Kit Clark Senior Services - Mass.Gov

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1500 Dorchester Ave. Dorchester, MA 02122



October 29, 2013



Written Testimony Submitted to the Department of Public Health On
:

Proposed Regulation 105

CMR 158.000

-

Licensure of Adult Day Health Programs


Kit Clark Senior Services

Erica Johnson

Director, Adult Day Health Services

1500 Dorchester Ave

Dorchester, MA 02122

(617) 533
-
9214


2


To whom it may concern:

I am writing in support of the testimony submitted by the MA Adult Day Services
Association, regarding the proposed ADH Licensure Regulati
ons 105 CMR 158.
Additionally, I am submitting concerns about some of the proposed provisions, and have
highlighted how this will impact my programs directly.


This opportunity to submit testimony is much appreciated. Kit Clark has been providing
communi
ty based services for seniors in Dorchester, and the surrounding area, for over
35 years. We have 5 Adult Day Health programs, including a secure Memory Loss facility
and two cultural programs for the Haitian and Vietnamese communities. Our total
enrollm
ent is 242, with an average daily census of 133 currently. These 5 programs
range in size from an average daily census of 17


43, and are located at 3 different
facilities. We are excited about becoming licensed by DPH, and are enthusiastic about
many of

the regulations, especially as it will provide strong standards and oversight that
will help ensure programs are providing high
-
quality, uniform services. However, there
are several proposed requirements that have caused concern, especially due to the
im
pact they would have on our ability to continue to provide quality, flexible, culturally
-
sensitive services across each of our programs.



158.032 (B) (3) ADH Staffing Requirement

I’d like to express strong concern and opposition for two areas of the Staffing
Requirements that will have a severely negative impact on the functioning and daily
operations of our programs. The proposed nursing ratio of 19.8 minutes per ADH
participant
will put undue financial burden on our programs, without clear indication of the
benefits. This regulation could cost us over $117,000 annually


an increase of 30


50
3


hours of nursing coverage a week across our programs, without any increase in
reimburs
ement. Our current MassHealth regulations ratio nursing in terms of hours of
coverage per average census. This allows flexibility in scheduling to best meet the needs
of client and family schedules, and the ability to determine how to best staff above th
e
minimum requirements. With the proposed structure, our programs would struggle to
increase nursing to meet this regulation
, with

severe financial burden. Currently, our
nursing teams provide care in a manner that is flexible and cost effective, while d
elivering
the highest quality care. Increasing the ratio to the extent that is proposed will not only
have a financial impact but will arbitrarily disrupt the nature of the community based
nursing we provide. The current flexibility is crucial
-

we are n
ever without adequate
nursing coverage under our current system, and have the leeway to adjust the availability
according to client/program need. This allows us to ensure that clients get the best care.
For example, in our programs in our Codman Square loc
ation, which include the Memory
Loss program and a general ADH, we are staffed with 3 registered nurses, all with varied
schedules, so they can be adjusted according to need, which has worked efficiently and
cost effectively.

105 CMR 158.032 (B) (2): Staff
ing Requirements

Our current regulations require a minimum number of RN hours based on average daily
census. This has been a cost effective way to provide nursing care, ensuring that there is
nursing coverage by both RN’s and LPN’s, during program hours.

Our nurses are staffed
and scheduled to account for shifting daily census, and client hours of attendance (i.e.
8:30


2:30, 9:00


3:00, 9:30


3:30). The new regulations state that “At least one
Registered
Nurse shall be on
-
site during all hours of ope
ration.” This is a significant
change that will impact all 5 of our programs, which are structured with a combination of
RN and LPN coverage based on our current regulations. Th
is has been effective in
4


maintaining feasible nursing costs

without jeopardiz
ing quality of care. An ongoing
challenge within ADH is to recruit high
-
quality registered nurses, since we cannot pay
salaries comparable to other clinical settings


this is especially challenging for us, and
other programs located in Boston, as we have

to compete with multiple medical settings
for recruiting. Increasing the staffing requirements for RN will only add to this burden.
When hiring, we look for nurses with strong clinical skills, experience working with the
elderly and a genuine interest i
n community nursing so we are confident LPNs on our staff
are highly qualified and a good fit for our programs and our client population.



105 CMR 158.032 Staffing Responsibilities:

The proposed requirements for Social Work and Activity documentation ev
ery 45 days will
double the amount of documentation currently required under the MassHealth regulations.
Since our enrollment is 55% higher than our average daily census, our social services and
activities staff have a large caseload of notes to complete.

Currently, they spend
approximately 32


52 hours a quarter to complete the notes. These quarterly notes have
historically proven to adequately document a participant’s involvement, needs, and
challenges. To increase this to 45 days will take valuable
resources away from the ADH
participants, without improving the quality of care, and can be quantified as approximately
$69,489 in documentation time. In fact, our social service and activities coordinators
responded to this proposal with statements that
they would have to significantly adjust
their time providing direct care with clients, to allow for so much documentation.
Immediate concern was expressed, indicating that documentation would severely impact
the quality of the services they provide. To s
pend 32
-
52 hours every 45 days instead of
90, shifts focus from the clients to the paperwork. As they would have to decrease the
time spent in direct contact with clients, the content of the notes would be at risk of being
less in
-
depth simply due to the d
ecrease in time spent working with them. Since a large
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amount of our clients only attend 2 times per week, staff would only be documenting at
most 12 visits. The time spent on this would pull them out of the therapeutic programming
and activities that ar
e the foundation of the ADH service. In addition, it would place
additional burden to other staff, who would have to cover activities on the floor in the
absence of the activities coordinator and social services staff. We strongly oppose this
change and
recommend that current regulatory requirements for Social Service and
Activity documentation be maintained.

105 CMR 158.033 (H) (2) Staffing Responsibilities:

Activity Director Requirements:


Currently, our programs employ an Activity Director, and Activ
ity Coordinators with a
variety of training and work backgrounds. This has proven to make our activities
programming diverse and meet the unique, individual needs of the many cultures
represented in our client population. This flexibility has allowed us
to hire quality staff
without undue financial burden. Our therapeutic activities programming reflects the
diversity of the cultures we serve in Dorchester, and our activities staff work as part of the
multi
-
disciplinary team within ADH. With oversight fro
m the Program Director, and input
from the team, the activities director has successfully planned therapeutic programming
that individualizes the services and is culturally sensitive. The requirement of a certified
Recreational Therapist or Occupation The
rapist or an OT consultant to oversee every
activity plan is clinically unnecessary and costly. This regulation would result in a
minimum of $49,905 additional staffing annually.

Licensed Social Worker/Supervision

The current ADH social service staff re
quirements state that a bachelor’s degree is the
minimum qualification. This has proven to be sufficient, allowing high quality staff, and is
in line with community based elder services industry standards. To increase the
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education and licensing qualific
ations for social services staff, will cause a financial
burden, again without an increase in reimbursement.

105 CMR 158.030 (K) Program Director:


We at Kit Clark support DPH’s goal for effective management and oversight of the ADH
programs.
However, limiting the ways in which management is structured, does not take
into account the shifting daily census, and the flexibility that has made ADH such a
successful community resource to reduce healthcare costs. Specifically, Kit Clark’s ADH
progra
ms are managed by a services director, with higher
-
level administrative oversight of
all ADH programs. Each site is then managed by a Program Manager. The program
managers hold dual roles, based on our current regulations. This includes an RN
manager, w
ho provides direct care on lower census days, and a bi
-
cultural, bi
-
lingual
manager who provides social services to one of our small cultural programs. For each
program, it has proven beneficial for the manager to be involved in the direct provision of
ca
re to clients, for more than just a fiscal reason. It has allowed insight and knowledge of
the clients and day
-
to
-
day operations on a deeper level, which allows for more efficient
management of the services and staff. This flexibility has allowed us to m
aintain smaller
-
sized programs, which meet an identified need in our community, without extending
operating costs that would prohibit such operations. If we were to have to separate out
the direct care portions of their roles, this would cause an increase

of more than $47,000
in staffing.

New Requirement for MDS (assessment) upon admission:


Kit Clark supports MADSA’s request that we are able to use the MDS forms completed by
ASAP’s during their screening. If this is not possible, we support MADSA’s reques
t that
the state reimburse us for this effort. We anticipate it would take an increase of $20,000
in RN hours annually to support this regulation.

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Dementia
-
Specific ADH guidelines

Kit Clark supports and requests that DPH consider the Elder Affairs ASAP
Dementia
-
Specific guidelines.

The specific nature of memory loss and Alzheimer’s might not
present with the same physical needs however there is greater need for the oversight and
structure of a day program.

158.045: Physical Plant

Upon reviewing the ph
ysical plant requirements in the proposed regulations, there were a
number that cause concern. Without a process to grandfather current programs or apply
for waivers, these requirements would challenge us to be able to maintain a number of our
programs at

a location that has successfully served clients for years. Specifically, one of
our facilities that houses 3 of our programs, utilizes program space on the second floor.
This space was designed and built for ADH use, so it has been extremely successful
in
the delivery of services. Due to our urban location, finding space that is conducive to the
unique needs of the populations we serve, and is on the ground floor, is challenging. Our
physical space has continuously met program needs, whether it be thro
ugh how the
nursing office and treatment room were designed and situated, ease of “traffic flow” for
walkers and wheelchairs, administrative offices situated to be within easy access of the
clients, and multiple elevator access including direct from the pr
ogram floor, as well as a
second elevator from the entry way. Our current rate structure does not allow for funding
for capital improvements, such as relocating all programs to the ground level in our
current facility, or for relocating the programs to a
new building altogether.

Similarly to MADSA’s report, we have also estimated that installing handrails could cost
between $5,000
-

$10,000


however we have no reports of falls that could have been
prevented had a handrail been accessible.

8


Kit Clark su
pports the additional physical plant requirements as stated in MADSA’s
testimony:

a.

Requirement for classification
-

Group I
-
4. (Sprinklers, etc.)

b.

Hand washing sinks and paper towels that operate without hands.

c.

Handrails

d.

Mixing valves outside of the shower
stall

e.

Dedicated staff toilet:


Thank you for taking the time to consider our testimony, and how these regulations would
impact Kit Clark’s Adult Day Health programs.