ARIZONA STATE LEGISLATURE
Forty-eighth Legislature – Second Regular Session
IN-HOME HEALTH CARE PROVIDERS AD HOC COMMITTEE
Minutes of Meeting
Senate Hearing Room 1 -- 9:30 a.m.
Co-chair Aguirre called the meeting to order at 9:42 a.m. and attendance was noted by the secretary.
Members Present
Lola Judy for Karen Barno Representative Chad Campbell
Kathleen Collins-Pagels Guy Mikkelsen
Dawn DeMers Alan Oppenheim
Victor McMurry Dr. Gail Silverstein
Senator Aguirre, Co-chair Representative Nancy Barto, Co-chair
Members Absent
Virginia Pottenger
OPENING REMARKS
At Co-chair Aguirre’s request, the Members introduced themselves.
Co-chair Aguirre said she and Co-chair Barto met previously and discussed items the Committee could recommend during this challenging fiscal year.
Co-chair Barto thanked the Members for their participation. She said the “elephant in the room” is implementation, and one idea is to add this new regulation to an existing 90-10 board whereby licensed agencies would certify individuals.
Dan Brown, Majority Research Analyst, House Health Committee, advised of potential 90-10 boards under which the new regulation could be placed: Board of Nursing; Board of Physical Therapy; Board of Occupational Therapy; and Board of Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA). He said these boards are the most closely related in terms of the definition of the professionals licensed by the boards and the definition of in-home care professional services.
Mr. Mikkelsen advised of a Direct Care Workforce Committee chaired by Alan Schafer from the Arizona Health Care Cost Containment System (AHCCCS) that includes several Members of the Ad Hoc Committee. The Workforce Committee has been working on various curriculums for the direct care workforce and subcurriculums for caregivers, developmental disabilities and memory care modules. He said consideration is being given to having curriculums approved and training providers certified or licensed by a secondary education board. The curriculums could be slightly modified as long as approval is granted. Designated training agencies would be reviewed and monitored for their curriculum and held accountable for keeping a roster of those who successfully complete the training curriculum with competency testing.
Ms. Collins-Pagels stated that she serves on that committee, but has not been active in the discussions about curriculum because there are many technical elements and she works more on the policy side. She believes the curriculum is excellent and covers a wide swath of issues that need to be addressed. She conveyed that the NCIA and Board of Nursing are at capacity and in difficult financial positions. It would be practical to take this to a 90-10 board, but if the agencies are licensed, perhaps the Department of Health Services (DHS) would be appropriate.
Mr. Campbell asked the expected cost of the program. Ms. Collins-Pagels said others could speak to that, but whenever a specific number of hours of training are required, there is a cost to the organization or individual that would exceed most contract requirements. An incentive through a contract has always been her preference.
Mr. Mikkelsen agreed there is a cost. He said he understands AHCCCS is considering including training requirements by October 1, 2009, which means agencies that contract with AHCCCS will be playing under a different set of rules than the private sector.
Co-chair Aguirre stated that the certified nursing assistant (CNA) is closest to this type of work, but operates under a nurse as the supervisor.
Mr. Mikkelsen stated that AHCCCS and the Department of Economic Security (DES) operate under the same autonomy of services that is well defined in terms of tests and educational and supervisory requirements. He suggested that AHCCCS aggressively seek its fair share of federal funds.
Mr. Oppenheim stated that in looking at where to place this, DHS Licensing is currently at capacity as there has been no decrease in applications from health care providers to go into business.
DISCUSS REIMBURSEMENT FOR SERVICES
Presentation by DES
Barbara Brent, Assistant Director, Division of Developmental Disabilities (DDD), Arizona Department of Economic Security (DES), gave an overview of DDD, including the clients served, home and community based services (HCBS): in-home services, qualified vendors, qualified vendor published rates, independent providers, fingerprinting and background checks, training requirements and monitoring for DDD providers (Attachment 1). She advised that there is a basic curriculum for Article 9 training and client intervention training. There are standards for the other training requirements, but not a set curriculum.
Ms. Brent indicated to Co-chair Aguirre that the agencies provide home health aides and home nurse aides and must be Medicare certified in order for AHCCCS to grant a license. AHCCCS has two components that allow someone to be non-Medicare certified, which is centered around not being able to find anyone under any circumstance that is Medicare certified; however, similar supervision requirements must be set up, and DDD does not have the nursing capacity for delegation and oversight, so it is not something they are anxious to do.
Ms. Brent conveyed that registered nurses (RNs) are generally used for home health, but the service staffs may use a licensed practical nurse (LPN) with supervision. CNAs are used for home health aides at just over $19 per hour, short-term nursing (periodic visits) is $40.57 per hour and continuous nursing is a heftier daily rate, which kicks in after 12 hours. If families need a break from respite care and skilled nursing is required to provide that respite, there is a skilled nursing rate. DDD has been working to make the nursing rates more competitive, but it has not been easy with the shortage of nurses. Nurses are asked to go through much of the core training, particularly around the specific needs of the individual.
Lynn Larson, Acting Assistant Director, Division of Aging and Adult Services (DAAS), Arizona Department of Economic Security (DES), gave an overview of DAAS, including the clients served, non-medical HCBS, the agency network, requirements for non-medical HCBS, non-medical HCBS statewide average rates and the Direct Care Workforce Initiative (Attachment 1). She added that collaboration among state agencies and providers resulted in a competent and professional staff and development of a website: www.azdirectcare.org.
In response to questions, Ms. Larson advised that training averages about 40 hours, which includes the fundamentals and one other module. Pima Community College has two courses per semester for direct care professionals where a credit can be obtained, and Gateway Community College has two courses per semester, but she believes it is just a course and will confirm that. She acknowledged that there is a waiting list for HCBS.
Mr. Mikkelsen anticipated that with the changes in Washington, D.C., the Title 20 program, Older Americans Act and other similar funding streams could realize significant increases that should be taken advantage of in order to implement the comprehensive HCBS program that is needed.
Ms. Larson advised Co-chair Barto that if someone does not receive training at a community college, each provider agency provides a certain level of training, which is about two days’ worth. Area agencies monitor to ensure that providers abide by the training requirements. She related to Co-chair Aguirre that she does not believe a competency test is given to home health aides, but as the work on curriculum proceeds, she hopes there will be a competency test across the state.
Dr. Silverstein stated that 40 hours of training for caregivers who earn about $9 to $10 per hour is a hefty commitment and could become so cost prohibitive that seniors and others would not be able to obtain needed services. Ms. Larson clarified that 40 hours is an average; it varies from agency to agency and depends upon the methods used and size of the class.
Ms. Larson related to Co-chair Aguirre that supervision of home health aides depends on the services that are provided.
Dr. Silverstein indicated to Mr. Campbell that AHCCCS provides a list of topics that must be covered in training, but does not require a specific number of hours, so suddenly requiring about 40 hours is a significant cost to businesses that will ultimately be passed on to the consumer or state agency providing the funds. She related to Co-chair Aguirre that there are no training requirements for agencies that serve private clients; the training provided is up to them.
Ms. Collins-Pagels remarked that a framework for accountability needs to be established.
Co-chair Aguirre indicated that she agrees with Mr. Mikkelsen’s comment about leveraging federal funds.
Co-chair Barto asked the anticipated difference in cost for agencies that now contract with Arizona Long Term Care System (ALTCS) DDD and when the new requirements begin in October 2009. Dr. Silverstein answered that current ALTCS training requirements involve two full days, including CPR and first aid, compared to 40 hours, so she will try to see if she can come up with some numbers.
Presentation by AHCCCS on Medicaid reimbursement
Alan Schafer, ALTCS Manager, Division of Health Care Management, Arizona Health Care Cost Containment System (AHCCCS), conveyed that all in-home care, personal care and homemaker agencies must register with AHCCCS, and those agencies must contract with program contractors or managed care organizations throughout the state, which is how the providers get into the system and begin providing care to ALTCS members. There are a few ways to provide oversight of the agencies and caregivers:
Mr. Schafer said there are about
11,800 Elderly Physically Disabled (EPD) members living at home and about 2,300
in assisted living facilities. The remaining approximately 9,000 members live
in nursing facilities, and about 2,000 ALTCS fee-for-service members are
Native Americans who live on reservations or have an on-reservation status. Intergovernmental
agreements are entered into with tribal entities for case management that is
paid from the
Fee-for- Service Fund, and about 70 percent of those people live in their own
home.
Mr. Schafer added that AHCCCS sets fee-for-service rates and rates for attendant care, personal care homemakers, nursing facilities, etc. Program contractors or managed care organizations are responsible for setting rates with the various provider agencies with whom they contract.
Ms. Collins-Pagels asked if there will be additional costs to the provider for implementation of additional training requirements for the direct care worker module and questioned if the market will address that or the state through contractual rate changes. Mr. Schafer answered that AHCCCS will have to ask the cost. He noted that by implementing standardized training, the training will be transportable so the patient can go from agency to agency. For example, the nurse aide training program implemented in the 1980s involved more upfront cost for training, but after three or four years, nurse aides were trained and moved from job to job. Many of the caregivers work for more than one agency and have that portability, which is good. It does not mean the agencies will not provide training about the specifics of a particular member.
Mr. Schafer indicated to Co-chair Aguirre that whenever possible, standards are aligned with DES. He related to Ms. Collins-Pagels that if this requirement is implemented and there is a draft process on how to obtain verification, Agency A would provide verification for Agency C that an employee received training and passed the test.
Dr. Silverstein asked if the thousands of caregivers that have been working for years would have to take a competency test or go through the training if the direct workforce module was adopted. Mr. Schafer answered that options were discussed with some of the subcommittees and the Direct Care Workforce Committee. The initial idea was that all existing workers would have to pass a competency test within one year of implementing the standards, but many concerns were voiced about that, so they will have to listen to the industry and others to figure out what might be best. He added that when the nurse aide training program was established, federal regulations allowed grandfathering of current caregivers prior to a specific date and every state had to keep a grandfathering database.
Public Testimony
Debbie Seplow, Owner, Home Instead Senior Care, Scottsdale testified that she has the privilege of working with the AHCCCS program and sends caregivers into the homes of care recipients. Training is provided, and caregivers are not sent out until they are able to deliver the services that are needed; however, it takes more than pennies on the dollar to provide the training. All caregivers receive the same training, whether they work for a private paid client or under contract.
She indicated to Co-chair Aguirre that because of the AHCCCS contract, training is very similar to that provided by DES. There is some involvement in hands-on and ethics training. There is no competency test, but before caregivers are sent out, they must be competent in all areas where they are asked to perform. The training takes one to two days to include the activities of daily living plus CPR and first aid. Adding three additional days could become an imposition.
Ms. Seplow advised Mr. Campbell that
the training is provided by two individuals in the office who went through the
Train the Trainer program, but prior to that, she did the training for
13 years. She is a member of a franchise organization that wrote four
textbooks and she was trained in presenting information through the textbooks.
She told Mr. McMurry that fingerprint clearance cards are required, and they do
drug testing prehire, random drug testing, criminal background checks, and driving
record checks, which continues on an ongoing basis.
Ms. Seplow said the industry would like to see 10 to 12 hours of required training and six hours of continuing training per year.
Ms. DeMers commented that mandating a specific number of hours can cause difficulties.
Mr. Campbell suggested certifying the agencies and allowing them to dictate how to train caregivers, which might be a compromise as long as some standards are met, and more importantly, there should be recourse for anyone wronged by an agency or provider.
Co-chair Aguirre remarked that it is important for training to be recognized by the receiving agency when a person moves from one agency to another.
Co-chair Barto asked if a competency test along with a fingerprint and background check would be a good start or if it is enough. Ms. Collins-Pagels answered that those are basic, and she sees a requirement for a licensing agency in a 90-10 board knowing the difficulties DHS faces. Some of the items listed in SB 1605 and corrections to SB 1605 made sense.
Co-chair Aguirre noted that the Members were provided with a copy of SB 1605 (Attachment 2). A competency test covering the basic training recommended in the bill may be sufficient.
Mr. Oppenheim advised Ms.
Collins-Pagels that the training requirement for assisted living is
64 hours. There is enforcement action on the training programs, and a number
of programs were put out of business because they were not doing what they were
supposed to do, so some type of regulatory perspective is needed. He advised
cautioned about how that process is put together with DHS’ limited resources.
Mr. Campbell remarked that SB 1605 is probably a good framework, although he has some concerns with the language and the amendment brought forth when the bill went through the process. The fundamental question is who would oversee this, a 90-10 board or DHS, so he would like to know more about the 90-10 boards.
Co-chair Aguirre said that can be arranged for a future agenda, and she would like to have DHS discuss this issue with the Committee.
Co-chair Barto suggested that the Committee make recommendations on everything but the accountability aspect, and more specific meetings can be held with the industry when Session starts about the ability to provide funding to the 90-10 boards.
Ms. Collins-Pagels said she believes the 90-10 boards only license professionals, not agencies. Mr. Brown said she is correct. The agency owner or agency operator would have to be licensed as opposed to the agency.
Ms. Seplow indicated to Mr. McMurry that the trade association for the industry is a national private duty association based in Indianapolis with a bit over 1,000 members across the U.S. and a full staff. Dr. Silverstein is the Arizona Chapter President and that chapter was formed in April 2005.
Mr. McMurry stated that trade associations are helpful in exchanging information.
THE MEETING RECESSED AT 11:35 A.M.
UNTIL 12:30 P.M. THE MEETING RECONVENED AT 12:43 P.M. ALL MEMBERS WERE
PRESENT EXCEPT
VIRGINIA POTTENGER.
DISCUSS AND DEVELOP RECOMMENDATIONS FOR IN-HOME CARE SERVICE PROVIDERS
General Training Requirements
A lengthy discussion ensued concerning recommendations for general training requirements specific to private agencies.
Co-chair Aguirre moved that the Committee recommend that the overseeing state agency (to be determined) will review, as part of the application process to be a licensed home care facility, to include a competency test that would include and prove that the agency has provided the basic training needed as required by SB 1605.
Co-chair Aguirre withdrew the motion.
Co-chair Aguirre moved that the Committee recommend that part of the process of applying for licensing as a home care provider agency include a competency test. The motion carried.
Co-chair Aguirre moved that the Committee recommend that the competency test include the recommended training components or educational classes as indicated in the draft amendment 36-1307 Subsection E 1-12 (Attachment 3). The motion carried.
Basic Education and Continuing Education Requirements
Discussion followed on basic education and continuing education requirement hours.
Senator Aguirre
moved that the Committee recommend that the agencies that hire home care
employees are required to provide a minimum of
10 hours of continuing education. The motion carried.
Dr. Silverstein said in order not to place an undue burden on agencies, she would recommend a full day of basic education training, i.e., 8 to 12 hours plus CPR and first aid.
Dr. Silverstein moved that the Committee recommend establishing a minimum of eight hours of initial training plus training for certification of CPR and first aid. The motion carried.
Fingerprinting and Criminal Background Checks
Ms. Collins-Pagels moved that the Committee recommend a fingerprinting card be required. The motion carried.
Ms. Collins-Pagels noted that the draft amendment (Attachment 3) changes the powers of inspection in SB 1605 to include client and employer records and conduct in-home client visits, which makes sense. Also, she did not understand some of the exemptions for religious organizations, etc.
Co-chair Barto said that would be a good discussion for when the bill is heard in the Legislature.
Mr. Campbell remarked that it is important to put some “teeth” into the legislation so there are consequences in the case of violations.
Mr. Campbell moved that the Committee, when considering regulation of the in-home care industry, provide standards for accountability and oversight by a regulatory body. The motion carried.
Mr. Mikkelsen advised Mr. McMurry that it is not uncommon for those doing business with the state, federal government or other private entities to routinely provide certificates of good standing from the Corporation Commission, certified audits, various resolutions to enter into that business activity, etc., from boards of directors. Privately held corporation would have certificates of good standing and an audit would be required.
Co-chair Aguirre stated that the Committee’s task in moving forward with the recommendations is to make sure the agency in which this process is placed is able to do what is recommended while protecting the safety of citizens at the same time.
Co-chair Barto cautioned that any regulation of private agencies will have a fiscal impact, but noted that this is not legislation; merely recommendations.
Without objection, the meeting adjourned at 2:04 p.m.
_______________________________
Linda Taylor, Committee Secretary
December 29, 2008
(Original minutes, attachments and audio on file in the Chief Clerk’s Office: video archives available at http://www.azleg.gov).
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2
IN-HOME HEALTH CARE PROVIDERS
AD HOC COMMITTEE
December 16, 2008
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