03/08/2018
To our Colorado Legislators,
To begin, I am writing this letter to all Colorado representatives & not just the representatives in my district because this is not just about Fort Collins Assisted Living facilities. This is about ALL of the Assisted Living homes that have 20 beds or less in Colorado. Currently, there are approximately 400 homes and this is increasing.
I am a Nurse Practitioner who has specialized in the field of Geriatrics for over 30 years. I have had my own private practice in caring for elderly persons confined to Long Term Care Facilities as well as large Assisted Living Facilities and home settings. For the past 10 years, I have been the owner of Northern Colorado Living Solutions, doing business as Turnberry Place, Fox Meadows and Monarch Greens Assisted Living homes. NCLS homes are licensed for 8 beds and operate in a home/family environment. We are considered an "Assisted Living Residence" or "ALR".
While quite unique in our delivery of care as a “family”, we are be considered ALR and grouped in with facilities of 19 beds or less according to the Colorado Department of Public Health & Environment. As an owner / administrator/ operator, I am personally involved with all of my residents and their families pretty much on a daily basis. My staff ratios are low and at least with 1 caregiver to 8 residents 24 hours daily. There are many times where we have a 2:8 ratio as well.
I am writing you concerning a grave concern I have for the future of this type of small “ home” facility. In recent years, this type of living alternative has become the choice of many families (and seniors) as a preferred option to placement into larger and more institutional options. We currently offer “aging in place” to further support our older population and the difficulties dealing with change and loss that they face daily. I am also concerned because of the enormous need in the near future for small to mid-sized communities to be an affordable living option to our seniors in Colorado especially in the rural areas.
I will say up front that there has been recent horror stories of those facilities who don't provide the level of quality and safety that is the representative of these smaller communities. Additionally, I will say that I appreciate the adjustment to ALF administrator requirements that CDPHE has proposed in hopes that MAY help to deter just anyone coming into the industry. However, the real fact is that so many of the exceptional care homes get put into the same bucket as those who operate under less quality standards. The same can be said of any industry whether highly regulated or not. Here in, lies the real point of this letter.
The Colorado Department of Health & Environment "CDPH&E" has taken on the task of throwing out all previous regulations affecting ALRs and has a completely new set of proposed regulations that they will have presented to the Department of Regulatory Agencies (DORA). Although the CDPH&E has retained some of the previous regulations, they have written in many new regulations that will be unattainable for the smaller assisted living homes, more so, ones that currently serve our elderly Medicaid population. Just last week, even before the regulations have been accepted and implemented, facilities in the Denver area have closed due to funding issues with a resultant displacement of over 100 elderly persons. I understand that there is proposed increased funding for Medicaid Facilities currently under review in legislation, however, even this increase will not address the increased financial implications that the new regulations will impose on the industry. Further closures will result if these regulations are passed without modifications.
In digest form the statutory authority and applicability of the CDPH&E is "Authority to Establish MINIMUM Standards through Regulation and to Administer and Enforce Such Regulations" as provided by 25-1.5-103, 25-27-101, and 25-27-104, C.R.S.
These new regulations, I believe, are a well-intended over-reach with the intent on quality improvement of the ALR industry and I support continual quality improvement of any industry, especially in health care. However, I would argue that these quality issues would be better addressed via robust, transparent legislative debate rather than insular, rule-making processes. As the senior population grows, increased demand for safe and affordable care options will result. Practical and fiscal impact of some proposed rules will likely force small to mid-sized communities to close, or at the very least, dramatically increase costs to consumers in order to comply. Colorado draws older consumers with its known supportive communities for older individuals and as a great place to retire. The loss of small to mid-sized communities will be a devastating blow to the already limited menu of affordable living options for seniors.
Many have written, attended and voiced our concerns of this impending over-reach in regulations to those that are responsible for the writing of these new regulations. I don't believe, as many others don't believe, we have been heard and our concerns have fallen on deaf ears. Our comments and suggestions were seemingly used to further arguments to support the cause instead. CDPHE presented the proposed Chapter 7 regulations to DORA as “industry supported” – a gross hyperbole if you would have been in attendance at any of the town hall meetings that were held across the state.
Following is a sample of our voiced concerns and the impact that is probable to happen:
• Impact on small business (unable to implement the new rules with the current Medicaid reimbursement and rates charged to private pay residents)
• Administrator qualifications will make it difficult to hire new administrators to run facilities.
• The "Facilities Guidelines" institute guidelines that will make it impossible for small businesses to open including construction requirements for commercial kitchens, full bathrooms, parking, etc. (These are not clearly identified other than mentioned as reference links to other regulations).
• ALF Administrators will probably need to be paid between $60,000 and $80,000 per year based on proposed requirements. Many owner / operators work at less than $30,000 per year currently.
• A significant increase in mandatory staff training. While some courses can be taken on-line at $10.00 per course, an increase of hours to pay staff the time to train, arrange staff to cover while other staff is being trained, etc… adds up very quickly. (we are working on data right now as to the Time, Effort and Money that it will impact the small business community).
• Staffing Requirements will include: Resident Engagement Director + dedicated staff and experience requirements, Kitchen Staff, Personal Care Workers + Practitioner to supervise, train and test, QMAPS (Qualified Medication Administration Person) + Supervisor. Just the addition of kitchen staff and enrichment director will add at least 1.5FTE to small facilities.
• Skilled practitioners must provide much of the training - more costs. New proposed requirements for licensed persons to oversee the initial trainings and competency trainings-
o The average salary for a licensed nurse or equivalent ranges between $40-80K for FT equivalent. Consultant fees for RN consultants range from $100 to $200 hourly.
• Awake staff for secure units and oversight/awake staff for safety checks every four hours. While I am not opposed to awake staff at night, additional salaries to compensate for small and rural facilities.
• Kitchen and food safety regulations (difficult for small homes to meet Restaurant Guidelines with suggested inclusion of commercial type kitchens for small “ home” facilities)
• Wound care/discharge residents with Stage 3 wounds- despite proper involvement of RN / homecare providers for management. This is not congruent with “person-centered care”.
• Difficulty in meeting hospice oversight requirements- again limiting "person –centered care” and aging in place options for ALRs.
• Delivery of care to more complex residents- most ALRs recognize their own limitations and are pro-active in making sure they are able to meet needs adequately.
• Secured environments - very high standards of staffing, training, and protective oversight.
The above examples are only a sampling of the contents of the proposed regulatory changes to Chapter 7. Are these the "MINIMUM" standards of care?
My passion for my entire nursing career has been in caring for older individuals. Providing quality care and affordable living options is my mantra. I have recently transferred ownership of one of my three homes and am considering the transfer of another in part, because I feel I cannot devote the time requirements to meet all of the documentation required from a small assisted living that a larger facility with more department heads can more easily accomplish. In my local area, 2 smaller “homes” have closed and another 4 have sold over the past year. I am fearful of the future when these proposed regulations are implemented. There will be many older individuals left displaced without places to go other than skilled nursing facilities. I fear lack of choice as I age and am forced into institution if alternate environments are no longer an option.
One could say the lack of monitoring or surveying on a regular basis has contributed to the “slacking” of some in the industry. CDPHE has presented the need for more surveyors and more revenue to accomplish this. In a time of modern technologies, re-structuring the “survey process” should be a feasible endeavor and may even save the department money. It’s not so difficult to determine, within a few hours, if the facility is performing to standards without “digging up the grave.” Recently, a surveyor spent 3.5 days in a 7 bed facility with a history of zero deficiencies. The culture of the surveys used to be helpful and supportive to assist the ALR to be successful in their care for residents. The culture is now punitive with a perceived quest to “find something wrong” and “dig until they do” approach. As a result, many stake-holders likely have not spoken up for fear of retaliation.
Small “home” assisted living residences are very fragile to increases as such we have never seen before in regards to CDPHEs new rules and regulations. These new regulations has caused myself and others to seriously consider if remaining in this industry is feasible from a myriad of stances.
I fully believe that these new regulations will NOT provide the quality of care or life enrichment to our seniors. These regulations were a reaction to a few very sad experiences from a very few number of providers. Those that choose to not provide quality care will find other options that will eliminate any regulations and continue to do what they choose. Causing hardship for the entire industry is not the answer to the problem.
I believe that the love for our senior population and our desire to provide life enriching, quality care is going to be replaced by cold, hard, institutional / hospital –like environments that many seek to avoid in their last days of life.
Please help us to take a stand for our elderly individuals in Colorado. The revised Chapter 7 regulations are likely to cause a different and dangerous “tsunami” by eliminating affordable care options for many. Thank you for your service and consideration into this matter.
Sincerely,
Tamra Meurer, MSN, RN, FNP-BC
Owner / Operator/ Administrator/ Human Resources/ Life Enrichment/ Facilities Management/ etc..
Northern Colorado Living Solutions
Fort Collins
