Assisted living homes: Alaska Statute §47.33.005 et seq.; 7 Alaska Administrative Code §75.010 et seq.; 7ACC 43:1050 (g)
Medicaid waivers: Amounts of reimbursement for HCB services General Approach and Recent Developments
General Approach and Recent Developments
During 2003-2004, Alaska has been developing plans to consolidate state statutes for licensing. The changes are expected to be completed in 2004 and effective by the end of 2005. The Assisted Living Licensing Unit is being transferred from the Division of Senior and Disability Services to the Division of Public Health and should be completed by July 2004.
The State continues to support the expansion of assisted living homes into rural areas. Assistance with planning and technical support is provided wherever possible. One area of concern in some of the assisted homes is the language differences between administrators, staff and residents. Plans to evaluate the scope of this concern and to develop a plan of action are under way. Key informants noted there has been an increase in assisted living homes that have specialized in providing care to specific populations, such as residents with dementia, residents with physical disabilities, behavioral health residents and men-only or women-only homes.
|Assisted living homes||162||1,650||143||1,497||123||1,346|
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 and food service; and that provide, obtain, or offer to provide or obtain assistance with activities of daily living, 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), or a combination of ADL assistance and personal assistance.
The term “adult foster care” is the prior name used for what is now known, and 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” in connection with that facility.
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 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 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
Alaska implemented a new assessment tool, Consumer Assessment Tool (CAT), in May 2004 for the Medicaid waiver program. Individuals meet the level of care 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. Twenty-four hour skilled care may be provided for not more than 45 consecutive days.
Hospice services may be provided. Homes are required to have copies of living wills or advance directives for residents who have them.
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 U.S. Department of Agriculture 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.
A residential services 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.
A person may not begin residency in an assisted living home unless a representative of the home and either the person or the person’s representative sign a residential services contract that complies with the provisions of this section. Upon signing of the contract, the home shall give the resident and the resident’s representative, if any, a copy of the contract and place a copy of the contract in the resident’s file.
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 registered nurses 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 $907 and the personal needs allowance is $100 a month. Family supplementation is allowed for room and board. A new payment standard is being created for assisted living homes ($654, including a $100 personal needs allowance). Funds previously used to support a higher payment standard will be used to increase the basic Medicaid rate $8 a day.
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 adult foster care, 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 “augment 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 adult day care (ADC). The basic service rate is lower for residents attending day care at least 3 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.
|Anchorage Area||ADC Basic
|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|
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 10 or fewer units must fulfill at least one of the following requirements: complete an approved management or administrator training course and 1 year of documented experience relevant to population to be served, or complete a certified nurse aide training program and have at least 1 year of documented experience relevant to the population to be served, or 2 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 2 years, and a national criminal history check based on fingerprints and conducted by the Alaska Department of Public Safety initially and every 6 years.
Both the Department of Health and Social Services 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 the Department of Health and Social Services. 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 3 months, but training can be extended out to 6 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, 6 or more residents--$150, plus $25 per resident over three residents.
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