Legislature(1999 - 2000)
03/25/1999 03:33 PM Senate STA
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* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
SENATE STATE AFFAIRS COMMITTEE
March 25, 1999
3:33 p.m.
MEMBERS PRESENT
Senator Jerry Ward, Chairman
Senator Lyda Green
Senator Gary Wilken
Senator Randy Phillips
Senator Kim Elton
MEMBERS ABSENT
None
COMMITTEE CALENDAR
PIONEER HOME REVIEW
PREVIOUS SENATE COMMITTEE ACTION
See Senate State Affairs minutes dated 3/18/99.
WITNESS REGISTER
Commissioner-designee Robert Poe
Department of Administration
PO Box 110200
Juneau, AK 99811-0200
Alison Elgee
Deputy Commissioner
Department of Administration
PO Box 110200
Juneau, AK 99811-0200
James Kohn, Director
Alaska Longevity Programs
Department of Administration
PO Box 110211
Juneau, AK 99811-0211
Lisa Caress-Beu
2420 Chinook Ave
Anchorage, AK 99516
POSITION STATEMENT: Asked questions
Marty Margeson
1401 W 13th
Anchorage, AK 99501
POSITION STATEMENT: Asked questions
Bud Caress
6808 Spruce
Anchorage, AK 99507
POSITION STATEMENT: Asked questions
Kathy Emmons
PO Box 770416
Eagle River, AK 99577
POSITION STATEMENT: Asked questions
ACTION NARRATIVE
TAPE 99-7, SIDE A
Number 001
CHAIRMAN WARD called the Senate State Affairs Committee to order at
3:33 p.m. to continue the hearing on Alaska's Pioneer Homes.
Present were Senators Green, Phillips, Elton and Chairman Ward.
SENATOR ELTON moved to add a letter from Mary Elizabeth Johnson to
the record. There being no objection, CHAIRMAN WARD announced a
copy would be distributed to all committee members.
CHAIRMAN WARD informed those present that the Senate State Affairs
Committee held a previous hearing about perceived problems with the
Pioneer Homes. Since that hearing, he met with Commissioner-
designee Poe several times. Today the Commissioner will address
the concerns expressed at the previous hearing.
COMMISSIONER-DESIGNEE ROBERT POE, Department of Administration
(DOA), informed committee members he visited with families, staff
and residents of the Anchorage and Palmer Pioneer Homes after the
previous Senate State Affairs Committee hearing to discuss and see,
first-hand, the concerns expressed about those Homes. He prefaced
his discussion by saying the Pioneer Home Program is one of the
unique things about Alaska; not many states provide similar
programs for their long term residents, and many people have
wonderful things to say about the Pioneer Homes. He pointed out
many families have commented that the Pioneer Homes' staff are very
dedicated to their jobs.
COMMISSIONER-DESIGNEE POE said most of the concerns expressed at
the last meeting relate to the Anchorage Home, but some relate to
the Palmer Home as well. The concerns centered around three areas;
inadequate staffing levels at the Alzheimer's Disease and Related
Dementia (ADRD) and Comprehensive Care Units; the distribution of
medications by Certified Nursing Aides (CNAs) and poor
communication with management. Families are concerned about the
number of medication errors that occur and RNs believe they can
better monitor residents' health by administering medications
themselves. Families believe the management of the Anchorage
Pioneer Home gives unsatisfactory responses to their complaints.
COMMISSIONER-DESIGNEE POE stated he believes the management staff
may be a bit defensive because they are very proud of the good
things they do, but they need to be more open to constructive
criticism. Many of the concerns expressed are related to an
insufficient budget; with limited funding, only so many staff
members can be hired.
COMMISSIONER DESIGNEE POE identified three areas where improvements
can be made, in the near future, particularly to the Anchorage
Pioneer Home. Regarding the administration of medication, only RNs
and LPNs will be administering medication to residents in the ADRD
and Comprehensive Care Units. In addition, DOA will work with the
University of Alaska to develop a longer term medication
administration program for CNAs.
The second improvement relates to the criticism that the Anchorage
Pioneer Home changed from a skilled nursing license facility to an
assisted living facility to avoid regulatory oversight.
COMMISSIONER-DESIGNEE POE disagreed the change was made for
regulatory reasons, and said the change was made because assisted
living homes have been shown to expand the quality of life for
residents with ADRD. He noted statistics show a high number of
Pioneer Home residents have Alzheimer's Disease and related
dementia, therefore the change to assisted living facilities was a
good response to dealing with the resident population. However, as
residents need more medical attention in the later stages, the
assisted living model may not be have the same beneficial effect
and a different model may be more appropriate. COMMISSIONER-
DESIGNEE POE stated he will research what is necessary to change
the Pioneer Homes to dual-license facilities: assisted living and
skilled nursing facilities for the ADRD and Comprehensive Care
Units. A dual model approach will come with increased costs as
facility and staffing changes will be required, and a request for
increased funding will have to occur.
COMMISSIONER-DESIGNEE POE stated the third improvement involves
communication between the Pioneer Home administration and concerned
families. Last Monday he met with family members of Anchorage
Pioneer Home residents to discuss creating family councils. He has
committed his support to that idea, provided the group represents
a broad base of families of residents. He offered to hire two
consultants from Minnesota to meet with the group to provide advice
on setting up the council.
COMMISSIONER-DESIGNEE POE repeated his approach to resolving the
three main areas of concern are to increase staffing levels, work
on skilled nursing facility licensure, and create family councils
to facilitate communication.
ALISON ELGEE, Deputy Commissioner of DOA, and JIM KOHN, Director of
Alaska Longevity Programs, joined Commissioner-designee Poe to
answer questions.
Number 273
SENATOR PHILLIPS commented that at a recent constituent meeting, he
heard many uncomplimentary remarks about Commissioner-designee
Poe's approach to the Pioneer Home complaints, and questions about
which nurses can administer drugs. He noted most people concerned
about the Anchorage, Palmer, and Fairbanks Pioneer Homes felt they
are being patronized rather than listened to.
SENATOR ELTON acknowledged the significant amount of time spent on
this issue by Commissioner-designee Poe, Deputy Commissioner Elgee,
and Director Kohn. He asked for DOA's position on the proposal to
move some of the oversight functions of the Pioneer Homes from the
Department of Administration to the Department of Health and Social
Services.
Number 316
DEPUTY COMMISSIONER ELGEE responded SB 20 transfers the assisted
living licensing function from the Division of Senior Services in
DOA to the Department of Health and Social Services, and is before
this committee. DOA supports the concept, as the assisted living
licensing functions are currently split; DOA licenses senior
residential facilities and DHSS licenses assisted living facilities
for the developmentally disabled and mental health groups. The
same regulations apply to both. DOA has been working with the
sponsor's staff on this proposal and agrees that a combined
function in certification and licensing is a workable idea and will
address some of the concerns raised. MS. ELGEE pointed out the
problem with consolidation is that both departments are
understaffed. Consolidation will not provide the surety that the
public is looking for.
Number 338
SENATOR ELTON clarified that DOA likes the idea but believes more
funds will be required to accomplish the goal. MS. ELGEE said that
is correct.
SENATOR GREEN questioned whether a skilled nursing facility is
staffed with RNs or CNAs. COMMISSIONER-DESIGNEE POE replied a
skilled nursing facility license is equivalent to a nursing home
license.
SENATOR PHILLIPS asked if the lesser qualified staff at the Pioneer
Home were given a pay increase when they were given the duty of
administering medications. COMMISSIONER-DESIGNEE POE said Senator
Phillips was actually referring to two separate issues. CNAs
dispense medications under the supervision and license of an RN.
After discussing that issue with families and staff, he agrees that
only RNs and LPNs should dispense medications in the Comprehensive
Care and ADRD Units, and that an intensive training program should
be offered to CNAs.
Number 373
CHAIRMAN WARD interjected to ask what the Pioneer Homes' policy is
to reduce the number of medical error reports, and whether a
security problem exists regarding medications in the facilities.
COMMISSIONER-DESIGNEE POE acknowledged that medication errors did
occur, and repeated his belief that allowing only RNs and LPNs to
administer medications will minimize the problem.
Regarding Senator Phillips' question about the pay raises, DIRECTOR
JIM KOHN stated each Pioneer Home has an assisted living
coordinator. The Anchorage Pioneer Home recently filled three
assisted living coordinator positions. During the hiring process,
the Home decided the team leaders would best fit the positions so
three long-time staff members were reclassified and promoted.
Those employees were LPNs. Although their pay range changed from
13 to 17, the amount of their raises was minimal because their
longevity had placed them at a step almost equivalent to a range
17.
Number 438
SENATOR GREEN asked whether reluctance on the part of RNs to put
their licenses on the line and allow CNAs to administer medications
will have any effect on whether they are hired or retained.
COMMISSIONER-DESIGNEE POE replied the employee should follow the
rules set by the Board of Nursing.
SENATOR GREEN questioned whether the Board of Nursing has taken any
action or a new position on CNA administration of medications.
COMMISSIONER-DESIGNEE POE said it has not, and that he just began
to address the issue last week.
CHAIRMAN WARD asked what assurance of safety and quality care a
level 4 or 5 resident can expect. COMMISSIONER-DESIGNEE POE
replied he spoke with the daughter of the resident who broke her
hip after being pushed by another resident. The daughter, an RN in
geriatric care, was remarkably understanding about the situation.
The daughter pointed out inadequate staffing lead to the problem.
He stated the 60 new staff positions requested in the FY00 budget
will increase the number of staff in the more critical wards. In
addition, he and Deputy Commissioner Elgee have been looking at
ways to concentrate more staff members in those critical areas.
Number 476
CHAIRMAN WARD referred to a memo written by a Pioneer Home
supervisor to the nursing staff directing that time spent on
medical error reports be minimized. He asked about that policy and
questioned what happens to prescribed narcotics that are not
administered.
MR. KOHN replied the Pioneer Home policy is to write down any
unusual occurrence regarding medications, whether harm was caused
or not, and include whether medications are given at the correct
time. He explained if a medication is to be given at 8:00, it can
be administered between 7:00 and 9:00; that is hospital procedure.
If a medication is not given within that time period, a report is
written. Often, the medication is given ten minutes after the
allotted time span. He noted the memo was written to inform staff
that if medications can be administered within the allotted time
span, that should be done, and medical error reports need not be
written. He emphasized the Pioneer Homes' policy and practice is
to report any irregular activity regarding medications.
CHAIRMAN WARD again asked Mr. Kohn to speak to the issue of the
security of drugs and what happens to drugs that are not
administered properly.
MR. KOHN noted that the incident Chairman Ward referred to, in
which a medication was left on a nightstand, involved an RN, and
was unacceptable. MR. KOHN stated, regarding the security of
medications, the in-house pharmacy allows restocking of some unused
medications if they remain in their original packaging and are
untouched. In the past when the Pioneers Homes contracted with
independent pharmacies, all unused medications had to be destroyed.
CHAIRMAN WARD asked if an accounting of unused medications exists.
MR. KOHN said such a report is kept, and he would provide a copy to
the Chairman. He added the in-house pharmacy has recently raised
the level of safety of unused medications. MR. KOHN also offered
to provide committee members with a forthcoming report from Dr.
Brad Williams, Chairman of the pharmaceutical department at the
University of Southern California, who recently spent a week
assessing the Pioneer Home pharmacies.
CHAIRMAN WARD asked if patients are charged for prescription
medications they do not receive.
MR. KOHN answered in the past, medications provided by independent
pharmacies could not be returned, even if unused. Most unused
medications can now be returned to the in-house pharmacy.
Inexpensive medications are not returned because it is not worth
the handling charge, but narcotics do not fall in that category.
CHAIRMAN WARD asked if patients were charged for medications they
did not receive and were disposed. COMMISSIONER-DESIGNEE POE
stated they were charged for medications that were not worth the
cost of restocking.
CHAIRMAN WARD verified that COMMISSIONER-DESIGNEE POE could supply
an accounting to the committee of when unused medications were
disposed of, and by whom.
MR. KOHN clarified the Pioneer Home tracks all prescribed
medications that are disposed of and a log is kept of medications
that are returned to the pharmacy.
SENATOR GREEN asked if the pharmacy at the Anchorage Pioneer Home
supplies drugs to the Anchorage and Palmer Homes. MR. KOHN
explained that pharmacy supplies medications to five of the six
homes; all but the home in Juneau.
TAPE 99-7, SIDE B
SENATOR GREEN asked why the Juneau Home is not included. MR. KOHN
replied it will be after the first of July.
SENATOR GREEN asked if using the Anchorage in-house pharmacy has
resulted in a cost savings. MR. KOHN replied the normal cost
savings to residents ranges from 25 to 75 percent. The in-house
pharmacy has a contract that allows it to buy large quantities of
medications at a very low cost. About one-half of the residents
receive state assistance because they are no longer able to pay the
rate. At that point, the state pays for the medications. Keeping
the cost of medications down also enables patients to stretch their
money farther and stay off state assistance longer.
SENATOR GREEN asked if the pharmacy is licensed. MR. KOHN said it
is.
SENATOR WILKEN asked about the structure of the pharmacies. MR.
KOHN explained prior to the creation of the centralized pharmacy,
the Pioneer Homes had six individual contracts with pharmacies; one
for each home. Several problems existed with that system: some
homes had difficulty finding a willing pharmacy to contract with;
uniform packaging of medications for ease of administration was
difficult; and the homes needed pharmacy consultations geared to a
geriatric population.
SENATOR WILKEN questioned whether the pharmacy manager at the
Anchorage Pioneer Home is responsible for reviewing the records of
residents at the individual homes, and whether the manager is a
state employee.
MR. KOHN replied two pharmacists are employed at the Anchorage
Pioneer Home pharmacy and both are state employees. They access
all residents' records through a statewide computer system. All
medication orders are checked against the patients chart for
possible drug interactions and polypharmacy.
Number 541
COMMISSIONER-DESIGNEE POE pointed out the centralized records are
useful for several reasons. Contraindications are built into the
pharmacy system and several people track medical prescriptions for
residents.
SENATOR ELTON asked for a definition of "medications." MR. KOHN
stated he was referring to FDA-approved medications and a few over-
the-counter drugs taken for therapeutic reasons.
SENATOR ELTON asked what practice is used to destroy drugs in
nursing facilities and who is charged for the drugs. MR. KOHN
replied Medicaid provides a standardized amount of money for each
patient in a Medicaid facility, and those facilities struggle with
that method.
SENATOR GREEN noted the opening of the Anchorage Pioneer Home
pharmacy was not without incident and conversations about its
problems continue.
MR. KOHN agreed the opening of the pharmacy was a big undertaking.
However, he noted, no one suffered from not receiving medications.
He repeated the forthcoming report from Dr. Brad Williams should be
helpful to all involved.
Number 482
CHAIRMAN WARD announced testimony would be taken from
teleconference participants. He informed those participants their
questions will be responded to in writing by Department of
Administration staff.
KAREN ROBERTS, former Assisted Living Care Coordinator at the
Palmer Pioneer Home, stated COMMISSIONER-DESIGNEE POE's statements
have been directed to problems at the Anchorage Pioneer Home. She
asked if the problems at the other five homes will be addressed.
COMMISSIONER-DESIGNEE POE replied most of the concerns expressed to
date have been about the Anchorage Pioneer Home so his immediate
focus has been on that home.
SENATOR GREEN recommended that the new policy on the administration
of medications be applied to the Palmer Pioneer Home immediately.
MS. ROBERTS emphasized her belief that assisted living is a great
concept, but regulations need to be put in place. She also asked
that management review the job classifications of range 17 LPNs.
She believes they are under worked and overpaid.
Number 440
COMMISSIONER-DESIGNEE POE informed Ms. Roberts he looked at that
issue and explained the State pay scale system with ranges and
steps. He noted that those LPNs received a minor pay increase
overall. He added the three coordinator positions are mid-level
management positions in a home with 226 residents.
LISA CARESS-BEU stated she has never received a credit for
medications that were prescribed but not given to her mother at the
Anchorage Pioneer Home. She asked whether she is being double-
billed.
MR. KOHN answered that any medications not given on schedule would
eventually be given. However, if medications were returned to the
pharmacy, she should get a credit, unless the medication is too
inexpensive to warrant the time taken to give the credit. He
offered to review her mother's medication record. CHAIRMAN WARD
thought all records should be checked against the disposal
documentation.
MS. CARESS-BEU stated, regarding medication security, she has dated
photographs of a medication cabinet left open wide and also with
the key in the lock. The most recent photograph is less than ten
days old. She expressed concern that the medication security
policy is not followed. MR. KOHN suggested Ms. Caress-Beu tell
someone right away.
Number 375
CHAIRMAN WARD noted the State Affairs Committee's top priority is
the safety and health of Pioneer Home residents and that the
committee is not interested in placing blame, but on getting
resolution to the problems discussed.
COMMISSIONER-DESIGNEE POE said he also saw an unlocked medicine
cabinet while he was at the Anchorage home, and although he did not
believe the situation was dangerous, the cabinets should be locked
at all times. He repeated his plan to only allow RNs and LPNs to
administer medications, and to provide a CNA training program in
alignment with the Board of Nursing policies.
Number 239
SENATOR PHILLIPS stated that it was not the previous witness'
responsibility to do something about an unlocked medicine cabinet,
it is the responsibility of the Department of Administration. He
added he heard more emotional complaints from constituents on this
issue than on any other, and it is DOA's responsibility to do
something to solve the problem.
MR. KOHN apologized for giving the impression that he thought it
was the witness' responsibility. He clarified he meant to empower
her to report such a situation immediately so that it can be
corrected right away. SENATOR PHILLIPS repeated DOA needs to
investigate those complaints.
MR. KOHN stated the policy is to keep medication cabinets locked at
all times.
CHAIRMAN WARD asked COMMISSIONER-DESIGNEE POE to respond to a fax
from Marty Margeson regarding health and safety concerns at the
Anchorage Pioneer Home.
COMMISSIONER-DESIGNEE POE stated he met with Ms. Margeson and
viewed photographs of her father. He repeated that more staff has
been requested in the FY00 budget, and the increased staff will
focus on the problem areas. He added the resident who assaulted
Ms. Margeson's father has been moved to the Alaska Psychiatric
Institute (API). He noted Ms. Caress-Beu suggested placing video
cameras in residents' rooms so that residents can be observed by
nurses at the nurses station. COMMISSIONER-DESIGNEE POE stated he
can only try to make sure that resources will be allocated to
protect the residents, and that is what he will do.
Number 239
MARTY MARGESON stated a current resident caused injury to her
father on three occasions and has harmed other residents. The
Anchorage Pioneer Home has responded by putting this resident on a
one-to-one staff watch, and physically and chemically restraining
the resident. However, the harm continues because the techniques
are applied inconsistently. She asked what DOA's plans are for
this resident, and whether DOA will order the Pioneer Homes to
provide a safe environment for all residents. If violations occur,
those violations should be reported to the Ombudsman and licensing
board.
COMMISSIONER-DESIGNEE POE said he has no problem with a policy that
says that DOA wants to guarantee the health and safety of the
residents, but he needs time to think about how that will be done.
In the case of the resident who continues to cause harm,
COMMISSIONER-DESIGNEE POE said he will discuss the situation with
Mr. Kohn to determine the best course of action. He reminded
everyone that Alzheimer's patients sometimes become physically
aggressive, and that he cannot make a snap decision about what that
patient needs.
CHAIRMAN WARD asked Ms. Margeson if she was satisfied with
COMMISSIONER-DESIGNEE POE's reply that he would review the
situation and come to a decision expeditiously.
MS. MARGESON said she would like to know how families should
respond when licensees violate policy and refuse to implement
systems to protect residents.
MR. KOHN replied that the Pioneer Home reports violations to Adult
Protective Services (APS). DOA does its own investigation and APS
has the option of doing a separate investigation.
MS. MARGESON asked Mr. Kohn if APS would have six reports of
violations against her father. MR. KOHN stated he could not tell
her what APS would have.
CHAIRMAN WARD interjected that if no reports exist, then the
procedure does not work and a new procedure must be part of the
overall change.
Number 160
KATHY EMMONS from Eagle River asked why LPNs were hired to fill the
Assisted Living Coordinator positions at range 17, when RNs are
paid at a range 15 and supervise LPNs.
MR. KOHN replied the Assisted Living Coordinator position does not
require a nursing background, although it is helpful. He explained
Assisted Living Coordinators do not supervise the professional
nursing staff, they schedule activities and coordinate staff.
COMMISSIONER-DESIGNEE POE pointed out that RNs receive about $1827
per pay period and the Assisted Living Coordinators receive about
$1699.
MS. EMMONS said she has a problem with the fact that the Assisted
Living Coordinators who are LPNs are telling RNs when to make out
medication error reports.
CHAIRMAN WARD informed Ms. Emmons that COMMISSIONER-DESIGNEE POE
would provide a response to her question in writing.
BUD CARESS from Anchorage stated he met with COMMISSIONER-DESIGNEE
POE last week and was very impressed with him. He asked
COMMISSIONER-DESIGNEE POE what the odds are that the FY 00 budget
requests for the Pioneers Homes will be granted.
CHAIRMAN WARD interjected to ask COMMISSIONER-DESIGNEE POE to
address Mr. Caress' question and to sum up his proposed changes, as
those will have an effect on putting additional funds in the FY 00
budget for the Pioneer Homes.
COMMISSIONER-DESIGNEE POE said he was optimistic that additional
funds will be added to the Pioneer Homes budget, even though it is
late in the budget process. He clarified that the additional funds
are not in the supplemental budget, they are in the FY 00 budget
request. The FY 00 budget contains funds for 60 additional
positions, and that money would be available in July, 1999. He and
Mr. Kohn plan to use those 60 positions to deal with the immediate
concerns in the ADRD and Comprehensive Care Units. He pointed out
it will take time to research the dual model approach, including
the licensing requirements and other necessary changes. He hopes
to talk to family council members this summer about alternatives to
solve the problems that are occurring. He repeated he is
optimistic about the FY00 budget increase because he believes
legislators understand changes cannot be made without funding.
COMMISSIONER-DESIGNEE POE concluded the Pioneer Homes would be
improved by three changes: medication administration by RNs and
LPNs only; dual licensing to include a skilled nursing facility
license; and enhanced training for CNAs that is aligned with Board
of Nursing policies.
TAPE 99-8, Side B
Number 000
SENATOR WILKEN pointed out this Legislature funded a $500,000
request in the supplemental budget for staff for the Pioneer Homes
and legislation has been introduced that will designate Pioneer
Home receipts which will amount to $2.6 million in FY00.
CHAIRMAN WARD informed COMMISSIONER-DESIGNEE POE that many people
are concerned about retaliation against their family members
residing at the Pioneer Homes.
SENATOR GREEN read a fax sent to the committee that said APS and
the Long-term Care Ombudsman have no reports of harm from the
Anchorage Pioneer Home. The sender asked what Commissioner-
designee Poe plans to do to ensure that reports of harm get
reported to the Office of the Long-term Care Ombudsman (OLTCO).
MR. KOHN said he would be agreeable to having the OLTCO be involved
in reports of harm. The current statute requires reports of harm
be made to APS.
CHAIRMAN WARD asked for a more detailed written response to
determine what the Commissioner's intentions are. He also asked
the Commissioner to explain his policy on retaliation.
COMMISSIONER-DESIGNEE POE said he talked with many employees and
others when in Anchorage, and he told them then, and repeats now,
that no retaliation will occur for honest discussion of the
problems. He also gave some of them his business card so that they
can call him directly if retaliation does occur. He emphasized the
important thing to recognize is that frequently those who complain
are viewed as detracting from the positive things that are
occurring. He noted the criticisms do not make the statement that
the Pioneers Home is not doing good things.
CHAIRMAN WARD informed Commissioner-designee Poe that the questions
that were faxed to the committee would be forwarded to his office
for responses. He then adjourned the meeting at 5:10 p.m.
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