Legislature(1999 - 2000)
05/06/1999 03:05 PM House HES
| Audio | Topic |
|---|
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
HOUSE HEALTH, EDUCATION AND SOCIAL
SERVICES STANDING COMMITTEE
May 6, 1999
3:05 p.m.
MEMBERS PRESENT
Representative Fred Dyson, Co-Chair
Representative John Coghill, Co-Chair
Representative Joe Green
Representative Carl Morgan
Representative Tom Brice
Representative Allen Kemplen
MEMBERS ABSENT
Representative Jim Whitaker
COMMITTEE CALENDAR
SENATE BILL NO. 125
"An Act relating to school crisis response planning."
- MOVED HCS CSSB 125(HES)OUT OF COMMITTEE
HOUSE BILL NO. 16
"An Act transferring to the Department of Health and Social
Services the authority to license all assisted living facilities;
eliminating the authority of the Department of Administration to
license assisted living facilities; and providing for an effective
date."
- HEARD AND HELD
HOUSE BILL NO. 175
"An Act requiring the Department of Health and Social Services to
provide notice to a community council on receipt of an application
for a license to operate a certain kind of foster group home."
- BILL HEARING POSTPONED
(* First public hearing)
PREVIOUS ACTION
BILL: SB 125
SHORT TITLE: SCHOOL SAFETY PLAN
SPONSOR(S): SENATOR(S) HOFFMAN, Mackie, Lincoln, Elton, Phillips,
Kelly Tim, Ellis, Wilken
Jrn-Date Jrn-Page Action
3/29/99 721 (S) READ THE FIRST TIME - REFERRAL(S)
3/29/99 721 (S) HES, CRA
4/14/99 (S) HES AT 1:30 PM BUTROVICH 205
4/19/99 (S) HES AT 1:30 PM BUTROVICH 205
4/19/99 (S) MOVED OUT OF COMMITTEE
4/19/99 (S) MINUTE(HES)
4/21/99 984 (S) HES RPT 3DP
4/21/99 984 (S) DP: MILLER, PEARCE, ELTON
4/21/99 984 (S) ZERO FISCAL NOTE (DMVA)
4/26/99 (S) CRA AT 1:30 PM FAHRENKAMP 203
4/26/99 (S) MINUTE(CRA)
4/27/99 (S) RLS AT 12:00 PM FAHRENKAMP 203
4/27/99 (S) MINUTE(RLS)
4/27/99 1132 (S) CRA RPT CS 3DP SAME TITLE
4/27/99 1132 (S) DP: TIM KELLY, PHILLIPS, MACKIE
4/27/99 1132 (S) PREVIOUS ZERO FN (DMVA)
4/28/99 1150 (S) RULES TO CALENDAR 4/28/99
4/28/99 1151 (S) READ THE SECOND TIME
4/28/99 1152 (S) CRA CS ADOPTED UNAN CONSENT
4/28/99 1152 (S) COSPONSOR(S): MACKIE, LINCOLN, ELTON,
4/28/99 1152 (S) PHILLIPS, TIM KELLY, ELLIS, WILKEN
4/28/99 1152 (S) ADVANCED TO THIRD READING UNAN
CONSENT
4/28/99 1152 (S) READ THE THIRD TIME CSSB 125(CRA)
4/28/99 1152 (S) PASSED Y18 N- E2
4/28/99 1156 (S) TRANSMITTED TO (H)
4/29/99 1064 (H) READ THE FIRST TIME - REFERRAL(S)
4/29/99 1064 (H) HES
5/04/99 (H) HES AT 3:00 PM CAPITOL 106
5/04/99 (H) SCHEDULED BUT NOT HEARD
5/06/99 (H) HES AT 3:00 PM CAPITOL 106
BILL: HB 16
SHORT TITLE: LICENSURE OF ASSISTED LIVING FACILITIES
SPONSOR(S): REPRESENTATIVES(S) CROFT, Dyson
Jrn-Date Jrn-Page Action
1/19/99 22 (H) PREFILE RELEASED 1/8/99
1/19/99 22 (H) READ THE FIRST TIME - REFERRAL(S)
1/19/99 22 (H) STATE AFFAIRS, HES
2/24/99 307 (H) COSPONSOR(S): DYSON
4/13/99 (H) STA AT 8:00 AM CAPITOL 102
4/13/99 (H) HEARD AND HELD
4/13/99 (H) MINUTE(STA)
4/15/99 (H) STA AT 8:00 AM CAPITOL 102
4/15/99 (H) SCHEDULED BUT NOT HEARD
4/20/99 (H) STA AT 8:00 AM CAPITOL 102
4/20/99 (H) SCHEDULED BUT NOT HEARD
4/22/99 (H) STA AT 8:00 AM CAPITOL 102
4/22/99 (H) SCHEDULED BUT NOT HEARD
4/27/99 (H) STA AT 8:00 AM CAPITOL 102
4/27/99 (H) WAIVED OUT OF COMMITTEE
4/27/99 (H) MINUTE(STA)
4/27/99 1034 (H) STA REFERRAL WAIVED
4/27/99 1034 (H) REFERRED TO HES
4/29/99 (H) HES AT 3:00 PM CAPITOL 106
4/29/99 (H) HEARD AND HELD
5/06/99 (H) HES AT 3:00 PM CAPITOL 106
WITNESS REGISTER
TIM GRUSSENDORF, Researcher
for Senator Lyman Hoffman
Alaska State Legislature
Capitol Building, Room 7
Juneau, Alaska 99801
Telephone: (907) 465-4453
POSITION STATEMENT: Presented SB 125.
WES KELLER, Researcher
for Representative Fred Dyson
Alaska State Legislature
Capitol Building, Room 104
Juneau, Alaska 99801
Telephone: (907) 465-3759
POSITION STATEMENT: Provided information on SB 125.
REPRESENTATIVE ERIC CROFT
Alaska State Legislature
Capitol Building, Room 400
Juneau, Alaska 99801
Telephone: (907) 465-4998
POSITION STATEMENT: Testified as sponsor of HB 16.
ALISON ELGEE, Deputy Commissioner
Department of Administration
P.O. Box 110200
Juneau, Alaska 99811
Telephone: (907) 465-2200
POSITION STATEMENT: Testified in support of the concept of HB 16.
ELMER LINDSTROM, Special Assistant,
Office of the Commissioner
Department of Health and Social Services
P.O. Box 110601
Juneau, Alaska 99811
Telephone: (907) 465-1613
POSITION STATEMENT: Testified in support of the concept of HB 16.
KAY BURROWS, Director
Division of Senior Services
Department of Administration
3601 C Street, Suite 310
Anchorage, Alaska 99503
Telephone: (907) 269-3666
POSITION STATEMENT: Answered questions on HB 16.
SHELBY LARSEN, Administrator
Health Facilities Licensing and Certification
Division of Medical Assistance
Department of Health and Social Services
4730 Business park Boulevard, Suite 18
Anchorage, Alaska 99503
Telephone: (907) 561-8081
POSITION STATEMENT: Answered questions on HB 16.
FRED LAU, Administrator
Homer Senior Citizens, Incorporated
3935 Svedlund Street
Homer, Alaska 99603
Telephone: (907) 235-7655
POSITION STATEMENT: Testified on HB 16.
FRANCIS PURDY, Long-Term Care Ombudsman
3601 C Street
Anchorage, Alaska 99503
Telephone: (907) 563-6393
POSITION STATEMENT: Testified on HB 16.
ACTION NARRATIVE
TAPE 99-52, SIDE A
Number 0001
CO-CHAIRMAN DYSON called the House Health, Education and Social
Services Standing Committee meeting to order at 3:05 p.m. Members
present at the call to order were Representatives Dyson, Coghill,
Morgan, Brice and Kemplen. Representative Green joined the meeting
at 3:15 p.m.
SB 125 - SCHOOL SAFETY PLAN
CO-CHAIRMAN DYSON announced the first order of business as Senate
Bill No. 125, "An Act relating to school crisis response planning."
Number 0109
TIM GRUSSENDORF, Researcher for Senator Lyman Hoffman, Alaska State
Legislature, presented SB 125. He didn't go through the sponsor
statement because they heard the same bill, HB 165, last week. He
thanked Representative Kapsner, her staff and the Department of
Education for all their work. Senator Hoffman and staff are fine
with the amendments and agree that they strengthen the intent of
the legislation. He informed the committee they have copies of a
letter in their packets they just received from the North Slope
Borough School District which includes an example of a template
that could be used in school crisis planning.
REPRESENTATIVE BRICE made a motion to adopt the proposed House
committee substitute (CS) for CSSB 125, version 1-LSO774\I, Ford,
5/5/99, as a work draft. There being no objection, Version I was
before the committee.
CO-CHAIRMAN DYSON clarified that this CS incorporates into the
Senate Bill the amendments that they made to HB 165. He wondered
if it includes the amendment they thought they made but didn't.
WES KELLER, Researcher for Representative Fred Dyson, Alaska State
Legislator, replied that there is an extra word "crisis" in there
but it doesn't change the meaning of the bill.
The committee took an at-ease from 3:09 p.m. to 3:10 p.m.
Number 0337
REPRESENTATIVE BRICE made a motion to amend page 2, line 15, to
delete the word "crisis" after (7). Line 15 then would read:
(7) policies for enforcing school discipline and
maintaining a safe and orderly environmental during the
crisis.
CO-CHAIRMAN DYSON asked Representative Brice the reason for
removing the word "crisis."
REPRESENTATIVE BRICE answered that the word "crisis" is also at the
end of the sentence so it is redundant.
Number 0420
CO-CHAIRMAN DYSON asked whether there was any objection. There
being none, Amendment 1 was adopted. Now SB 125 is consistent with
HB 165.
Number 0461
REPRESENTATIVE BRICE made a motion to moved HCS CSSB 125(HES),
Version 1-LSO774\I, Ford, 5/5/99, as amended, out of committee with
individual recommendations and zero fiscal note. There being no
objection, HCS CSSB 125(HES) moved from the House Health, Education
and Social Services Standing Committee.
HB 16 - LICENSURE OF ASSISTED LIVING FACILITIES
Number 0523
CO-CHAIRMAN DYSON announced the next order of business as House
Bill No. 16, "An Act transferring to the Department of Health and
Social Services the authority to license all assisted living
facilities; eliminating the authority of the Department of
Administration to license assisted living facilities; and providing
for an effective date."
Number 0537
REPRESENTATIVE ERIC CROFT, Alaska State Legislature, sponsor, came
forward to present HB 16. He said HB 16 started as a simple idea
but the issues got complicated in discussion. The simple idea of
at separating the people who run the Pioneers' Home in the
Department of Administration (DOA) from the licensing function came
out of a report of the Long-Term Care Ombudsman regarding issues
surrounding the Pioneers' Homes. That is all that HB 16 does, but
it got them into a fascinating and long discussion about the role
of assisted living facilities in the entire set of care facilities
for elder Alaskans; how it evolved out of nursing homes; possibly
some of its benefits; some of the growth it has had over the last
ten years; how they should license them and how it should be
changed; and whether the current licensing structure for assisted
living homes is sufficient. Simply removing the potential for
conflict of interest between an administrative function and a
licensing function brought them into some of those issues.
REPRESENTATIVE CROFT referred the committee to a chart in their
packets labeled Assisted Living. The chart shows the structures of
the Department of Administration and the Department of Health and
Social Services (DHSS), and where the people are now who do this
function, and where the bill would move them to and some of the
issues that have been brought up. Assisted living facilities have
grown tremendously in the last five to ten years and have prevented
a mushroom growth in nursing home residences. In many ways, the
assisted living model has advantages over the traditional nursing
home model in terms of cost efficiency and service. It is a
different vision of care and probably deserves a different
licensing structure, which it has now. The chart shows only the
assisted living licensing community. There will be a lot of
discussion and work by the department this summer on rewriting the
regulations for licensing assisted living facilities. The current
situation has 1.5 people in the DOA, Division of Senior Services,
Longevity Programs, handling licensing of assisted living
facilities and one person in DHSS, Division of Mental Health. Most
of the nursing home licensing is done in DHSS, Division of Medical
Assistance, Health Facilities Licensing and Certification. The
nursing home licensing is not shown on the chart.
Number 0869
REPRESENTATIVE CROFT indicated that they are proposing
consolidating these two areas into where nursing home licensing is
now. The reason he didn't show the nursing home licensing on the
chart is because it is a different community, has a different
funding source, largely federal funds, and has a fairly large
contingent of people. The assisted living licensing group is
fairly small, probably adequate for the assisted living facilities
they had five or ten years ago, but arguably not now. The original
version of HB 16 consolidated the 2.5 people they have doing this
function into Health Facilities Licensing, with a nominal low
fiscal note to move them. The DHSS said in response to the
original HB 16, they feel uncomfortable taking on this entire area
of responsibility which has grown like a weed over five to ten
years with the current people, some in DOA, some in Division of
Mental Health. That is what he put in line 3 of the chart. The
DHSS's response is about an $800,000 fiscal note to have the nine
people that they feel is sufficient to do this job.
Number 0956
CO-CHAIRMAN DYSON asked Representative Croft how many people in the
DHSS are doing the licensing of nursing homes.
REPRESENTATIVE CROFT answered he didn't know but referred that
question to Elmer Lindstrom of DHSS.
CO-CHAIRMAN DYSON asked if the DHSS came back and said they would
need nine people to do the work that is presently being done by 2.5
people.
Number 0988
REPRESENTATIVE CROFT answered yes. It was somewhat of a shock to
get an $800,000 fiscal note for something he thought was simply
moving 2.5 people. In deference to the DHSS, he doesn't feel that
the fiscal note is fictitious or imaginary. The DHSS has been
worried about the adequacy of this effort as it grows.
CO-CHAIRMAN DYSON asked Representative Croft if the DHSS was using
HB 16 as the vehicle for bringing the staffing up to where it
should be.
Number 1028
REPRESENTATIVE CROFT indicated that the DHSS is asking that if they
consolidate it in a new place, that the legislature fund it at the
appropriate level. Option four on the Assisted Living chart is the
result of several months' work. The DHSS came back and said "Let's
see what we can do," in light of the idea that all assisted living
homes are not created equal. The licensing of the very largest
ones, including the Pioneers' Home, probably has to have an
intensity and frequency that is closer to the nursing home model,
but slightly different in the amount of medical oversight. The
oversight over a small home could be lighter and done in a "leaner
and meaner" fashion. That mirrors to some extent the regulatory
distinction that they were contemplating as a way to deal with this
area.
REPRESENTATIVE CROFT mentioned that because nursing home licensing
is within Health Facilities Licensing now, there is at least a
tendency for them to use the same intensive standard. If they put
assisted living in with the nursing home licensing, they might
accidentally get that same level, even in the smaller homes, and it
might not be needed. It was suggested to distinguish between small
and large assisted living homes. That is what he means by less
than 16 and greater than 16 on the chart. They could have a
different licensing structure for the small homes kept in the DOA
and have the big homes licensed under Health Facilities Licensing
in DHSS because they can do a lower intensity type of oversight;
they don't need as many people as they did before, and they can do
it for that much less. There is a range of possible approaches.
Representative Croft wanted to bring it to the Health, Education
and Social Services (HES) committee because there is growing
concern over the state of assisted living facilities, their safety
and the adequacy of the state oversight on it.
Number 1202
REPRESENTATIVE KEMPLEN commented that he would be interested in
seeing some statistics on how many people the state uses to license
child care facilities. He wondered what type of administrative
procedures were in place to ensure those facilities are "up to
speed" in terms of their integrity and safety.
Number 1307
ALISON ELGEE, Deputy Commissioner, Department of Administration,
came forward to testify in support of the concept of HB 16. She
agreed there is a lot of merit to consolidating the functions of
assisted living licensing. The assisted living law that they are
operating under today is five years old. They have learned a lot
since its inception, but it was designed so that the DOA, Division
of Senior Services, would license assisted living facilities that
were providing care for the seniors throughout the state. The
DHSS, Division of Mental Health and Developmental Disabilities
would license those assisted living facilities providing service to
the mental health and developmentally disabled community. Both
departments license under the same set of regulations.
MS. ELGEE explained that they have found that as the program has
matured and expanded, they are sharing a number of the facilities
that house both seniors and mental health consumers. The initial
regulations envisioned an assisted living industry that was
primarily made up of "mom and pop" operations so the regulations
are geared toward the smaller homes. They are finding that they
are not sufficient, or necessarily appropriate, for some of the
larger homes. This summer the DOA and DHSS will begin to
differentiate the licensing standards for the larger homes from
their expectations of the smaller homes. There may be areas of the
existing assisted living licensing statutes that they would also
suggest modifying, and they are just beginning that work now.
Number 1421
ELMER LINDSTROM, Special Assistant, Office of the Commissioner,
Department of Health and Social Services, came forward to testify.
He said currently, the Division of Medical Assistance,
Certification and Licensing, certifies and licenses various types
of facilities: acute care hospitals, nursing homes and home-health
agencies. The licensing function for assisted living is split
between the Division of Senior Services, DOA and the Division of
Mental Health and Developmental Disabilities, DHSS. The licensing
function is just one of the things that those staff do. They are
not full time licensing people; they also provide technical
assistance to assisted living facilities, some of the business
planning, community development and are advocates for building the
capacity of the assisted living industry. Assisted living didn't
exist five years ago; now there are hundreds of these facilities
that have been instrumental in keeping the pressure off the nursing
home growth.
MR. LINDSTROM referred to the large fiscal note from the DHSS. He
said if the desire is to consolidate that licensing within
Certification and Licensing, Division of Medical Assistance, they
are not simply going to get the same thing at a much higher cost.
If the licensing function for assisted living is centralized in
Certification and Licensing, and if they were to adopt the fiscal
note, they would be getting something very different that will cost
more. It will be a more rigorous and different kind of licensure
and inspection system.
CO-CHAIRMAN DYSON asked if that was appropriate.
Number 1556
MR. LINDSTROM answered their conclusion is, getting back to the
differentiation between the smaller and larger facilities, it
probably is appropriate. The Anchorage Pioneers' Home has 240 beds
and while they would not inspect and license to the nursing home
standard, nevertheless, that facility resembles the type of
institutional care more like a nursing home rather than a "mom and
pop" assisted living facility. They do believe it would be
appropriate to bring more rigor and yes, it will cost significantly
more. The narrative on the fiscal note will give them an idea of
the type of rigor that will be brought to this. For facilities
having 51 beds or more, which includes all the pioneers' homes,
they would be averaging inspections that would last 4.5 days, and
it would include a team of three or four staff persons from
different disciplines, and that is not the kind of inspection going
on today. He suggested that Shelby Larsen on teleconference could
answer questions.
Number 1663
MS. ELGEE clarified that there are two pioneers' homes that are
under 50 beds. They acknowledge that they don't have the resources
necessary today to rigorously enforce assisted living licensing the
way they would like to. Presently they only do on-site licensing
every other year. They agree that the bigger homes need to be
visited and licensed on an annual basis, but with the existing
level of resources, they cannot provide this now.
Number 1701
REPRESENTATIVE GREEN asked whether the additional people would be
brought on board or are they available now to review the licensing.
MR. LINDSTROM answered that they are requesting a significant
number of additional staff. They would for the most part be the
same type of staff currently in Certification and Licensing. They
would be cross trained with existing staff so they could mix and
match on the inspections.
Number 1736
REPRESENTATIVE GREEN is concerned that for approximately $1 million
that is a lot of staff. He asked for Mr. Lindstrom's view on
option 4 on the Assisted Living chart that cuts it in half. They
are trying to cut bureaucracy, not add it.
MR. LINDSTROM said the scenario described by the sponsor would cut
the fiscal note by half. He feels they would have a much improved
system. If they are going to do this, the DHSS would like to do it
in a way that there will be greater assurance of safety in these
facilities and more rigorous inspection of these facilities. They
would be buying an improved system of surveillance and licensing
for these facilities.
REPRESENTATIVE GREEN asked what it is they will be doing that is
more rigorous that requires more than what is being done now.
Number 1869
MR. LINDSTROM answered that now the inspections are done once every
two years. The certification and licensing people feel very
strongly that the best and appropriate practice for these larger
facilities is to have annual reviews, and that is a significant
part of the difference. If they compare the time appropriate for
assisted living facilities, it is still 40 or 60 percent of the
intensity of the review that they would do for a nursing home.
When they compare the standard to what they do under federal
standards for nursing homes and acute care hospitals, it is
significantly less intense than those inspections. A team of
people goes into a hospital or nursing home and will spend a longer
period of time than they are showing on assisted living homes. If
they contrast it to the standard for acute care and nursing home,
it is substantially less than that; the fiscal note is credible.
Number 1947
REPRESENTATIVE KEMPLEN asked if there are national standards for
assisted living facilities.
MS. ELGEE said there has just been some work on the national level
to develop assisted living standards, and she asked Kay Burrows to
speak to that.
Number 1973
KAY BURROWS, Director, Division of Senior Services, Department of
Administration, testified via teleconference from Anchorage. She
acknowledged that there are very recent standards that have come
out in terms of quality. Nationally, assisted living is very new,
as is the whole issue of licensing and regulatory standards. The
things that have come out nationally did not have specific
requirements in terms of regulatory (indisc.). However, it did
acknowledge the need for a team of people, particularly in the
larger assisted living homes, which is not how they currently do
licensing in the division. Currently, they have a person who is
qualified as a social worker and occasionally in the more difficult
investigations, they will also use a nurse from their Medicaid
waiver team.
MR. LINDSTROM noted that the licensing and certification for the
acute care hospitals and nursing homes are driven by federal
standards, and he suggested that Shelby Larsen could speak to that.
Number 2028
SHELBY LARSEN, Administrator, Health Facilities Licensing and
Certification, Division of Medical Assistance, Department of Health
and Social Services, testified via teleconference from Anchorage.
He said there are federal regulations for Medicare certification
for acute care hospitals and nursing homes and many other provider
types which they certify. There are also licensure regulations for
nursing homes as well. When they do a survey or inspection of a
facility, they look at that facility in relation to both the
federal and state requirements.
REPRESENTATIVE KEMPLEN asked if the state is seeking to establish
standards for assisted living which are not linked to any national
standards.
MR. LARSEN said he would imagine that the standards developed by a
national association would be a guideline in how they would
establish standards for assisted living facilities in Alaska.
Different states have different concepts about what assisted living
is so they would be tailored to the state's needs.
Number 2117
REPRESENTATIVE KEMPLEN asked why the department feels there needs
to be a linkage with these more rigorous licensing standards for
assisted living when there is not agreement for these standards on
a national level. He asked if there are documented instances of
abuse that are occurring in Alaska's assisted living facilities now
that warrant more rigorous licensing requirements.
Number 2152
MS. ELGEE noted that the licensing is only the beginning of the
activity of the people that are responsible for the licensure of
these facilities. A major activity is complaint investigation.
The more people in a facility, the more potential for complaint.
It is the licensing people who will also do the complaint
investigation for the facilities. When they started this process
five years ago on the senior services side, they were licensing
nobody. Today they license 90 homes throughout the state. This is
quite an effort for the 1.5 people that they have dedicated to
this.
Number 2191
REPRESENTATIVE KEMPLEN said that it seems a case has not been made
for this increased oversight of the assisted living facilities
unless there is additional information that he is missing.
Number 2218
MS. ELGEE said their concern is that the potential is there. They
have not had any serious incidents that have resulted in the death
of a resident in an assisted living home. They are concerned
because of their lack of resources to address the entire licensure
effort in a way that would assure them of quality of care and
safety of the residents.
Number 2243
MS. BURROWS said while they have been fortunate in not having any
incidents, they are seeing a significant increase in the number and
intensity of investigations. She mentioned a situation in
Anchorage where she has had to involve several staff and send them
out to some homes on at least four occasions, and they are still
dropping in on a daily basis at least once or twice unannounced.
They are seeing a need for professional oversight particularly in
the larger homes with 16 beds or more. One consideration is to
increase the standards for the larger homes, while to continue the
current methods for the smaller homes.
CO-CHAIRMAN DYSON asked Mr. Larsen if he felt that the organization
that does the licensing and inspections should be different than
the organization that runs and administrates a service.
MR. LARSEN answered yes. He always has concerns when one
organization has both program development and quality oversight
within the same group. The direction it takes can often be
influenced by the priorities that are established by the
management.
TAPE 99-52, SIDE B
Number 2347
MR. LARSEN said if the priorities are established for program
development, then they run a risk of not having or not putting
enough resources into the quality oversight. From his perspective,
it is better to have the programs separated.
CO-CHAIRMAN DYSON asked Mr. Larsen if it makes sense to have the
inspection and licensing of the variety of services that are
provided for seniors in one organization.
Number 2310
MR. LARSEN said there could be advantages to that.
CO-CHAIRMAN DYSON asked Mr. Larsen if there were any disadvantages
to having the senior licensing and inspection and quality control
in one organization.
Number 2299
MR. LARSEN said the main disadvantages would be if there were a
lack of resources. The DHSS based the fiscal note on the
assumption that an annual survey would be required. There are 225
assisted living homes, the 90 or so from Senior Services and rest
from the Division of Mental Health and Developmental Disabilities.
If they were to take that on, they would be looking at a
considerable project from their perspective. Now they have 15
nursing homes that they do licensure for, which represents 720
beds, and their fiscal note, including the Medicare/Medicaid and
state licensure, was slightly less than the fiscal note for HB 16.
There would be an increase in the oversight, but it would still not
be at the level of the nursing homes.
Number 2225
CO-CHAIRMAN DYSON asked Mr. Larsen if it is too difficult for the
inspectors to do highly intensive inspections in some facilities
and do lower intensity inspections in others where it is not
required.
MR. LARSEN indicated that it could sometimes represent a challenge.
They have about 16 different provider types that they either
license or certify or both, and they all have their own sets of
requirements so they are constantly shifting. He pointed out that
they don't do the same kind of survey in outpatient physical
therapy that they would do in a nursing home or hospital. Another
concern is the medical model versus other models. They have had to
shift from the medical model to behavioral model. The inspectors
have had that experience.
Number 2170
CO-CHAIRMAN DYSON asked Mr. Larsen if other states have privatized
the licensing and inspection and oversight successfully.
MR. LARSEN answered that he is not aware of any states that have
privatized. He is only aware of those agencies in state
government.
Number 2129
REPRESENTATIVE GREEN did some figuring and came up with a figure of
$1,300 per person per investigation day and wondered if that seems
like too much.
MR. LARSEN explained that there are other things to consider that
might throw the fiscal note off like time on-site, time off-site in
report preparation and communication with the facilities. The
outside time was so they could calculate travel.
REPRESENTATIVE GREEN wondered if after the initial review, would
the following years' inspections require the same degree of review
and discussion that could possibly happen in transferring over from
DOA to DHSS. He wondered if there was a standard "go by" that
would reduce this cost. The committee is extremely sensitive to
these kinds of fiscal notes. He wondered if there was a
possibility that they could do these reviews with a lot less money.
Number 1959
MR. LARSEN said the initial survey that they do on acute care
facilities is usually the easiest. The facilities have an idea of
what they are supposed to do, they get everything ready, they get
started and a year later the state returns, and it is totally
changed. The first inspection is the easiest; the subsequent ones
are more difficult.
Number 1932
MS. BURROWS commented that the assisted living facilities actually
see the opposite often times. The smaller homes often get into it
with their heart instead of their head. They often have a lot of
work to do up-front, and after a couple of years it slows down, and
they have a level playing field unless there is a crisis. That is
a difference between assisted living and some of the businesses
that Mr. Larsen is used to.
Number 1861
MS. ELGEE reiterated that they need to remember how new this
industry is to the state and the nation. Some of the things they
thought would initially work need modification, and that is why
they are going to take on the regulatory review project this
summer.
Number 1834
CO-CHAIRMAN COGHILL said with the Long-Term Health Care Task Force
recommendations that have come through this committee this year,
they are going to have to sit down and look and see how all the
issues interface. They have seen several licensing bills, and it
will be important to see if they have connected them right. They
want to work with the departments on this.
Number 1811
REPRESENTATIVE KEMPLEN commented that he feels it would be
premature to accommodate changes before the departments meet this
summer to review their regulations. Perhaps it would be more
appropriate to request the new staff after the review has been
accomplished. He suggested that they have their regulatory review
and then if they need legislation, they could come back and deal
with this next session. It seems they should keep HB 16 as simple
as possible.
Number 1658
REPRESENTATIVE BRICE said that in the meetings this fall of the
Alaska Caregivers Association, they were developing their own
standards to ensure quality care of their clients. He asked what
the departments have done in terms of being able to incorporate
that idea or concept into the idea in HB 16.
MS. ELGEE replied that they have just begun the process of setting
up a work plan for the regulatory review they intend to do this
summer, and they will be working very closely with industry.
MS. BURROWS agreed they have just begun the discussion of what will
help them toward looking at regulations this summer and any needed
statute and regulatory changes. She expects that will include
continuation of a public process with the assisted living home
owners on standards and ethics. There is good national work being
done. The General Accounting Office (GAO) has just released a
federal report on assisted living, and they will be looking at
that. They probably will be holding forums on a monthly basis
throughout the state as they move towards creating a work plan.
MS. BURROWS informed Representative Brice that the care
coordinators are working closely with the state because they work
closely with the assisted living industry as well.
CO-CHAIRMAN COGHILL mentioned to Ms. Burrows that some of the
committee members may be interested in attending their meetings.
Number 1528
MR. LINDSTROM noted for the record that the child care facility
licensing is not part of Mr. Larsen's business or involved in any
way with the assisted living licensure. That responsibility
currently rests with the Division of Family and Youth Services.
There is pending legislation that would transfer that
responsibility to the Department of Education as part of the
restructuring bill.
Number 1481
FRED LAU, Administrator, Homer Senior Citizens, Incorporated,
testified via teleconference from Homer. They operate an assisted
living facility apartment in Homer. He is encouraged by the
discussion. If he had testified at the beginning, he would have
testified against HB 16. The issues that have been brought up
point out a need for further discussion. The states have different
ideas about assisted living, and that is one reason why there are
not national standards. Alaska is going to have to develop their
own in this particular situation.
MR. LAU doesn't agree with splitting the licensing by size of
institution. The standards ought to be the same and perhaps have
different tiers for size. One of the initial problems they had
with this bill has to do with the model that is applied to assisted
living. They are concerned that if the licensing is shifted to
DHSS that the medical model would be what is applied. If this is
the case, the cost of assisted living will go up. Assisted living
came about to fill a gap, and it is providing an alternative for
seniors, which is a lower cost than long-term care in the state.
He agrees that HB 16 needs further discussions and offered to be
involved. There are many issues that need to be addressed, and
statewide standards is one issue they need to get on right away.
CO-CHAIRMAN DYSON asked Mr. Lau if they have an association of
providers.
MR. LAU answered not now. The meeting they had in Anchorage was
their first attempt to get together. They have set up a second
meeting and that may be the beginning of forming a group and
sitting down and discussing standards and regulations and all of
these issues.
Number 1293
CO-CHAIRMAN DYSON mentioned that the committee has been talking
about work they might do during the interim. He asked Mr. Lau if
they did get together and come up with some standards and so on, to
let them know.
MR. LAU said there are a couple organizations that belong to the
assisted living affiliation, the Northwest Alaska group associated
with the Assisted Living Federation of America (ALFA). That is an
organization that has done some work on standards in other states,
particularly in the northwest.
REPRESENTATIVE GREEN asked Mr. Lau if there would be a potential to
set up a "go by" that could reduce the cost evaluations.
MR. LAU said he can't speak to the cost of each one of the
divisions. Presently they are under a two-year review, however,
they are being reviewed annually even now. He would think once the
standards are established, that the cost could be reduced.
Number 1151
FRANCIS PURDY, Long-Term Care Ombudsman, testified via
teleconference from Anchorage. She spoke from a resident's
standpoint. She applauded the committee for wanting to take a look
at a change in regulations, but the issue of this legislation is
not changing the regulations; it is just enforcing it on a
consistent basis. The issue came up because residents are treated
differently, based on how the regulations are enforced across the
two departments and within the two departments, depending on which
assisted living home it is. There is a perception, or an actual
conflict of interest, depending on that home's relationship to the
other programs within the division. From a resident's perspective,
the solution would be to move the licensing to a neutral place
where it is not entangled, or appears to be in conflict with other
programs. That is the primary reason for supporting this
legislation.
MS. PURDY told the committee that she is working on a task force
nationally to take a look specifically on why the changes are
happening in assisted living. Now the movement is to merge
assisted living licensing with nursing home licensing at least in
the same department since nursing homes are moving away from just
a medical model. They are looking at assisted living homes ranging
from a total social model to an integrated social/medical model to
everything in between. They are starting to see differentiation,
not necessarily by type of facility, but by the corporate culture
of the facility. The advantage of having assisted living home and
nursing home licensing and home health licensing all with the same
regulators is that they have the broad knowledge of everything what
is needed in home services to what is needed in the most
institutionalized form of delivery service, which is the nursing
home.
Number 0942
REPRESENTATIVE CROFT commented that he originally intended to just
solve a perceived conflict of interest. There are a lot of people
who fear if they move it into Health Facilities Licensing, the
standards will be changed. He never intended to do that. The
standards may need to be changed, re-evaluated, and that process
can go on without him. He only meant a location change to solve a
potential or real conflict of interest. He commented that it does
not mean if the licensing functions are consolidated in the same
area, that the same standards would have to be applied.
REPRESENTATIVE CROFT referred the committee to other groups who
support this but were not able to testify today: the Older
Persons' Action Group, the Alzheimers' Association, the Alaska
Caregivers' Association in North Pole, Marty Margeson (ph) who
represents herself and her father who is in the Anchorage Pioneers'
Home, and lot of pioneers' home groups. House Bill 16 has support
in its general concept. Mainly the opposition comes from an
assumption that he means to change the standards of licensing, and
he truly does not, though he understands that may be a productive
discussion.
REPRESENTATIVE CROFT feels there is a problem when they have the
same people running the facility saying every year they meet the
minimum requirements. It creates a perception that it is not
getting as thorough a review as it should. He does feel there is
a qualitative and a quantitative difference between the bigger and
smaller homes. That gets back into a standards discussion of
should they have different licensing criteria for lesser homes. It
may then be appropriate to move that licensing in a different area.
That is what option four is on the Assisted Living chart. They
should be able to consolidate with a small as possible increase in
people and give a clear directive that this is not meant to assume
that all of the heavy licensing requirements would be applied to
assisted living facilities. He cannot seem to get around that with
people, but it seems to him that they can consolidate without
merging the standards.
Number 0692
REPRESENTATIVE BRICE asked Representative Croft if this was part of
the Long-Term Care Task Force recommendations.
REPRESENTATIVE CROFT answered that this was one of the
recommendations of the Long-Term Care Ombudsman.
Number 0664
CO-CHAIRMAN DYSON asked Mr. Lindstrom and Ms. Elgee if they thought
there were better or more appropriate ways to do this.
Number 0623
MS. ELGEE answered that this is a conversation Commissioner Perdue
had begun with her about trying to consolidate the licensing
function for assisted living. They find that they are licensing
under the same set of standards, the same kinds of homes, in some
cases they are actually mixing the two populations that they
represent in a single facility. Under those circumstances, they
don't go in and license twice. As the industry has grown, they
have found they will get people shopping for who is going to
license. They feel there is real merit in combining the assisted
living licensing function in a central location. They were not
predisposed in that conversation as to where that might be. They
had only begun the conversations.
CO-CHAIRMAN DYSON noted that was an excellent and candid answer.
He asked Ms. Elgee if she had done it on her own, would she have
anticipated a fiscal note like the one given to HB 16.
Number 0532
MS. ELGEE answered it was their intent, before they attempted to
merge anything, to do the regulation review this summer so they
would have a better idea of what they are faced with in terms of
licensing expectations for small versus big homes, and then
reassess the resource needs of how they would proceed. She felt
they had to put something together right now based on what they
know. By the end of the process this summer, they may be back
supporting option four on the Assisted Living chart, which carries
a different cost. At this point, they are not prepared to say that
one approach is better than the other, but they will be by the time
session begins next year.
CO-CHAIRMAN DYSON asked Ms. Elgee if she felt that they are doing
an adequate job of licensing and inspecting now.
MS. ELGEE answered no. They feel that they are very resource poor
in this area. One and a half people are not adequate under the
best circumstances. They are presently licensing 90 facilities,
and they are interested in being able to expand that. She doesn't
know how they will cope with additional licensing responsibility.
Frankly, the only reason it works right now is that most of the
assisted living industry resides in Anchorage or Fairbanks.
Number 0409
CO-CHAIRMAN DYSON asked anybody listening if they know if other
jurisdictions have used third parties, or non-governmental
organizations to do licensing and inspections.
MS. PURDY answered that she queried all the states, and unless
something has happened since December, there is no state that has
privatized that function.
CO-CHAIRMAN DYSON asked if they leave the departments alone and
they go off to do this right, what is a reasonable time frame.
Number 0330
MS. ELGEE answered that they hope to have this work completed on
the regulation review and where they are headed by early fall, but
she would not anticipate having brand new regulations in place at
that point. They would hope to know what they were going to
propose and also at that time have identified any statutory change
that they would also want to have reviewed in this process.
Number 0287
REPRESENTATIVE GREEN asked whether the assisted living homes are
privately or publicly operated.
MS. ELGEE replied that the only state-operated assisted living
homes are the six pioneers' homes; all the rest are private.
REPRESENTATIVE GREEN asked if there is any concept now of how close
either the state-operated or privately operated facilities may be
to meeting the standards.
Number 0189
MS. ELGEE answered at this point she does not anticipate changes in
the assisted living regulations that would subsequently result in
increased cost to the pioneers' home operations. Because the
pioneers' homes go beyond what assisted living regulations require,
they really have an operation that is a hybrid of a nursing home
environment and an assisted living environment today. They have
some documentation that compares the licensing requirements of a
nursing home and an assisted living home and shows where the
pioneers' homes are in the context of those two licensing
standards.
REPRESENTATIVE GREEN asked what they are going to gain with the
additional reviews.
Number 0075
MS. ELGEE answered that nobody is perfect. There is always an
opportunity for things to fall through the cracks, go unnoticed if
they are not rigorous in the oversight. When they are dealing with
vulnerable populations, it is important to be vigilant so they can
assure the residents and the families that the residents are
receiving quality care.
REPRESENTATIVE BRICE mentioned that the Alaska Caregivers'
Association in the interior have been working to develop specific
standards of care.
TAPE 99-53, SIDE A
Number 0001
REPRESENTATIVE BRICE commented it would be interesting to find out
where in the process the Alaska Caregivers' Association is now
because they had some interesting insight.
CO-CHAIRMAN DYSON asked Mr. Lindstrom and/or Ms. Elgee if many of
the people being cared for are receiving federal or state monies to
pay for their costs.
Number 0060
MS. ELGEE answered that they have a variety of clients. The
pioneers' homes have a rate schedule with the ability to pay. In
the private assisted living homes, they will find private-pay
clients, where the state has no involvement beyond the actual
licensure of the home; they have clients on waivers: the Medicaid
waiver for elderly Alaskans and the Medicaid waiver for adults with
physical disabilities, who would be eligible for levels of nursing
home care, but without an assisted living opportunity, they would
most likely be in a nursing home. They also have the general
relief clientele who are vulnerable adults who need a protective
environment. They sometimes need assisted living services, their
needs may not actually be to the level of a nursing home, but they
are unable to live independently.
CO-CHAIRMAN DYSON asked Ms. Elgee to estimate the percentage of
Medicare/Medicaid reimbursement for the clients.
Number 0189
MS. ELGEE answered that between the two waivers that they operate,
the elderly Alaskan waiver has almost 600 people on it today, and
the adult with physical disabilities waiver has just over 200
people out of a total population of 30,000 seniors in the state.
CO-CHAIRMAN DYSON asked what the total of seniors are in
out-of-home placement.
MS. ELGEE couldn't answer that.
CO-CHAIRMAN DYSON asked Ms. Elgee if the subsidized programs would
allow for part of the rate structure to cover a part of the cost of
providing a bed and services, and would it allow for the cost of
the licensing and inspections to be a part of that rate.
Number 0274
MS. ELGEE answered that they don't see the potential there to fully
cover the cost, but Shelby Larsen could expand what he has looked
at in terms of the potential for fees.
Number 0299
MR. LARSEN answered that the fee collection for the way it is
currently done would amount to about $35,000 per year, which is a
long ways from covering the cost.
CO-CHAIRMAN DYSON asked if the federal laws or regulations preclude
them from recapturing the licensing and inspection costs from out
of the federal funding stream.
Number 0387
MS. BURROWS answered that the current waiver rate allows a portion
of the administrative costs of fees be collected, but it doesn't
currently allow enough so that it would meet the total cost of this
fiscal note. In order to do that, they would be looking at the
total population of about 760 or so people on waivers, 40 percent
of them currently use assisted living. Whatever 40 percent of that
is would be responsible for having sufficient fees to do all the
inspections and regulations, and she doesn't think that would be
feasible.
CO-CHAIRMAN DYSON suggested that the committee continue this
hearing until Tuesday. He would like to know if they charge the
providers for the cost of the process they go through for licensing
and inspection, what would be that figure per institution. He also
asked if anyone knows of any jurisdiction that has penalized the
care providers for failure to perform and/or rewarded them for
excellence in this area of providing for senior care.
Number 0577
REPRESENTATIVE KEMPLEN wondered if there is actually a successful
model of voluntary self-regulating organizations out there
providing social services.
Number 0674
MS. BURROWS answered that there are a couple of commissions. The
largest one is the Joint Commission on Accreditation of Healthcare
Organizations, which has recently included home-health agencies for
nursing homes and have been doing hospitals for a long time. That
was set up on a private, nonprofit basis a type of review that is
more peer review and certainly has that kind of caveat to it and
charges big fees. The hospitals spend thousands of dollars on
self-surveys done over a period of time. They do not at this time,
nor any other to her knowledge, include assisted living, although
they have been looking at assisted living. The work done by the
Alaska Caregivers' Association did look at the quality piece of
peer review that was their beginning attempts to not only set
standards but to do their own kind of association peer review. The
professional associations have tried to take this on.
Number 0772
MS. PURDY said one of the difficulties of having the private
organizations monitor is that it is based on the idea that the
private sector can regulate what happens. That does not protect
the individual resident. One of the problems of the joint
commission is that it can recommend that the participating parties
no longer be accepted, but that does nothing to the facility's
ability to continue to operate. That means the individual
residents may not know that there are individual problems, and that
there is no limitation about the organization continuing to
operate. The result is that the residents are not protected.
Number 0840
REPRESENTATIVE CROFT said this bill was originally intended to take
care of the risks that come along with self-regulation. The
perception or reality of a conflict of interest is what they were
trying to fix in government. The Department of Administration
running the program and licensing it, to the extent that they try
and fix it with business regulating itself, they have gone full
circle to the problem again. It is difficult when the same
organization both runs and monitors whether they are running
sufficiently well. Those two functions probably need a separation.
REPRESENTATIVE CROFT loved the idea of seeing if the federal
funding stream could pay for some of the monitoring, they hadn't
done that; they talked in terms of can the mental health pay for
some of the mental health patients. They are not going to do that
steadily; they might fund some of the research into redoing the
regulations or reforming the system, but they are not going to be
supplanting state money in this regard. The legislature could
apply fees so that it pays for itself; but right now the assisted
living people feel very strongly that they haven't had a raise in
rates for a number of years, and what they are getting paid per bed
is unconscionably low now. There is a bill in Senate Finance to
raise those rates.
MR. LINDSTROM said the proposed rates go from $35 to $50 for two
fiscal years and then up to $75 in the third fiscal year.
Number 0945
REPRESENTATIVE CROFT commented that that bill has about a $1.2
million fiscal note now and a steady state of between $3 million
and $4 million later, and it is now stuck in Senate Finance. To
tell the providers they aren't going to get a raise, instead they
are going to charge the providers for the licensing, might not be
well received. If they apply to that all the things they license,
including hospitals and nursing homes, they could to some extent
subsidize that pressure. The hospitals would want to say something
about a great increase in the hospital inspection rate. Some of
those ideas are not closed, they just have their own dangers.
CO-CHAIRMAN DYSON suggested that the committee consider what they
can do to facilitate this process. He encouraged the departments
to figure out what needs to be done, the best way to do it, define
what should be done, and set a time line for that.
MR. LINDSTROM mentioned that they should expect to see a resolution
for a continuation of the Long-Term Care Task Force.
[HB 16 was held over.]
ADJOURNMENT
Number 1117
There being no further business before the committee, the House
Health, Education and Social Services Standing Committee meeting
was adjourned at 4:58 p.m.
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