The 2nd meeting of the Interim Joint Committee on Health and Welfare was held on Wednesday, August 15, 2007, at 1:00 PM, in Room 149 of the Capitol Annex. Representative Tom Burch, Co-Chair, called the meeting to order at 1:12 PM, and the secretary called the roll.
Present were:
Members: Senator Julie Denton, Co-Chair; Representative Tom Burch, Co-Chair; Senators Charlie Borders, Tom Buford, Perry B. Clark, Denise Harper Angel, Joey Pendleton, Dick Roeding, Ernesto Scorsone, Dan Seum, Katie Stine, and Johnny Ray Turner; Representatives James R. Comer Jr, Bob M. DeWeese, David Floyd, Joni L. Jenkins, Mary Lou Marzian, Darryl T. Owens, Ruth Ann Palumbo, Ancel Smith, Kathy W. Stein, David Watkins, Susan Westrom, and Addia Wuchner.
Guests: Sherry Currens, Executive Director, and LeTonia Jones, Training and Advocacy Training Programs Administrator, Kentucky Domestic Violence Association; Mark A. Washington, Commissioner, Department for Community Based Services, Cabinet for Health and Family Services; Jim Richardson, President, Cedar Lake Lodge; Mark D. Birdwhistell, Secretary, Cabinet for Health and Family Services; Joseph Toy, CEO, Bluegrass Regional Mental Health/Mental Retardation Board; Dr. Claude Farley, parent of child at Communities at Oakwood; Karen Quinn, Assistant General Counsel, Kentucky Medical Board; Terry Brownson, Wendell Foster's Campus for Developmental Disabilities; Bill Doll, Kentucky Medical Association; Elizabeth Caywood, Rissie Forbes, and Charlene Manuel, Department for Community Based Services, Cabinet for Health and Family Services; Jim Marchal, and Jim Evans, Cedar Lake Lodge; Nathan Goldman, Kentucky Board of Nursing; Michael Burleson, Kentucky Board of Pharmacy; Jay Trumbo, Kentucky Health Care Association; Beth Myurl, The Herald-Leader; Donna Brown, Bluegrass Mental Health/Mental Retardation; Jim Kimbrough, Protection & Advocacy; Sarah S. Nicholson, Kentucky Hospital Association; and Prentice Harvey, Norton Healthcare.
LRC Staff: Murray Wood, CSA; Barbara Baker, Miriam Fordham, DeeAnn Mansfield, Ben Payne, and Gina Rigsby.
A motion to approve the minutes of the June 20, 2007 meeting was made by Representative Owens, seconded by Representative Wuchner, and adopted by voice vote.
Senator Stine reported that the Families and Children Subcommittee met that morning and heard an update on the First Steps Program from Dr. Steve Davis, Deputy Commissioner, Department for Public Health, Cabinet for Health and Family Services. Lisa Lee, Director of Children's Health, presented an update on K-CHIP and the reauthorization of the federal SCHIP Program. Also, Chris Corbin, Executive Director of the Governor's Office of Wellness and Physical Activity, presented an overview of current activities. A motion to accept the report was made by Representative Owens, seconded by Representative Palumbo, and accepted by voice vote.
Senator Roeding reported that the Aging, Disabilities, Independent Living, and Long-Term Care Subcommittee met that morning and heard testimony from Debbie Anderson, Commissioner, and Phyllis Culp, Acting Staff Assistant, Department for Aging and Independent Living, Cabinet for Health and Family Services, on priorities of the department that include safety, access, resource development, quality living, quality care, and healthy aging. New initiatives the department has started are the Consumer Directed Option (CDO), the Self Directed Option (SDO), Money Follows the Person (MFP), and Nursing Home Diversion. Commissioner Anderson also testified about the Kentucky Resource Market and the second phase of the Kentucky Elderness Readiness Initiative. The subcommittee also heard a presentation by Dr. Jill Johnson, Lexington Veterans Administration Medical Center, about the role of the pharmacist in elder health care.
The following administrative regulations were referred to the committee for review: 201 KAR 2:250 - renames the Impaired Pharmacists Committee to the Pharmacy Recovery Network Committee and specifies the manner by which the Kentucky Board of Pharmacy's PRNC consultant works with the board in intervention, evaluating and treating a pharmacist or intern, and providing for continuing care an monitoring by the consultant through a treatment provider; 201 KAR 9:460 - establishes the requirements for certification of acupuncturists an specifies the requirements for a written plan; 201 KAR 20:070 & E - establishes the licensure requirements of nurses by examination and permits a nursing graduate to complete the National Council Licensure Examination prior to completion of the required clinical internship if the applicant intends to complete the internship in another state that has enacted the Nurse Licensure Compact; 201 KAR 20:370 - establishes requirements and procedures for nurse licensure and registration and incorporates new application forms and requirements and includes new form for annual advanced registered nurse practitioner (ARNP) renewal application for ARNP with registered nurse (RN) compact license from another state other than Kentucky; 201 KAR 20:411 - establishes the requirements relating to a sexual assault nurse examiner course and the credentials of a sexual assault nurse examiner and includes new forms for applying for the Sexual Assault Nurse Examiner (SANE) Credential; 201 KAR 22:020 - establishes the eligibility and application procedures for physical therapists and physical therapist assistants and eliminates the temporary license provision; 201 KAR 22:040 - establishes the renewal and reinstatement procedures for physical therapists and physical therapist assistants and deletes the inactive status of credential holders; and 900 KAR 6:050 - establishes the requirements necessary for the orderly administration of the Certificate of Need (CON) Program. The Cabinet for Health and Family Services requested that the committee defer consideration of 900 KAR 6:050 for the cabinet to work with the long-term care provider community to address concerns regarding the statewide distribution of long-term beds and to propose amendments to the administrative regulation if necessary. Senator Stine said that the Staff Note in 201 KAR 9:460 stated "if a patient has one of the abovementioned conditions, the acupuncturist shall consult with the physician before providing treatment, but the statute is silent on whether the acupuncturist is required to withhold treatment if the treating physician recommends against it". She asked if the regulation would require the acupuncturist to consult with the physician, but not follow the physician's advice. Karen Quinn, Assistant General Counsel, Kentucky Board of Medical Licensure, stated the acupuncturist is an independent professional and the physician cannot forbid the acupuncturist from prescribing and going through certain treatment. The problem would arise if something were to go wrong with the treatment by the acupuncturist. Ms. Quinn said that the statute does not address the issue.
A presentation on the "Until the Violence Stops: Kentucky" Campaign was given by Sherry Currens, Executive Director, and LeTonia Jones, Training and Advocacy Programs Administrator, Kentucky Domestic Violence Association. Ms. Jones and Ms. Currens stated that Kentucky has been selected by V-Day, a global anti-violence movement, as one of two locations to replicate a festival focusing on ending violence against women and girls that was first held in New York City in 2006. Kentucky's festival will use theater and the arts, community events, informational workshops and a statewide public awareness campaign to bring women and girls and their safety, center stage in Kentucky.
Representative Burch asked if there has been a decrease in domestic violence. Ms. Currens stated that national information indicates there is a decrease.
An update on Senate Bill 59 from the 2007 Regular Session (Boni Bill) was given by Mark A. Washington, Commissioner, Department for Community Based Services, Cabinet for Health and Family Services. Commissioner Washington testified that the cabinet plans to: 1) hire staff to manage the records check process and finalize plans to implement direct access to the Law Enforcement Information Network (LINK) for state criminal background checks; 2) fill central office and regional office safety liaison positions; 3) monitor requests for relocation and/or renovation of local DCBS office space and initiate new requests as assessments are completed; 4) continue to address resources needed, communication needs and operational issues including staff risk assessments and safe family visitation through the Human Services Worker Safety Study Group; 5) continue to proactively manage staffing levels during time of retirements and increase the number of filled frontline staff positions; and 6) reissue the Request for Proposal on emergency alert technology.
Representative Burch asked if new social workers positions would be added in the cabinet's 2008-2010 budget proposal. Commissioner Washington stated that the safety workgroup is looking at the national standards on caseloads to come up with recommendations, and he estimated 300 positions may be needed, which would include social workers, support staff, supervisors, administrative staff, and social service aides. Buildings would also be requested. Representative Burch asked how many renovated buildings are safer. Commissioner Washington stated four buildings are in the process of being renovated and 15 have been requested from the Finance and Administration Cabinet. Representative Burch asked how many cell phones have been issued to social workers since the death of Boni Frederick. Commissioner Washington stated approximately 2,000.
Senator Denton asked about the average of caseloads per county as it relates to the incidence by population versus staffing issues. Commissioner Washington stated he would furnish the committee with that information. Senator Denton said if specific incidences such as substance abuse, child abuse, domestic violence could be tracked by county, it would provide information to help target counties with higher caseloads that may potentially put social workers in harmful situations. This not only would bring down the average of caseloads, but would help the people in these situations.
Representative Owens asked about the job description of social service clinicians, why there has been a decrease in this position and an increase in the social worker positions, and if the position was critical. Commissioner Washington stated that the decrease was due to promotions, and the social service clinician was a very important part of the team. Representative Owens asked what happens after reported incidences of threats or attacks. Commissioner Washington stated some could have had a referral to law enforcement, and help workers file claims if there was an accident, but there is always some resolution. Central, regional, and local offices automatically review an incident.
Senator Buford asked if the timeframe from when a local office recommends someone to be hired and Central Office actually hires someone had improved. Commissioner Washington stated some positions such as social worker I & II had become shorter. Senator Buford asked about assigning vehicles to local offices to help transport children. Commissioner Washington stated that the cabinet is examining all the facts before making a decision.
An update on Cedar Lake Lodge was given by Jim Richardson, President, and Jim Marchal, parent of daughter living at Cedar Lake Lodge. Mr. Richardson stated that Cedar Lake serves over 200 individuals with mental retardation and offers a wider choice of residential options than any other Kentucky provider. Cedar Lake Lodge, Cedar Lake Residences, and The Cedar Lake Foundation, Inc. are a not-for-profit, publicly supported, independently functioning, charitable and tax-exempt corporation. Cedar Lake Lodge's licensed capacity was increased from 76 beds to 87 beds in November 2006 when 11 beds were transferred from Oakwood. This was Cedar Lake Lodge's first and only increase in bed capacity since 1982. Demand for Cedar Lake Lodge's ICF/MR services is high, primarily due to the absence of specialized nursing and high-intensity residential care in the Supports for Community Living (SCL) program. Few SCL programs are licensed to provide nursing services.
Mr. Richardson said Cedar Lake Lodge provides ICF/MR licensed residential treatment services and outpatient rehabilitation (therapy) services. Cedar Lake Residences residential care options include: 1) resident homes with 24-hour a day supervision; 2) apartments with 24/7 staff support; 3) transitional independent living homes with partial-day staff; 4) supported independent living apartments; 5) in-home support services; and 6) adult day health program at Cedar Lake Enrichment Center. He said that financial comparisons with other Kentucky ICF/MR facilities reveal that Cedar Lake Lodge is more efficient and saves Kentucky approximately $6 million per year.
Mr. Marchal stated that he and his wife had to wait ten years to get their daughter, Laura Ann, who has severe physical handicaps and profound mental retardation, into Cedar Lake Lodge. He and his wife, Joanne, are two of the four original founders of the regional mental health programs in Louisville. During the past six years Laura's health has deteriorated, but her life has blossomed at Cedar Lake Lodge. He and his wife are thankful there is a facility where their daughter has 24-hour medical care.
Representative Burch stated that Cedar Lake's care and services are exceptional because of long-time dedicated staff.
Senator Seum asked if the per diem for Cedar Lake was lower because of Cedar Lake's charitable foundation. Mr. Richardson stated that all equipment and property are acquired through donations. Senator Seum asked why they did not get an increase in reimbursement rates. Mr. Richardson stated ICF/MR providers have a cost-based reimbursement methodology with Medicaid as opposed to SCL which is a fixed-price methodology. The cost incurred in a year will impact how the rate will be allocated in the following year along with trending and indexing that Medicaid performs. Facilities with higher rates have higher degress of acuity levels of residents.
Representative Stein asked about Cedar Lake's staff to resident ratio. Mr. Richardson said for the ICF/MR facility it is 230 staff to 87 residents and 90 staff to 126 residents in the community setting. Representative Stein asked if the ratios had increased or decreased in the past decade, and he said that staffing had increased as the acuity of residents in the ICF/MRs change and residents are moved to community settings whenever possible.
Representative Marzian asked what is the criteria for ICF/MR facilities and who sets it. Mr. Richardson stated the Department for Medicaid Services sets the criteria. The criteria for ICF/MRs and SCL is identical. The difference is SCL is a price-based reimbursement methodology with caps. She asked about the location of the individuals on the Cedar Lake Lodge waiting list, and Mr. Richardson said that most are living with parents or family. Mr. Marchal said that there are some people who cannot be served in a community setting because they need 24/7 medical care.
Representative Owens asked why six individuals were transferred from Oakwood. Mr. Richardson stated that the individuals were from the Louisville area and transferring the bed to Cedar Lake allowed families to make more frequent visits and be more involved in their loved one's life and it saves $5 million to the Medicaid program.
Representative Floyd asked if the staffing ratio figures were the total of all employees or the number of employees on duty at any one time, and Mr. Richardson said the total number of employees employed. He thought approximately one-fourth of employees are on duty at any one time. Representative Palumbo asked Mr. Richardson to get the exact ratio to the committee.
Senator Borders stated that priorities would have to be addressed during the 2008 Regular Session budget, and it would be up to the legislature to help the people who could not help themselves.
Secretary Mark Birdwhistell, Cabinet for Health and Family Services, Joe Toy, CEO, Bluegrass Regional Mental Health and Mental Retardation Board, and Dr. Claude Farley, parent of a child at Communities at Oakwood, gave an update on the progress at Oakwood. Secretary Birdwhistell stated that Bluegrass has been able to: 1) provide strong leadership; 2) established a single point of accountability; 3) have flexibility to take action with staff; and 4) provide good quality care for less. Secretary Birdwhistell stated that the cabinet still needs to get certification back from the Centers for Medicare and Medicaid in order to not lose its Medicaid funding. The Department of Justice and the Centers and Medicare and Medicaid Services have been kept apprised of Oakwood's progress. Secretary Birdwhistell said that there are 10,500 individuals living with parents over the age of 65 who are not in the system that will need care in the future.
Mr. Toy stated that there have been three Type A citations since November 1, 2006 when Bluegrass took over management of Oakwood, and two are being appealed. There is a four to one staffing ratio required and monitored by the court and federal government. There are 233 residents and all of them but one are there on 202B commitments. Since November, 13 residents have been transitioned to community placements and 26 residents are in the process of being transitioned. There is no incentive not to transition residents to the community. Some barriers to moving residents to the community are guardian and family resistance and that providers cannot provide adequate and safe supervision. He said that the condition of the resident should dictate placement and above all other considerations. Residents at Oakwood receive 24/7 medical care. Bluegrass's contract with the cabinet for eight months was $56,750,000, but the actual costs incurred were $42,049,236, a $15 million savings. This was accomplished by reducing overtime costs, abolishing unnecessary administrative non-direct care positions, reduced worker's compensation claims and payouts, cancelled expensive contracts with several vendors. There are no systemic problems present at Oakwood, and no employee will ever be excused for any type of negative action directed at a resident.
Dr. Farley's son, Richard, has been at Oakwood for approximately 25 years. He thanked the cabinet and Bluegrass for addressing the problems at Oakwood and turning things around.
Representative Burch asked if all the buildings at Oakwood were occupied, and Mr. Toy said yes. Representative Burch asked if staff had any transition problems because of not being able to obtain community services. Mr. Toy stated yes. Representative Burch asked if the courts receive notice when someone who is at Oakwood under a 202B commitment is transitioned into the community, and Mr. Toy said yes. Representative Burch said that there needs to be more step-down facilities like Cedar Lake, but commended Mr. Toy for the turnaround at Oakwood.
Senator Harper Angel asked Mr. Toy to provide the committee with the termination date of the staff member who left a footprint on a resident's face. Mr. Toy said he would provide any information he legally can. Senator Harper Angel asked about discharge criteria and transition teams. Mr. Toy said that Oakwood is not in a legal position to require transition, but will send staff to follow-up on a former resident for a period of time to make the process smooth. Secretary Birdwhistell stated that there needs to be additional options for community living.
Senator Seum asked why there is a discrepancy in the increase in per diem rates. Secretary Birdwhistell said that the Centers for Medicare and Medicaid Services approved the higher rate for Oakwood and the others are based on a formula of acuity and cost.
Representative Westrom asked about the process of disciplinary actions against employees abusing patients. Mr. Toy said that Bluegrass' personnel policy requires that a decision has to be made within ten days. She asked about the average age of the residents, and he said that he would have to provide that information at a later date. She asked what happens to the frail and elderly residents. Mr. Toy said that residents remain at Oakwood, but they are increasingly difficult to provide care for. Secretary Birdwhistell said that individuals with mental retardation and developmental disabilities are living longer, and we need to learn how to care for them.
Representative Marzian asked what happens when guardians do not want to transition residents into the community. Mr. Toy said that they cannot make guardians transition anyone into the community. Representative Marzian asked for the percentage of the budget that goes for ICF/MR facilities and for community services, and Secretary Birdwhistell said that he would provide that information to the committee.
Senator Buford said that he hoped Bluegrass would present its proposal again to build a new facility for Eastern State Hospital. Mr. Toy said that he would.
The 2008-2009 Community Services Block Grant and Community Plan was referred for review. Commissioner Mark Washington and Elizabeth Cawood, Department for Community Based Services, Cabinet for Health and Family Services, were available for questions.
Executive Order 2007-566 relating to the reorganization and transferring of funds and staff from the Department for Public Health to the Governor's Office of Wellness and Physical Activity was referred for review. Secretary Birdwhistell, Cabinet for Health and Family Services was available for questions.
There being no further business, a motion to adjourn at 3:45 was made, seconded, and adopted by voice vote.