Assisted living homes, Alaska Statute § 47.33.005 et seq.; 7 Alaska Administrative Code § 75.010 et seq.
The state's assisted living regulations are being reviewed by the state aging office to strengthen license revocation and appeal procedures and other aspects of the program. Proposed revisions are being developed for public comment. No timetable has been set for issuing revised regulations.
In 1997 legislation was passed requiring a criminal background check on all staff. Prior to 1997, criminal background checks were in regulation but not in statute. Rules to implement the amended law are being drafted. A new methodology for reimbursing Medicaid beneficiaries is also being developed.
The states assisted living law was passed in 1994 to encourage the development of assisted living homes to provide a homelike environment for older persons and persons with a mental or physical disability needing assistance with activities of daily living. The law promotes resident participation in the community, recognizes the resident's right and responsibility to evaluate and make choices concerning the services to be provided. The law provides for licensing assisted living homes for elders, people with dementia, and people with physical, mental or developmental disabilities. The Department of Health and Social Services licenses homes for people with mental or developmental disabilities and the Department of Administration licenses homes for older people, people with dementia and people with physical disabilities. The agencies issued joint regulations in 1995 setting additional requirements and standards.
In March 1998, 78 homes with a total of 478 beds had been licensed by the Division of Senior Services. This total does not include the state's Pioneer Homes which are six state operated homes that also provide supportive services. Of the licensed homes, 85% have five or fewer beds. One home has 60 units which are individual apartments. An estimated 50% of the units are private rooms.
The regulations set minimal requirements which are defined in more detail in policies and procedures. Based on their initial experience, state officials are reviewing the regulations governing the overall enforcement and sanctions procedures to expedite action when warranted; to make the criminal check procedures consistent with those used by other agencies; and to clarify liability insurance requirements. To expedite reviews and maximize staff capacity, the licensure staff conduct regular orientation sessions to explain the program and its requirements to interested providers. The sessions are held about every six weeks and have reduced the amount of staff time spent explaining the application process to individual providers or others interested in obtaining a license.
The law creates "Chapter 33. Assisted Living Homes" to emphasize that assisted living serves as the resident's home. The statute applies to residential facilities serving three or more adults who are not related to the owner of the residence by blood or marriage that provide housing, food service, and provide, obtain or offer to provide assistance with activities of daily living, personal assistance (help with IADLs, obtaining supportive services [recreational, leisure, transportation, social, legal, et. al.], being aware of the resident's whereabouts when traveling in the community, and monitoring activities) or a combination of ADL assistance and personal assistance.
No requirements are specified for the type of unit. Shared rooms are allowed. Facilities 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. In view of the vast expanse and geographic variation within the state, 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.
The home and each resident must sign a residential service contract that describes the services and accommodations to be provided, rates, the rights, duties and obligations of the resident, and the policies and procedures for terminating the contract. 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, discussed the consequences and risks and a revised plan without 24-hour nursing has been reviewed by a registered nurse. Terminally ill residents may continue to reside in the residence if a physician certifies that the person's needs are being met.
Evacuation. These requirements are included in life safety code standards and facility procedures for emergency evacuation drills.
Each resident must have a service plan of care developed within 30 days of move-in 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. 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. Twenty four hour skilled care may be provided for not more than 45 consecutive days.
In a limited number of cases, room and board and some services are covered by the state's "general relief" program. The payment amounts in the Anchorage area are $30.00 a day for Level I homes, $33.95 for Level II homes and $40.90 for Level III homes.
Services for Medicaid waiver certified individuals in assisted living homes are funded under the state's Choice Program, a Medicaid HCBS waiver. The Senior Services Division is in process of revising the reimbursement methodology which is currently based on levels of care related to the previous licensure categories. Rates vary by area of the state. In the Anchorage area, Level I homes, formerly adult foster care, provide 24-hour awake staff but do not meet unscheduled needs directly and receive $40.38 a day. Level II homes receive $50.89 a day and have staff capacity to meet unscheduled needs, particularly at night. Level III homes receive $61.39 a day. Homes caring for residents needing extra staff (incontinent, skin care, added supervision, help with medication) can receive a $15.76 per day add-on to the rate. If a resident is also attending adult day care three or more days a week, the rate is reduced to between $29 and $51 a day depending upon the level of the facility. A multiplier is applied to the rates which results in higher payments in rural and frontier areas.
The levels of reimbursement were originally based on the size and staffing level of the three licensing levels of facilities. The rate structure will be revised to reflect residents needs and acuity rather than the size of the facility.
A preliminary methodology would develop a payments for low, intermediate and high needs for medical and acute care needs, physical care needs and cognitive needs. See table.
About 30% of the elderly Choice participants, 175 people, reside in assisted living homes. Case managers from local organizations contract with the Division of Senior Services to conduct assessments, determine eligibility and develop a plan of care for Choice participants who reside in assisted living homes.
"Home staff persons" may provide medication reminders, reading labels, opening containers, observing a resident while taking medication, checking self-administered dosage against the label, reassuring the resident that the dosage is correct, and directing/guiding the hand of a resident at the resident's request.
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. Administrators must be 21 years of age or older and have sufficient experience, training or education to fulfill the responsibilities of an administrator.
No additional training requirements are specified for administrators or staff.
An administrator must provide a sworn statement as to whether the person has been convicted of a felony, a misdemeanor involving drugs or physical or sexual abuse or a misdemeanor involving alcohol. Individuals must also provide the results of a name check, criminal background check and fingerprint investigation conducted by the Alaska Department of Public Safety. Further regulations implementing criminal background checks are being developed.
Both the Department of Health and Social Services and the Division of Senior 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 the department. Case managers monitor Choice waiver participants monthly.
Facilities receiving a voluntary license pay a fee of $25, homes serving 3-5 people pay $75 and homes serving six or more residents pay $150.
|ALASKA PAYMENT RATES--ANCHORAGE AREA|
|Level I||Level II||Level III|
|Room and board||$900.00||$1018.50||$1299.77|
|DRAFT PAYMENT METHODOLOGY|
|Category||Low Impairment Care Service Rate||Intermediate Care Service Rate||High Impairment Care Service Rate||Augmented Service Factor|
|Medicaid and acute care needs||Chronic health problem may be present and treatment may be ongoing. No need for ongoing specialized equipment or procedures.||Chronic health problems are typically present and treatment ongoing. Minimal need for ongoing specialized equipment and/or procedures to intervene.||Acute medical/health care needs typically present and needs ongoing treatment. Need for ongoing specialized medical equipment and procedures to intervene.||Examples of factors which may justify granting an augmented rate:
|Physical care needs||Level of physical impairment minimally impact ability to perform self care.
0-1 ADL dependent.
Needs assistance with 1-2 ADLs.
|Level of physical impairment adversely affects ability to do self care.
Needs assistance with 3-4 ADLs.
|Level of impairment significantly and adversely affects ability to perform self care.
4 or more ADLs.
Needs assistance with 5 or more ADLs.
|Cognitive needs||Level of cognitive functioning adequate to survive independent of 24-hour supervision.||Level of cognitive dysfunction impacts ability to survive independent of ongoing oversight. (mild dementia)||Level of cognitive functioning significantly and adversely impact ability to survive independent of oversight. Mild to late stage dementia.|