very much.   She opined  that the cap  is restrictive                                                               
and needs to be removed; [assisted  living homes] "need to be put                                                               
on the same level as the pioneers' home[s]."                                                                                    
4:37:18 PM                                                                                                                    
MONTA LANE  said that she  had just barely  taken a look  at CSHB
193,  Version G,  and supports  the  changes that  Representative                                                               
Anderson has proposed.   She said she doesn't agree  with many of                                                               
the past  regulations.  She  stated, "If they're  having problems                                                               
in  ...  Alaska  with  [assisted   living]  homes  that  are  not                                                               
compliant and  not doing their  job, they have  the prosecutorial                                                               
authority to  go in there  and pull  the license of  those homes,                                                               
without  making all  of these  regulations  and these  amendments                                                               
that ...  [are impossible] to  follow."  Ms. Lane  emphasized the                                                               
number of  regulations that the  assisted living homes  have been                                                               
required to follow by various  state boards and departments.  She                                                               
related  that  many  of  them have  been  impossible  to  follow.                                                               
Nevertheless,  she  reiterated  her support  of  "[Representative                                                               
Anderson's bill."  She added:                                                                                                   
     I  hope you  guys do,  too,  because there's  a lot  of                                                                    
     things in assisted living that  you guys need to get it                                                                    
     together and see  to it that it's done.   Because we do                                                                    
     a great  service for the State  of Alaska.  We  are the                                                                    
     cheapest rent  in town  and now you've  got us  down to                                                                    
     rock  bottom.   Man, we  can't  go any  lower, and  I'd                                                                    
     really like  to see  some of you  down there  in Juneau                                                                    
     ... [pay for room and board] on $18.65 a day.                                                                              
MS. LANE  noted that two  assisted living homes in  the Fairbanks                                                               
area  have closed  and two  more  that may  have to  close.   She                                                               
indicated that she [runs] the  oldest assisted living home in the                                                               
Interior   and  if   anyone   comes  to   her   for  advice   and                                                               
recommendations, as  they have  for the  past 15  years, "believe                                                               
me, my  attitude is going  to change about assisted  living," she                                                               
CHAIR WILSON  reminded those  testifying that  she would  like to                                                               
hear about the amendment, not the bill, itself.                                                                                 
MARY RAYMOND,  Coordinator, LVR, explained that  she was speaking                                                               
on behalf  of five  different assisted  living homes:   Johnson's                                                               
Assisted  Living,  Main  Street Assisted  Living,  Fernridge  TLC                                                               
Assisted Living, the [Indisc.] Assisted  Living, and the Majestic                                                               
View Assisted Living.  She stated:                                                                                              
     We  are all  very concerned  about how  the regulations                                                                    
     have come  down on us  and how the financing  has gone.                                                                    
     The amendments do look like  they promise some, but for                                                                    
     the last  20 years, the  assisted living home  has been                                                                    
     promoted   because  it   is  more   efficient,  it   is                                                                    
     financially  better, and  people  can  stay where  they                                                                    
     wish.   And ...  the big issue  is the  assisted living                                                                    
     home.  So, please hear us.                                                                                                 
MS.  RAYMOND indicated  that the  Legislative Information  Office                                                               
(LIO)  teleconference  connection  was  down;  therefore  a  good                                                               
portion of  the committee's  comments was  missed.   However, she                                                               
stated  her  appreciation  that   the  committee  is  willing  to                                                               
consider the issue  carefully.  She concluded that  if people are                                                               
going to be able to get the  care that they have asked for, "this                                                               
needs to be looked into and it needs to be financed."                                                                           
4:44:49 PM                                                                                                                    
SHERRY  METTLER,   Northern  Lighthouse  Assisted   Living  Home,                                                               
testified  on  behalf  of  herself  and  "representatives  of  38                                                               
different  assisted living  homes."   She stated,  "We're all  in                                                               
agreement  on  the  same  thing  -  that  we  stand  behind  this                                                               
amendment because of what the cut  in the room and board has done                                                               
to the assisted living homes."   She clarified that the amendment                                                               
of which she  spoke was Amendment 1.   She said the  support is a                                                               
wholehearted  one, because  the amendment  is necessary  to allow                                                               
the homes to stay in  business and supply necessities, especially                                                               
under the new regulations that  are coming out that are mandating                                                               
"so  many  different things  that  are  still allocated  to  that                                                               
$18.57 a  day room and board."   Ms. Mettler said  that concludes                                                               
the shared testimony, but indicated  she could say more regarding                                                               
the original bill version.                                                                                                      
CHAIR WILSON said  she would send Ms. Mettler Version  F, and she                                                               
assured  her that  she would  have  an opportunity  to voice  her                                                               
opinions again on the following Thursday.                                                                                       
4:48:41 PM                                                                                                                    
DR. MANDSAGER  stated that the  intent of the  administration was                                                               
to "put  licensing and  regulation in one  place and  the payment                                                               
elsewhere in the  department."  He said his area  of expertise is                                                               
not in  regard to  payments.  He  offered his  understanding that                                                               
"none of these  organizations have talked to us about  all of the                                                               
issues  we've heard  about for  the  last hour,"  but rather  the                                                               
issues have been heard through  the regulatory commission process                                                               
and  the appeals  process.   He  said, "I  would  appeal to  keep                                                               
thinking  about  the  intent  of  this bill,  which  is  to  keep                                                               
licensing  here  and   financing  there.    And  it   may  be  an                                                               
appropriate bill, I don't know, but  I would advocate that it not                                                               
be in this bill."                                                                                                               
4:49:48 PM                                                                                                                    
JON  SHERWOOD, Medical  Assistance Administrator,  Office of  the                                                               
Commissioner, Department of Health  and Social Services, related,                                                               
on behalf  of the Department,  that the changes made  to assisted                                                               
living  home reimbursement  were  on par  with "cost  containment                                                               
measures"  contained in  the FY  '05 budget.   He  explained that                                                               
reversing  those  changes  would  have a  budget  impact  on  the                                                               
general  fund.   He  mentioned,  "Only about  30  percent of  the                                                               
people  living in  assisted living  who  receive waiver  services                                                               
actually  have   more  than  their   basic  'APA   [Adult  Public                                                               
Assistance] payment'  available, and  a percentage of  those live                                                               
in facilities that  don't charge differing room  and board rates.                                                               
So, we  are talking about  some subset of  that 30 percent  who I                                                               
think the concerns that were raised would apply to."                                                                            
CHAIR WILSON inquired  as to the number of  assisted living homes                                                               
across the state.                                                                                                               
DR. MANDSAGER said  that there are about 480  presently, and they                                                               
are growing at an annual rate of about 10 to 15 percent.                                                                        
CHAIR WILSON clarified that of  the 480, about one-third of those                                                               
have  clients  that have  extra  income  which  can be  used  for                                                               
additional or improved [assisted living home] services.                                                                         
MR. SHERWOOD  said that about 30  percent of the people  for whom                                                               
the department pays  for care, through the  Medicaid waiver, have                                                               
the  benefit  of extra  income.    He  explained that  not  every                                                               
assisted living home serves Medicaid waiver clients.                                                                            
CHAIR WILSON asked if wealthy people used Medicaid services.                                                                    
MR. SHERWOOD explained:                                                                                                         
     There are  income limits to  the Medicaid  program, and                                                                    
     there  are  certain  ways, through  the  use  of  trust                                                                    
     devices,   people   can  ...   voluntarily   impoverish                                                                    
     themselves  to qualify,  but it's  not someone  who has                                                                    
     ...  unrestricted access  to high  levels of  income or                                                                    
     has a lot of assets.                                                                                                       
CHAIR WILSON ruminated:                                                                                                         
     So, these people  are on Medicaid but  they've got more                                                                    
     than  the  minimum to  spend  ...,  and so,  these  are                                                                    
     people that want more services  than you are willing to                                                                    
     pay for?                                                                                                                   
MR. SHERWOOD explained as follows:                                                                                              
     Under  Medicaid, if  we  pay for  care  in an  assisted                                                                    
     living home,  federal law requires  that we do  not pay                                                                    
     for  room  and  board;   individuals  are  supposed  to                                                                    
     provide for their  room and board, either  out of their                                                                    
     personal income  or any cash assistance  they might ...                                                                    
     qualify for.   ...   So,  we have to  make sure  that a                                                                    
     certain part  of the cost  of the assisted  living home                                                                    
     rate  is  allocated  to  room and  board.    There  are                                                                    
     virtually no  federal requirements about how  the state                                                                    
     does  that, but  we do  have to  ensure that  there's a                                                                    
     room and board  charge, we cannot pay  for some portion                                                                    
     of the care, it must be allocated to room and board.                                                                       
CHAIR  WILSON summarized  that  the bottom  line  is whether  the                                                               
assisted  living  home or  the  state  gets any  available  extra                                                               
MR.  SHERWOOD  said  that  Chair   Wilson's  comment  is  a  fair                                                               
summation of  the situation.   He explained  that there can  be a                                                               
standardized room  and board charge  and the excess money  can go                                                               
to reduce  the costs  of Medicaid  or assisted  living homeowners                                                               
can  charge  varying  amounts  for   room  and  board,  and  then                                                               
additional monies would go to the providers.                                                                                    
CHAIR  WILSON  inquired as  to  additional  payments in  assisted                                                               
living homes and what the possible benefits could be.                                                                           
MR. SHERWOOD said that every  assisted living home has a contract                                                               
of care  and most people  would have standardized  care according                                                               
to the contract.                                                                                                                
4:55:22 PM                                                                                                                    
REPRESENTATIVE  MCGUIRE  said  that  as   a  result  of  the  new                                                               
regulations, assisted  living homes are  closing.  She  asked Mr.                                                               
Sherwood  where  these  adults   will  be  placed  if  regulation                                                               
constraints continue and assisted living  homes are not an option                                                               
in the future.                                                                                                                  
MR.  SHERWOOD   related  that  the   last  statistics   that  the                                                               
department  presented  to  the Administrative  Regulation  Review                                                               
Committee indicated  that the number of  licensed assisted living                                                               
homes was still  increasing in Alaska.  In response  to a follow-                                                               
up  question   from  Representative   McGuire,  he   offered  his                                                               
understanding that those statistics were compiled in March.                                                                     
REPRESENTATIVE MCGUIRE proffered:                                                                                               
     What  I  really think  is  happening  is ...  you  have                                                                    
     certain types of  people that operate these  homes in a                                                                    
     way that their whole family  might live in the home and                                                                    
     some of our  folks that are in the homes  might be kind                                                                    
     of  cramped  into  rooms and  given  meals  that  maybe                                                                    
     aren't as  good as they  are in other places,  but they                                                                    
     can definitely  meet your  number.   And ...  those are                                                                    
     probably going to  be the homes that  stay in business.                                                                    
     And as a result, what you're  going to see is the folks                                                                    
     in places that  are getting good meals and  have a nice                                                                    
     room and  a nice place to  go to the bathroom  and live                                                                    
     in dignity will  be moving to some of  these others, or                                                                    
     alternatively,  they're  going  to be  in  the  Pioneer                                                                    
     Home, which isn't taking anymore seniors.                                                                                  
4:58:00 PM                                                                                                                    
REPRESENTATIVE CISSNA  referred to a legislative  research report                                                               
that was published  in February of 2004.  She  noted that a chart                                                               
on  page 4  of  the report  shows a  comparison  of the  assisted                                                               
living beds  available in Alaska  as of  2002, and the  number of                                                               
assisted living beds that will be  needed in 2025.  The projected                                                               
need  shows  a  change  from  1,500 to  5,000.    Therefore,  she                                                               
surmised  that there  will be  a need  for [more  assisted living                                                               
homes]  for which  she  expressed concern  about  the quality  of                                                               
those homes.   She said if  there are not enough  assisted living                                                               
homes, people will  end up in a nursing home  or "long-term beds"                                                               
that are significantly more expensive.                                                                                          
5:00:23 PM                                                                                                                    
DR. MANDSAGER opined  that if quality suffers, that  will be seen                                                               
on  the licensing  side.   He said  he thinks  the commissioner's                                                               
idea  to separate  the two  functions  is to  create an  internal                                                               
tension within the  department.  Today the tension is  out on the                                                               
table with  regard to the  data available, how the  financing can                                                               
impact the quality,  and how that can be measured.   According to                                                               
Mr. Sherwood's data,  the number of assisted living  units, as of                                                               
"last March,"  is 14 percent  more than it  was last year  at the                                                               
same time.   He concluded, "So, there clearly is  a tension right                                                               
now about  the financing  that we've heard  about today  and then                                                               
other  industry  operators  that  are  trying  to  get  into  the                                                               
5:02:02 PM                                                                                                                    
MERRI BELLE  DIAS, testifying  on behalf  of herself,  noted that                                                               
she  runs two  homes  in the  Matanuska/Susitna (Mat-Su)  Valley.                                                               
She  stated,  "I'd   like  to  express  our   support  for  these                                                               
amendments."  She  confirmed that the choice of a  resident in an                                                               
assisted  living home,  should that  home close,  could be  to go                                                               
into  a nursing  home, the  cost  of which  is $10,000-$12,000  a                                                               
month.   She said that would  end up costing the  State of Alaska                                                               
lot more  money.   She said  she knows of  three homes  that have                                                               
recently closed in  her area.  She said the  state just started a                                                               
new certification process, which  increased her paperwork from 3-                                                               
4  pages  to certify  a  home,  up  to  approximately 150.    She                                                               
predicted that by next year there  would not be more than a dozen                                                               
homes in the Mat-Su Valley.                                                                                                     
MS.  DIAS, in  response to  a  question from  Chair Wilson,  said                                                               
there currently  are about 30  homes in  the Mat-Su Valley.   She                                                               
opined  that they  will not  be  able to  meet the  certification                                                               
requirements,   paperwork,  anti-harassment   policies,  internal                                                               
monitoring  systems,  and  consumer satisfaction  surveys.    She                                                               
related that  the administrative rate [currently]  covers all the                                                               
required orientation, blood borne  pathogen training program, and                                                               
the  cardiopulmonary  resuscitation  (CPR)  continuing  education                                                               
requirement.   However, there  is a possibility  that it  will be                                                               
cut.  Regarding previous comparisons  of assisted living homes to                                                               
the pioneers' homes, she said, "I  think a lot of assisted living                                                               
homes ...  give better,  more personalized care  and as  a larger                                                               
facility,  the pioneers'  homes should  be able  to operate  more                                                               
efficiently and cheaper."                                                                                                       
CHAIR WILSON  asked how many  committee members would  be willing                                                               
to  be on  a  "work  force" to  continue  working  on the  issues                                                               
raised.   She also  requested that the  Department of  Health and                                                               
Social  Services  provide a  copy  of  the packet  that  assisted                                                               
living homes fill out in order to get certified.                                                                                
5:06:09 PM                                                                                                                    
DR. MANDSAGER offered  to provide a copy of  the current assisted                                                               
living  home regulations  as well  as the  [assisted living  home                                                               
certification] proposal  that has been made  available for public                                                               
5:06:31 PM                                                                                                                    
REPRESENTATIVE GARDNER  requested copies of any  monthly reports,                                                               
annual reports, and anything else  required for someone who would                                                               
be opening an assisted living home.                                                                                             
MR. SHERWOOD  clarified that there  is a  state-required Medicaid                                                               
provider certification  and an enrollment packet  that testifiers                                                               
have mentioned, and the department would  provide a copy of it to                                                               
the committee.                                                                                                                  
5:08:10 PM                                                                                                                    
VIRGINIA  STONKUS,  Acting  Chief, Certification  and  Licensing,                                                               
Division  of  Public  Health, Department  of  Health  and  Social                                                               
Services, in response to a  question from Chair Wilson, said that                                                               
the  "behavioral health  side" and  the "senior  side" have  been                                                               
consolidated  and there  is an  orientation  plan, training,  and                                                               
several technical assistance programs.                                                                                          
5:10:36 PM                                                                                                                    
CHAIR WILSON announced that a  subcommittee will meet tomorrow to                                                               
plan how to  address the incorporation of the  new amendments for                                                               
HB  193  and  any  other   relevant  issues  brought  forth  from                                                               
interested parties.                                                                                                             
[HB 193 was held over.]                                                                                                         

Document Name Date/Time Subjects