SD8 - Homes for Adults in Virginia
Executive Summary: Homes for adults provide a basic level of residential care (room, board, and general supervision) to four or more aged, infirm, or disabled persons. Homes for adults have been regulated in Virginia since 1954. The Department of Social Services (DSS) is responsible for regulation through licensure and monitoring of adult homes. The adult home system of care has been the object of repeated and continuing study over the last decade. At least seven different reports have addressed various aspects of adult home problems in Virginia. Concerns have been raised about the health and safety of residents, the effectiveness of adult home licensure and monitoring, and the adequacy of State funding through the auxiliary grants program for some adult home residents. Additional concerns have surfaced about the effective administration of the Auxiliary Grants Program. In 1979, JLARC evaluated the adult home system and identified numerous problems affecting the health and safety of residents, licensing standards and procedures, and the Auxiliary Grants Program. This follow-up review, directed by Item 545 of the 1990 Appropriations Act, generally found improvements in the system to protect the basic health and safety of residents. However, no action has been taken on a number of previous recommendations, and the problem of providing adequate care and protection has been exacerbated by a sharp increase in residents who have serious mental health or medical needs. In addition, administration of State funding through the Auxiliary Grants Program is no better now than it was in 1979, despite a 272 percent increase in program expenditures. There has been a notable change in the nature of adult home care and the size of the adult home system from 1979 to 1990. Adult homes now appear to be caring for a more diverse population of mentally and physically impaired adults. In addition, mental and physical impairments of adult home residents seem to be more severe now than they were in 1979. Some residents are receiving medical-type treatment to care for their impairments. Ten years ago this care would have been available only in a nursing home. The number of homes has grown by almost 50 percent, while the capacity of the system has more than doubled. The number of licensed beds has increased from 10,420 to 22,538 beds, and the number of residents has grown from 8,800 to about 18,000. In addition, the number of mentally disabled residents in adult homes has almost tripled to 5,200 since 1979. Most of the recommendations in this report focus on improving the regulatory and funding systems to accommodate the evolving role of adult homes in providing care to mentally and physically disabled populations. However, before these changes can be successful, modifications will be needed to the current placement and needs assessment processes for adult home residents. While some of the proposed changes will not require substantial effort or the infusion of additional State resources, some will require additional funding. And, although current fiscal constraints may not allow for immediate implementation of these changes, planning for the system can begin with gradual implementation over the next few years as resources become available. This will ensure that residents are adequately protected and their needs are appropriately met in adult homes. This report summary briefly references study findings and recommendations. Full statements of specific recommendations and supporting details are contained in the text of this report. System-Wide Changes Are Necessary to Address the Changing Role of Adult Homes in Providing Care to Diverse Groups Reports on the adult home system have repeatedly questioned whether adult homes are appropriate settings for the mentally disabled as well as some physically disabled adults. Regardless of one's position on this question, it is important to realize that, in fact, adult homes have become a primary source of long-term care for these populations. The statutory and regulatory framework for the system does not adequately recognize this changing role of adult homes. Consequently, significant system-wide changes are necessary to address the problems facing the current adult home system of care. The adult home system was originally designed to provide only basic services to residents, such as room and board, general supervision, and personal care. For the mentally disabled, adult homes have adapted to provide the first level of care for clients released from State mental health or mental retardation facilities. Approximately one quarter of the residents in adult homes have some type of mental disability. Yet the provision of services to this population has been cited as deficient by JLARC reports in 1979 and 1986; an Ernst & Whinney report in 1985; and a report by DSS and the Department of Mental Health, Mental Retardation and Substance Abuse Services (DMHMRSAS) in 1988. Recommendations to improve the needs assessments and services provided to this group have not been implemented, partly due to funding limitations. Adult homes are also increasingly providing care to physically disabled elderly with more intensive needs for care than the system was originally intended to provide. Homes may be providing medical services to residents who do not progress to institutional settings that provide higher levels of care. Current adult home licensing standards and licensing staff in DSS are unable to provide adequate guidance and oversight to ensure these residents' needs are appropriately met. System-wide changes are needed to ensure that the changing role of the adult home system of care is recognized and regulated accordingly. First changes are necessary to ensure residents are properly placed in adult homes that can provide adequate care. Next, the regulatory framework needs to be redesigned to recognize varying levels of care provided to residents. This will allow for more thorough protection and oversight of adult home residents. In addition, modifications to specific licensing standards and the enforcement process are needed to better protect home residents. Finally, changes should be made to ensure the Auxiliary Grants Program is properly administered and recognizes varying levels of care needed by residents. Measures Are Needed to Ensure Appropriate Client Placement Currently, there is no State policy to ensure that adult home placements, particularly for residents who receive State auxiliary grants, are appropriate and cost-effective. This means that State funds paid to residents who receive adult home care may not be used in the most effective manner to ensure the delivery of an appropriate level and type of care. If residents are inappropriately placed in adult homes, problems can arise. For example, more rapid physical and/or mental deterioration could occur if resident needs are not adequately met by adult homes. This could result in a need for treatment and care in a substantially more costly nursing facility or psychiatric hospital. Premature institutional care could negatively impact State resources because auxiliary grant recipients would be eligible for Medicaid-funded, long-term care, which is more expensive to provide. Some savings might be realized if needs assessments completed during the placement process identified that a resident's needs could be met in a less restrictive setting. For example, some community-based services could address needs by delivering care such as meals, medical care, or chore services in a client's home. Generally, community-based services such as these are less costly than 24-hour care in an adult home. Proper placement of clients in homes for adults has long been considered a necessary element for appropriate care. A structured placement process ensures that the needs of the client are identified, and that a link exists between the needs assessment and the provision of services to clients in an appropriate care-giving setting. The General Assembly has recognized the importance of systematic assessment and management of care of clients. During the 1990 legislative session, the General Assembly appropriated $3 million to implement a case management system currently being developed in several localities by the Long-Term Care Council for elderly Virginians. As a result of budget cuts, funding has been reduced to $2 million. Without such a system to ensure proper placement, it is impossible to determine if adult home care is the most cost-effective and appropriate setting for auxiliary grant recipients. To address concerns about the placement process, the following recommendation is made: The Secretary of Health and Human Resources should pursue the development of a client needs assessment instrument and process for use in placing and monitoring auxiliary grant recipients in adult homes. The Regulatory System Should Be Modified to Address Levels of Care The current regulatory system for adult homes does not reflect changes in resident populations and the role these homes play in caring for residents. Adult home licensing standards and enforcement activities continue to focus on the provision of basic domiciliary and supervisory care for mildly impaired populations. Consequently, they do not adequately protect more seriously impaired residents. One of the primary problems with the current regulatory system is that one set of licensing standards applies to all homes regardless of the services provided or the functional level of the residents. Licensing standards do not delineate the medical conditions of residents who may be cared for within an adult home; the number, qualifications, and training required of staff in homes caring for more seriously impaired populations; or many of the "specialized" services needed by impaired residents. At least three distinct resident populations reside in homes for adults: residents who are moderately impaired with a need for supervision, residents who suffer from significant mental disabilities, and residents with physical disabilities requiring medical care and treatment. Standards should be established to accommodate at least these three resident populations now living in adult homes. Therefore, the following recommendation is made: The Commission on Health Care for All Virginians should consider directing the Secretary of Health and Human Resources to develop a plan to comprehensively revise the statutory and regulatory framework of the adult home system to incorporate standards for several levels of care. Licensing Standards and Enforcement Activities Need to Be Modified Through regulation or the enforcement of mandated standards and requirements, the Department of Social Services seeks to protect the physical and emotional well-being of adult home residents. This protection is particularly important since regulatory authorities may be the only outside entity concerned with resident care who enters the adult homes on a regular basis. The effectiveness of DSS' enforcement is determined largely by the ability of licensing staff to identify problems and require corrective action. Deficiencies in the current licensing standards and in enforcement activities, however, limit the effectiveness of DSS' regulation. To enhance the protection of residents and the enforcement capabilities of licensing staff, the following recommendations are made: The State Board of Social Services should promulgate additional standards regarding qualifications and training for administrators and staff of adult homes, staffing guidelines, medical procedures, medication management, and facility design. The Commissioner of Social Services should ensure that fees assessed adult home licensees are used to provide training for adult home staff as intended by the General Assembly. The Department of Social Services should enhance enforcement by: • modifying existing standards to specify a minimum staff age, requiring physicians' orders be followed, and clarifying food service requirements; • training and overseeing regional licensing staff to promote consistency; • employing a certified dietitian to supplement enforcement of nutrition and food services; and • using Supplemental Security Income data to assist in obtaining search warrants for illegally operating homes. The General Assembly may wish to amend the Code of Virginia to require unannounced annual renewal inspections of homes for adults and authorize the use of intermediate sanctions by the Commissioner of Social Services. Relocating the Licensing Function Will Not Solve Current Problems Appropriate placement of the adult home licensing function within the Department of Social Services was assessed during this review. The General Assembly considered moving responsibility for licensing homes for adults from the Department of Social Services to the Virginia Department of Health during the 1990 legislative session. This review indicates that there is no compelling reason to move the responsibility from DSS at this time. Retaining licensing within DSS would support the type of care provided in most homes, facilitate coordination between licensing and auxiliary grant administration, and be more cost-effective than moving the responsibility to the Department of Health. In addition, the regional structure of DSS enhances oversight of adult homes. Licensing specialists are located closer to the homes they investigate and license, so they can respond quickly when problems arise. If recommended changes to the current licensing program are not made however, the General Assembly may wish to reconsider transferring the licensing function. The following recommendation is made: Responsibility for licensing homes for adults should remain within the Department of Social Services. Numerous Problems Continue to Affect State Funding for Residents Previous reviews of homes for adults, including the 1985 Ernst & Whinney report, have documented numerous problems with the State funding system for eligible adult home residents through the Auxiliary Grants Program. This review revealed that almost no improvements have been made to address weaknesses in the administration of the program, although expenditures have significantly increased to $15.5 million. Problems continue to affect the program's adult home cost-reporting and rate-setting processes. These problems have resulted in questions about the validity of adult home auxiliary grant rates. Failure to correct these problems has resulted in a State funding system that does not reflect the various types of adult homes and the diverse needs of their residents. As a result, adult homes generally receive the same auxiliary grant rate regardless of the type and intensity of services they provide their residents. Cost-Reporting Process. The current cost-reporting process is inadequate. The validity of the reported adult home costs collected from adult homes through the cost-reporting process cannot be determined. Cases were identified that cast considerable doubt on the validity of the cost data. Adequate policies and procedures do not exist to guide DSS staff in reviewing and evaluating the cost data. This results in inconsistent evaluation of the costs reported by adult homes and inequitable treatment of some home owners. The current cost-reporting cycle does not allow sufficient time for DSS staff to appropriately review more than 300 cost-reporting packets. Such a short time period leads to inadequate review of the forms by DSS staff and limits the amount of follow-up conducted on identified problems. Rate-Setting Process. The adequacy of the maximum monthly rate for adult homes ($602) has been constantly debated. Cost data submitted to DSS for a FY 1991 grant rate indicates this maximum rate may be inadequate. The median monthly cost of operating an adult home statewide is about $663, which is ten percent higher than the current maximum rate. Yet, the need for a higher rate cannot be substantiated because the cost data on which this figure is based are not audited or verified. Lack of valid cost data may result in the improper use of State funds. In addition, the rate-setting process does not provide an adequate interim auxiliary grant rate for newly licensed homes; nor does it clearly articulate what services are to be provided through the auxiliary grant benefit. To improve the ability of the current Auxiliary Grants Program to meet the needs of eligible adult home residents, the following recommendations are made: The Department of Social Services should establish an effective cost reporting process by: • developing guidelines for certain cost items; • establishing clear policies, procedures, and standards for the cost-reporting process; • conducting financial audits of reported costs; • adjusting the cost-reporting period and revising the forms; • providing an adequate interim auxiliary grant rate; and • consolidating agency facility rate-setting functions. The Secretary of Health and Human Resources should develop a proposal for regulatory changes governing charges for services received by auxiliary grant recipients. Once regulations are established, DSS should evaluate the adequacy of the monthly personal allowance. The Adult Home Funding System Should Be Redesigned In its present form, the Auxiliary Grants Program is unable to differentiate adult home rates based on the varying types and amounts of services provided by adult homes. Correcting identified problems with the cost-reporting/rate-setting process will certainly contribute to increasing the effectiveness of the program. However, for the Auxiliary Grants Program to better meet the needs of all recipients, the funding system could be linked to the proposed regulatory structure to recognize variations in the level of care provided by adult homes. This would improve the effectiveness of the State's Auxiliary Grants Program by providing adequate funding to eligible residents needing more intensive levels of care. Funding the proposed tiered regulatory system can only take place after DSS has formally categorized and licensed all adult homes based on the care they provide. DSS would have to collect facility cost data and determine what costs would be allowed. A maximum monthly auxiliary grant rate could then be established for each licensed level of care. This maximum rate could be based on the average or median cost of care which could become the maximum amount homes could charge auxiliary grant recipients. Preliminary estimates using program costs for FY 1990 demonstrate the cost for the proposed funding system to be about $22 million. This represents an increase of more than $6 million over actual FY 1990 Auxiliary Grants Program expenditures. The following recommendation is made: The Secretary of Health and Human Resources should develop a proposal to link auxiliary grant funding to the proposed regulatory framework that recognizes the different levels of care to be provided by homes for adults. |
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