Legislature(2021 - 2022)BUTROVICH 205

03/18/2021 01:30 PM HEALTH & SOCIAL SERVICES

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           SB  89-ASSISTED LIVING HOMES: HOUSE RULES                                                                        
1:32:48 PM                                                                                                                    
VICE CHAIR HUGHES announced the  consideration of SENATE BILL NO.                                                               
"An  Act relating  to  house rules  for  assisted living  homes."                                                               
intent  to hear  an overview  and take  testimony. She  called on                                                               
Director John Lee to testify.                                                                                                   
1:34:11 PM                                                                                                                    
JOHN  LEE,   Director,  Division   of  Senior   and  Disabilities                                                               
Services,  Department  of  Health  and  Social  Services  (DHSS),                                                               
Palmer, Alaska, asked his team to introduce themselves.                                                                         
1:34:28 PM                                                                                                                    
TONY   NEWMAN,   Deputy   Director,  Division   of   Senior   and                                                               
Disabilities Services,  Department of Health and  Social Services                                                               
(DHSS), Juneau, Alaska,                                                                                                         
LYNNE  KEILMAN-CRUZ, Chief  of Quality,  Division  of Senior  and                                                               
Disabilities Services,  Department of Health and  Social Services                                                               
(DHSS), Anchorage, Alaska, and                                                                                                  
CRAIG  BRAXTER, Program  Manager,  Residential Licensing,  Health                                                               
Care Services,  Department of Health and  Social Services (DHSS),                                                               
Anchorage, Alaska, introduced themselves.                                                                                       
MR.LEE said  that SB  89 deals with  assisted living  homes, home                                                               
and community-based services. In  Alaska these are 1915(c) waiver                                                               
services.  That means  that Alaska  gets  a federal  match of  50                                                               
percent  for  the  waiver programs.  The  waiver  programs  offer                                                               
optional, low-cost  home and  community-based options  for people                                                               
who would  otherwise be in  institutions. These  programs provide                                                               
services that  keep people  in their  communities and  keep costs                                                               
1:36:24 PM                                                                                                                    
MR.  LEE said  that Alaska  statutes are  not in  compliance with                                                               
federal  regulations   that  require  home   and  community-based                                                               
service  providers to  give people  who are  on waivers  the same                                                               
access to  community as people  not on waivers. For  example, the                                                               
state law allows  assisted living homes to  establish house rules                                                               
around visitations,  but the federal statutes  require that these                                                               
providers  allow individuals  to  exercise the  same choices  and                                                               
options as  if they were  in their own  homes. This bill  makes a                                                               
couple of  statutory changes  so the state  can be  in compliance                                                               
with the final rule of  federal codes that govern these programs.                                                               
Ongoing participation  in the waiver  depends on the  state being                                                               
compliant. The federal government has  given states until 2023 to                                                               
make the  statutory changes  to be in  compliance with  the final                                                               
MR.  LEE said  that the  simple  insertion of  language into  the                                                               
assisted  living   home  statute   will  bring  the   state  into                                                               
compliance with  the Centers for  Medicaid and  Medicare Services                                                               
(CMS)  home and  community-based setting  requirements. The  bill                                                               
would ensure that  recipients of waiver services will  be able to                                                               
live under conditions  as much like a person's  home as possible.                                                               
About  700  assisted  living  home providers  in  state  will  be                                                               
required to  abide by  the conditions defined  in the  bill. This                                                               
new  statutory  language  will afford  all  residents  living  in                                                               
assisted living homes the same  rights, regardless of whether the                                                               
home accepts  Medicaid for  payment or not.  There are  650 homes                                                               
already  in compliance  with  the conditions  set  forth in  this                                                               
legislation.  The  states have  until  March  of  2023 to  be  in                                                               
compliance  with  this  rule.  That   was  an  extension  of  the                                                               
timeline.  Because of  the pandemic,  CMS gave  states additional                                                               
time to  be in  compliance. There  is no  fiscal impact  from the                                                               
MR. LEE presented the sectional:                                                                                                
     Section  1: Amends  AS 47.33.060  House  Rules for  Assisted                                                               
     Living Homes to explicitly  require consistency with federal                                                               
     regulation when house rules are established.                                                                               
     Section 2:  Adds a new  section to AS 47.33.060  House Rules                                                               
     for  Assisted Living  Homes to  make explicit  that assisted                                                               
     living  homes that  provide waiver  services  may not  adopt                                                               
     house rules inconsistent with federal regulations.                                                                         
     Section  3: Carries  the  statutory  amendments proposed  in                                                               
     Section  1 and  Section 2  of  the bill  to AS  47.33.300(a)                                                               
     regarding a resident's rights to have visitors.                                                                            
1:40:02 PM                                                                                                                    
SENATOR COSTELLO said  that a number of individuals  in Alaska in                                                               
assisted  living  homes and  community-based  homes  have a  high                                                               
percentage  who  experience  early   onset  of  dementia  or  are                                                               
somewhere  on the  spectrum of  dementia. When  she looks  at the                                                               
highlighted portion  of the bill  that says individuals  can have                                                               
visitors  of their  choosing  at any  time,  she wonders  whether                                                               
people who  have power of  attorney or family  members overseeing                                                               
their matters can determine who the visitors are.                                                                               
MR.  LEE  answered  that  if   individuals  have  guardians,  the                                                               
guardians do  have the ability to  make choices on behalf  of the                                                               
individual. One  of the  responsibilities of  the guardian  is to                                                               
make decisions as  close to what those individuals  would make on                                                               
their own.                                                                                                                      
SENATOR BEGICH  asked if Section  4 is still required,  which has                                                               
provisional language  relating to the executive  orders submitted                                                               
by  the governor  to the  32nd  Alaska State  Legislature in  the                                                               
first regular  session. Since that  has been withdrawn,  he asked                                                               
whether Section 4 should be eliminated.                                                                                         
MR. LEE deferred to Tony Newman.                                                                                                
1:42:08 PM                                                                                                                    
MR.  NEWMAN said  that Section  4  could be  eliminated, but  the                                                               
division would need to defer to the Department of Law.                                                                          
SENATOR BEGICH  explained that  he is not  intending to  slow the                                                               
bill. He  is just bringing that  to the attention of  the author.                                                               
That could  be removed later  in the process  if it is  no longer                                                               
VICE  CHAIR  HUGHES  said  an   order  may  be  reissued  if  the                                                               
legislature did  not reconvene. Mr.  Lee might want to  make sure                                                               
that it would suit that possible future scenario.                                                                               
SENATOR BEGICH  said he  received a legal  opinion on  the order.                                                               
Unless it  is issued tomorrow,  there will  be no ability  in the                                                               
first regular  session for there to  be a regular order.  At this                                                               
point, if it  is left in it would be  irrelevant. He doesn't know                                                               
the answer. He doesn't  want to hold the bill up  for that but is                                                               
bringing it to the attention of the bill's author.                                                                              
VICE CHAIR  HUGHES said that if  the words "in the  first regular                                                               
session" would be removed it would  be possible an order could be                                                               
reissued and if  the legislature decided not to  convene and stop                                                               
it, it would be applicable. She leaves it to Mr. Lee.                                                                           
SENATOR WILSON asked what the  consequences are for the providers                                                               
who are not in compliance with the new guidelines.                                                                              
MR.  LEE  explained  that  once the  statute  goes  into  effect,                                                               
licensed providers will need to be in compliance.                                                                               
1:45:06 PM                                                                                                                    
MR.  BAXTER  said that  the  residential  licensing agency  would                                                               
reach out  to those  providers and have  them update  those house                                                               
rules to  reflect the change. Of  the 50 or so  providers who are                                                               
not  currently  certified, as  new  licensees  their house  rules                                                               
would  now  have  to  reflect   the  visitation  requirements  if                                                               
certified. A  fair number of  the 50 providers  are provisionally                                                               
licensed and are  in the process of seeking  certification. It is                                                               
probably even  fewer than 50  who would be affected.  The handful                                                               
that would not be affected are the  ones who have opted not to be                                                               
certified or  who have lost certification.  They essentially just                                                               
have to expand visitation hours.  Most facilities have visitation                                                               
hours usually  between 8 to  8. They  would need to  update those                                                               
visitation hours.                                                                                                               
SENATOR WILSON  asked what the penalty  is if they don't  do this                                                               
or if they aren't notified or fall through the cracks.                                                                          
MR.  BAXTER replied  that if  they refuse  to update  their house                                                               
rules, probably the  first time someone had a  visitor barred the                                                               
agency would intervene and notify  them of noncompliance and then                                                               
ask for  a plan of  correction and try  to resolve that  with the                                                               
facility. If  the facility continued  to not allow  visitation in                                                               
compliance with those rules, then  the agency may issue a warning                                                               
notice or elevate it to a  higher enforcement action. They do try                                                               
to  work with  a facility  to  come into  compliance. If  someone                                                               
filed  an  appeal, the  agency  goes  through the  administrative                                                               
appeals process to resolve the issue as well.                                                                                   
1:47:22 PM                                                                                                                    
SENATOR COSTELLO noted  that many assisted living  homes were not                                                               
able to  accept visitors because of  COVID. She asked if  this is                                                               
in response to that or is that a separate issue entirely.                                                                       
MR.  LEE answered  that is  a  common question.  This statute  is                                                               
needed regardless  of COVID.  COVID has nothing  to do  with this                                                               
bill except  that during COVID  certain regulations were  able to                                                               
be suspended.  The bill is  needed to  be in compliance  with the                                                               
code of federal regulations.                                                                                                    
SENATOR  COSTELLO asked  how many  complaints  are received  from                                                               
individuals  or families  in  homes and  what  agency deals  with                                                               
those complaints.                                                                                                               
MR. LEE  responded that  it depends  on the  complaint. If  it is                                                               
about a  program that Senior  Disability Services  provides, then                                                               
the  complaints   will  come   to  Senior   Disability  Services.                                                               
Licensing complaints  about providers  could go to  Craig Baxter.                                                               
The recipient  community is in favor  of this bill, to  make sure                                                               
providers and the state allow people  to live their lives as they                                                               
choose. This  will be well  received by the  recipient community.                                                               
There  are  already  more  than  650  providers  out  of  700  in                                                               
SENATOR  COSTELLO  said  that  her  questions  are  not  directly                                                               
related to the bill. She asked  if the division requires a survey                                                               
of residents' families.                                                                                                         
MR. LEE said the division  partners with providers and recipients                                                               
frequently. He deferred to Ms. Keilman-Cruz.                                                                                    
1:51:52 PM                                                                                                                    
MS. KEILMAN-CRUZ  replied that Senior Disabilities  has a central                                                               
reporting intake.  Individuals and  families can  make complaints                                                               
that are then routed to each  of the oversight divisions, such as                                                               
residential  licensing and  the  quality  assurance program.  The                                                               
division does not  do surveys but does require  homes or entities                                                               
with  certifications to  conduct their  own satisfaction  surveys                                                               
and report those to the division.                                                                                               
SENATOR  COSTELLO said  that was  her question.  The surveys  are                                                               
done and the  results are provided to  Ms. Keilman-Cruz's office.                                                               
She asked if the results are public.                                                                                            
MS.  KEILMAN-CRUZ answered  they  are not  typically public.  The                                                               
division uses  them as  a quality overview  of how  the providers                                                               
are  doing. They  conduct  their own  internal  surveys. Until  a                                                               
complaint  is  completely  adjudicated, the  division  would  not                                                               
release those complaints.                                                                                                       
SENATOR COSTELLO  asked if Ms.  Keilman-Cruz' agency  can provide                                                               
information on  complaints that have  been finalized so  that the                                                               
public officials can  have sense of a nature of  the situation in                                                               
Alaska.  The  state  has  one   of  the  fastest  growing  senior                                                               
populations. It  would be interesting  for the committee  to know                                                               
the nature of some of the complaints after the past five years.                                                                 
MS. KEILMAN-CRUZ said the division  could give an overview of the                                                               
types and amounts of complaints  and Craig Baxter can discuss the                                                               
licensing inspection and investigation process.                                                                                 
VICE CHAIR HUGHES  asked her to provide that  to Senator Wilson's                                                               
office.  She has  general questions,  like  Senator Costello,  to                                                               
help the committee  be informed about assisted  living homes. She                                                               
asked if a person  is looking for a home for  loved one, is there                                                               
a  resource to  look at  ratings or  a way  to evaluate  assisted                                                               
living homes.                                                                                                                   
MR.  LEE  replied that  are  not  a  lot  of online  ratings  for                                                               
assisted living  facilities. One of things  his division provides                                                               
for individuals  who qualify for the  waiver program is a  way to                                                               
connect them with care coordinators  who are charged with helping                                                               
individuals  navigate their  options and  help them  evaluate the                                                               
quality of care of facilities they may be placed in.                                                                            
MR.  BAXTER  said  that  his   office  conducts  between  500-600                                                               
inspections  annually and  300-400 investigations  annually. Once                                                               
those reports become  public, any member of the  public can reach                                                               
out to  his office for copies  of reports or surveys.  His office                                                               
has a  list of  licensed providers  on its  website. There  are a                                                               
handful  of agencies  that some  facilities are  associated with,                                                               
like A Place  for Mom. Those agencies  request routine inspection                                                               
reports from his  office so they can make  sure their recommended                                                               
facilities are in compliance. Outside  of that there is no rating                                                               
system  that the  state  or  anyone else  publishes  for all  the                                                               
assisted living homes.                                                                                                          
SENATOR  HUGHES  asked if  700  providers  are adequate  for  the                                                               
growing senior population.                                                                                                      
MR. LEE  answered that to  be 100  percent honest, it  depends on                                                               
where  someone lives.  In Anchorage,  Mat-Su, Fairbanks,  and the                                                               
larger areas, there is an adequate  supply. The real issue is the                                                               
more remote populations. It depends on where someone lives.                                                                     
1:59:59 PM                                                                                                                    
MR. NEWMAN said  that to his knowledge no analysis  has been done                                                               
recently  that demonstrates  either a  surplus or  a shortage  in                                                               
Alaska, but they  know that Alaska does have  the fastest growing                                                               
senior  population  in  the  country.   The  number  of  licensed                                                               
assisting  homes in  Alaska has  been  growing dramatically.  The                                                               
stakeholders  would probably  say  Alaska could  always use  more                                                               
assisted living  homes that are  well tailored to meet  the needs                                                               
of varied clients.                                                                                                              
VICE CHAIR HUGHES  noted there is a Pioneer Home  in her district                                                               
and the residents suffered from  loneliness and the home tried to                                                               
make better arrangements for visits  during the high point of the                                                               
pandemic as  the homes  were trying  to protect  that population.                                                               
She asked  if assisted living  homes had similar strict  rules as                                                               
far as visitation.                                                                                                              
MR. BAXTER  answered that the  Pioneer Homes are licensed  in the                                                               
same way as  the rest are. The same guidelines  and health orders                                                               
applied to all.                                                                                                                 
VICE CHAIR HUGHES said that  to come into compliance with federal                                                               
law, her understanding  is that assisted living  homes would need                                                               
allow visitors  at any time.  Mr. Baxter had mentioned  that some                                                               
had visiting  hours from 8 a.m.  to 8 p.m. She  asked if assisted                                                               
living homes must accept visitors 24/7 now.                                                                                     
MR. LEE said  that the statute will require  that the individuals                                                               
have  opportunities  to  have  visitors  at  the  time  of  their                                                               
choosing, so yes.                                                                                                               
VICE  CHAIR HUGHES  said that  the  state must  be in  compliance                                                               
March  2023 and  about  50 homes  that still  need  to come  into                                                               
compliance. She  asked if  they will  be relicensed  before March                                                               
2023, so will that occur naturally.                                                                                             
2:03:27 PM                                                                                                                    
MR. BAXTER answered  that will happen naturally.  The majority of                                                               
licenses  are biennial,  a  two-year cycle.  Most  new homes  are                                                               
provisionally licensed on a one-year  cycle. It would be easy for                                                               
the division to  do it as part of the  natural licensing cycle by                                                               
2023. If a  home was not able  to be in compliance  by that time,                                                               
the division will reach out to the home to work on that.                                                                        
SENATOR COSTELLO asked if the bill addresses online visits.                                                                     
MR.  LEE said  that  is an  excellent question  in  light of  the                                                               
pandemic value of distance delivery.                                                                                            
MR. BAXTER  replied that residents  already have the  right under                                                               
AS 47.33.300 to engage  in private communication, telephonically,                                                               
in person, or using the internet.  That cannot be restricted by a                                                               
facility.  If a  facility were  restricting someone's  ability to                                                               
get online  and contact people, that  would be an issue  unless a                                                               
guardian had restricted that.                                                                                                   
SENATOR  COSTELLO  said  she  is   not  thinking  of  a  facility                                                               
restricting that but more in  terms of the facility providing the                                                               
opportunities. She asked if visitors  include online visitors and                                                               
if  the  resident doesn't  own  a  device, does  the  legislation                                                               
require the facilities to provide the opportunity.                                                                              
MR. LEE  answered that the final  rule does not direct  states to                                                               
have that  requirement. The  proposed bill  does not  require the                                                               
provider to provide that. There  are resources to help people get                                                               
devices, but  the bill is  silent on  that. The attempt  with the                                                               
bill  is for  the  state to  be compliant  with  the final  rules                                                               
without adding any additional requirements.                                                                                     
SENATOR COSTELLO clarified that her  line of inquiry is about the                                                               
definition of  visitor. She  is hearing that  it is  an in-person                                                               
visitor and  not an electronic  visit. That  is how she  read the                                                               
bill,  but  she  thought  it   worth  bringing  up  because  many                                                               
individuals do  not have family  here in  Alaska and it  would be                                                               
nice for that opportunity to be provided to residents.                                                                          
VICE CHAIR  HUGHES shared that  she knows the facility  in Juneau                                                               
was  accommodating during  her father's  final weeks  with visits                                                               
through phones or tablets during the pandemic.                                                                                  
2:08:39 PM                                                                                                                    
SENATOR WILSON asked knowing that  assisted living providers have                                                               
a  lot  of  issues  with  billing  Medicaid,  if  the  department                                                               
provides technical  assistant for that. Medicaid  audits are high                                                               
for assisted living facilities.                                                                                                 
MS.  KEILMAN-CRUZ  answered  that  her agency  supplies  lots  of                                                               
technical assistance and  has an open door  policy for facilities                                                               
to  ask   questions  through   the  provider   certification  and                                                               
compliance unit. When her agency  does investigations, many times                                                               
it  is offering  technical  assistance to  come into  compliance.                                                               
Residential  licensing  supplies  the   same  sort  of  technical                                                               
assistance. For  billing specifically, there are  online programs                                                               
and trainings to assist with billing.                                                                                           
MR.  BAXTER said  his agency  also offers  a variety  of training                                                               
opportunities to new and  existing facilities regarding licensing                                                               
complaints.  It does  not  deal with  Medicaid  billing but  with                                                               
compliance and standards.  Providers can reach out  to his agency                                                               
for help.                                                                                                                       
VICE CHAIR  HUGHES noted  there is  no fiscal  note and  asked if                                                               
there  is potential  for  increased staffing  if  there are  more                                                               
visitors in an assisted living home or will that be minimal.                                                                    
MR. BAXTER replied  his office already works  closely with Senior                                                               
and Disabilities Services to bring  the 650 homes into compliance                                                               
and he has not noted any increase in staffing because of this.                                                                  
2:12:32 PM                                                                                                                    
VICE CHAIR HUGHES opened public testimony.                                                                                      
2:12:46 PM                                                                                                                    
ROBIN   MINARD,  Chief   Communication  Officer,   Mat-Su  Health                                                               
Foundation, Wasilla,  Alaska, said  that currently  Alaska allows                                                               
assisted living to establish house  rules for visitors. While the                                                               
state  law  says   the  house  rules  may   not  be  unreasonably                                                               
restrictive,  the federal  regulation is  more explicit,  stating                                                               
that  individuals on  waivers must  be able  to have  visitors of                                                               
their  choosing  at  any  time.   The  Mat-Su  Health  Foundation                                                               
supports  this change  because it  affords residents  of assisted                                                               
living  homes  the  ability to  make  decisions  for  themselves.                                                               
Alaskans in these settings deserve  living conditions as close as                                                               
possible to those they would have  in their own homes. Mat-Su has                                                               
the fastest growing senior population  in the state. By 2030 more                                                               
than one in five Mat-Su residents  will age 60 or older and those                                                               
over age  85 will  increase by 188  percent. These  residents are                                                               
often the most vulnerable and  require more intense services. She                                                               
urged the  committee to  pass SB  89 so  the most  vulnerable and                                                               
most  treasured citizens  can enjoy  the  living conditions  they                                                               
2:14:57 PM                                                                                                                    
VICE CHAIR HUGHES  closed public testimony and  noted the written                                                               
testimony that  had been  submitted in support  of the  bill. She                                                               
held SB 89 in committee.                                                                                                        

Document Name Date/Time Subjects
SB 89 Version A.PDF HHSS 5/4/2021 3:00:00 PM
SHSS 3/18/2021 1:30:00 PM
SB 89
SB 89 Transmital Letter.pdf SFIN 4/7/2021 9:00:00 AM
SHSS 3/18/2021 1:30:00 PM
SB 89
SB 89 Sectional Analysis Version GS 1675 A.pdf HHSS 5/13/2021 3:00:00 PM
SFIN 4/7/2021 9:00:00 AM
SHSS 3/18/2021 1:30:00 PM
SB 89
SB 89 Fiscal Note 1 DHSS.PDF HHSS 4/29/2021 3:00:00 PM
HHSS 5/4/2021 3:00:00 PM
HHSS 5/13/2021 3:00:00 PM
SHSS 3/18/2021 1:30:00 PM
SB 89
SB 89 FAQ on Final Rule prepared by Coalition for Community Choice.pdf HHSS 4/29/2021 3:00:00 PM
HHSS 5/4/2021 3:00:00 PM
HHSS 5/13/2021 3:00:00 PM
SFIN 4/7/2021 9:00:00 AM
SHSS 3/18/2021 1:30:00 PM
SB 89
SB 89 Final Rule 42 CFR 441.301c.pdf SFIN 4/7/2021 9:00:00 AM
SHSS 3/18/2021 1:30:00 PM
SB 89
SB 89 One Page Summary.pdf HHSS 4/29/2021 3:00:00 PM
HHSS 5/4/2021 3:00:00 PM
HHSS 5/13/2021 3:00:00 PM
SFIN 4/7/2021 9:00:00 AM
SHSS 3/18/2021 1:30:00 PM
SB 89
SB 89 Settings Information webpage.pdf HHSS 4/29/2021 3:00:00 PM
SFIN 4/7/2021 9:00:00 AM
SHSS 3/18/2021 1:30:00 PM
SB 89
SB 89 All Ways Caring Letter of Support.pdf HHSS 4/29/2021 3:00:00 PM
HHSS 5/4/2021 3:00:00 PM
HHSS 5/13/2021 3:00:00 PM
SHSS 3/18/2021 1:30:00 PM
SB 89
SB 89 Letter of Support Samash_Redacted.pdf HHSS 4/29/2021 3:00:00 PM
HHSS 5/13/2021 3:00:00 PM
SHSS 3/18/2021 1:30:00 PM
SB 89
SB 98 Version 32 GS 1708 A.PDF SHSS 3/18/2021 1:30:00 PM
SB 98
SB 98 Transmittal Letter.pdf SFIN 4/7/2021 9:00:00 AM
SHSS 3/18/2021 1:30:00 PM
SB 98
SB 98 Sectional Analysis Version GS 1708 A.pdf SFIN 4/7/2021 9:00:00 AM
SHSS 3/18/2021 1:30:00 PM
SB 98
SB98 Fiscal Note 1 DHSS Medicaid.PDF SHSS 3/18/2021 1:30:00 PM
SB 98
SB98 Fiscal Note 2 DHSS Senior Svcs.PDF SHSS 3/18/2021 1:30:00 PM
SB 98
SB98 Fiscal Note 3 DHSS Health Care Svcs.PDF SHSS 3/18/2021 1:30:00 PM
SB 98
SB 98 Adult Foster Care for Disabled Graphic.pdf SFIN 4/7/2021 9:00:00 AM
SHSS 3/18/2021 1:30:00 PM
SB 98