Steve Ankiel

Virginia Department of Medical Assistance Services

600 East Broad Street

Richmond, VA 23219

 

            RE:    Alzheimer’s Assisted Living Waiver

Dear Mr. Ankiel:

 

We write to comment upon the proposed changes to the Alzheimer’s Assisted Living Waiver which would, if approved, bring the waiver criteria in sync with Department of Social Services licensing standards. Because we believe these changes lessen protections for a very vulnerable population which is by definition eligible for nursing home level of care, we oppose the proposed changes.

 

The various organizations represented in these comments all advocate for nursing home and assisted living residents. We came to the examination of the proposed regulations with the belief that housing and treating people in the least restrictive environment is a desirable outcome and that greater utilization of the Alzheimer’s Assisted Living Waiver is also a desirable outcome. If the proposed regulations would increase provider participation in the waiver and if they did that without compromising resident care, we would support the proposed changes. However, as we reviewed the proposed regulations and discussed them further, we came to the conclusion that the changes probably would not significantly increase provider participation; and, regardless of their impact on provider participation, the proposed regulations would compromise necessary care for residents in assisted living facilities who have nursing home level acuity needs.

 

From the provider participation perspective, most of the existing Alzheimer’s units have significant waiting lists. Providers can likely draw largely from private pay residents to fill their beds. We question whether the changes in the proposed regulations would, in reality, attract additional providers. Furthermore, these changes suggest that providers should be paid more to provide no additional services. To receive the enhanced payment rate, providers should be required to provide more staffing and more services than are required for other assisted living residents. Instead, the proposed regulations reduce staffing and services to the same level received by all assisted living residents, providing nothing new in return for the additional funding. This does not make sense from a fiscal perspective. It makes even less sense from a care perspective. By definition, the people served by the Alzheimer’s Assisted Living Waiver have functional and medical/nursing needs which are at the nursing home level. They need more care than do other assisted living residents. To maintain them in assisted living facilities without providing the additional care they need puts them at risk.

 

In particular, we have serious concerns about the elimination of the requirement that an RN complete the initial comprehensive assessment and monthly assessments, develop the plan of care, supervise medication administration, and provide training, consultation and oversight of direct care staff. The proposed regulations effectively eliminate the need for any RN involvement in the care of the waiver participants. If the residents’ only diagnosis was Alzheimer’s this might be sufficient. However, to qualify for the waiver, the resident must have other medical nursing needs. The revised regulations do not ensure that properly trained RN staff will be involved in the development of the plan of care and in the day-to-day monitoring of the residents’ treatment and care needs. We are concerned that residents could develop significant medical problems which could go unnoticed without effective RN monitoring. By eliminating even the requirement that at least a certified nursing assistant be present at all times, the proposed regulations further weaken existing protections. In short, we do not think that the proposed regulations adequately address the greater medical and treatment needs that this population of residents has such that resident safety and health are put at risk.

 

Though a lesser concern, we are also concerned about the reduction in activity hours. Those with Alzheimer’s have a greater need for stimulation and attention to keep them engaged and functioning at the highest possible level of cognition. The provision of activities is the primary source of such stimulation. To increase the level of reimbursement to serve this group of residents while reducing the level of services offered them through a reduction in the hours of offered activities is neither fiscally sound nor fair to this population of residents.

 

We applaud DMAS’s effort to find ways to encourage greater provider participation in the Alzheimer’s Assisted Living Waiver and hope that other ways to enhance provider participation can be found. However, we think that these proposals risk resident safety and health without ensuring greater provider participation. We urge you not to implement the proposed regulations. Thank you for your consideration of these comments.

 

Carter Harrison

Alzheimer’s Association

 

Joani Latimer

State Long Term Care Ombudsman

 

Claire Curry

The Community Partnership for Improved Long-Term Care, an initiative of the Legal Aid Justice Center

 

Kathy Pryor

Virginia Poverty Law Center