Attn: Hope Roberts, HCBS Policy Administrator Ohio Department of Medicaid FROM: RE: LeadingAge Ohio Home and Community-Based Services (HCBS) Settings Evaluation Provider Self-Assessment February 18, 2016 To Whom It May Concern: Thank you for the opportunity to comment on the draft Provider Self-Assessment Form for Home and Community-Based Services (HCBS) Settings Evaluation. LeadingAge Ohio is a membership organization representing mission-driven, values-based providers of pre- and post-acute services and supports in the state of Ohio. Our membership is comprised of continuing care retirement communities, affordable housing providers, home health agencies, hospices, skilled nursing facilities, assisted living communities and adult day providers. Our members serve approximately 400,000 Ohioans annually. Regarding the proposed form, we have the following overarching concern: The form is structured such that a service setting has three options: checking yes or no as to whether the setting meets a given requirement and presumably, if they do not, to describe what remediation may be needed. LeadingAge Ohio is concerned that this structure does not adequately address some circumstances in which providers take appropriate actions which ensure the health and safety of those they serve, but which also may result in them not meeting one of the requirements for home and community-based care. The best illustration of this may be locked doors for memory care assisted living units or in adult day health settings, which frequently serve individuals with cognitive impairments such as dementia. It is inappropriate and unsafe to allow residents with advanced dementia of a memory care unit to lock their doors, given that an emergency could arise for which immediate access would be required. Similarly, a person with dementia who is in an adult day setting may be restricted to a certain area of a facility for his or her safety and best interest. Neither of these scenarios would warrant remediation, in our view, but the form as written does not facilitate the explanation of some of the specific circumstances which would lead a provider to not adhere to one of these requirements. We encourage the Department of Medicaid to provide an appropriate space under each section of this assessment where a provider might include these additional details. Additionally, LeadingAge Ohio encourages the Ohio Department of Medicaid to consider a Not applicable (N/A) choice for some of the questions. For example, under The setting
offers privacy in the sleeping/living unit appears the question, Do the setting policies afford privacy in the individual s living/sleeping unit? For adult day providers, there are no living/sleeping units, since the space used is generally communal. A N/A option would be logical in this case. Our specific comments, by section of the form, are as follows: Regarding The setting is not located in building/on grounds with institutional characteristics. LeadingAge recognizes that this is carried over from federal rules, however we are concerned that this requirement does not keep pace with the current trend toward reurbanization, walkable neighborhoods and mixed use living spaces. Within this context, it would be considered innovative for a provider to locate themselves near amenities that are frequently used by those they serve. It makes logical sense that individuals who regularly need healthcare might want to be closer, not farther away, from their providers. A great example of this is Ohio State University. On or near its campus, there is a mixture of housing, resources agencies, education, hospitals, community based housing for disabled (Creative Living). Regarding The setting does not isolate individuals from broader community of individuals not receiving HCBS. While LeadingAge Ohio does not condone any actions which would isolate an individual from their community, we take exception to the assumption underlying this requirement: that facility-based living is inherently more socially isolating than community-based living. Indeed, it is our members experience that often, those individuals who reside in homes out in the community may experience a greater level of isolation than those residing in assisted living facilities. Regardless, assisted living facilities are required to have activitiy programs which provide outings so residents can be exposed to individuals not receiving HCBS, so this requirement should not be a challenge for our members. Regarding, The setting provides opportunities and support for employment in competitive, integrated settings. Most of our members who provide HCBS serve a population that is largely retired from the workforce. This is one requirement that would be irrelevant for most of them, and the self assessment should be modified to accommodate this difference.
Regarding, The setting has a process for protecting individuals rights of privacy, dignity, respect and freedom from coercion and restraint. LeadingAge Ohio agrees that all settings should have a policy that carefully weighs these rights, but also acknowledges that these rights have limits. For example, an individual with cognitive impairment may need some restraint to prevent wandering activity. Similarly, an adult day program can only provide a measure of privacy, such as for health care or personal care. It would not be feasible for an adult day participant to have a private room, especially since social isolation is antithetical to the adult day model of care. Regarding, The setting optimizes opportunities for individuals to make choices and control schedules regarding daily activities. LeadingAge Ohio agrees that settings should maximize an individual s ability to make choices and control schedules. The only limitations to this should be: 1. If a choice will likely compromise the health and safety of the individual, or 2. If a choice or schedule would infringe upon the ability of other individuals to make their own choices and control their own schedules. Regarding, The setting optimizes opportunities for individuals to make choices regarding the physical environment. In general principle, LeadingAge Ohio supports this requirement but also acknowledges that certain settings, such as the communal spaces used in most adult day programs, may offer significantly fewer choices regarding the physical environment simply by virtue of the fact that they are shared spaces. Additionally, this is an area where the limitations described above may also apply. An assisted living resident may be able to swim and want to use the pool. However, if he is incontinent, he may be restricted from using a pool, as doing so might cause a health and safety issue for other individuals wishing to use the pool. Regarding, The setting optimizes opportunities for individuals to choose with whom to interact. LeadingAge Ohio is fully supportive of this section. Regarding, The setting facilitates choice regarding services/supports and agency staff who provide them. All facilities should do their best to match individuals with the most appropriate services and personnel to meet their needs. That said, the current staffing environment is particularly challenging for care providers and desired accommodations are not always possible. Furthermore, LeadingAge Ohio believes that this sort of accommodation is not unique to a community setting, but rather, should be a priority for providers of facility-based care as well. As such, LeadingAge Ohio believes that this is not a particularly useful barometer to distinguish facility-based from community-based settings.
Regarding, The setting offers privacy in sleeping/living unit. This requirement is not appropriate for adult day settings, as they typically use communal spaces. That said, LeadingAge Ohio believes all individuals, regardless of setting, should have privacy for their health-related care and personal care. Regarding, The setting offers residential options based on individual resources for room and board. The phrase room and board is not appropriate for all settings and should be rephrased if this assessment will be used across all settings. LeadingAge Ohio agrees that all settings should have a policy regarding how the individual will be informed when residential services are limited because of an individual s resources. Furthermore, LeadingAge Ohio believes that in order to foster trust and transparency, an individual and/or surrogate decisionmaker should be informed of these limitations prior to admission, ideally within the context of a financial assessment. Regarding, The setting has a legally enforceable agreement specifying responsibilities and protections from eviction. Again, eviction only applies to those settings where an individual is a resident. The language should either be modified, or an N/A option should be added. Regarding, The setting provides living unit doors lockable by individual, and The setting provides a living unit key availability limited to appropriate staff. This requirement is not appropriate for memory care units where locked doors could slow or prevent the staff s response in the event of an emergency. While many settings solve this problem by also providing a key to particular staff members, LeadingAge Ohio asserts that individual settings be permitted the flexibility to resolve these issues on their own for individuals with advanced dementia for example, rather than having a one-size-fits-all solution expected of them. LeadingAge Ohio encourages the Department of Medicaid to modify this section to allow it to be inclusive of this large subpopulation of individuals receiving HCBS. Regarding, The setting has a legally enforceable agreement that addresses how individuals may furnish/decorate sleeping/living units. LeadingAge Ohio fully supports the spirit of this requirement, but again, this requirement does not apply to all settings, since adult day programs do not provide sleeping units.
Regarding, The setting supports individuals freedom to control schedules and activities. LeadingAge Ohio again references the limitations noted above: that an individual s freedom to control schedules and activities should be limited only inasmuch as that freedom would 1. Jeopardize the individual s health and safety, or 2. Infringe upon another individual s freedom to control his/her schedule, activities, or jeopardize his/her health or safety Additionally, there may be additional consideration for memory care units, as individuals may need reminders for mealtimes, routines and other daily activities. Regarding, The setting ensures food is available to individuals at all times. While LeadingAge Ohio agrees with the spirit of this requirement, we are concerned with how it might be applied. For example, an individual on a physician-prescribed restricted diet cannot be allowed unrestricted access to food, particularly if there is any cognitive impairment or compromised decisionmaking capacity. This can place a setting at odds with other regulators, such as the Ohio Department of Health. This is one example of why it is important to include space for a setting to explain the rationale for departing from a given requirement. Regarding, The setting allows visitors of individuals choosing at any time. Again, LeadingAge Ohio agrees with the spirit of this requirement, but this should be subject to the aforementioned limitations. One obvious example is late-night visitors may infringe on a roommate s ability to sleep. Regarding, The setting is physically accessible for each individual. LeadingAge Ohio agrees with the spirit of this requirement but notes that some items which make a space more accessible are considered durable medical equipment, and may be the responsibility of the resident. One example of this might be a wheelchair: a setting should ensure that there are ramps, grab bars in bathrooms, and doors are an adequate width for wheelchair accessibility. It is the individual s responsibility to acquire the wheelchair itself. Regarding, The setting has a protocol for modification of the additional conditions for provider owned/controlled residential settings. LeadingAge Ohio finds the wording in this section somewhat confusing, as there is no citation for what the additional conditions are. Our understanding is that this section allows communication back to the HCBS case manager in the event that an individual s needs cannot be accommodated by a setting, to develop a plan for modifications to the setting. LeadingAge anticipates working with the Department of Medicaid to better understand the implications of this section for our members and those they serve. LeadingAge Ohio thanks you for the opportunity to provide input on this Provider Self- Assessment. Any questions regarding this document may be directed to Anne Shelley, Director of Regulatory Relations at ashelley@leadingageohio.org.