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New York State Center for Assisted Living

Mid-Winter Conference

Carla Williams, MPA, O’Connell & Aronowitz

Shelley Sabo, Executive Director, NYSCAL

• Chapter 165 of the Laws of 1991

• Address OBRA 87 changes that eliminated Health Related Facilities and beds in Nursing Homes

• Address growing desire to age in place in congregate setting of adult home

• “Program”= add services to existing structures

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• An entity which is approved, established and operated for the purpose of providing long term residential care, room, board, housekeeping, personal care, supervision, personal care, case management and providing or arranging for home health services to five or more eligible adults unrelated to the operator.

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• Medicaid Payment is based on assessment of participant and related to the RUGS system

• Medicaid program is approved under the State Plan Amendment for Personal Care Services

• Contract with Local Social Services District indicates ALP as provider of personal care services as well as providing program oversight

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• First need identified in 1993: 4200 beds

• Chapter 58 of the Laws of 2009: included an additional 6,000 beds linked to the decertification of RHCF beds

• Chapter 56 of the Laws of 2012: removed the requirement that RHCF bed decertification be linked to the 6,000 ALP beds

• Chapter 56 of the Laws of 2013: authorized the approval of 4,500 additional beds beyond those determined available as of April 2012 for certain adult homes.

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Authorizations for ALP Beds

1993 2007 2009 2012 2013 Total as of 9/2013

Number of New Beds Authorized

4200 1500 6000 0 4500 16,200

Number Approved 3800 1986 1282 1320 ??? 8,388

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Beds in operation as of June 2013: 6,679

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ACF/EH

LHCSA

ALP

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ACF/EH

CHHA

ALP

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ACF CON

LEGAL

ARCH

NEEDCHAR

& COMP

FIN$

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PART ONE APPROVAL

REGIONAL OFFICE REVIEW

PART TWO APPROVAL CON APPROVAL

Two Step Process:

1. Submit the ALP response to Request for Applications

2. After receipt of DOH approval to proceed, submit the ACF/ALP and HC CON

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• Identify the Eligible Applicant and Facility• Name, Address, Contact Information, Op Cert # and Legal

• Proposal Summary‒ Assuring resident living skills, choice and confidentiality‒ Access and privacy

• Program Information‒ Capacity/Bed Numbers – Current and Proposed

• Legal‒ Narrative/organizational chart of current and proposed

entity‒ Proof of site control‒ Current Operating Certificate

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• Financial Information

• Projected cost and source of funding (including rehabilitative, architecture and soft costs)

• Architectural

‒ Narrative describing auto sprinklers, smoke and thermal detectors, emergency lighting, fire alarm system, call system, exit lighting, exits and cost of renovation

• Home Care Component

• Proof of existing license/certificate or statement of willingness to obtain licensure/certification

• Notarized Certification/Attestation

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• Purpose:• Expedite review and approval of license applications through the

establishment of a streamlined application process for existing licensed ACF and ALR operators in good standing.

• How:

• In collaboration with industry representatives• Expand upon creative options already developed

• Create the streamlined process

• Make it available for use on or before 1/1/2014

• Existing operators in “Good Standing”• Relates to approval of an additional facility of the

same type• Certification process to verify sufficient financial

resources, revenue and financing• Certification process to verify legal, corporate and

organizational docs comply• Certification process to verify substantial compliance• Conditional approval to operate for limited period w/

commitment to satisfactorily complete the cert. process within that time

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• Conditional approval to construct, at own risk,

upon substantial completion of arch. component

• Eliminate duplicative submission and review requirements for any docs submitted, reviewed and approved within the last 2 years

• Create an electronic application submission process

• Create a combined application for all ACF facility types and programs

• RO review of program info on-site at pre-opening or first full annual inspection, if DOH approved operator to run same program at another facility within past 2 years

• DOH created an ACF Application Streamlining Workgroup in Spring 2013

• Charge: To review and analyze current ACF licensure application and approval processes, documents, required information, content and review processes and make recommendations to streamline and simplify the process, while maintaining quality, thoroughness and process to achieve appropriate determinations on applications.

• The Streamlining Workgroup has met monthly.

• Subgroups for Part 1, Part 2, Architectural, Legal and Financial have met on a bi-weekly schedule since June.

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• Consolidated existing legal and financial schedules and tables

• Combined the CON Schedule for ALP and ALR applications

• Revised the format, shortened and eliminated duplicative and unnecessary questions

• Deleted Schedules/information not relevant to ACFs

• Combined, clarified and simplified increase in bed capacity applications for ACFs (9 or fewer) and SN/EALRs (5 or fewer)

• Created abbreviated apps for Business Conversion and Limited Change in Ownership notices or approval

• Created optional legal certifications and attestations for applicant’s counsel to attest to compliance with routine requirements and identify potentially non-compliant provisions and issues for further review

• Modified financial projections and created attestations for short or abbreviated applications

• Eliminated requests for SS#, bank account #s and other information not utilized for Personal Financial review

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• Created a standard waiver to simplify requests by lenders for restricted account arrangements and assignment/security interests in operational assets

• Created process for submission of Part 2 documents with Part 1 for faster RO review

• Simplified, clarified and centralized application Instructions

• Revised and combined applications for Respite and Day Care and created an improved process for review of those applications

• Created process for early start of construction, at applicant’s risk

• Revised and clarified the Architectural Matrix

• Modified and streamlined the Architectural Schedule and Certification

• Suggested further statutory and regulatory revisions

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• Insufficient narrative on market need

• Insufficient program description

• Thoroughness of submission

• Management of consultants

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• Chapter 454 of the Laws of 2013 provides ALP providers the ability to retain residents who are considered chairfast under certain circumstances. Specifically, this new law amends the Social Services Law to include persons who are chronically chairfast to the definition of “eligible person” in an ALP facility.

• Law authorizes an ALP to admit or retain such an individual so long as the facility is staffed to meet the needs of the resident and the individual’s physician approves the placement.

• Resident must otherwise be in “stable medical condition” and not in need of continuous nursing care.

• Requires ALP providers to notify the Department of its intention and capacity to admit and or retain chairfast residents prior to doing so.

• Waiting for DOH guidance.

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• Eligible person: requires more care and services to meet his or her daily health or functional needs than can be directly provided by an ACF.

• Medically eligible for placement in a nursing home but can be cared for in an ALP. Does not need the institutional setting to have physical needs met.

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• Assessed as having a stable medical condition.

• Take direction and action for self-preservation in an emergency.

• Not in need of continual nursing or medical care.

• Not physically or medically impaired to such a degree that his or her safety would be endangered.

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• Medical evaluation within 30 days prior to admission

• Interview between ALP administrator/designee and prospective resident/ family

• UAS - NY

• Mental health evaluation for prospective residents with known history of chronic mental disability or if medical eval/assessment suggests that a disability exists.

• Prospective resident must enter voluntarily and documentation of informed choice

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• Functional Status

• Health Conditions

• Cognition

• Social Support

• Financial

• Mental Health

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• Role of LDSS/CHHA

• ALP Requirements beyond ACF

• Reimbursement and billing

• Assessment/UAS

• Audit and role of OMIG

• Case management

• Workforce27

• The operator is responsible for providing or arranging for resident services which must include, at a minimum: room, board, housekeeping, supervision, personal care, case management activities and home health services.

• Services included in the Medicaid capitated rate are:

(1) personal care services; (2) home health aide services; (3) personal emergency response services; (4) nursing services; (5) physical therapy; (6) occupational therapy; (7) speech therapy; (8) medical supplies and equipment not requiring prior authorization; and (9) NYS DOH approved adult day health care

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• If an assisted living program is not a certified home health agency or long-term home health care program, the assisted living program must contract with a certified home health agency or long-term home health care program for the provision of nursing and therapy services. An assisted living program may contract with more than one certified home health agency or long-term home health care program.

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• Must have contract with LDSS for payment

• NYC ALP operators contract directly with NYSDOH

• Contract represents approval for the ALP to provide, and receive Medicaid payment for services.

• Post-admission audits for eligibility and appropriate placement are at LDSS discretion

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• Services necessary to support the resident in the maintenance of independence and personal choice.

• Formal documentation of needs and activities• Initial and periodic assessment, no < 12 months

or change of condition.• Orientation of resident and family to program• Transition • Maintenance of community ties

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• Facility and community activities

• Arrangement of services for income, health, mental health and social services.

• Assistance for income entitlements and public benefits

• PCP for overall management of health (including mental) needs

• Referrals for services (e.g., mental health, dental, meds, discharge, transfer, etc. )

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• Receive referrals for ALP services and provide information to resident

• Permit access by ALP resident to case records

• Establish linkages to services provided by other community agencies; provide information to the ALP resident; and establish criteria for referring to the services.

• Achieve economic efficiencies

• Arrange for the reduction or discontinuance of services when the ALP reassessment determines the resident must be reduced of discontinued.

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• Based on initial assessment and periodic reassessments; change of condition; no less than six months

• Any changes must be reflected in the resident’s plan of care

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• Staffing requirements

• Staff medical assessments

•Flu masks and influenza reports

• Criminal History background checks

• Home Care Services Worker Registry

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• Requirements for qualifications for administration, case managers and personal care aides.

• Personnel credentials under a LHCSA or CHHA must be adhered to

• Operator qualifications: identical to Adult Home administrator or Enriched Housing Coordinator. Must meet or be an approved director of the home health program.

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• HOME HEALTH AIDE SCOPE OF TASKS a Guide to Home Health Aide Training and Competency Evaluation (The Matrix)

• The Matrix delineates the activities associated with the provision of health related tasks by home health aides. Designations of permissible activities, permissible under special circumstances, and non-permissible activities are very specific and detailed to reflect the collaborative work and agreement by the State Education Department (SED) to clarify which activities that would be permissible by SED without violating the Nurse Practice Act and to assure that:

• there is a common understanding of all activities associated with each task; and

• the home care industry clearly understands which parts of the activity may be performed by the home health aide without violating the Nurse Practice Act in New York State (Article 139 of the State Education Law).

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• HOME HEALTH AIDE SCOPE OF TASKS a Guide to Home Health Aide Training and Competency Evaluation

• HHA health related tasks are grouped to include the following areas:• 1. preparation of meals in accordance with modified diets or complex

modified diets;

• 2. administration of medications;

• 3. provision of special skin care;

• 4. use of medical equipment, supplies and devices;

• 5. change of dressing to stable surface wounds;

• 6. performance of simple measurements and tests to routinely monitor the patient's medical condition;

• 7. performance of a maintenance exercise program; and

• 8. care of an ostomy after the ostomy has achieved its normal function.38

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• Case managers• < 50 beds, administrator or home care director may assume case

management functions.• Current RN with one year FT experience• MSW from an accredited university• Bachelor’s degree with major work in human services and one

year FT experience in providing services to an adult dependent population

• AA degree, major work in human services, three years of FT experience in providing services to an adult dependent population.

• ALP > 50 beds, a case manager must be on staff and on duty for ½ hour per week per each additional bed over 50, up to 40 hours per week.

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• Personal Care Aides

•ALP must develop and submit a plan to DOH to assure that all staff assigned to perform personal care functions are trained or successfully complete a basic training program in HHA services or an equivalent examination approved by DOH.

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• Transitional Adult Homes

• Staff exclusion list

• State Central Registry

• Effective 020110 LHCSAs associated with ALP are subject to CHRC.

• Unlicensed staff (HHA, PCA and volunteers) in direct contact with residents or access to resident property are subject to CHRC.

• Home Care Services Worker Registry

• Each DOH approved education/training program for HHA or PCS as well as LHCSAs, CHHAs, and LTHHCPs must request and submit information about the employment history and training of aides into the Home Care Services Registry

• Home care agency accountable for information entered

• Required information must be entered into the registry within 10 business days after a triggering event such as a hire or completion of training.

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• DAL 071713: Prevention of Influenza Transmission by Healthcare and Residential Facility and Agency Personnel

• Effective July 31, 2013

• Applies to LHCSAs

• Requires documentation of influenza vaccination status of personnel

• Requires unvaccinated personnel to wear masks at all times while in resident areas

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• DAL 13-19 Revised Medical Eval for ALP• DAL 13-18 Revised Equivalency List• 071713 Prevention of Influenza Transmission• DHPCO Memo 011413• DAL 060712= Recent Changes to ALP• GIS dated 062812• GIS dated 020911• GIS dated 110910• DAL DRS ACF 09-07 Criminal background checks• DAL HCBC 08-04 ALP DME Claims• Administrative Directive 112202- Hospice

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• Linked to UAS

• Contract with LDSS

• Formulation of ALP rate

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• Rates of payment: direct versus indirect• Direct component

• Nursing administration, activities, social services, transportation, PT/OT/ST, pharmacy, central service supply.

• Indirect component

• Fiscal services, administrative services, plant operations and maintenance, grounds, security, laundry and linen, housekeeping, food services, cafeteria, non-physician education, medical education, housing and medical records.

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• Final ALP Audit Protocols Published

• Effective 11.22.13

• Stated purpose: evaluate if programs are in compliance with Medicaid requirements under federal and state statutory and regulatory law.

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• Missing patient record• Missing medical evaluation• Missing/invalid signature on med

evaluation• Missing interim assessment• Missing/invalid signature on interim

assessment• Missing plan of care (POC)• Missing date and/or signature on

POC• Missing nursing/functional/social

assessment• Missing date and/or signature on

N/F/S assessment• Missing PRI• Missing date and/or sig on PRI

• Incorrect PRI LEVEL CLAIMED• No service rendered• Missing service documentation• Incorrect rate code billed• Billed for services while inpatient at

another facility• Failure to complete minimum training

requirements• Missing certificate of immunization• Failure to complete required health

assessment• Missing documentation of a PPD skin test

or follow-up• Missing personnel record(s)• Failure to complete annual performance

evaluation

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• Audit criteria

• Regulatory references for protocols

• PRI versus UAS

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Understanding the OMIG’s Assisted Living Program Medicaid Audit ProtocolsPresenter: David R. Ross, Esq. , O’Connell and AronowitzJanuary 23, 2014 at 10:00am—12:00pm

Purpose: The New York State Office of the Medicaid Inspector General (OMIG) has released its final audit protocols for Assisted Living Programs (ALPs). These protocols became effective November 22, 2013 and are the OMIG’s audit tool that they will use when conducting their audits of ALPs. The protocols contain 22 areas of potential disallowances based upon various documentation requirements and timelines. The protocols explain what will constitute an error to the OMIG and lead to the OMIG’s attempting to recoup money previously paid for Medicaid claims. The audio conference will discuss the audit protocols and issues related to them, including compliance and self-audits.

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• ALP is required to provide residents with all the necessary rights and protections that an adult home or enriched housing program is obliged to provide

• Copy of the resident right’s must be posted conspicuously in a public place

• Each staff member must receive a copy

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• Include but not limited to:• Resident’s civil and religious liberties, independent personal choice shall not be infringed

upon.

• Private communications and consultations

• Right to present grievances without repercussions

• Right to manage own affairs

• Privacy in treatment and care of personal needs

• Confidentiality of personal and medical information

• Courteous, fair and respectful treatment

• Right to receive and send personal mail without interference or interruption

• Responsible for compliance of facility regulations

• Responsible to treat other residents with respect and observe their rights

• Personal version of incidents within the home

• Ability to receive visitors as authorized by resident

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• eFINDS

• HEC

• NCAL Risk Page

• HCS Portal

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Major challenges include:

• Medicaid rates often inadequate.

• Payment for AL incomplete: Housing, food, utilities not covered; SSI check insufficient to fill gap.

• States shifting to managed care for long term services & supports:• # of managed care states rose from 8 in 2004 to 16 in 2012.• By 2014, about half are expected to used managed care for LTSS.

• Many recent federal initiatives tend to exclude assisted living, including CMS’ proposed rules defining HCBS settings.

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By FY 2011, 47percent of Medicaid LTSS spending was on HCBS: CMS

% HCBS v. institutional care expected to continue rising as states respond to consumer demand and public policy initiatives including:

• 1915i HCBS state plan option (12 states)

• State Balancing Incentive Program, offering increased Medicaid federal match to state meeting HCBS expansion targets

• Money Follows the Person grants (>40 states)

• Community First Choice Option under which states can provide HCB attendant services under their state plan with increased federal match (2 states so far)

• Managed Care: Population vs. Benefits

• ALP Benefit to be added in 2015 for MLTC and MMC

• Residents of ALP (population) excluded from FIDA (Fully Integrated Duals Advantage)• “Facility-based Long Term Services and Support” i.e. nursing home

residents start opt in 7/1/2014

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• Most ALP beds in the FIDA region

• ALP residents may be in managed care plans (Duals –Medicare Advantage Plans; Medicaid- only – Medicaid Managed Care Plans)

• Need to be prepared to work with many Plans; demonstrate value of aging in place; facilitate admissions and discharges back to community

• IT and billing resources will be critical

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• 1115(a) “Partnership Plan”= demonstration waivers to implement Medicaid Redesign initiatives.

• Medicaid managed care; Managed Long Term Care

• 08.31.12: requirement that all dual eligibles needing more than 120 days of community based long term care to enroll in managed long term care plans.

• Nursing Home long stay residents starting in March 2014 in Metro NY

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Special Terms and Conditions (STC)

• Attachment A- HCBS in MLTC must be provided in a setting that has home-like characteristics and not in institutionalized settings, unless the enrollee is in need of short-term respite.

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• Language drawn from the CMS proposed rule on HCBS• private or semi-private bedrooms

• decisions about sharing a bedroom

• full access to facilities in a home (kitchen and cooking, small dining areas)

• private or semi-private bathrooms that include provisions for privacy

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• common living areas and shared common space for resident interaction

• access to food storage or pantry 24/7

• resident decision making about activities, visitors eating times, etc.

• respect, choice, privacy, access

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• Provider owned or controlled residential settings, additional conditions:• privacy in sleeping unit

• lockable entrance doors

• shared units only at enrollee’s choice

• setting is physically accessible

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SOI Written Questions via the Department's Email August 14, 2013.

Response to Written Questions

ON HOLD

SOI Response Deadline

ON HOLD

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Schedule of Events

• NYSCAL submitted questions as requested. To view:http://www.nyscal.org/files/2013/08/080713-Draft-ALP-Questions-FINAL.pdf

Thank you!

Questions?

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New York State Center for Assisted Livingwww.nyscal.org