[A PDF [http://aspe.hhs.gov/daltcp/reports/2007/07alcomAK.pdf] of only this state's summary also available]
Assisted living homes: Alaska Statute §47.32.010 et seq.; §47.33.01 et. seq.; 7 Alaska Administrative Code §75.010 et seq.; 7 AAC 10.010; 7 ACC 43:1058(h)
Medicaid waivers: Amounts of reimbursement for HCBS
General Approach and Recent Developments
A law centralizing licensing and procedures for multiple types of entities, including assisted living homes, became law in 2004. The Assisted Living Licensing Unit was transferred from the Division of Senior and Disability Services to the Division of Public Health in 2004. Changes in the safety and sanitation requirements were effective in 2006. The Alaska BCU was created in 2007 and provides centralized background check support for programs that provide for the health, safety, and welfare of persons who are served by the programs administered by DHSS.
The state continues to support the expansion of assisted living homes into rural areas. Assistance with planning and technical support is provided wherever possible.
Adult Foster Care
Assisted living rules include adult foster homes that serve three or more residents. The term “adult foster care” is the prior name used for what is now licensed as assisted living homes. Nothing in the regulations prohibit an assisted living home that is licensed and that serves five or fewer residents from using the term “adult foster home” or “assisted living foster home.”
|http://www.hss.state.ak.us/dph/CL/ALL/forms.htm||Provider tools, guide|
|Assisted living homes||229||1,912||162||1,650||143||1,497|
An assisted living home means a residential facility that serves three or more adults who are not related to the owner by blood or marriage, or that receives state or federal payment for services regardless of the number of adults served; the department shall consider a facility to be an assisted living home if the facility provides housing and food services to its residents; offers to provide or obtain for its residents assistance with ADLs; offers personal assistance as defined in Alaska Statutes 47.33.990; or provides or offers any combination of these services. Personal assistance services includes assistance with ADLs and/or personal assistance (help with IADLs, obtaining supportive services [recreational, leisure, transportation, social, legal, etc.], awareness of the resident’s whereabouts when traveling in the community, and monitoring activities).
Single occupancy units must provide 80 square feet and double occupancy units, 140 square feet. No more than two residents may share a room. A facility must meet life safety code requirements applicable for buildings of its size. Homes for six or more people must meet applicable state and municipal standards for sanitation and environmental protection. Because of the size of the state and the geographic variation within it, the licensing standards are based on community and neighborhood standards rather than a statewide standard. This allows homes to be licensed that are consistent with prevailing local housing standards.
Residents who have exceeded the 45 consecutive day limit for receiving 24-hour skilled nursing (see below) may continue to live at the home if the home and the resident or resident’s representative have consulted with the resident’s physician and discussed the consequences and risks. In addition, a revised plan without 24-hour nursing must have been reviewed by a RN. Terminally ill residents may continue to reside in the residence if a physician certifies that the person’s needs are being met.
Evacuation requirements are included in life safety code standards and facility procedures for emergency evacuation drills.
Since the regulations governing admission/retention are broad, waivers of the requirements are not needed. The rules do allow variances of any provision of the chapter that will promote aging-in-place and meet the goals of the rules.
Nursing Home Admission Policy
Individuals meet the HCBS LOC criteria if they:
- Receive a listed nursing service daily;
- Receive a nursing service less than daily and require limited, extensive, or total assistance with two ADLs (bed mobility, transfer, locomotion, eating, toilet use, personal hygiene, walking, bathing);
- Have impaired cognition and require limited, extensive or total assistance with two ADLs; or
- Have behaviors (wandering, verbal or physical abuse, socially inappropriate) and require limited, extensive, or total assistance with two ADLs.
Each resident must have an assisted living plan (developed within 30 days of move-in and approved by the resident or their representative) that identifies strengths and weaknesses performing ADLs, physical disabilities and impairments, preferences for roommates, living environment, food, recreation, religious affiliation and other factors. The plan also identifies the ADLs with which the resident needs help, how help will be provided by the home or other agencies, and health-related services and how they will be addressed. Health-related services include assistance with self-administration of medication, intermittent nursing services, 24-hour skilled nursing for 45 days, and hospice services.
The plan must promote the resident’s participation in the community and increased independence through training and support, in order to provide the resident with an environment suited to the resident’s needs and best interests.
Negotiated risk is addressed during the care planning process. The plan must recognize the responsibility and right of the resident or the resident’s representative to evaluate and choose, after discussion with all relevant parties, including the home, the risks associated with each option when making decisions pertaining to the resident’s abilities, preferences, and service needs; and recognize the right of the home to evaluate and to either consent or refuse to accept the resident’s choice of risks.
The plan must also identify the resident’s reasonable wants and how those will be addressed. If health-related services are provided or arranged, the evaluation must be done quarterly. If no health-related services are provided, an annual evaluation is required. Assisted living homes may provide intermittent nursing services to residents who do not require 24-hour care and supervision. Intermittent nursing tasks may be delegated to unlicensed staff for tasks designated by the Board of Nursing.
An assisted living home shall offer three balanced, nutritious meals and at least one snack daily at consistent times. A home shall ensure that the meals and snacks offered include the recommended number of servings of each food type set out in the USDA publication, The Food Guide Pyramid, as revised October 1996 and adopted by reference. The home shall offer a wide variety of food that includes fresh fruits and vegetables as often as possible. Additionally, the home shall consider each resident’s health-related or religious restrictions, cultural or ethnic preferences in food preparation, and preference for smaller portions, as reflected in the resident’s residential services contract.
Terms for the residential services contract are specified in statute. The contract must be signed prior to move-in that describes the services and accommodations; rates charged; rights, duties and obligations of the resident; policies and procedures for termination of the contract; amount and purpose of advance payments; and refund policy.
Provisions for Serving People with Dementia
The rules do not include specific provisions.
Aides (home staff persons) may provide medication reminders, read labels, open containers, observe a resident while taking medication, check self-administered dosage against the label, reassure the resident that the dosage is correct, and direct/guide the hand of a resident at the resident’s request. The authority for RNs to delegate tasks is contained in the nurse delegation statute and rules.
A broad HCBS waiver covers services in assisted living homes for elders and adults with disabilities. The room and board payment is negotiated between the home and the resident. In a limited number of cases, room and board and some services are covered by the state’s “general relief” program. The payment standard for SSI recipients is $985 a month and the PNA is $100 a month. Family supplementation is allowed for room and board. A new SSI payment standard is being created for assisted living homes ($654, including a $100 PNA).
Services for Medicaid waiver certified individuals in assisted living homes are funded under the state’s Choice Program, a Medicaid HCBS waiver. Rates vary by area of the state. A multiplier that ranges from 1.0 to 1.38 is applied to the rates, resulting in higher payments in rural and frontier areas (i.e., $100 service in one region may be reimbursed at $138 in another region). Providers receive a basic service rate that varies for AFC, adult residential I, and adult residential II. An “augmented service rate cost factor” is available for clients whose needs warrant the hiring or designating of additional staff. The “augmented care” payment recognizes the added staffing needed by homes caring for residents needing incontinent care, skin care, added supervision, and help with medication. Some residents also attend ADC. The service rate is lower for residents attending day care at least three days a week.
Contracted homes have the option of receiving payment according the tiers or cost-based reimbursement. About half the contracted homes have applied for cost-based reimbursement. The average cost-based rate is $130 a day but is as high as $234.
|Medicaid Payment Rates, July 1, 2004|
|Adult foster care||$32.93||$44.52||$17.37||$70.54|
|Adult residential I||$44.52||$56.10||$17.37||$82.13|
|Adult residential II||$56.10||$67.68||$17.37||$93.70|
|* Total rate includes an $8.65 daily service rate. See http://www.hss.state.ak.us/dsds/pdfs/ChoiceRSLRate20046-30-04.pdf.|
Administrators must be 21 years of age or older and have sufficient experience, training, or education to fulfill the responsibilities of an administrator. Administrators in homes with ten or fewer units must fulfill at least one of the following requirements: complete an approved management or administrator training course and one year of documented experience relevant to population to be served, or complete a CNA training program and have at least one year of documented experience relevant to the population to be served, or two years of documented care experience relevant to the population to be served.
Staff. Homes must have the type and number of staff needed to operate the home and must develop a staffing plan that is appropriate to provide services required by resident care plans. Staff must pass a criminal background check.
Regulations require that administrators receive 18 hours of training annually, direct care staff, 12 hours annually. Staff providing direct care without supervision must have sufficient language skills to meet the needs of residents. Staff must receive orientation that covers emergency procedures, fire safety, resident rights, universal precautions, resident interaction, house rules, medication management and security, physical plant layout, and reporting responsibilities.
No person may be employed who has been convicted of crimes listed in the regulations. Administrators and staff must provide a sworn statement regarding conviction of listed crimes, the results of a name check criminal background check initially and every two years, and a national criminal history check based on fingerprints and conducted by the Alaska Department of Public Safety initially and every six years.
Both DHSS and the Division of Senior and Disabilities Services are responsible for screening applicants, issuing licenses, and investigating complaints. The departments may delegate responsibility for investigating and making recommendations for licensing to a state, municipal, or private agency. Homes must submit an annual self-monitoring report on forms provided by DHSS. Case managers monitor Choice waiver participants monthly.
Regulations require an annual monitoring visit or self-monitoring report filed by the facility. The licensing agency may impose a range of sanctions: revoking or suspending the license, denying renewal, issuing a probationary license, restricting the type of care provided, banning or imposing conditions on admissions, or imposing a civil fine.
The state describes its oversight and monitoring process as consultative. The state acts as a licensing body first, but also sees itself as educators and teachers. If violations are found through the inspection and monitoring process, the state will hand out notices of violation, but will provide education regarding how to improve care, or address the violation.
Currently, the state has limited staff resources to provide as much education and training, as they would like. When a pattern of violations is identified, a more industry-wide, versus a one-on-one, training approach is implemented. The state still holds planned orientations for new or potentially new assisted living homes every three months, but training can be extended out to six months if there is not staff available to conduct formal orientation training.
Licensing staff currently monitor homes as well as provide consultation through education and teaching. After the consolidation of Assisted Living Licensing with Public Health this process may change at some point in the future. They envision possibly rearranging, or reassigning existing staff to perform separate functions.
Voluntary license: $25 per resident. License for 3-5 residents -- $75, six or more residents -- $150, plus $25 per resident over three residents.
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