6/22/2020

Presentation toThe Robert G. (Bob) Bethell Joint Committee on

Home and Community Based Services and KanCare Oversight

Updates on Requested TopicsDepartment for Aging and Disability Services

Laura Howard, Secretary

KDADS Updates on Requested Topics

KDADS Updates on Requested Topics

KDADS Update on Requested TopicsLaura Howard, Secretary

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Chairman Landwehr, Vice Chair Suellentrop and members of the Committee:

Thank you for the opportunity to provide testimony on the Kansas Department for Aging and Disability Services (KDADS).

KDADS Updates on Requested Topics

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REPORT – Overview of Olmstead Decision and HCBSDeputy Secretary Janis DeBoer

Olmstead Plan

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History of HCBS Services in Kansas

• A report titled Overview of the Olmstead Decision and Home Community Based Services in Kansas is included in your packets. KDADS sponsored the report in response to your legislative request.

• In 1982, nine years before the passage of the Americans with Disabilities Act of 1990 and its subsequent protections for individuals with disabilities, and seventeen years before the Supreme Court’s 1999 Olmstead decision, Kansas Medicaid received approval for its first HCBS waiver for people with disabilities and the elderly. Throughout the 1990s and into 2000, Kansas received approval for seven HCBS waivers to provide services that would meet the needs of youth, seniors and adults with different disabilities. At the same time, Kansas began closing its institutions, maintaining several for specific populations with specific needs. As of December 2019, 24,453 youth, seniors and adults with disabilities were receiving HCBS services.

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RECEIVERSHIPSDeputy Secretary Janis DeBoer

Receiverships

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Priorities and IssuesNursing Facility Receiverships

KDADS took 22 adult care homes into receivership due to insolvency or because life-threatening or endangering conditions existed at the facilities.

The Receivership Statute was updated during the 2019 legislative session: K.S.A. 39-954.

Of the twenty two nursing facilities in receivership: o One facility closed in 2018, one sold in early 2019. o The fifteen Skyline facilities sold effective October 1, 2019.o One of the three Pinnacle Receivership facilities sold November 1, 2019.o One facility is sold June 1, 2020.o One facility is expected to close on August 1, 2020.o Two facilities remain on the market for sale.

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HOME AND COMMUNITY BASED SERVICES (HCBS) Commissioner Amy Penrod

Home and Community Based Services

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HCBS Waiver Enrollment—April 2020

HCBS Program Number of People Eligible to Receive HCBS Services

Number of People on Wait List

Number of Proposed Recipients

Autism 45 358 (as of 5/20/2020)

Serious Emotional Disturbance (SED) 3,184

Technology Assisted (TA) 582

Frail Elderly (FE) 5,027

Brain Injury (BI) 512

Intellectual and Developmental Disabilities (I/DD)

9,103 4,203

Physical Disability (PD) 6,149 1,298

Notes: • Data as of May 20, 2020• The HCBS Monthly Summary is posted under Monthly Waiver Program Participation Reports at http://kdads.ks.gov/commissions/home-community-based-services-(hcbs)

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HCBS Waiver Renewals & Proposed Amendments

• Currently, the Physical Disability and Frail Elderly Waivers are in the CMS waiver renewal process.

• Once the PD & FE Waivers are approved, KDADS will shift its focus on a number of proposed amendments to multiple waivers:

• Unbundling Assistive Services (DME, Home Modifications, Vehicle Modifications)• Unbundling of IDD Day Services and IDD Prevocational Employment Services• Updating Waiver Performance Measures• Lift Cap on Specialized Medical Care• Permit Additional Telehealth• Provisional Plan of Care Creation Process

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HCBS Final Rule

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Self-Assessment of Sites

• Sept. 2019-Feb. 2020

• 2,815 HCBS sites were self-assessed and evidence submitted.

Desk Review

• Sept. 2019-Sept. 2020

• Reviewing self-assessments and submitted evidence for Final Settings Rule compliance.

• Approximately 50% of submitted assessments have been reviewed, to date.

Remediation

• March 2020-July 2021

• Providers that have areas of non-compliance require remediation.

• KDADS is committed to working with providers to come into compliance.

• Approximately 25% of the assessed and reviewed sites have entered the remediation phase.

Heightened Scrutiny

• July 2020-Dec. 2020• Sites that have

features that institutionalize or isolate HCBS participants will receive an on-site assessment.

• Feedback will be offered to the provider to bring the site into compliance with the Final Settings Rule.

Administrative Case Management

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Administrative Case Management provides eligibility and enrollment assistance to individuals who have been found functionally eligible for the Brain Injury, Physical Disability, and Frail Elderly waivers, as well as PACE.

• Administrative Case Management services launched statewide on May 1, 2020.

• In May, approximately 101 individuals received Administrative Case Management services.

Program of All-Inclusive Care for the Elderly (PACE)

PACE EnrollmentPACE Program Enrollment

Ascension Via Christi Hope 268

Midland Care 333

Bluestem Communities 93

Total PACE Enrollment 712

Note: Data as of June 11, 2020.

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Program of All-Inclusive Care for the Elderly (PACE)

Via Christi Hope

• Sedgwick

Midland Care

• Douglas• Jackson• Jefferson• Leavenworth• Lyon• Marshall• Nemaha• Osage• Shawnee• Pottawatomie• Wabaunsee• Wyandotte

Bluestem Communities

• McPherson• Ottawa*• Saline• Rice*• Marion• Reno*• Harvey

*PACE is available in limited zip codes within these counties.

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COVID-19 Response

Appendix K for HCBS Waivers

Appendix K is a standalone appendix that may be utilized by states during emergency situations to request amendment to approved 1915(c) waivers. It includes actions that states can take under the existing Section 1915(c) home and community-based waiver authority in order to respond to an emergency.

CMS-approved Appendix K flexibilities include:• Suspend Settings Rules to Allow Services to be Provided in Homes or Temporary Settings• Permit Payment to Family Caregivers to Provide Personal Care Services• Expansion of Telehealth Opportunities• Home-delivered Meals• Permit Provisional Employment Pending Background Checks• Provider Retainer Payments for Habilitation Services and Personal Care Services

KDADS-issued COVID-19 guidance can be found at https://www.kdads.ks.gov/covid-19

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COVID-19 Response

Outstanding Issues to be Addressed as Normal Operations Resume:

• TCM Stakeholder Forum: KDADS is working with a facilitator to schedule a day-long meeting to identify the key values, purpose, and future direction of IDD Targeted Case Management.

• Continuing Waitlist Evaluations with Stakeholder Feedback• Eliminating Waitlist• Prioritizing Existing Waitlist

• Evaluate COVID-19 Response with Participant and Stakeholder Feedback

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BEHAVIORAL HEALTHDeputy Secretary Janis DeBoer

Behavioral Health

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Behavioral Health

Kansas Department of Aging and Disability Services (KDADS) has been working closely with KDHE to respond to COVID-19 in Behavioral Health Services.

KDADS quickly issued guidance to providers that allowed for the expansion of telehealth and verbal consent to facilitate social distancing during treatment service delivery in outpatient settings. KDADS also provided flexibility to providers to provide continuity of essential services allowing for additional infection control measures to be taken in residential treatment facilities. As a result there have been very few cases of positive COVID-19 cases among newly admitted patients and no reported transmissions between staff and patients.

KDADS worked with KDHE to establish new telehealth policies for KanCare providers and MCOs that helped mitigate some of the negative financial impact on providers and allowed for continuity of essential services during the pandemic.

KDADS has been working at the federal level to advocate for continued flexibility in CMS regulations for the telehealth delivery of behavioral health services in Medicaid and Medicare.

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Update on Planning

KDADS is responding to the legislation passed this past session that requires a Children’s Psychiatric Hospital to be opened in Hays, Kansas.

The KDADS Deputy Secretaries and Commissioner for Behavioral Health Services met with representatives from Hays Med and KU Med and toured potential locations in Hays this spring and discussed the role of State Institution Alternatives in Children’s Psychiatric Hospitals. KDADS has been working with KDHE on the State Institution Alternatives policies for KanCare and has submitted a State Plan Amendment to CMS for approval.

Children's Psychiatric Hospital in Western Kansas

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Psychiatric Residential Treatment Facilities

• Current MCO wait list as of 6/1/20 was 112 down from 124 individuals in February.• Of the 112 individuals, 24 were in foster care down from 33 in February

• Current number of PRTF licensed beds is 336 in the system of care.• KDADS is currently working with providers to license additional PRTF facilities and

anticipates between 50 to 120 beds being added to the system of care by January 2021.• Updated PRTF Regulations are drafted and will soon be available for public comment.• Meeting with MCOs and DCF weekly to review individual cases on the wait list. • Working with MCO Care Coordination to facilitate community-based services.• During COVID-19 PRTFs have continued operations as an essential service and

implemented appropriate infection control policies to respond to the public emergency. In some cases this has also meant limiting home visits during treatment and using telehealth to deliver family therapy services instead of having family attend sessions at the PRTF.

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LONG TERM CAREDeputy Secretary Scott Brunner

Long Term Care

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Kansas is Making Progress in Reducing the Use of

• In 2011, Kansas ranked 51st in the nation (42nd in 2018), in the use of anti-psychotic drugs in nursing facilities.

• Kansas now ranks 37th in the nation and expects to continue to show improvement based on the activities undertaken.

20.50% 20.30% 19.90% 19.60% 19.80% 19.20% 18.40%17.40% 17.40% 17.30% 17.00% 16.30% 16.10%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

Q2 2016 Q3 2016 Q4 2016 Q1 2017 Q2 2017 Q3 2017 Q4 2017 Q1 2018 Q2 2018 Q3 2018 Q4 2018 Q1 2019 Q2 2019

Percent of Long-Term Stay Nursing Home Residents Receiving Antipsychotic Medications*

*Excludes residents diagnosed with schizophrenia, Huntington's Disease, or Tourette's SyndromeSource: National Partnership to Improve Dementia Care in Nursing Homes: Antipsychotic Medication Use Data Report (April 2019) https://qioprogram.org/sites/default/files/Overall%20Data%20Report%20FINAL.pdf

Antipsychotic Drugs in Nursing Homes

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Antipsychotic Medication Use Data Report

Per CMS in the National Partnership to Improve Dementia Care inNursing Homes: Antipsychotic Medication Use Data Report (October 2019):

o In the Second Quarter of 2019, 16.1% of long-stay residents in Kansas were receiving an anti-psychotic medication.

o The national quarterly prevalence is 14.3%.

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Nursing Facility and Adult Care Home COVID-19 Actions

March 4 – CMS suspended non-emergency surveys of nursing facilities, redirected activities to conduct targeted infection control surveys, immediate jeopardy complaints and allegations of abuse and neglect.

March 9 – CMS directed nursing facilities to close to visitors, outside services and non essential health care personnel.

March – KDADS followed the Governor’s executive order to allow Nursing Facilities to request permission to create alternative care sites, temporary licensed space or additional rooms to allow for isolation and cohortingof COVID-19 positive patients.

March 13 – CMS updated the guidance to restrict visitors and non-essential health care personnel in nursing facilities. This guidance cancelled communal dining and group activities, required active screening of residents and staff, and required facilities to identify alternative was for residents to stay in touch with family members.

April 13 – KDADS and CMS conducted on site surveys of all Life Care Facilities with outbreaks in the other facilities owned by LifeCare in Kansas City, Burlington, Andover, Seneca, Wichita and Osawatomie.

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Nursing Facility and Adult Care Home COVID-19 Actions

April 29 -- KDADS issued recommendations on reporting COIVD-19 positive residents to KDADS and KDHE to reinforce the CMS and CDC guidance document.

May 18 – CMS allowed nursing facilities to begin the process of reopening to visitors based on phases depending on the local conditions, testing of staff and residents, and when there is a clear plan for isolating and responding to positive COVID-19 cases.

June 1 – CMS redirected state survey activities to require infection control surveys in all nursing facilities by July 31, follow up surveys within 3 to 5 days of a report of appositive COVID-19 case,

June 12 – KDADS issued guidance to allow nursing facilities to reopen to visitors and outside services in cooperation with Local Health Departments. Nursing facilities must have a plan to respond to positive COVID-19 cases, including a testing approach, screening protocols for residents, staff and visitors, coordination with reopening orders issued by Local Health Departments, and reporting of positive cases to residents, family members, and following reporting requirements to KDHE and the federal government.

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Priorities and IssuesCovid and Adult Care Homes

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Nursing Facilities KDADS Nursing Facility Re-opening Guidance Released 6/12/2020 114 Federal Infection Control Surveys(FICS) Completed 57 IJ Complaint Investigations Completed 15 IJ Citations 15 Infection Control Citations at D and F Level 8 IJ level infection control citations 217 FICS outstanding to be in compliance with QSO-20-31-ALL and HB 2016/SB 7 Survey Prioritization per QSO-20-31-ALL

Presently IJ Complaint Investigations Outstanding FICS surveys Perform on-site surveys (within 30 days of this memo) of nursing homes with previous COVID-19 outbreaks, defined as:

Cumulative confirmed cases/bed capacity at 10% or greater; or Cumulative confirmed plus suspected cases/bed capacity at 20% or greater; or Ten or more deaths reported due to COVID-19.

Perform on-site surveys (within three to five days of identification) of any nursing home with 3 or more new COVID-19 suspected and confirmed cases in the since the last National Healthcare Safety Network (NHSN) COVID-19 report, or 1 confirmed resident case in a facility that was previously COVID-free. State Survey Agencies are encouraged to communicate with their State Healthcare Associated Infection coordinators prior to initiating these surveys.

Priorities and IssuesCovid and Adult Care Homes

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Enhanced Enforcement per QSO-20-31-ALL Mandatory requirements in notes below

HMS Contract CMP Grants for Technology Devices

193 Facilities Approved 940 Total Number of Devices

Temporary Licenses Granted

Region ACS DFU CBC DFU/AGrand Total

NE 2 5 2 7 16NW 3 3 4 1 11SE 1 2 6 9SW 1 5 2 6 14Grand Total 7 15 8 20 50

Priorities and IssuesCovid and Adult Care Homes

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KDADS Adult Care Home Re-opening Guidance Released on 6/17/2020 Home Plus/Adult Day Care/Boarding Care Home

129 Off-Site Infection Control Surveys (ICS) Completed 0 IJ Complaint Investigations Completed 0 IJ Citations 0 Infection Control Citations 0 IJ infection control citations 176 ICS outstanding to be in compliance with HB 2016/SB 7

Assisted Living/Residential Healthcare Facility 48 Offsite Infection Control Surveys (ICS) Completed 1 IJ Complaint Investigations Completed 1 IJ Citations 0 Infection Control Citations 1 IJ infection control citations 296 ICS outstanding to be in compliance with HB 2016/SB 7

STATE HOSPITALSDeputy Secretary Scott Brunner

State Hospitals

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Recruiting and Retaining StaffLarned State Hospital

Since the salary increases through the Executive Directive (19-510), LSH has experienced decreases in vacancy rates for direct care staff:

Direct Care Staff Vacancy Rate Comparison Overall Vacancy Rate Comparison

January 1, 2020 June 10, 2020 January 1, 2020 June 10, 2020 RN 58.7% 50.5% 37.7% 34.7%LPN 73.1% 66.0%MHDD 31.9% 32.7%Security 17.7% 11.6%

Although vacancy rates continue to be high, LSH has experienced increased success in hiring direct care staff in 2020. The wage increases have been helpful as well as the increased unemployment rate, which has brought in increased numbers of staff over the last quarter.

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Recruiting and Retaining StaffLarned State Hospital

LSH continues to focus on recruiting and retention of staff, including:• Actively promoting larnedcares.com and the “Be the One” brand through marketing and

branded apparel to promote the agency in a positive manner. • Concentrating on the positive aspects of LSH through an active Facebook page that

highlights positive endeavors, accomplishments and events.• Participating in job fairs prior to the COVID-19 pandemic and working to develop a virtual job

fair.• Advertising in local newspapers and creating new ads.• Contracting with the Rural Health Education & Services Recruitment and Retention Center to

assist with recruiting.• Actively recruiting on social media – Facebook, Simply Hired, and LinkedIn as well as

advertising on Indeed.• Offering two annual $500 educational scholarships through LSH Endowment.

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(cont.)

Recruiting and Retaining StaffLarned State Hospital (continued)

• Serving as a student nursing site for the psychiatric rotation (prior to COVID-19).• Recruiting social work students, engaging with Fort Hays State University Social Work Program

and providing a practicum site for LBSW and MSW students.• Utilizing agency RN, LPN, and CNA staff to provide supplemental unit coverage.• Employing temporary staff to supplement the nursing department.

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During the COVID-19 pandemic, LSH has increased the staff to patient ratio by closing one State Security Program unit, which freed up space for an isolation unit and allowed for staff to be distributed among other units. The Program is moving forward to increase use of Mobile Competency evaluations.

Employees who participated in the MHT class have reassigned across treatment units while the class is on pause during the pandemic.

These efforts, contributed to reducing nursing staff hold-overs and overtime needs. The graph on the next slide depicts this.

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Nursing Staff Mandates

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2012

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Tota

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ber

January 2019 - June 14, 2020

LSH Nursing Department - Number of Mandates Per Day

Trend (Mar 2020 - June 14, 2020)

Trend (Jan 2019 - Feb 2020)

This graph shows a reduction in

mandatory hold-overs for direct care nursing staff with a

downward trend since March, 2020.

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Lifting the MoratoriumOsawatomie State Hospital

Lifting the moratorium on voluntary admissions includes a mix of bed capacity at OSH and increasing community-based capacity for inpatient treatment.

• FY 2021 Approved Budget for KDADS includes $5.0 million from the State General Fund to expand the number of regional psychiatric hospital beds to serve individuals with mental illness meeting the criteria for state hospital admission.

• Expand the number and scope of community crisis stabilization programs and crisis intervention centers• Allow involuntary commitment of patients at RSI, Inc. in Wyandotte as an alternative to placement at OSH• FY 2021 Approved Budget includes $2.0 million, including $1.5 million from the State General Fund, to

increase licensed beds at the Adair Building by 14. • The Approved Budget also includes $5.3 million from the State Institutions Building Fund in FY 2021 to

renovate the Biddle Building to become CMS Certified space• With additional space at OSH and in communities, KDADS plans to lift the moratorium in May 2021

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Lifting the MoratoriumOsawatomie State Hospital

Since the end of the 2020 Legislative Session, several units at OSH have been repurposed to respond to COVID-19:

• West Biddle – OSH unit (licensed) This unit has a capacity of 17 for confirmed cases of COVID-19. This unit has been revamped with AIIR room airborne infection isolation room capabilities in patient rooms.

• East Biddle – OSH unit (licensed) continues to have the capacity of 30. The size of the rooms on this unit only allow for single occupancy.

• B2 – OSH unit (licensed) The unit had a capacity of 14 private patient rooms. This licensed unit was proposed to be remodeled with the lifting of the moratorium. Since April, B2 was used to quarantine new admissions to OSH for 14 days prior to integration to other OSH units. OSH has stopped using this unit for isolation since June 19.

• A1 & A2 – AAC unit (certified) At the beginning of the pandemic, capacity was reduced to 30 (patients having private rooms) to provide adequate space for social distancing in case of COVID 19. After an increase in patients on the moratorium list, OSH Leadership increased AAC’s capacity from 30 to 44 patients.

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Lifting the MoratoriumOsawatomie State Hospital

C2– OSH unit (licensed) This unit has a capacity of 30. This unit specializes in treatment and competency restoration. It will also serve as a quarantine unit for OSH admissions that may be transferred to other OSH units, pending a 14-day quarantine. This unit previously included high-risk patients identified through a medical review. (patients with comorbidities that are at increased risk for serious health complications and/or death from COVID-19.) These patients will be transferred to other OSH units to prevent increased COVID-19 exposure and to provide increased space for quarantining OSH patients on C2.

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Appendix

Appendix

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Savings Resulting from Transfers to HCBS

• In most, but not all cases, services provided in the community do cost less than those provided in an institutional setting such as an ICF/IDD or a nursing facility.

• However, “savings” are only realized if a bed is closed behind the person transferring to HCBS.

• Due to demand, beds are typically refilled by individuals requiring the level of care provided by the facilities, therefore, the beds are not closed.

• As certified by the Secretary for Aging and Disability Services, despite individuals moving into community settings that does have the effect of cost avoidance, the savings resulting from moving the individuals to home and community based services, as of March 31, 2020, was $0.

• The balance in the Kansas Department for Aging and Disability Services Home and Community Based Services Savings Fund as of March 31, 2020, was $0.

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Average Monthly Caseload for ICFs

39

And Head Injury Facilities

137 133 137119 114 111 109

305 300 291 297 293 291 286

29 28 34 33 24 31 33

SFY 2016 SFY 2017 SFY 2018 SFY 2019 SFY 2020Q1

SFY 2020Q2

SFY 2020Q3

Mon

tly A

vera

ge E

ligib

ility

Cas

eloa

d

Private ICFs

State I/DD Hospitals

Head InjuryRehabilitation Facility

Number of Persons Transitioned on

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Money Follows the Person (MFP)

3125 25

33 3020

0

3732

46 49 54 49

3

148

113

131

148

102

83

40

13 10 94 4 0

SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 SFY 2018 SFY 2019

Mon

thly

Ave

rage

Elig

ibili

ty C

asel

oad

MFPI/DD

MFP FE

MFP PD

MFP TBI

Average Monthly Caseload for

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HCBS IDD/PD/FE/TBI Services

8801 8926 9043 9062 9080 9116 9121

5049 4863 4690 4545 4610 4789 4866

56476071 5896 5790 5790 6021 6111

486 453 434 390 411 440 469

SFY 2016 SFY 2017 SFY 2018 SFY 2019 SFY 2020 Q1 SFY 2020 Q2 SFY 2020 Q3

Mon

thly

Ave

rage

Elig

ibili

ty C

asel

oad

I/DD

FE

PD

TBI

Average Census for State Institutions and Long-Term Care Facilities

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10,788 10,783 10,491 10,235 10,047 10,049 10,226 10,416 10,543 10,514

-

2,000

4,000

6,000

8,000

10,000

12,000

SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 SFY 2018 SFY 2019 SFY 2020 Q1SFY 2020 Q2SFY 2020 Q3

Nursing FacilitiesMonthly Average Eligibility Caseload

KNI Average Daily Census

43

145

143144

141142

140

138

134

132131

130

132

134

136

138

140

142

144

146

148

SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 SFY 2018 SFY 2019 SFY 2020 Q1SFY 2020 Q2SFY 2020 Q3

Kansas Neurological InstituteAverage Daily Census

Parsons Average Daily Census

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176174

173

163

159160

162

159158 158

150

155

160

165

170

175

180

SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 SFY 2018 SFY 2019 SFY 2020 Q1 SFY 2020 Q2 SFY 2020 Q3

Parsons State HospitalAverage Daily Census

Long Term Care PoliciesFrom Kansas Insurance Department

12 companies selling LTC

• Bankers Life and Casualty Company• Country Life Insurance Company• Genworth Life Insurance Company• Knights of Columbus• Massachusetts Mutual Life Insurance Company• Mutual of Omaha Insurance Company

Insurance in Kansas

• National Guardian Life Insurance Company• New York Life Insurance Company• Northwestern Long Term Care Insurance Company• State Farm Mutual Automobile Insurance Company• Thrivant Financial for Lutherans• Transamerica Life Insurance Company

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We do not have information on the number of plans sold in Kansas. According to our research, the data collection and tracking of sales of Partnership Plans was being collected by the Federal government as a result of the enactment of the Deficit Reduction Act. Congress has since cut off funding for the collection. At this time, there does not appear to be any information available for Kansas or any other state.

The carriers need to have riders approved in order for their plans to qualify as partnership plans. However, because a rider was once approved does not mean that the company is continuing to offer it for sale. This is a link to the carriers that have had partnership riders approved in the past. https://insurance.ks.gov/ltc-partnership-site/LTC_PARTNERSHIP_COMPANIES.pdf Some of those carriers no longer sell new policies in Kansas.