State Residential Care and Assisted Living Policy: 2004. Arkansas

03/31/2005

Assisted living facilities; Arkansas Annotated Code §§20-10-1701
Residential long-term care facilities; Arkansas Annotated Code §§20-76-201 (b)(3), 20-10-203, and 20-10-224

General Approach and Recent Developments

Regulations establishing two levels of assisted living facilities were finalized in 2002 and updated in 2003 and requires that any newly-constructed Level II facility shall have to be in accordance with the requirements for I-2 Groups as specified in the International Building Code (IBC) 2000, with exceptions as listed. This regulation formally required “I-1 Groups” compliance.

Assisted living facilities in both levels provide services in a homelike setting for elderly and disabled persons. The philosophical tenets of individuality, privacy, dignity and independence, the promotion of resident self-direction and personal decision-making while protecting resident health and safety are emphasized.

While there have been no facilities who have requested special care units, the State is exploring the possibility of adopting the nursing home special care unit requirements for all assisted living facilities, particularly as it relates to staffing. Currently, the assisted living facility regulations require separate staff for special care units. In nursing facilities, special care units require sufficient staff across the entire facility to meet resident needs. The State Assisted Living Association is pushing to eliminate the residential care home regulations, and create one set of rules for assisted living facilities. There is no identified time frame for accomplishing this.

Additionally, residential care facilities would like to see changes in the assisted living regulations in the areas of programming and staffing. The State is exploring this request. There has been no timetable set to address this.

Supply
  Category   2004 2002 2000
  Facilities     Units     Facilities     Units     Facilities     Units  
Assisted living level 1   1 54 NA NA NA NA
Assisted living level 2 5 221 NA NA NA NA
Residential care 111 4,369 122 4,647 152 5,438

The Living Choices Assisted Living 1915 (c) Waiver Program was implemented in January 2003. Legislation revising Alzheimer’s special care standards passed (HB 1407) in 2001. Personal care services are covered under the state plan for Medicaid beneficiaries.

Definition

Residential long-term care facility (RCF) means a building or structure which is used or maintained to provide, for pay on a 24-hour basis, a place of residence and board for three or more individuals whose functional capabilities may have been impaired, but who do not require hospital or nursing home care on a daily basis but could require other assistance with activities of daily living.

An assisted living facility (ALF) is any building or buildings, section, or distinct part of a building, boarding home, home for the aged, or other residential facility whether operated for profit or not that undertakes through its ownership or management to provide assisted living services for a period exceeding 24 hours to more than three adult residents of the facility who are not relatives of the owner or administrator. ALF means facilities in which assisted living services are provided either directly or through contractual arrangements or in which contracting in the name of residents is facilitated. An ALF provides, at a minimum, services to assist residents in performing all activities of daily living on a 24-hour basis.

An Alzheimer’s special care unit (ASCU) is a separate and distinct unit within an assisted living or other long term care facility that segregates and provides a special program for residents with a diagnosis of probable Alzheimer’s disease or related dementia, and that advertises, markets, or otherwise promotes the facility as providing specialized Alzheimer’s or related dementia care services.

Unit Requirements

Residential long term care facility. A minimum of 100 square feet is required for single rooms and 80 square feet per resident in shared rooms. Rooms may be shared by two residents. A minimum of one toilet/lavatory is required for every six residents and one tub/shower for every 10 residents.

Assisted living facility. All units must be apartments of adequate size and configuration to permit residents to carry out, with or without assistance, all the functions necessary for independent living, including sleeping; sitting; dressing; personal hygiene; storing, preparing, serving, and eating food; storing clothing and other personal possessions; doing personal correspondence and paperwork; and entertaining visitors. Each apartment or unit shall be accessible to and useable by residents who use a wheelchair or other mobility aid consistent with the accessibility standards. Each apartment must have a lockable door. Separate bathroom and kitchen areas are required. Single occupancy apartments must be at least 150 square feet excluding entryway, bathroom and closets, and 230 square feet for two persons. Apartments may not be occupied by more than two persons. Each unit must provide for a small refrigerator as well as a microwave oven, except as may be otherwise provided in the regulations, and a call system monitored 24-hours a day by staff.

Admission/Retention Policy

Residential long term care facility. Tenants must be 18 or older; independently mobile (physically and mentally capable of vacating the facility within 3 minutes); able to self-administer medications; be capable of understanding and responding to reminders and guidance from staff; do not have a feeding or intravenous tube; are not totally incontinent of bowel and bladder; do not have a communicable disease that poses a threat to the health or safety of others; do not need nursing services which exceed those that can be provided by a certified home health agency on a temporary or infrequent basis; do not have a level of mental illness, retardation, or dementia or addiction to drugs or alcohol that requires a higher level of medical, nursing, or psychiatric care or active treatment than can safely be provided in the facility; does not require religious, cultural, or dietary regimens that cannot be met without undue burden; and do not require physical restraints or have current violent behavior.

Waivers of the admission/retention policy are not available. Residents who require frequent skilled nursing services from a home health agency must be assessed by the Office of Long Term Care to determine if a nursing home placement is needed.

Level 1 assisted living facilities cannot serve nursing home eligible residents or residents who need 24-hour nursing services except as certified by a licensed home health agency for a period of 60 days with one 30-day extension; are bedridden; have transfer assistance needs that the facility cannot meet, including assistance to evacuate the building in case of an emergency; present a danger to self or others; and require medication administration performed by the facility.

Level II facilities are allowed to serve nursing home eligible residents but cannot serve residents who need 24-hour nursing services; are bedridden; have a temporary (more than 14 consecutive days) or terminal condition unless a physician or advance practice nurse certifies the resident’s needs may be safely met by a service agreement developed by the assisted living facility, the attending physician or advance practice nurse, a registered nurse, the resident or his or her responsible party if the resident is incapable of making decisions, and other appropriate health care professionals as determined by the resident’s needs; have transfer assistance needs, including but not limited to assistance to evacuate the facility in case of emergency, that the facility cannot meet with current staffing; present a danger to self or others or engage in criminal activities.

Nursing Home Admission Policy

To be determined a functionally disabled individual, the individual must meet at least one of the following three criteria as determined by a licensed medical professional:

  1. The individual is unable to perform either of the following:
    • At least one of the three ADLs of transferring/locomotion, eating, or toileting without extensive assistance from or total dependence upon another person; or
    • At least two of the three ADLs of transferring/locomotion, eating, or toileting without limited assistance from another person; or,
  2. The individual has a primary or secondary diagnosis of Alzheimer’s disease or related dementia and is cognitively impaired so as to require substantial supervision from another individual because he or she engages in inappropriate behaviors which pose serious health or safety hazards to himself or others; or,
  3. The individual has a diagnosed medical condition which requires monitoring or assistance at least once a day by a licensed medical professional and the condition, if untreated, would be life threatening.

Services

Residential long-term care facility. Facilities may provide personal care; supportive services (occasional or intermittent guidance, direction, or monitoring for ADLs); activities and socialization; assistance securing professional services; meals; housekeeping; and laundry. Residents have a choice of providers for receiving personal care services, and they may use an agency that is not the facility. RCFs may not provide medical or nursing services. Home health services may be provided by a certified home health agency when ordered by a physician.

Assisted living facilities. Level 1 facilities provide 24-hour staff supervision by awake staff; assistance in obtaining emergency care 24 hours a day (this provision may be met with an agreement with an ambulance service or hospital or emergency services through 911); assistance with social, recreational, and other activities; assistance with transportation (this does not include the provision of transportation); linen service; three meals a day; and medication assistance. Other services include attendant care, homemaker, and medication oversight. Level 1 facilities may provide occasional guidance, direction or monitoring, or assistance with ADLs and social activities and transportation.

Level II facilities offer services that directly help a resident with certain routines and activities of daily living such as assistance with mobility and transfers; hands-on assistance to resident with feeding, grooming, shaving, trimming or shaping fingernails and toenails, bathing, dressing, personal hygiene, bladder and bowel requirements, including incontinence; and assistance with medication only to the extent permitted by the state Nurse Practice Act. The assessment for residents with health needs must be completed by an RN.

Health services are available that assist in achieving and maintaining well-being (e.g., psychological, social, physical, and spiritual) and functional status. This may include nursing assessments and the monitoring and delegation of nursing tasks by registered nurses pursuant to the Nurse Practice Act, care management, records management, and the coordination of basic health care and social services in such settings.

The regulations provide for negotiation of a compliance agreement to deal with risk of an adverse outcome. In the agreement, the facility identifies the specific concern(s); provide clear, understandable information about the possible consequences of his or her choice or action; negotiates a compliance agreement with the resident or his or her responsible party that will minimize the possible risk and adverse consequences while still respecting the resident’s preferences.

The compliance agreement must address any situation or condition that is or should be known to the facility that involves risk; the probable consequences; the resident or his or her responsible party’s preference concerning how the situation will be handled and the possible consequences of action on that preference; what the facility will and will not do to meet the resident’s needs and comply with the resident’s preference to the identified course of action; alternatives offered to deal with the risk; and the agreed-upon course of action.

Dietary

Residential long-term care facility. Facilities must provide three balanced meals a day and make snacks available, served at about the same time each day, not more than 5 hours apart between breakfast and lunch and between lunch and the evening meal, and no more than 14 hours between breakfast and the evening meal. Facilities must notify the physician if a resident does not eat meals for more than 2 consecutive days. State, county, and local health departments may have rules that deal with sanitation, safety, and health. Recommended daily allowances are established in the regulations. In large facilities (> 17), staff involved in food and dietary services cannot perform other duties on the same shift.

Assisted living facilities. Three balanced meals, snacks, and fluids are required.

Agreements

Residential long-term care facility. Residents must receive a copy of the resident agreement at or prior to moving in that covers: services, materials and equipment, and food to be included in the basic charge; additional services and charges to be provided; residency rules; conditions and rules for termination; provisions for changing the charges; and refund policy.

Assisted living facilities. Covers core services (24-hour staff supervision by awake staff; assistance obtaining emergency care; assistance with social, recreational, and other activities; assistance with transportation; linen service; three meals a day; medication assistance); additional services; health care services available through home health agencies; parameters for pets; current statement of all fees and daily, weekly, or monthly charges; 30-day notice of changes in charges; identification of the party responsible for payment; refund policy; procedures for nonpayment; policy on acceptance of responsibility for personal funds and valuables; responsibility for medication; a copy of facility rules; provisions for emergency transfers; and conditions of termination of the occupancy agreement.

Provisions for Serving People with Dementia

Residential long term care facility. The admission and retention rules limit a facility’s ability to serve anyone with dementia.

Assisted living facilities. Facilities must provide a disclosure statement that includes: the philosophy of how care and services are provided to the residents; the pre-admission screening process; the admission, discharge and transfer criteria and procedures; training topics, amount of training time spent on each topic, and the name and qualification of the individuals used to train the direct care staff; the minimum number of direct care staff assigned to the ASCU each shift; and a copy of the Residents’ Rights.

The licensing rules include program requirements that provide 24-hour care; promote social, physical, and mental well-being and protect resident rights. Nursing, direct care, and personal care staff cannot perform the duties of cooks, housekeepers, or laundry staff during their direct care shifts. An individual support plan must be prepared. Standards for the physical design of the unit are described. Policies are required for egress control and standards for locking devices are specified. Staff must have 30 hours of training on policies (1 hour); etiology, philosophy, and treatment of dementia (3 hours); stages of Alzheimer’s disease (2 hours); behavior management (4 hours); use of physical restraints, wandering, and egress control (2 hours); medication management (2 hours); communication skills (4 hours); prevention of staff burn out (2 hours); activities (4 hours); ADLs and individual centered care (3 hours); and assessment and Individual Service Plans (3 hours). Staff must receive 2 hours of ongoing training each quarter. A disclosure statement must be provided that includes the treatment philosophy; pre-admission screening process; admission, discharge, and transfer policies; assessment, care planning, and implementation; training topics and time required; minimum number of direct care staff; residents rights; assessment; individual support plan and implementation; activities; and the stages for which care is provided.

Medication Administration

Residential long-term care facility. Residents must be familiar with their medications and the instructions for taking them. Aides may remind residents to take medications, read label instructions, and remove the cap or packaging, but the resident must remove the medication from the package or container. The State does not have provisions for nurse delegation.

Assisted living facilities. Staff of Level I facilities may assist with self-administration of, but cannot administer, medications. Staff of Level II facilities may administer medications. A pharmacy consultant is required.

Public Financing

The State implemented the Living Choices Assisted Living HCBS Waiver Program in January 2003. A Living Choices Assisted Living Waiver “assisted living services” provider must be licensed as a Level II Assisted Living Facility or a licensed Class A Home Health Agency who has a contract with a licensed Level II Assisted Living Facility to provide waiver “assisted living services” and provide pharmacy consultant services.

The assisted living waiver program serves clients who are age 65 and over, or who are 21 years of age or over and blind or disabled. A Division of Medical Services, Office of Long Term Care registered nurse determines level of care eligibility. A Division of Aging & Adult Services assisted living waiver registered nurse completes the comprehensive assessment and establishes the tier of need, and completes the service plan upon admission to the program, and annually or at times of significant change.

Services provided under the waiver include attendant care (assistance with ADLs); therapeutic social and recreational activities; medication oversight to the extent permitted by law; medication administration; periodic nursing evaluations; limited nursing services; and non-medical transportation as specified in the plan of care.

Personal care services are reimbursed as a state plan service under Medicaid based on a plan of care. Residential Care facilities are reimbursed on a fee-for-service basis. A maximum of 64 hours of care per month at $12.35 an hour (maximum payment of $790.40) may be covered without prior authorization. Services may exceed the cap if approved. Approximately 1,155 residents living in residential long-term care facilities receive personal care services under the Medicaid state plan. The State uses a presumptive eligibility process to expedite determinations.

Medicaid Participation
  Source   2004 2002 2000
  Facilities     Participation     Facilities     Participation     Facilities     Participation  
State plan   NA 1,155** NA 1,178** NA 1,143**
Waiver 5 50 NA NA NA NA
** Unduplicated number of residents in residential long-term care facilities.

Medicaid reimbursement under the Living Choices waiver is determined through the comprehensive assessment and a four-tier method of need (see table below). The daily rate pays for all direct services in the participant’s plan of care. Pharmacy consultant services are a daily rate. The waiver will pay for 3 prescription drugs beyond the Medicaid State Plan Prescription Drug Program’s monthly benefit limit. Persons receiving assisted living waiver services may not receive Medicaid State Plan Personal Care. Reimbursement is for services only and may not pay for room and board.

Based on the level of assistance, scores are assigned for ADLs (eating [2], toileting [2], ambulation [2], bathing [2], transfer [1], and body care [1]); medication assistance; sensory ability; and psycho-social/cognitive ability. Points are awarded for ADLs for people who need substantial supervision, physical assistance, or total assistance. Points for medication assistance vary with the type of assistance multiplied by the number of medications (see table).

Staffing

Residential long-term care facility. Ratios for the number of direct care staff varies by the time of day (daytime, evening, and night) and the number of residents. Staffing must be sufficient to meet the needs of residents.

Assisted living facilities. Administrators must be certified as an ALF, RCF, or Nursing Home administrator. Staffing sufficient to meet the needs of residents is required according to staff ratios that vary by facility size and shift.

Level 2 facilities must designate a full-time (40 hour per week) administrator who must be on the premises during normal business hours. Sharing of administrators between assisted living facilities and other types of long-term care facilities is permitted. The facility may employ an individual to act both as administrator and as the facility’s registered nurse. At no time may the duties of administrator take precedence over, interfere with, or diminish the responsibilities and duties associated with the registered nurse position. Level 2 facilities must employ or contract with at least one RN. The assisted living Level 2 RN is responsible for the preparation, coordination, and implementation of the direct care services plan portion of the resident’s occupancy admission agreement. The Living Choices waiver plan of care developed by the Division of Aging & Adult Services assisted living waiver RN is to be filed in the resident’s occupancy admission agreement with the assisted living facility’s direct services plan of care. The assisted living facility RN, in conjunction with the physician, shall be responsible for the preparation, coordination, and implementation of the health care services plan portion of the resident’s occupancy admission agreement and shall review and oversee all LPN, CNA, and PCA staff. Level II facilities must employ a consulting pharmacist. The assisted living facility RN need not be physically present at the facility, but must be available to the facility by phone or pager.

Training

Residential long-term care facility administrators must have a current certification as a residential care facility administrator or complete a course of instruction and training prescribed by the department.

Residential long-term care facility staff. An orientation covering, at a minimum, job duties, resident rights, abuse/neglect reporting requirements, and fire and tornado drills is required. For direct care staff, four hours of in-service training or continuing education must be provided on a quarterly basis covering residents’ rights, evacuation of a building, safe operation of fire extinguishers, incident reporting, and medication supervision.

Assisted living facilities. Staff must receive orientation on the following topics: philosophy of independent living in an assisted living residence; residents’ rights; abuse, neglect, and exploitation; safety and emergency procedures; communicable diseases; communication skills; review of the aging process; dementia/cognitive impairment; resident health and related problems; job requirements; medication supervision/management, and incident reporting. A minimum of 6 hours of ongoing training a year is required.

Monitoring

Written policies and procedures for monitoring quality of care are required. Remedies for violations include Civil Money Penalties, denial of admissions, directed in-service training, directed plan of correction, state monitoring, temporary administrator, temporary license, and transfer of residents.

Assisted Living Facilities: The State provides more education than consultation in their oversight and monitoring processes. This process has been very successful. With newly licensed facilities, the State will conduct mock surveys to educate the facility about the process and expectations. This has become more of a teaching/learning model regarding the interpretation of the regulations.

Education is provided on an industry-wide level versus facility-based consultation. The education is typically provided through the assisted living association. Survey nurses do not provide consultation and training. There are separate staff to perform each individual function.

Background Check

Residential long-term care and assisted living administrators may not have any prior conviction pursuant to Arkansas Code Annotated §20-10-401 or relating to the operation of a long term care facility nor any conviction for abusing, neglecting, or mistreating individuals. Administrators must also successfully complete a criminal background check pursuant to Arkansas Code Ann. §20-33-201, et seq.

Criminal background checks are required for all employees. Checks include the Adult Abuse Registry.

Fees

  • Residential long term care facility: $5 per bed.
  • Assisted living: The application fee is $250 plus $10 per bed.
Assisted Living Waiver Program Tiers and Daily Rates
Tier 1 0-5 total ADL points and 0-39 total other points $39.51/day  
Tier 2 0-5 total ADL points and 4-60 total other points or 6-10 total ADL points and 0-39 total other points $42.83/day
Tier 3 0-5 total ADL points and 61 or more total other points or 6-10 total ADL points and 40-69 total other points $47.47/day
Tier 4 6-10 total ADL points and 70 or more total other points $49.97/day
NOTE: The Living Choices Waiver has a built-in annual rate increase of 2.9% for Year 2 based on the FY 04 market basket forecast and 3.0% for Year 3 based on the FY 05 market basket forecast. The rates shown in the above chart are the rates for Year 2.

 

Task Points
Tier Calculation Point Scale
Eating 2 points
Toileting 2 points
Ambulation 2 points
Bathing 2 points
Transfer 1 point
Body care 1 point
Medication reminding/monitoring 0.5 times number of medications
Needs RX assistance 0.75 times number of medications  
Dosage prep 1 times number of medications
Needs administration 2 times number of medications
Speech not understandable, unable to speak, unable to communicate   10 points
Sight: Legally blind with corrective lenses/blind 10 points
Hearing: Must be loud even with aides; unable to hear 10 points
Disorientation 12 points
Memory impairment 16 points
Impaired judgment 17 points
Wandering 15 points
Disruptive behavior 20 points

View full report

Preview
Download

"04alcom.pdf" (pdf, 212.04Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom1.pdf" (pdf, 654.07Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom2.pdf" (pdf, 566.6Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-AK.pdf" (pdf, 189.06Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-AL.pdf" (pdf, 185.52Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-AR.pdf" (pdf, 417.61Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-AZ.pdf" (pdf, 194.53Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-CA.pdf" (pdf, 185.56Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-CO.pdf" (pdf, 190.03Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-CT.pdf" (pdf, 191.73Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-DC.pdf" (pdf, 174.39Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-DE.pdf" (pdf, 181.57Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-FL.pdf" (pdf, 214.18Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-GA.pdf" (pdf, 188.2Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-HI.pdf" (pdf, 174.09Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-IA.pdf" (pdf, 180.15Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-ID.pdf" (pdf, 194.3Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-IL.pdf" (pdf, 211.87Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-IN.pdf" (pdf, 191.49Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-KS.pdf" (pdf, 185.93Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-KY.pdf" (pdf, 181.73Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-LA.pdf" (pdf, 175.83Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-MA.pdf" (pdf, 194.61Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-MD.pdf" (pdf, 191.88Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-ME.pdf" (pdf, 197.55Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-MI.pdf" (pdf, 197.84Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-MN.pdf" (pdf, 197.76Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-MO.pdf" (pdf, 186.65Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-MS.pdf" (pdf, 178.68Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-MT.pdf" (pdf, 625.75Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-NC.pdf" (pdf, 632.84Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-ND.pdf" (pdf, 632.04Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-NE.pdf" (pdf, 633.94Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-NH.pdf" (pdf, 622.4Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-NJ.pdf" (pdf, 630.32Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-NM.pdf" (pdf, 624.59Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-NV.pdf" (pdf, 625.02Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-NY.pdf" (pdf, 671.88Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-OH.pdf" (pdf, 617.34Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-OK.pdf" (pdf, 626.4Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-OR.pdf" (pdf, 648.61Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-PA.pdf" (pdf, 611.04Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-RI.pdf" (pdf, 625.46Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-SC.pdf" (pdf, 623.16Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-SD.pdf" (pdf, 624.49Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-TN.pdf" (pdf, 622.33Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-TX.pdf" (pdf, 636.97Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-UT.pdf" (pdf, 621.24Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-VA.pdf" (pdf, 629.52Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-VT.pdf" (pdf, 658.07Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-WA.pdf" (pdf, 677.93Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-WI.pdf" (pdf, 642.21Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-WV.pdf" (pdf, 629.83Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"04alcom-WY.pdf" (pdf, 623.59Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®