Senate Children and Youth & House Aging, Children and Youth

To go and looked in depth at assisted living and the issues facing assisted living several of you representatives and senators had come to me and said that there are facilities in your area that have either closed are on the verge of closing and we're very concerned about what will happen with the folks living in those facilities so that is the reason for today's meeting to look at these issues try to ascertain the facts and to let everybody have a chance to ask the questions. The first thing we're going to be doing that let me ask you senator Wallace did you have any comments. Right we want to consider to the Motion to adopt the December fourteenth twenty twenty meeting minutes that's exhibit C. I see a motion for that. We have a motion and a second all in favor say aye. Those minutes are adopted. Next item on the agenda. If you will look at them. And that he appointments to the child maltreatment investigations oversight committee. You don't have one so let me just read the appointments to the child maltreatment investigations oversight committee we have Amanda Wilkerson nominated as the position of one current or former representative from the court appointed special advocate or casa program and then Glen Hoggard nominated as one attorney employed as a parent council so do I see a nomination to accept these. We'll do this one by one first on the nation to accept Amanda Wilkerson FOR this committee. I have a motion and a second all in favor say aye. Jose now. And then Glen Hoggard. I have a motion and second. We have that all in favor say aye. Opposed say no. So those two are accepted for that committee. And now will move into the meat of today's committee we have that discussion of at twelve thirty of two thousand and one and in your handouts that is exhibit else. And I would like to call to the table Mister ed Hohman he is the chairman of the Arkansas residential assisted living association Mr Homan you are recognized. Morning madam chairman good morning to all of you in the committee other legislators. My name is at home and and with the Arkansas residential assisted living association Mr home if you'll pull your might just a little bit closer to I sure will. That's better that's better. Give you a brief history of how assisted living came about here in Arkansas was created by the legislature with that twelve thirty of two thousand and one this was in response to a growing demand nationwide for program to offer nursing services in the comfort of someone's home. We're all facing the aging crisis whether it's for ourselves a spouse or a loved one and we all want placement in the best possible option. Care and assisted living as provided by nurses aides and LPNs just like in a nursing home and services are available to anyone who does not require twenty four hour care. We now have a hundred to assisted living facilities in the state with seven thousand two hundred and seventy five builds of these facilities fifty three or approved waiver providers who participate in the waiver or Medicaid program we are however limited to a maximum of no more than twelve hundred residents statewide at any time. Some of you may be wondering why we even need a waiver program for assisted living it's because not every elderly or cans and can afford to privately pay three to five thousand dollars per month and do not feel the need or desire to go into a nursing home for care. Instead of being put into a twelve by sixteen foot room with a roommate we give them a studio or one bedroom apartment provide their care all while preserving their safety dignity and privacy. For years there was a wives tale passed around on Amendment show that skilled nursing was cheaper to the state general revenue fund an assisted living cost. This is flawed and we'll show you that that's not the case if you look at that first handout that's up there it's comparison of this to your Klosters nursing and assisted living. And I'll go fast here **** C. highlighted in yellow under nursing homes the cost last year to the state general revenue fund was twenty five dollars and thirty five cents per day for a nursing home patient. Going below there you see the assisted living cost the cost of the state general revenue fund is seventeen dollars and twenty four cents so instead of assisted living costing the state more money over nursing homes we've actually saved a bunch. This year the savings will be much more as nursing home reimbursement has gone up due to COVID cost labor increases in rising insurance costs meanwhile assisted living rates have dropped again. We're not here to tell her savings because we're in desperate need of more money in order to survive and provide proper care for our residents. The four of us towards back here operate sixteen assisted living facilities between us and the German if you would I'm sorry to interrupt you if you go ahead and introduce a let the others at the table introduced themselves in case they want to make some comments here sure I want to talk appear to all right. That might work out better to have all of you here once in case their questions if any of you to take okay on my left Scott Kingsborough on our board. Thank you good morning my name's Scott king's Berlin I own and sister living in Pulaski County called the manner on canis road right over by Baptist hospital. I'm tired Hightower's Health Marc Services. It operates and assisted living facilities in the state of Arkansas all that are certified or living choices Medicaid waiver program I'm also on the board of the road. I Mark shepherd shepherd group we own and manage assisted living facilities here in Arkansas in rural communities. Thank you. In twenty eighteen I told a different legislative group and the press that if the twenty eighteen cuts took place the facilities would close. Sadly that's proven true and we had eight facilities close these facilities had roughly four hundred residents and about three hundred employees lost their jobs all summer due to operational issues are reimbursement program was making it impossible to even sell those facilities after the close of the eight buildings that were closed only one was saver able to be resold and it was converted to a skilled nursing facility. So now rather than a healthy industry we have roughly five hundred million dollars invested in buildings that are facing an ugly future along with the potential for thousands of residents to be displaced. And thousands of our Kansans losing their jobs. Today we want to show you the cost structure of assisted living as compared to nursing homes we also want to show the rate history of assisted living versus minimum wage we're going to talk to you about what neighboring states are doing and paying and we're going to show you the calculations for labor and other costs from DHS records and what the real costs are of operating an assisted living there's a summary an outside consultant prepared last year and he suggested an eighty six dollar rate for covert costs hit us. Last you'll see some eye opening information from and for about the cost of the state of Arkansas. Due to cutting these rates. Another Speaker here today is gonna be mark white he's here to talk to you about assisted living from DHS is point. What will be interesting to hear an ask mark is why all the studies have been done and all the experts opinions about trying to rebalance health care and provide options for not going into nursing homes that Arkansas has resisted this there'll always be plenty of business for nursing homes with the explosion of baby boomers just starting to need long term care all of their bills will be full very soon and I might add at a tremendous cost to the state. We just want to offer an affordable option for people who do not require twenty four hour care and we want to program can be made available in every corner of the State. The rate cuts right now all ensure that thirty of our seventy five counties who don't have assisted living will never have it this means that residents and forty percent of our counties. Are forced either travel outside of their area to get assisted living care or going to the local nursing home. Bottom line to anything that DHS tells you is that from our highest single rate of eighty dollars and thirty three cents to the present rate of sixty seven dollars and twenty five cents the state has saved a maximum of three dollars and eighty three cents per day on assisted living residents with the maximum savings being one point six million if all twelve hundred slots have been used. We'll if you look at exhibit two in your package. This will show the. Reimbursement that we've experienced that our facility at Indian rock village. We have both Skilled nursing and assisted living in the same building. Your if you look at the rates. You can see that Mark my rates at the nursing home level of started a hundred and sixty two dollars per day in January of twenty seventeen and as of January first this year they've gone to two hundred and seven dollars today an increase of twenty seven point seven percent. Now if you look at the other side you can see what the assisted living rate is done its dropped fourteen point two percent. But think about this we we've got C. N. A.'s working on both sides of the building we've got nurses we've got crooks we've got housekeepers we got maintenance and the cost of the same food costs the same utility supplies everything else costs the same but they tell us we don't need more money in fact they want to the car rates so we were really bothered by this DHS may try to explain that we were getting paid too much to begin with and this is the proper rate well. That's not right either our outside study as well as the information that DHS house and they're Milliman report doesn't support this at all in our most recent report that DHS requested they gave us two weeks to complete we submitted all the information it showed that are cost were up. And what they do the response was to talk about chiropractic care and when they got to assisted living they said the rates for adequate they didn't explain it at all they didn't explain the Mets Chris study if anything was wrong with that they just said the rates are adequate. Some. I'm hoping that all of the Alaska what we're doing to survive the fact it's rather tough all waiver facilities had to cut costs wherever possible rather than generous staffing and higher paying positions we cannot afford to do that anymore but my assisted living we used to have twenty four hour LPN coverage when cuts were made we cut back to eighteen then the sixteen now work twelve hours we may go to eight or we may just go really low it's just what the budget will allow but the the cost or absolutely out of hand the structure of the DHS is paying the song was based upon a ten dollar an hour minimum wage may be a slight inflation increase but you're gonna hear the people are paying a whole lot more than that and this is just unsustainable some that's pretty much it for my part I've got a couple quick things I want to read from small letters from some operators around the state this first one is from St Bernard's hospital they have a an assisted living and this is from their director there and I'm just going to give you a couple lines of this talking about they open their assisted living in twenty fifteen and they wanted to try with just a few residents to see if assisted living would work for them he says reality has been even worse than we could ever imagine reimbursement is shrinking expenses are rising and there seems to be no recovery in sight each month between November twenty and April of twenty twenty one we rode off an average of eight thousand two hundred and sixty nine dollars for or for waiver participants. So many like us for choosing to accept the waiver program while others are being forced to close in the end it's the residents who suffer. I'm gonna do one more here just because this really hits home this is from an operator and Glenwood Arkansas the Tamon Paul operation if there ever was one. It's from Wanda Jones she's the owner she says we've been in the care giving business for twenty six years at this point we are barely keeping our doors open financially there been three minimum wage increases numerous utility increases food costs are through the roof and while all this is occurring or reimbursement rates have been cut three times. Please consider this a plea for an increase instead of another kick in the pants. Thank you. Thank you got it if you have there's of you have a comments go ahead I'm not seeing any questions yet my Shepherd. I want to thank the committee and the chair for inviting us. I have been involved in Arkansas assisted living sentences section in two thousand and one. At that time I was a nursing home provider and they invited me to participate in the promulgation of the rules around the waiver program. The program was slow to start around two thousand and nine it really hit high gear when the rate went to sixty seven dollars. It's sixty seven dollars. Assisted living could work as a team for delivering the highest quality care possible. Between two thousand and nine and two thousand thirteen the program flourished. In two thousand thirteen Robert Jenkins of the Robert wood Johnson foundation testified before the Senate aging committee when he was asked who has the best assisted living program in the country he said Arkansas does. From that time Arkansas has gone from being the best to being one of the worst. No my credentials are significant I'm the past chair of the national center of assisted living in Washington and I sat on their board for ten years. I'm familiar with national assisted living as well as CMS rules and regulations. And one two thousand and nine came up in the rate finally got to a livable rate we went to our banks and we said here's a new program I want to borrow five million dollars I don't want to build this building and I wanted twenty five your mortgage. And the bank said well that's wonderful but your business plan is for Medicaid residents how do we know that the Medicaid program will survive. And these banks went to the state in the state said we promise you the program will be viable through its inception. And the banks took that is good faith and in my particular case I have twenty four million dollars worth of loans with banks of which I'm personally guaranteed all of which are outside of their loan covenants now due to the continued reduction in rates. In Benton we have a facility that sixty five percent Medicaid the Medicaid rate is sixty seven dollars and twenty five cents twenty five cents more than two thousand and nine. Our private pay rate is a hundred and thirty two dollars a day that's almost a sixty dollar difference per day to take care of residents that are private pay versus residence or Medicaid and with the labor rate being sixty percent of our cost when we get these rate cuts the only thing that can cut is labor and labor is what provides the care. So I would encourage this committee to look hard at these issues and understand that when it started to come apart in two thousand and fourteen when the state revised its waiver plan with CMS and took away our cost of living increase the next five years we ended up having to pay out of the facilities labor increases. Food increases insurance increases last year our insurance rates went up almost a hundred percent. These costs are just not sustainable at this present rate so please take a hard look at this and I encourage you all if you have any questions to ask take a look at this in terms of helping assisted living thank you. I am seeing a couple of questions if we could go ahead with that in any of you who would like to answer these feel free a representative Springer. Good morning thank you Mr. This chair. I'm trying to understand this list that I have here so I hear you talk about assisted living facilities across the state can someone tell me how many are there in across the state of Arkansas how many are there. They're one hundred and two across the state one hundred and so this list consists of only certain ones so I guess I'm out I lost you on what what you were explaining to me what this is list consists of the F. is the exhibit itself what does this specifically and tell us about the system living facility I don't really want to go too much into that because one of our other speakers will be covering that he's from out the to talk about that those but that is some that are in distress situations. Okay well okay well of them so you're saying that you're not receiving enough money so I'm just trying to understand how many are there in the field can you. I'm I'm I guess I'm just really confused representative spring or the As I said earlier we've got a hundred and two facilities in the state that are assisted living of those fifty three are enrolled in the waiver program of those fifty three they're probably about twenty of them that don't do much just under a hundred thousand a year in billing that thereabouts something like Saint Bernards were they tried it and it doesn't work just it can't cash flow the others of like. The four of us to have programs for fifteen years and we can't just ballot now because we built these buildings and operate these buildings have all these people working there so we're we're stuck with the program that's it and there's probably thirty that have a lot of exposure to the to the rate cuts well I I guess I'm trying to understand the analysis so if there are a hundred and two and you're saying that your funding is not what it needs to be seems like to me what should have a list of all of them and then make a comparison as to all that are being that are in this state and then determine how much is being subsidized by the Department of Human Services or whatever so I guess that's what that's what I'm lost because I don't have the big picture as to what why it is that you're requesting what it is you want so if I could maybe go a little further into that part of that of the private pay facilities are in the the wealthier areas Little Rock Scott. Ten of them and only three of them can participate in the waiver program it's kind of strange that the largest city in the state only has seventy nine waiver belts total Fort Smith second largest city in the state doesn't have anywhere else can't afford it so you've got lots of part of the private four five assisted livings but they cater to private pay market Northwest Arkansas probably has a dozen facilities they've had three of those closed or waiver providers they can't afford the labor there's another one out there that's in deep distress was well that's about to close so the private areas where they can afford three four five thousand a month for the facility we're going to do great other areas of the rural areas where people can't afford to three four thousand a month that they're not going to survive well well thank you for that and and what you just told me would be something that I would like to see in order to determine whether you know given the big picture as to what you're talking about so if you could break it down the way that you just stated goal from each part of the state and tell me how men's facilities or in the cities of whether located and then the amount this of being so you know provided to them I think that would help us better understand your point that you're trying to make here because right now represents Springer will circle back around to you I have some other people all right thank you thank you senator Hammer. Thank you have thank you venture on a couple point you mentioned you said four hundred residents left the facility you know where those four hundred residents when do you have a discharge plan that tracks where they went are you required to keep on. We don't keep that on there. Somewhat I guessed in lot of cases kind of embarrassed even talk about it but we get calls when it's happening from DHS they're looking for places to move people They will either go I I know Mike can talk about what happened and Meena but that they gets just get scattered around because when a building close as you've got to move forty people out of there's not necessarily forty facility or facilities within a couple miles that can handle it when the Northwest Arkansas facilities have closed they have to go a long distance because there's not a supplier builds available so they may that if there Northwest Arkansas they can't go to Fort Smith has on any beds there so they're gonna go further than that. The the or to a nursing home. Okay and that's what I want to know do they go home to go out community with community support the end up at the nursing home or do you have to keep a discharge plan that when somebody leaves a facility because it shut down you have to say this one went home this one got community services is one want to live with the Shaner this one went to live with the in a nursing home. In the case of the oaks and media which closed three years ago. There was twenty eight residence in a thirty bed building of those twenty eight to one home. It went to the nursing home and others were placed in the local assisted living facility there. So it's a combination of of the Sturch okay The the other question and maybe I think you may hit on this of I noticed that several of the facilities. Have what appears to be ad for financing my correct on that a look maybe on the head but on exhibit death or remarriage talk about that yes. With assisted living started the Robert wood Johnson foundation was instrumental in introducing the coming home program. Which was called affordable assisted living. At that time. They would sell tax credits to investor groups so that the new assisted living facilities would not have a mortgage. Then. As well would take over the responsibility of managing that. In these loans in the case of the oaks which was a coming home program facility at the loan amount with Boston capital was around four million dollars. When they closed ad for becomes responsible for paying the federal government back those advanced moneys. And so there is a risk to the state in these coming home program of facilities or the state will have to cough up the money to to reimburse the feds for the program failure. And then maybe last question You mentioned that the state promised back when the program got started is that writing anywhere was that a gentleman's agreement was that just an understood policy or was written policy back then where we can go back and see that over the years we've deviated from the original policy or do any of you all know that. To my knowledge it was not a written policy as much as it was the bank's contacting ages aging adults services and talking about the program. It wasn't until two thousand and fifteen when we were brought forth the argument that the state had promised to keep the program viable there we were told the state's administration has changed and that's no longer the case and that's what's been happening since two thousand fifteen. Thank you thank you Mr. Senator Wallace. Good morning I will thank you all for being here and thank you for the great service you do for our state. There's did I understand that there's a hundred and to assist a living homes in Arkansas is that correct figure. Yes Sir that's correct thank you thank you what what number do you all represent today you represent all of them or is your your social issue represent all are or how many we have the eighty nine members with our association and probably of those sixty or seventy year assisted living providers mainly the waiver providers. Okay thank you. Representive Hudson. Thank you madam chair I've got a question for Mr Homan for Mr Smith as well and could you explain Mr home and just so we can be very clear on that what you're talking about when you're discussing the waiver program and what that means with regard to other forms of reimbursement for these facilities. The waiver program is the the Medicaid assistance that's given To pay for the care for the of the care for the resident the they're two components to our payments we get their social security amount which is twenty four dollars a day the pace for the room and board or a maximum of twenty four dollars a day that's the room board utilities and food and then the other part the sixty seven twenty five were receiving now pays for their nursing care assistant that's certified nurses aides LPNs the R. and supervisor of the cooks the housekeepers the maintenance administrative and all the other staff and that all the bundles up two sixty seven twenty five and for the most part all of our surveys have shown that that cost us right now is between eighty five and a hundred dollars a day to we're getting shorted quite a bit every single day. Thank you and then Mister Smith that kind of leads into what I was going to ask you What number have your crunch the numbers to figure out what number and what the rate would make this work and then also does that number changed by region or is that a step pretty steady state wide number. Each county costs are different. Things like insurance or uniform across all counties. But labor rate severity so in Little Rock the labor rate for a CNA a certified nursing assistant maybe fifteen dollars we're in me now it may be twelve dollars so there's a labor rate variance although the statewide rate is consistent sixty seven twenty prior. The the idea of our cost variances you know you have a food costs increase it's been about thirty percent since code started without significant COVID cost increases britischen the state put in a mandate that you couldn't have new admissions and so from March of last year up until April of this year we could have new admissions so as our senses fail then that put additional cost burdens on on the facilities county wide you know for every county in the state. And so in a combination of COVID combination of the decreases in and occupancy which that question decrease in revenue. Has put us in a pretty serious financial straits Les Paul Jr yes it in that leads to the natural follow up question talk to me about your costs over the past eighteen months DO Kopet how that's affected your your rate. Well as an infected are rated all that's stayed of stagnant these little mask that we used to buy for a few cents a piece when you can get on they were almost a dollar a piece the in ninety fives ridiculously priced gallons one up plastic face mask one up we couldn't buy him sanitizer at any price so I was going around to liquor stores buying cases of Everclear and aloe gel it's no good though but that's how we have to do it we had to improvise so everything is done just out of sight here all or paper products order to get all the sudden we're having to serve people in their rooms so instead of washing plates we've got to go out by foam containers for three meals a day plus snacks and all of that so just the degree of difficulty one up so so incredibly much and let me get back to the point on admissions we we weren't really restricted on the missions but we had to have people come in a moment isolation hall and they were gonna be in their separate and we do have separate staff handling them if we had someone with COVID in the building they were going to be separate in an isolation environment as well so even the precautions there were even more intense with gowns and masks and gloves and really trying to be as safe as possible another point on that we had to do testing lots of testing and unlike the nursing homes were not get reimbursed for it also for me to go out and with the machine to buy a box of thirty by Max test there were about nine hundred dollars a box for thirty test we didn't get the habit to estimates we have a lab in the building so that wasn't even a question or we had to go with an outside lab and hopefully it would be covered under the cures act or the the residents of a Medicare or Medicaid money but just the degree. A difficult if you're in a remote area you've got to take these labs and if there's no career you've got a driving the Little Rock two hours away every few days so we've had just JYJ increases with virtually no no cost recognition for. Senator Tucker. Thank you madam chair and and thank you all for being here represent Hudson actually it on some of my questions I really wanted to get a better idea specifically of of what you're asking for. In terms of support from the legislature and just looking at your exhibit one year as an example it looks to me like there's a federal match for every dollar the state spends that brings in about two dollars and fifty cents roughly from the federal government is that true. And just generally I mean what are you asking for the I thought I heard you say aye maybe I miss argue that the cost of living adjustment was removed are you looking for that to be reinstated or specific box. Plus the cost of living or what what were you looking for. I'll jump in there your that's about right on the federal match I think with our federal match ships in the but seventy percent of what the cost is that the feds will pay that and then the state general revenue fund pays the rest Right now our rate to go up to a hundred and two dollars a day. And we still save you money over a nursing home so it's it's gonna stay neutral or not adding any money to the budget anything less than that the state saving money We really need a rate that's kinda matching or cost which are in that ninety five dollar day range that's a big jump by a minute but we've been held back for so long you had all these facilities close you got five million dollar buildings that are empty because they can't be used so there's a cost their people lost their jobs people been uprooted and forced out of their home so I don't I don't know. He also cannot we've all seen it we see how upset these people get when they know they're gonna lose their home that the uncertainty for a ninety year old is devastating they think they're gonna die they think they're gonna be thrown on the street you can tell him all day long yeah it's going to be alright but all they know is that the home the place they love the people they love they're gonna have to leave and then they find out they're moving fifty miles away to a new place it's it's devastating for it's all because the state wanted to save three dollars and eighty three cents a day. What is the current rate is at seventy four thirty six now our current rate is sixty seven dollars and twenty five cents a day that's that's the old rate that they they provided for last year's comparison okay. All right thank you very much thank you representative Bentley. Thank you chairman just a couple quick questions have you all received and cares Act funding. Have you received any cares that funding with the nursing homes and hospitals have. Yes ma'am we have my name's Todd hi Taylor again we calculated our average we did receive care that money outside of the payroll protection loans that we were granted we received about eight hundred eighty eight dollars per license bad in cares Act money. in relation to that my skill units that I have in other states were closer to ten thousand per licensed bed so we received about to nine percent of what we did in the schedule for the Mike a little bit too yes ma'am I'm sorry is that better yeah we just said we don't yes yes we received about eight hundred eighty eight dollars on average or bad in in grand Care Act money during COVID in the assisted living my two skilled units in there are in other states but it was a lot of it was federal was close to ten thousand per licensed bed. Can I have another quick question yes so do you think I know looking at some of the nursing homes they've lost population because families are very concerned about putting their family members in a nursing home or assisted living because they will be able to visit them because we went there with not been in to see the family so the thing that maybe play into why some in some of the some of your units are not full to capacity at this point yes ma'am we saw overall about a thirty percent decrease instances across the board in our facilities people would needed to move into wanted to move in but they were not going to isolate for twenty one to twenty eight days in an apartment We've also seen the health of our residents that do the quarantines and and their health has declined the overall mental health has gotten worse the same thing with our staff or staff is beat up. And and we're we're running very short because of a the labor shortage he per nurses are leaving the healthcare arena after COVID because of burnout you can't pay enough to get enough good staff. it it's kind of funny but not funny at the same time I had I had two tickets to Saturday's football game to rights and we're like well let's have a lottery and given away to one of our staff members it's really you know gone above and beyond helpful lectureships and. But nobody was very happy their concern was well who's going to cover their shift if they go to a football game. But that's kind of the reality in part of what I prepared to speak about later you know ops I also operating upon the city back as soon as COVID started Oklahoma has three tier level still the highest one is ninety two dollars and forty seven cents a day. as soon as COVID hit they came out and and you have some handouts from from Oklahoma the H. C. that'll show this and they and they took all advantage Medicaid waiver residents to the third tier three payment for the whole year and we're still under that been going on six eighteen months now in addition they came back with the staffing shortages were so critical and we were we were actually if you bring agency and you know one month of agency can run you forty thousand dollars and seventy five bed facility and it's just catastrophic financially but they they gave us an additional twenty percent retro payment. that they're paying quarterly just for staffing bonuses to help us get through this time so it is been very critical of you know in Tennessee and in California Medicaid rate we got an automatic ten percent Bob with COVID to help us along with some of the federal matching cares Act monies that was that was available and that really helped us get through the program to the to the COVID to get to this point I've had COVID in five buildings in the last two weeks is predominantly been staff members are unvaccinated but we have to go back into full quarantine mode And that's been great if you've never been cussed out by ninety seven year old lady down are you have the courts in again. It's something that it's something that would but a resident the other tire and it and I don't know what to tell me more it's like do we do shift differentials there's no money to pay for you know what I told the state that I was going to shut down my facility and shared in April first it's financed with hud we started that process heard finally came through and they let me use all of our reserve escrow accounts. Two so that I can make payroll and I keep good staff I'm I'm in default now we're going to the default collection department with the Walker Dunlop folks starting this week tomorrow to a mother three had buildings will be in default again and I don't know what next steps that'll bring up I've depleted my reserve funds that were supposed to be replaced equipment to pay staff and try to keep the doors open all other buildings or in default on their loan covenants as well and we're talking to the bankers every week what we're gonna do and it you know we've we've cut our expenses we've cut staffing back we try to keep good staff I've got staff that are working double shifts every day which is not fair to them but they left the residence they don't do it for us they do it for the residents I will say we're still taking good care of residence they they may not be happy right now especially if you. You know I dare say the word COVID in quarantine it kind of the whole mood of the building completely changes You know a big problem our next big problem that's coming that we have to figure out how to face is that the federal government has. mandated that hospitals a nurse all nursing homes have to be fully vaccinated staff by the end of September I believe that's going to trickle down to us it's going to help us route for a minute our staff is probably forty percent at the Basque vaccinated the other sixty percent are dead set against getting vaccinated and have told they'll tell me they're gonna quit. So I don't know as an industry both in assisted living and skilled units and the hospitals even what we're gonna do for staff and what that's that it's going to cost and what it's gonna look like a specific asked today is is kind of been kind of difficult because it seems to change every week I don't know if you see in the bill board to drive around in their offering C. N. A.'s a five thousand dollar sign on bonus or an LPN ten thousand dollar sign on bonuses and. You know that we would we would want to do those things we when we would like to reimburse these folks for what they're doing because it is it's it's a very hard difficult job it is very gratifying taking care of people but we're out of funds I cannot borrow any more money So today is kind of a last is last ditch effort to see if we can do something a lot of the other states have really stepped up came to us is that we code written to help you out has it really been that way here in addition to that we've we've talked was Senator Hammer miss in Madam Fite who's been very good to help us. As we start to be noted many people you know I think between Mike and I we had seventy five residents that we moved in that we're still waiting to be approved for Medicaid and We finally get a hold of the H. S. is it was revamped it became difficult to find out who to talk to Mr stand it's been phenomenal in helping us though for the record We find out that well there in areas portal we're supposed to be using areas portal. And we didn't know about So it's been kind of difficult when we're not getting any communication even on what we're supposed to put these people on how to build them and how we go about getting approved so and I'll start with that thank you. I have a question I have a couple of years ago when we met and talked about some of these issues I believe it was a former representative Dan Douglas he talked about how other states did not have the building requirements that Arkansas does for assisted living facilities and I think he used the example that and now some other states you can retrofit a motel six and turned into a system living but Arkansas you certainly cannot and we have I'm wondering how much of the problem we have caused by putting some of these regulations on you. Yes ma'am in the beginning like Mister shepherd said my family was also there when we're writing the original regulations and we came from a skill background incentive for going to do this let's do it right let's build quality buildings that meet international building code level to I to dislike this like a you know almost to the nursing home level of care to make sure that we're providing safe Nice assisted living center that are providing protection and they're all private units with minimum square footage and that up front cost is substantial Other states on always had those ripped the pharmacist man that's correct. Senator Hammer. Thank you Mr would you would you talk about that tiered level are in Arkansas were single tear or we are we the trip here that you referenced in Oklahoma's model I think. When they. Started the cuts here in Arkansas we work our rates were frozen in twenty fourteen and then when they did the reviews they decided to go from four levels of payments. Which were based on the needs severity of needs that the resident had to a single rate and that was a combined rate of about eighty dollars and thirty five cents of and then started dropping and they said that was more efficient further budgeting purposes I guess other states were seen the trend going just the opposite of Oklahoma's Todd reference tells three different tiers so they can serve three different levels of care my talks with the state of Washington two weeks ago of they settle on thirteen different tiers anywhere from sixty dollars to a hundred and forty dollars a day Indiana has multiple tiers as well it maybe not so much for budgeting the first year but after awhile it kinda levels out and they see how much how the the mix is going to be so it can be done it's probably more efficient to pay more for a person that needs a lot of care and not as much for someone who doesn't. So the I would say from an operator standpoint if we're looking at and A. L. patient who's going to be extremely heavy duty as far as the logo's and we're relation or getting sixty seven dollars a day well we might not be able to meet their needs like we could when we were getting more money for a cure for patients that are I guess that's part of my. Wondering is the way you have presented on your exam to it's a daily rate but would it. Adversely affect your benefit if you were to go to the tiered system. Or would it matter. The tiered system would probably be more efficient because you're not paying too much for that low level person but the high level one that really doesn't want to be in a nursing home doesn't require twenty four were skilled care but still needs a lot of hands on time it probably would benefit so we could keep some of those people out of the nursing homes and that was even going back when we did the Medicaid task force when John Steven was questioning us about moving people out of the nursing homes and assisted living that was a big part of what re balancing was another state's Tennessee did it and move their bottom tier of nursing home residents the AHCF threes into assisted living Johnson would that work in Arkansas as well it would but we need more money he said what you need as much as the nursing homes get I said no but we would need more money but that would be an option at something as the. We're going to get on a budget crunch here in a few years with all the nursing home residents no getting around it and that may be an option to give assisted living a little bit more money to take care of those lower level people can get felt manager yes okay so date you mentioned about the cap how many how many of Medicaid assisted living residents are there now in all the assisted living so thank you said awhile ago only about fifty five of them actually take Medicaid patients and I right on that are there's fifty three that participate as you saw from St Bernard's K. some of the big guys are getting out there's about thirty that are kind of the core providers and and how many in those thirty or fifty three work were limited to twelve hundred residents at any time and I think right now DHS would have the numbers that we're we care about ninety nine eighty so they're still two hundred and twenty beds available but. Getting them qualified and get them to the red tape that DHS is really a problem to age is twelve hundred to cappers twelve hundred the daily average of twelve hundred as the hard cap we've got about nine hundred eighty right now okay then I guess you've seen the storm coming for a while a committee all. A committee all haven't gotten out of the Medicaid model before now if it's if it's not to put some yellow business bankrupt you why why haven't you gotten out before now. Well. Open Van Buren County I can't find that many people that can afford three or four thousand a month it's. Each year you built this thing you've got a mortgage on it you've started a program based on the state's good will when the program was not working early on DHS and the Office of Long term care said why aren't you guys doing more and we said well we can't afford it so they gave us a twenty dollar raise and two thousand and seven and eight that we had already had a annual multiplier of three percent and that sort of worked that made it where we could go out and borrow three four five million dollars to build a building and provide services across the state because you can't go down to Drew County actually County Chico county all these other places and expect to fill up a building with private pay you have to have these kind of the secretary service I'm just gonna hold up a map it's not part of the exhibit but you can see all the stuff an orange all these counties in orange those are counties that don't have any assisted living at all and they'd probably never will until rates. Something happened so you've got the entire group entire part of the state with only one facility there so. Okay they're stopping me I'm sorry. The Senator part of the problem that I know I have an ad for people that are on the list have is that it's written into our by laws or if the hud loans are under written at an eighty percent Medicaid population and it has to be a licensed facility The thought across some seller reminds that we would just unlicensed the building to go to independent living and try to provide some home health services things like that but our covenant with heard an ad for will not allow us to do that therein is the problem what you just said I think. Those those facilities were put in if what our strategy is to say those facilities were put in and financed by the understanding that they would maintain of certain Medicaid level population is that accurate statement that's the way by HUD buildings run a written and the absolute is under written with a sliding scale sixty percent. Yes go ahead Scott and that's exactly what my building over a canis it's it's has it actually in in our deed were we're committed to the ad for a loan and we have to maintain a fifty percent Medicaid population what did Medicaid cannot what else. What do. What did add for do as far as research or any of your financial institutions do as far as research to substantiate verify go out on the lam that if you're being regulated to maintain a certain number of Medicaid patients that you would be able to maintain a certain level of income on each one of those Medicaid patients in order to make your note on your building. Marcone honest here to test the to talk about that today he's here okay it's from that but he's from at the but they do it annual inspection to make sure that I've got those residents in those beds. With the head count every every every year they come check on us every year to make sure we're filling our side of the our side of the bargain and I think the you know what he's going to tell you is that that from a banking perspective he relied on the program that's that's written in and it had has been in existence since the early two thousands you know near what two thousand one two thousand and one that that that the program would continue and that's what bankers do they they under right based on that that's how they made their own okay we'll get to that when you get your thank you thank you Mister senator. Hello Clarence FOR okay I had you may answer questions for their **** the L. well program. Which is through the tax credit program requires that sixty percent of your residence. I'm sorry that eighty percent of your residents be at the sixty percent median income level in the county. So that precludes private pay in addition twenty percent of the residents have to be at the fifty percentile of the area median income and those loan covenants are very very strict and after then reviews that annually to make sure that you're falling within those requirements so private pay is not an option in these programs that were financed through the coming home program affordable assisted living at five. Representative berry. Thank you chairman by I can you educators real quick on the difference between nursing home and assisted living in respect to the quality assurance fees of the bed tax and the the federal matching is like a seventy five dollar difference in between the nursing homes assisted living. Yes Sir nursing homes to have a bed tax in the that's paid monthly we get a bill every month the nursing home for that and send that in in the federal matching is done a quote according to that so that's what's reduce that cost down so much of it was a great program when we of did that I remember back during governor Huckabee's administration I believe and it really helped save our programs for nursing homes assisted living does not have that as an option that we know of I know a few taxes and some other states but we don't have a bed taxes such bills all of the assisted living providers that's the reason this example you see on the exhibit one gets so right I guess almost out of whack showing it's like how can a nursing home that's a hundred ninety five a day be fairly close to an assisted living facility to the state general revenue fund that's that quality assurance fee is what makes the difference we don't have that for assisted living. Thank you jim. The representative Christiansen. John I appreciate what you're doing my family had an extensive background in hospitals and nursing and assisted living centers but my question is do you have a figure in mind that would help stave off the sinking of the ship so to speak of of what you're talking about we're we're talking around the issues and the differences between nursing homes and assisted living but do you have a figure in mind that would help support what you're doing. The recommendation last year from an outside study that was evaluating all of our debt of the DHS data came back at eighty six dollars a day for a rate that was pre COVID pre testing pre gallons pre isolation and all the other things that I just killed our business this last year. Yeah I'm pretty minimum wage it really didn't want in on the minimum wage hike was one thing but the labor scarcity after about the people that have exited the business and decided to work anywhere but in a nursing home or assisted living is just made outrageous we had just yesterday I had dishwashers are making seven fifty an hour a few years ago that are up to fourteen dollars an hour now so the park cost of going through the roof we need between that eighty six dollars from last year and ninety five dollars a day to survive to provide care and to be able to meet all the requirements that we need as operators. Follow up manager yes thank you very much that's what I was trying to hear from you and I appreciate that madam chair thank you. Senator Springer. Thank you madam chair do you have a copy of that report that you just mentioned that was done to share with the. Yeah that that I think that's what I was saying earlier that I want to see some numbers so that's an independent study. And this and this breaking a breakdown of costs for all the services that are being provided we probably could get that staff sent it out. If you want to provide that your staff later exhibit six. Has the con associate. And it'll be on the last page where they have their conclusion for their their rates suggestion we didn't include all the other exhibits but those are available to anybody wants us I can send those to you. Thank you in those two staffer and then he will get them out to the world of members. It's at the bottom of the page five and highlighted their. That's that's your pre covid. Cost analysis of eighty six dollars and forty five cents I kind of I kind of look through this but it's just month than one son is not broken down. Right there there's there's some analysis that goes with that report which we can get you that detail. Thank you gentlemen did you have anything else to to add before we go to the next person. Let's go person. Okay thank you all right thank you. And before we move to our next Speaker we need to a little housekeeping if you will move back up to item duty consideration to adopt a motion authorizing chairs to approve special expenses incurred by the committees to SEM motion for this. A motion and a second all in favor say aye. That item is approved next on our schedule is discussion of assisted living Medicaid funding with the mark white chief legislative and intergovernmental governmental affairs officer and chief of staff to procurement services and if you will look members this is exhibit G.. Mr what you're recognized. Thank manager Marc white form if you can services and I do have some folks from DHS here with me who can assist with answering questions as needed you know what questions to committee may have I thought it might be helpful for me to just very briefly talk through a few of the issues that arise sporting just want talk about number one helping sets in the context of the you've been missing from the discussion so far number to talk about how we got to this point students leading up to this and the number three to talk about how we compare to other states and how we handle this issue the first enter into context thanks importer understand they're very fundamental differences between assisted living and nursing home care we're talking about two different sets of residence assisted living we're talking about individuals who need some hands on assistance with their activities of daily living that's things like bathing toileting eating things like that they may need some occasional medical care their primary needs are for that hands on assistance from a care aide for notion nursing home we're talking about individuals who require skilled medical care on an ongoing basis it's not just they need help with bathing or toileting is that they need actual medical treatment in that facility on a regular and ongoing basis that's what makes the difference because Medicaid we don't pay for individuals in nursing homes who only need that hands on assistance with directors etal daily living conversely we don't pay for individuals in assisted living facilities who need that ongoing skilled medical care so two different populations so it also means two different types of steps that's one nursing homes they have nurses they registered nurses LPNs assisted living they are not required to have nurses on staff the staff requirement is that they have to have at least two workers on site at any time in one of those has to be ASEAN. Hey and then they also have to have an administrator on site during regular business hours and then in addition to that they have some additional ratios they have to mate and on how many beds they have the bottom line they are not required to have nurses in that facility and so that's what their costs are very different cost of nursing home. It is also different terms of who's paying for these facilities now as you know most nursing home patients in the state are paid by Medicaid some by Medicare but Medicaid is by far the largest payer for nursing homes for assisted living when this old current round of the dispute started back in two thousand nineteen Medicaid was paying for about twelve percent of the assisted living residents of the state there is in this state there are more than seven thousand licensed beds in assisted living facilities Medicaid is paying for as I said route nine hundred or so in any given month so we're paying for a small minority of the residents of assisted living around the state and I know you've been some discussion about there's been dropped there's been closures there have been some facilities that have been closed we have not seen a drop in participation in January of twenty nineteen we paid but we paid bills for eight hundred eighteen residents around the state in January of twenty twenty one we pay for it twenty five as we've seen a pretty consistent steady rate of patients in assisted living for what Medicaid is paying for I can't say the same for private pay because that's nothing that we regularly track list for Medicaid we seen some consistency there. The second leads to talk about how we got to where we are today As referenced there was an agreement for the children more than twenty years ago where DHS in the industry made an agreement Senator Rapert and they'd negotiate that right based on what the private pay cost was at the time and they also built into that an automatic three percent increase every year the rate there is no other Medicaid provider type the kitchen automatic annual increase there's no other Medicaid provider top where we base that rate solely on the private pay cost if you know much about Medicaid you know the Medicaid rates are almost always lower than insurance rates almost always lower than private pay rates because Medicaid is the payer of last resort we're using taxpayer dollars to pay it and so that's why Medicaid rates generally are lower than those other types and such important member in this conversation so we in twenty fifteen when governor Hutchinson came to office we stopped the item automatically increases because the push the rates too high and that's the bottom line of why this all started back in twenty eighteen was the rate was too high we could not justify that rate CMS and say this is an appropriate rate to pay for system living in so in three years since then we have done three separate rate reviews to look at this issue each one of those involved cost survey in which we sent that survey out to providers ask them to provide us their their information about what they pay with their cost or and three times what we come back to is all in this range of around sixty seven dollars a day as opposed to the eighty dollars a day that we had been paying for all this and a I and I don't want to go point by point response I will mention Mr Homan said that we didn't explain our decision this last time in reality we prepared a rate review report the sixty nine pages provided that to the providers they review that they. Provided us multiple pages of comments backs there is extensive discussion about that rate how we got there and how we made that decision. And then lastly let's see I'm sorry I lost my. A place in my notes. Couple of points to make around the rate one is these last two reviews they did specifically tailored to take into account the minimum wage increase but is something has been accounted for in the rate and I think for the most important thing for you understand about the rate you heard lots of discussion about increases in food costs building cost increases in utility cost here's the problem the federal government will not allow Medicaid to pay for room and board expenses and a waiver like this all we can pay for or the direct hands on assistance being provided to those clients in the facilities room board cost for Medicaid clients are paid or to be covered by the amount paid by the club present themselves out of their social security or SSI benefits we cannot pay those reward cost and Medicaid and that's where all the differences of calm as they've had their actually look at the rate we that are actually the rate that's where the biggest one based pieces the differences is in is that they are wanting to have a reward cost paid and we just can't do that and Medicaid through Medicaid waiver like this. How do you lower context of for Arkansas Medicaid residents when you look at what we pay for Medicaid plus that residents obligation to pay room and board cost of a facilities will receive about three thousand dollars a month according to Genworth the average private pay cost of assisted living in Arkansas is thirty five hundred a month so yes we are under that probably amount but not by huge amount. Hi Leslie want to mention just looking the other states this was somewhat mention but we listen we looked at as we do this for a review and trying to determine if the rate we're paying right now it's appropriate taxes they pay a dollar a day less than we pay for assisted living Mississippi pays thirteen dollars a day less for assisted living New Mexico is fourteen dollars and a less Oklahoma's when it was mentioned yes they do have a tiered structure but when you average out those to your rates Oklahoma is only two dollars and a more a person what you're hearing from the providers actuary saying they should be receiving twenty dollars a day for so that's what again that's why we came back and look at this rate in the first place was we saw three was unsustainable it was too high particular compared to what other states are paying for assisted living. Adventure I think that covers the points I wanted to make be happy to answer any questions we have any questions Senator Garner. Thank you madam chair. Mark the ballot ministration through CMS in collaboration with the CDC has put out a regulation that by September. The peace the mariners in homes that take Medicare or Medicaid. Choir their staff to be vaccinated we are from general earlier who said that could be roughly six percent of its staff decides not to get vaccinated. What would happen if say twenty twenty five to thirty percent of our workforce in September were forced out of that job and we had massive staffing shortages pushed on us by the federal government. I would say it would be a very serious since the severe situation if we were to lose those staff and not be able to replace because we have staffing ratios and staffing requirements in place for all long term care facilities because we're wanting we want that to ensure the health and safety of those residents and if so please get me that meet those ratios that'll be very concerning good with it Amanda last holler here you we discussed that through the Medicaid expanded expanded rate they now force us to leave people on the road even though they don't qualify now we have the federal government forcing people to make a decision between their jobs or be able to take part in its program which is the biggest part of government regulations I've seen is there any effort from either Director jealously or the governor to show some leadership on this to fight back and to push back against my administration is still CMS and this is overbearing regulations and they're gonna put thousands of Arkansas's most wanted populations in a health crisis situation from this dumb overbearing regulation. I can't speak for the governor I just I don't know communications you may have had with the federal government on that and I don't I don't speculate on that I know that for our part we we certainly talk program we've talked about you know that the issue of staffing and how important that is and that if we receive additional difficulties in getting staff and the facilities that we very problematic thank you. Mr white him in the Arkansas nursing home residents are assisted living residents died covid do you now I do not know the number off hand we can we should be able to get that but I don't have it offhand thank you. Senator Hammer. Thank you ma'am chair did you say that assisted living facilities are not required to have an RN. That's correct. How do we maintain medicine integrity then to make sure that the residents are getting the medicine they're supposed to be if a nurse is not handling that. This for assisted living the the intended population or folks who are. They are able to live somewhat independently they just need some occasional hands on assistance with what with what what they're doing as opposed to a nursing home where they need much more intensive much more on going twenty four seven medical care. Almost find that disturbing because that means the person clean in the room could be the person giving them or help them with their meds are they expected to totally function and keep that medicine in the room. Because some of them even though they can you know handle our personal leads they may be taking some prescribed medicine that could have some very adverse effects. If if it was this dispensing medication that will be governed by the nursing standards of practice and so you know there's certain things that only a nurse can do or only a med tech can do only help you can do and so that there are other restrictions apply to all long term care facilities around the dispensing medications and when it comes to the reimbursement rates and the discussion the reimbursement rates and taxes that's a dollar below in Oklahoma. Is that taking into consideration the regulations that Arkansas has on our system lettings verses the regulations that other states may have on their assisted living and those regulations could have direct bearing to the cost that it takes to run that facility. We've not looked that specifically in Texas but I would point out that for Arkansas our regulations around staffing are relatively mild as I said facilities required to have to staff one has to be seen in a one can be a a wrecker worker established meeting amid around minimum wage level employ and beyond that they might have some additional direct care workers depending on the size of the facility beyond that I mean that's the best and that's because we pay for and that's the regulations are not overly strict the others mentioned earlier of complaints about restrictions or requirements around the building itself and there there may be but Medicaid can't pay for that that's awesome that Medicaid can be responsible for because we can only pay for those direct services but then who drives the restrictions that are putting the assisted living in a position to have to comply with the rules rectors I know you all send people in to check and I know that they get being done you're just like a nursing home do you know they have to comply to regulations when the Milliman company did their analysis and then the assisted living hired the focus on exhibit six was there consideration in there that the requirements are contributing to the cost. Yes because with Parma Millman look that was one of the requirements facility has to meet and what does it cost to meet those requirements and I'll add that Millman in the their final recommendation they recognized as would did we that even though there's all a very really low level of required staffing many assisted living facilities actually do have an LPN on staff and they they will be on what's required and we recognize that accounted for that the rate. Senator Wallace. Thank you thank you a Mr what from intraday. Our system living homes. Hello to the same standard of inspections and state level as our nursing homes no. No there for nursing homes is a much stricter higher level because they not only have the state requirements they also the CMS requirements they must meet thanks to. Representative has. Thank you Mr right for being here today in my correct that reimbursement rates for nursing homes and in order to be reimbursed you have to be able to demonstrate medical necessity for purposes of Medicaid reimbursement yes okay and you heard testimony earlier today that some of these assisted livings are in such fiscal distress I think we have a. Exit have. And that they are in danger of closure or or endanger for closure what do you make of those concerns with regard to the effect that will have on the system. There have been a number of closures so far how want to say I think they mentioned earlier of eight closures and I had a reason to dispute that no we have not seen a decrease in participation in the program as a result those closures and so that indicates to us there is still sufficient access for beneficiaries and that's our primary concern is to beneficiaries they have access to the services they want and need and so far we're seeing these continue to have that access. just a couple more follow up yes okay so eight assuming that the testimony from from Mr Homan and and his organization is correct in some of these of facilities and not yet close but are about to where were those residents be placed. They could go to another system Lewisville the they could go home with family they could look for another setting it is possible they may go into a nursing home but what we have seen sometimes is individuals in that situation they go to a nursing home but in retrospect given their medical condition they likely needed to be in a nursing home anyway because they were they their condition had worsened to the point they were at that skill level of care. And if they aren't eligible for nursing home placement due to not having medical necessity for it what do we do with them then. I'm the has of those those other options they also the option of in home care we have our our choices waiver program where we can have an in home caregiver Rossello same type services they're provided in the facility thank you. Representative berry. Thank you ma'am sure course up missed what you know my can I have a concern about the Medicaid reimbursements and an account reminds me of soldiers pulling out of Afghanistan it was a very well planned when you rolled out the new system so we're we at in order and is as far as getting Medicaid reimbursements up to date are are we well behind is is going to take months longer down the road for those reimbursements or can we see the light at the end of the tunnel sure the S. maybe I'm sure member the governor had I did executive order directing us to review all Medicaid reimbursement rates and that was a first for Arkansas that's something that is never been done historically Medicaid rates were only revisited even when there's a crisis or someone complained loudly enough just to be blunt about it but the governor directed us to put those rent those rates on a regular review cycle so we've been working through those we're now working on the last round of read reviews for provider tops once we finish this round will reviewed every Medicaid provider top it will have on the schedule so that every provider type is reviewed at least once every four years. All represented Mayberry. Thank you mark always add good explanations but I'm just still kind of struggling on the whole rate decrease you said from you know about eighty to sixty seven dollars a day at the time that we've had minimum wage increases drastically and I I understand that the money can only go toward skilled labor and not the food we're not talking about all that you did a good job explaining that but I'm still really struggling with understanding how not just assisted living but are nursing homes R. D. Davis ylides they're all really hurting right now trying to find people to work because what we're saying is that they will work for minimum wage. That's not cutting it because they can go get a job at a fast food restaurant making fifteen sixteen dollars an hour and when they're trying to feed their family even though they love working with this population they're going someplace else so even though may be financially okay you've got enough money to pay someone minimum wage they're not able to get those employees or if they do get the employees they may not be the quality employee that they need and I'm hoping that maybe you can help address that how how we. Look at this issue not just about assisted living but overall our LPNs or CNA's we're losing them they're they're flocking right now. It is certainly is Michy we're seeing across healthcare industry in the state and that is something that everyone is struggling with to get folks and we see in our own facilities and what we saying that. It used to be was a money issue now it's not too early money issue there are folks that in the age covered they just don't want to work around people and that type of environment and so we certainly understand the struggle to get staff in in this no Meacher require staffing ratios and have folks there to ensure that your residents are protected and safe with us if assistance if we're a couple points one. This most recent call server we did what we saw was that the vast majority providers their actual cost what they're choosing to spend right now is less than the rate we're paying and so that tells of they've got some cushion there that if there have an additional staffing because they could meet that second point is we have worked to help assist providers including assisted living providers with that particular record difficulty in this environment so with cares Act you may recall that we spent I forgot how many tens of millions of dollars on cares money to provide retention payments to nurses and workers in long term care that's not just nursing that's also assisted living home committee based services other environments for people were going into facilities or in the homes provide that hands on care so proud of cures money we now with with the American river recovery act money we personally brought somebody nursing homes we have a proposal to CMS to provide nearly a hundred twenty million dollars to home committee by service providers including assisted living we're just waiting for CMS approval on that so we we put lots of money out the door to help with the staffing issue and we've got more money we're What's that specifically be used for gold little bit more in depth on that sure it's it's it's one hundred twenty million dollars that we have sorry request information what I heard. For the feds and that's what the split out for is we're proposing to you sixty million dollars for work for stabilization so that is why the providers can directly used to help recruit and retain staff for again for assisted living for other home committee based service providers we have is that also the D. D. population as well yes okay include them as well then sixteen million dollars for technology in education for the residents and for beneficiaries and then forty million dollars to expand and enhance the availability of home committee based services or on the State. Okay and I'm terribly sorry I have to wait or can I ask for the right correct in okay and then and then one other thing if all falls through you know I'm I'm an advocate I I I want people to stay in their home as long as possible but assisted living is certainly a wonderful option as well for many families but if it you know continues down this road just help kind of guide us into what is available for those families when they decide that they're not gonna go into assisted living what services are available and how can we get people some help who made the decision not to. The system sure we're talking about some specific about the frail elderly and services available for them assisted living is an option through living choices waiver other options include are our choices waiver in which they can receive increase in home assistance with their task and daily living so again bathing toileting eating and they hassle coming their home on a weekly or daily basis to assist them with that as well as other services to help them remain in their homes safely even us outside of the waiver if they meet the income requirements for Medicaid they give me the same services through regular Medicaid in the course we also have the pace program which is a program where it's similar in certain areas of the state it's managed care program where that organization provides all the medical care for that individual and that can include assisted living it could include nursing home but also include the those in home supports to help them remain in their home as long as possible. The representative Springer. Thank you madam chair you would you mentioned that you had a sixty nine page report regarding your decision as to the funding this been present again we get copies of that to police yes we will send that to you thank. Representative Bentley. Thank you chairman. Represent member as a couple more questions but marking you ask are there any pending rate increases for assisted living with your office right now are there any that been declined the past year. Where we're at right now is we we completed the review and are are the recommendation or decision was to leave the rate where it is now that is part of the renewal of this waiver with CMS and we're waiting for CMS approval that renewal. We have any idea when we might see that I'm expecting that just any time it's been with them for a while they'd asked that's in question they sent back to us we passed back and forth but I would expect Siemens Pro Bowl fairly soon. A couple call ups yes so apart from the American rescue plan before that are there any federal funds that are given to these homes that agree to take a certain population of Medicaid patients and assisted living homes to they get any federal bonuses or help or anything for agreeing to have a certain number of the population to be Medicare eligible the for from our standpoint there was cares dollars of course we have payments to the Director workers from sales that was paid through the facilities we also had cares funding is available to help them with some other code expenses health with PPA costs and things like that I believe there were other programs that the federal government administered through Medicare which we work directly involved with I know a number of facilities received funding through that I can't say how many of those would be would be assisted living at one final questions okay chairman yes circling back to the facility is what these facilities are required to have as far as saying some based on the beds per room and all that who is setting those requirements for these facilities in the state I believe we do we do have some of those requirements in place for office long term care because even for those facilities which are entirely private pay they're still licensed by the state they have to go through first health services permit agency to get a license bet and then there facility itself is subject to a survey by our office long term care and so that's where those regulations are set in terms of the construction and other things so do we are those requirements stronger here in Arkansas than they are in the states around us as we try to circle back to that requirements are requirements for facilities for assisted living stronger than they are in the states around us to you know that it I've heard that said a lot I have not been able to document that myself but I I don't see or tell you that it's actually were wrong I just I haven't seen it yet I'm certainly open to looking at some examples if you could look at that and get back to this and I appreciate it thank you thank you chairman career. And Mister white if you want to send that out to the staff and they can give it to committee members certainly. Senator Hammer thank you ma'am chair of the I was going back to some math that was work will go and I think would you did you say thirty three hundred dollars or you member that comment. about the amount they receive each month right sure when we take the Medicaid payment and add to that that room for payment of the resident is expected to make an assisted living facility is going to receive about three thousand dollars a month for that Medicaid client in comparison or indigent works the average private pay cost for assisted living if the five governors compete for myself in Arkansas is thirty five hundred a month do you know what facilities used to benchmark that thirty five hundred dollars for your illustration that I'm I don't know I know Jen worked as a survey of facilities I can't tell you how many facilities they survey must assumptions that have liable number House mission when this original rate was develop those two questions back and twenty and two thousand one they based it on the numbers compiled by Genworth at the time okay and how far behind are you on approval of Medicaid applicants because that's been something in discussion that some of been holding for a long time now waiting for those to be approved and the thing is they don't get paid retroactively like the nursing homes due on while waiting on the approval is that correct that's correct they they can only be paid from the point of that individual is approved and they have a care plan in place that designates that facility I don't have specific numbers here with me today I know we've been talking so as we've offered to if they have folks they think or are stuck or pending too long to let us know I know some of system listing our folks are seven working through those lists the so I'm I'm sure there are some that are pending long they should have we're working to expedite those as quickly as possible in one a nursing home gets a rate increase because one of the sheets that was handed to a shows the steady increase from seventeen to twenty one as far as the rate increase to nursing homes that that's not your document Aug knowledge that what goes into what goes into the justification of raising the nursing home rate. That is not allowed to be justified in the nursing home adjustment arming the assisted living to their rate increase sure for nursing home they they're reimbursed over entirely different structure nursing homes have to submit cost reports to us in which they provide us all the costs they incur in operating that nursing home and course for nursing home that includes the cost of the room board also includes all the services provided to that resident by that nursing home and so we have those costs of words they follow this regularly we audit those to make sure they're actually reporting it to us and then we use those cost reports to calculate a rate for each individual home and that rate renews at the first of the year based on what they reported to us as their actual cost with assisted living we don't have the ability to require cost reports from the. All we can do is ask them to share their information with us and they can do that voluntarily but we can't compelled to and so what we set a rate across the board for all facilities again based on that information that they volunteer to us as well as other national information we look at one thing last four is. When when you receive a patient into the nursing home you have to identify where they came from is that correct. I believe so okay because because what I wanna see is I want to see. Retroactively of the assisted living set of closed how many of the residents have ended up in nursing homes and moving forward if the testimony we heard today assisted livings begin to close I mean those residents are going to end up in nursing home to get a comparison of cost would have been better for us to have helped the assisted living and keep those residents their fault we can verses what is going to cost to go to the nursing home and and I'm not interested in a nursing home verses assisted living Fite even though it I know that's kind of a little bit of the small elephant room as much as I am what's it going to cost us if we could have done something different and in the long run we determined would been better to work toward adjust the rate of assisted living and keeping those people in that environment at a lesser cost and quality of life they want so heads up if you get your staff and work together on thank you Mr. Representative Hudson. Thank you madam chair and I want to kind of build off let us senator Hammer was talking about when you're talking about that using the cost report for the nursing homes to to set their rate from year to year do they get a modifier for inflation as well on annual basis. I don't believe so I want to verify that but do not believe they receive modifier conflation I believe we're simply looking at the actual costs that they are reporting to us thank heard in that previous year okay and is that the same answer for assisted living facilities as well they don't get a modifier for inflation correct okay I'm looking at this and I think you have all the exhibits up there that we have is that right I was social website okay this exhibit to that was presented by the assisted living organization which is titled Indian rock village nursing home and assisted living right yes. you testified just a moment ago that you know you're the cost reports for nursing homes have reflected that their costs are increasing year over year. which is reflected it appears in their nursing home right and is it your testimony today that the assisted living rates that their costs are decreasing year to year which is why we're going from seventy eight forty and January of seventeen to six seven twenty five by January twenty one knows what testimony if the rate was paid those paid to them earlier was substantially higher than it should have been the nursing homes receiving a windfall for Medicaid because we're paying for more money than we should have. Okay so the nursing homes are receiving a windfall for Medicaid I'm sorry if I said nurse I've noticed this living this is living rate was far too high then should have been we're paying for more than far more than their costs they were incurring is now we reduce that rate to more accurately reflect their true cost of providing services and and and that reduction in costs this is why we're reflecting many of these facilities are closing no not inside also they're cost reducing I said that the amount they're being paid far outpaced the cost they were if they were countering so we've lowered that rates that is closer to what their actual cost or I suspect it will not be all surprised if their costs have increased year over year but this is not what the issue there's not because the issue is that the rate we pay was too high was far in excess of that cost and now we brought it out so it's closer to what their actual cost is. One last question yes eighty eight and I appreciate what you're talking about with with the cost savings but my question and my concern is if we've got a spreadsheet where due to these cost savings from the rate decreases over the past four years that were about to lose several facilities statewide and particularly in underserved and rural areas is that cost savings worth it to the state if for shutting down facilities in an effort to to save money. Well two points number one if if because our rate exceeds with their cost or then that suggests that the reason having close is not the Medicaid rate because if if we're paying them sixty seven dollars a day and their actual cost for sixty dollars a day and they're having to close something else is going on number two Medicaid as I said only pays for a small number of assisted living residents around the state and I don't think it's fair appropriate is not fair to the taxpayers expect Medicaid to prop up assisted living facilities when Medicaid is again only among the small minority of the total since living patients around the state. Mr white who ultimately made the decision to reduce the rate. I was made by the Department services altering by sector Gillespie approved by the governor and then approved through a LC. And that was in twenty nine was the approval was in December twenty eighteen twenty and what came before council and who would make the decision now to increase the rate. Are we can we can make a recommendation on it's got to go through CMS approval and then we have to be in for rule change that would come through council's well and how would that happen. Hello we go about doing that we would pose as a and amendments to the waiver to change how the rates calculated and that would be in the form of a rule change and then be submitted through normal rule process for the legislature all right thank you. Senator Hammer. Thank you ma'am chair just on what you just said in answer to the question the representative. If the nursing homes submit their. Cost increase of which you review audit to determine right yes so if it's costing fifteen dollars an hour to hire somebody now that they use to be able to hire seven you're automatically going to give them an increase because they've been able to justify that through the process is that correct that increased cost war flick on their cost report and will ultimately flow back through that rate they're paid the assisted living should have to pay fifteen dollars an hour for the same people are competing for the same market which is part of the problem so are you are you saying that the three percent that was originally written in way back when was an inflated number that now by decreasing the rates you're trying to get it back to what you have determined that the the true cost is. If I say that correctly yes yes we're we're trying to get back to what the true cost is I guess where I'm struggling is. In one industry by virtue of the fact that they submit for audit that they are able to get a rate increase which is subsequently a built in cost of doing business we're allowing over here but over here we're not allowing the same it sounds like we're not allow the same privilege given the fact that you say that the three percent that's been accumulating over what ten fifteen years we're trying to like a stock market correction I guess. In the last two years an anomaly has occurred where they're having to pay fifteen dollars an hour just like the nursing homes or having to pay and and how can we say how do we justify. That the that the three percent that's been allowed over ten fifteen years and what's happened over last two years maybe we've gone too far down and we need to re evaluate that to get it back to what it is I don't think we'll ever go back to fifth two to ten calendar our people I think we're at where we are and I'm afraid that the intersection have passed each other. Well you know we'll look back because survey results we got in this last call server we did which was earlier this year. As I said the vast majority providers their cost are at least twelve percent below what the rate is now and so that there's are some cushion there if if they if they even see increased labor cost in these last few months there is some question there for them to work with and if labor costs continue to increase certainly we can come back and taking a look at that to see what effect that's had on their cost that's no we have the right review cycle for all provider types but for any provider top if there is a significant change in circumstances we can advance that the schedule will take the look at that's true of assisted living is true any of the Medicaid provider top is that all based on Milne's report. For the for the rate that we set yes we we set it partly on Miller's report partly on looking at other states and partly looking at our own data and that's all set out in that regard the report which Austin deal or thank you. Representative Mayberry. Thank you I'm just kind of following up on representative fights thoughts here and and see how we go about adding to this. I'm still struggling in twenty eighteen is when this cost reduction was done and it was not until the next year twenty nineteen that we saw the minimum wage increase and so now we're up to what was eight fifty an hour back in twenty eighteen to now eleven dollars an hour and there's been no rate increase and that is a definite you know definite change in things and at bare minimum that needs to be considered because that's putting a strain and once again I go back and reiterate that minimum wage is probably not going to recruit the type of folks that you need and they're working so whatever we can do I mean I'd like to reiterate with representative fights Dotson what can we do is a body to have this looked at again and increase these rates at least dealing with skilled labor I am all for that. Well I would just say that no. We look at the increases in minimum wage. We accounted for those increases and as we put these rates together not only for the workers at the minimum wage in the second review we actually even the projection of assuming there's will be upward pressure on other employees how that how that affect so as those other employees we will all that into that call study and even then that's we came back accounting for the minimum wage came back with this rate of around sixty seven dollars and help get help give you an idea of just far out of whack the original what rate was now we can increase the rate if we have evidence to do so CMS's will require us to justify what the radius so if there is evidence that we can point to to show that cost have substantially increased over what they were even a few months ago certainly we can take that CMS and ask and seek to increase that rate but has to be something that's supported by actual evidence. Representa Springer. Thank you once again I just would like to get a copy of that agreement as well between the DHS that they talked about were they set the rate. And the three percent increase per year a copy of that as well thank you the. That would be that would been set forth last I would set forth with them and our waiver agreement with CMS I should be able to get a copy that for let me see in terms of the original agreement going back two thousand one we just don't have a documentation from that there's too much time has passed none of the people who were involved at that time or do you just now because I know we we look for some of that when this first happened two three years ago and it's it's proxies been twenty years since that original agreement. Senator Wallace. Thank you Mr what again man here thank you chairman Mr. Manager over there have we in the past sit down with our system living folks and then offer any type of a rate increase. Rate increase no Sir we've or what we've done with these last three read reviews is we've brought in the actuaries they put together a cost survey so we can see what are the actual costs that writers are incurring we've worked with providers to on the call survey sent them drafts had then provide us feedback on this question does make sense or want to ask about this we've had that back and forth with providers and what like so within that cost serving out three times yes certainly that's something we can do again down the road and when we if we do expect the same process that will work providers on what's in the call survey what should look like what we asking for they will distributed and civil response we get back thank you Sir. Saying no more questions thank you Mr Y. thank you next we have a item H. discussion of assisted living facility statewide. Scott Kim's bro Kingsborough and I taught high tower. And Mr Homan Mr shepherd I think we're going to have some questions that have been brought forward for you as well if you wouldn't mind joining them at the table. And if you would H. a re introduce yourself to the committee. Holman Arkansas residential system living association. And my name's Scott king's burning on the manner in Little Rock for your microphone word you just sorry yes got Kingsborough and I operate the manner in assisted living facility in Little Rock Todd hi Tucker with health mark services owner operator assisted living in in Arkansas. Thank shepherd Shepherd group owned and managed facilities Arkansas. Madam chairman of I believe that I've covered up a majority of what what I had planned to speak about earlier and had to do with what Oklahoma is done in the other states as far as a covert assistance force with the rates and with the the way to help We did ask for back And matter chair and senator Hammer met with mark wide in September of last year and requested an emergency K. amendment much like Oklahoma done to to increase to the tier three Marcus I'm or Mr white was not sure that it can be done because our waiver was in renewal process he did submit a cave Amendment for us I waited requested about a nine percent increase at that time I was with COVID it came back that they would not take the fourth and final cut from the original Milliman study so that that was helpful for us but at the same time we have at a minimum wage increase and I understand DHS is believed that those minimum wages were included in that study with Milliman We we I thought there's a lot of disagreement I guess you would say on what Milliman would term the room and board portion I know it's. DHS's stance it's very black and white but I know one of the states of raw food is not included in your calls but a lot of times the labor in the prep and the cooking and the serving and those things can be at the state will allow it so I think there's some room that could have been allowed that wasn't allowed to come in with this rate and I think that's another reason when you look at the call survey that they say some of our folks were below twelve percent below the right they came out with as I think a lot of it has to do with the way the questions were asked I believe Mr Homan it created a call spread sheet that included some of those things in and of it was not included Again we are required to have a registered nurse on call and available by phone twenty four hours a day in assisted living that is a requirement if you have a resident that may be confused and need assistance with medication and doesn't understand what medication they're taking what they're diabetic Canadians insulin injections which is a very large portion and we do have to have an LPN by the nurse practice act granted I regulations of bare minimum staff is to a wake staff one of those person has to be a CNA twenty four hours a day I know I do not know anybody that operates those minimum levels we're getting close to that right now just because of the volume of. Turnover we've had So that is continue to be a big issue and one of the reason Oklahoma stepped up and gave us a twenty percent retro payment to help just the staffing costs we cannot hire minimum wage right now they laugh In I heard it said earlier we're we're not competing with each other anymore for staffing we're now competing with target Donald's Costco home depot who have all gone to. These high federal minimum wages I believe everything else I'd covered about it we did get some grant money and things of that nature assisted living it averaged about eight hundred eighty eight dollars per licensed bed in my facilities my skilled units average click right at ten thousand dollars per bad for example in Oklahoma the twenty percent or the. The twenty percent bonus that they gave us to help pay staffing they came to us the provider Average about thirty five hundred per bed when you include all the care we did get over there for assistance the federal monies we were not eligible for because we do not take Medicare so we had to rely upon the state. we did a qualified for the payroll protection loans and there were some SBA loans that you can apply for But I believe that's all I've got there any questions. Representative McKenzie. Thank you madam chair could you what what is the inventory right now beds an assisted living across state you know. I do you know if I do not have the total numbers for the we've got seven thousand two hundred and seventy five licensed beds as far as the occupancies I don't know the exact percentage we do get a survey every year but I would say this year it's going to be down considerably because of the isolation the quarantine as well as the difficulty of getting residents even qualified for Medicaid we we as and testimony here all of us have lots of resident's room backlog trying to get qualified for the six months is not unusual in the old days meaning a few years ago we can take someone Medicaid pending knowing that we would probably get approved and paid for a month or so but now you can't provide three thousand dollars worth of services for free for three four five months which that's just a recipe for going broke member already their bones and then DHS not paying us when they pay everybody else pay a nursing home a hospital but they won't pay us they could do it CMS will allow them to do it CMS rules say you can be collect from thirty days retro to when you were eligible they don't want to pay it that's that's a part of the struggle that's reason when someone comes out of the hospital from an advent of the call the nursing home they say yeah we can take you will get you Medicaid pending right away they call the assisted living this well it's protect three four five months to get you approved well what's somebody gonna do. No question and and if and if a home if an assisted living closes and these I know we access our inner but can you give me some indication here what's the likelihood that these residents how stringent isn't is it that they qualified to go into a nursing home it's the same standards so as those standards for assisted living as the same as an ICO three in a nursing home they will qualify they both have the same needs okay thank you. Replica Senator Hammer thank you the the history one went back when when assisted living started and they were able to get Medicaid patients and that three percent average in cost of living every year. Was it wasn't always that you would not get paid retroactively from the beginning I mean when when they start when you also take Medicaid patients was it from the very beginning that you would not get paid retroactively that's correct have you ever done a cost study or do you know if the actuary considered taker took into consideration. That sometimes and you correct me if I'm wrong but sometimes you might go to the three months with a Medicaid patient in your residency that you're not getting paid for because you don't get wrecked right to payment do you know if the actuary considered in there that that three percent cost adjustment was to help accommodate for that situation. That would be great if they considered that but that is goes into part of our cost structure and we have numerous days every year we have to write off for unreimbursed days how much you how much did you do you guys have how much you had to write off for on on for non reimbursed cost because you didn't get paid by Medicaid for taking care of patients during that blackout period I want a small building like mine it's easily of fifty thousand dollars a year. Here. US senator in two thousand and eighteen when they were when the study began then they they froze the bads because we had reached the cap at that time residents I had in four buildings for the time from the bad for you to let re opened February was eight hundred thousand dollars over eight months. Why did you keep taking Medicaid patients if you know you're going to. Well the bed freeze at that time under director cloud kind of came out of the blue no but we hit the cap and it was like a thirty day notice that they were freezing the freezing the slots and we already had those people living with this we've taken those people and pending their Medicaid approval and they were kind of stuck in limbo until February first of the following year Now that being said I I do I have never calculated what are annual right off cost is just based on the time delays. I'd like to get. I'd like to know. Where you are as far as the people there in your facilities that you're waiting for Medicaid approval and the dollar value to how much that is going to cost you to provide free services to those Medicaid patients if you can get a snapshot of time. The nursing home submit a cost increase you heard the conversation while ago why don't you all submit a cost increase so as to remove that reason for not giving you the increase. Senator dot com if you don't mind. The Medicaid program. What we call Medicaid pending is on a resident requires assisted living services. But their only choices you're going to the nursing home both admission requirements are the same. We develop the Medicaid pending program in order for those. Residents to come into assisted living in a less intensive care and level of care and provide for their needs. When we have a resident if that comes in let's say in December and we file for their Medicaid application in January. And it goes all the way to August and we're not paid. We're not paid until the president is approved has gone through the financial process the medical process so forth. So the delay is the DHS are very costly to us. Would you ask well why do you do it. You do it because these people have a need and we're in the care giving business. And so we put profits aside in order to take care of people the fundamentally frail por Arkansas residents that need our services. What's not being said here is you know what's missing in these discussions. As an example CMS allows the state broad latitude in the cost that it allows you to a. Right. Well in the middle man study and all three of them. They use to nurses and they years CNA is but they didn't use the administrator yet that administrator is of cost under the regulations. Activity is activities or cost under the regulations hello to all of those into overhead but they didn't use the real overhead figure of a hundred ten percent they used an arbitrary figure undecided because seventy five percent. So a big portion of that cost is lost in an arbitrary setting of overhead figure. In addition in states all across the country and I mentioned to you earlier that I have broad national experience in this. The states are allowed to offset certain. costs related to the buildings the buildings insurances the buildings maintenance in order to establish what CMS says is a fair rate Arkansas has made the decision not to do that. They have made the decision to run the program at the absolute minimum under the regulations so eleven dollars is the minimum wage we're paying fifteen dollars an hour for that person. And until Arkansas recognizes that this program can only be viable if we recover cost it's going to fail. Thank you Mr. Connect one comment yes going back to yes mark white steps to mony on the reimbursement question the S. when the nursing homes to their cost reports the number is calculated we get a letter from the state from a Medicaid sane or new rate but it also has the a modifier CMS has a modifier that the use of all kinds of different charts but that's a nursing home modifier it's more less the cost of living increase and they will apply that to the number and it's typically one and a half to two percent back when R. three percent was established back in right I think when it was agreed upon when we redid the rates and seven we talked about the the cost modifier and. If you can it's the same either way if you do one and a half percent on everything three percent on part of it it works out about the same so the nursing homes essentially yet they get one and a half percent on everything the assisted living would get three percent essentially on their labor component so that that was the reasoning we do have that but we need to have some kind of automatic feature for doing these increases we don't need to come back every year wasting y'all's time begging for money this is the support rendered to. Representive Hudson. Thank you madam chair I'd like to make a motion appropriate time. This is the appropriate time an eight I think that there's a lot of questions and the committee's minds as to whether or not these rates are appropriate and I would request that we make a motion to request another review of these rates by DHS with an eye towards increasing the rates for the assisted living facilities to be more commensurate with the actual costs of burning. That's appropriate motion any discussion on the motion. We need a second. I have a second all in favor say aye aye opposed say no. And the motion passes would you repeat the motion please for staff. I hope so. I I said I would make a motion that we we request that DHS increase the rates for assisted living facilities to be more commensurate with their actual costs. All right thank you. The gentleman was there anything else you wish to share with us today. Yeah I'd like to speak just a little bit about exhibit five and two. Representative Hudson's point There's been very little transparency in very little go back and forth Mr white talked about discussion with providers and. No one at this table is had any discussion what came out of you know the the way that the rate study came out this last time we received a letter in February and they gave us ten days to poles. fifty some odd. Providers across the state all with different accounting programs we had ten days to pull the data together they ended up giving us an extra week. when we. Tell them that we were having trouble getting all of these different components pulled together and compiled in the format that they wanted it and We we supplied that information for this last Milliman study to DHS. In very short notice we were we were able to pull eighteen providers together to to pull this data that you see on the screen and this is from a four year F. O. I. so this is. Dated directly out of the Milliman study that we received from DHS. And this is a depiction of. all of the costs that were submitted to DHS. We take those. Gross costume we divide by the number of it's very simple you take the cost divided by the number of patient days and you get a per patient day cost so per patient day in the twenty nineteen study was eighty seven dollars and fifty four cents. The data that we provided in February of twenty twenty shows a ninety two dollar ninety eight cent cost per day. And that's the basis in in addition to you know what what we feel every day and what everybody sees every day going to the gas pump the grocery store and everything else it costs of gone up since you know what this state it was in twenty twenty it's risen ever since you know he said every day your costs go up you know cost to run your lights go up but that's the basis for for a ninety five dollar rate ask and that's the basis for you know the three percent cost of living increase to be reinstated that was taken out in two thousand fourteen. And realize that this number on the bottom right the ninety to ninety eight per day was our cost from February of last year everybody knows how much cost of gone up since the labor costs so Ninety five dollars is probably low. Let me give you an example. Of our facility in Neenah. We have a full time are in. We have seven full time LPNs. And we have seventeen nurse's aides. The regulations do not require us to have LPNs regulations are not require us to have a full time foreign. But to meet the healthcare needs of the residents these people are necessary to provide the quality of care. And as long as you base your cost on minimum wage and minimum staffing in minimum everything then you're never going to have a program that can be successful. I see one questions Senator Hammer. Okay you just made a statement. Are you required by DHS by medical Medicaid or the waiver to CMS are you required to have a LPN or are in in your facility. Senator that's a recent development and. Pretty much all of us of the experience that recently were surveyors have been in our buildings and they have told us that we have to have an LPN doing these tasks it's really been an ongoing battle for thirty years where they say nurse practice act this and that but recently some people are getting tags because they do not have bill peons in there there is no rule for it. But you're getting tagged we're getting tagged for like lessons where she tag by a surveyor if it's not part of the requirements well the surveyor said that we got this from higher up so in my call with Martina Smith the director of the school a couple weeks ago I was asked about it and she said I'm not aware of this is what came from higher up so I assumed it was you so were having some things are sometimes these rules come out or were told the rules were told their directives but to come in and I mean literally terrifying operator saying you're going to increase your labor costs by X. dollars a day otherwise we're gonna take you find you restrict your admissions maybe even shut off your Medicaid that's unconscionable madam chair yes I'm not members committee been very gracious to me with a lot of latitude today and I appreciate that. But I would like to make a friendly suggestion to the chair that staff contacts the facilities and ask the facilities to provide documentation of where they have been deigned for lack of better term by surveyors for not having a peace having an LPN or are in in the facility because this this is a point of conflicting testimony today and if that is driving their cost and they are being told they've got to do something I'd like to get that verified y'all do get documentation when they walk out of the building that you that you have been told to that that's required is that right. Or is it all for generally. In the past we've gotten excellent documentation the last year and a half of its guiding gotten crazy you in the we will get be told not a written complaint or were given a verbal complaint saying respond to my personal email on this or other obscene call at home with your plan so what we have to correct something we've never even seen in writing and yet we're being told we're going to get to a citations possibility of fines and always the threat of losing your ability to admit residents or to get reimbursement so it and it's gotten very out of hand that's inconsistent directions and it's not something that's provided in the rule books and back to the chair thank you ma'am chair it. I'd like to add additional comments I might in the last two surveys that we've had in two of our buildings which is in the last thirty days in our Benton facility we were told you will have LPNs on staff and we will come back every thirty days to make sure that you do. No that's not a writing but is what was told to the administrator in our Star City facility the same thing. The the med tech made a perfect med pass but with the administrator was told you will have LPNs and so that's kinda what we're facing with the verbal threats purses they're putting it in writing. The manager goes deeper than what maybe time allows day maybe the chair could consider reconvening in addressing these issues I'll leave it at that thank you. Yes and if if you could even write these that even the anecdotal. Things that have been said get that to staff staff can get that to the committee members I think that would be very helpful. Seeing no more questions thank you for being with us. Hey is there any more discussion from committee members. Anymore business that needs to come before us today thank you very much for your time thank you for being here. Okay saying nothing else before us we are adjourned.