The2nd meeting of the Subcommittee on Families and Children of the Interim Joint Committee on Health and Welfare was held on Wednesday, August 20, 2003, at 10:00 a.m. in the University of Kentucky Nursing & Health Sciences Building, in Room 501C. Representative Tom Burch, Chair, called the meeting to order, and the secretary called the roll.
Members:Representative Tom Burch, Co-Chair; Senators Damon Thayer, Elizabeth Tori, and Johnny Ray Turner; Representatives Bob DeWeese, Mary Lou Marzian, Stephen Nunn, Jon David Reinhardt, Ancel Smith, Kathy Stein, and Susan Westrom.
Guests:† Rosanne Barkley, Cabinet for Families and Children; Mary Haynes, Nazareth Home; Tim Veno, Kentucky Association of Homes and Services for the Aging; Dianna McClure, Citizen; Keven Payton, Childrenís Alliance; Argene Jones, Long-Term Care Ombudsman, Hazard; Ed Wilson, Office of Inspector General; Bonnie Hommrich, Cabinet for Families and Children; Mary Ellen Nold, Cabinet for Families & Children; Carola Pike, Health and Human Services; John Sammons, Cabinet for Health Services; Doug Burnham, University of Kentucky; and Betty Hiins, Alzheimerís Association.
LRC Staff:† DeeAnn Mansfield, Murray Wood, and Cindy Smith.
The minutes of the July 16, 2003 meeting were approved without objection.
The first item on the agenda was a discussion regarding Child and Family Services Review by Bonnie Hommrich, Cabinet for Families and Children, and Carola Pike, Administration for Families and Children, Region IV Southeastern United States, Atlanta Federal Center.† Ms. Hommrich said the Cabinet has been working hard with the Child and Family Services Review staff and they feel this is a wonderful opportunity to give the members an overview to give a sense of where the Cabinet is and what the next steps are.† In preparation for this, the Cabinet talked to the Atlanta office and requested that the regional representative testify at the meeting.† Ms. Pike said the 1994 amendment to the Social Security Act authorized the Department for Health and Human Services to review state child and family service programs in order to assure compliance with the state plan requirements in Title IV-B and IV-E of the Social Security Act.† Programs subject to Child Family Services Review are: (1) child protection; (2) foster care; (3) adoptions; (4) family preservation and family support; and (5) independent living. The purpose of the Child Family Services Review is: (1) improve child welfare services; (2) improve outcomes for families and children; (3) identify statesí strengths and needs; (4) identify technical assistance that will lead to program improvement; (5) ensure federal funds are spent in accordance with federal statute, regulation and policy; (6) link the child family services review to joint planning, technical assistance, program improvement process between states and the regional office; (7) assist states to become self-evaluating; (8) assemble data that will inform national policy; and (8) provide feedback to states related to program performance and outcomes.† The phases of the child family service review are: (1) statewide assessment; (2) on-site review; and (3) program improvement plans. She said there are seven outcomes in the areas of safety, permanency and child and family well-being, and also seven systemic factors. There were 17 states reviewed in FY 2001, 15 states reviewed in FY 2002, 13 states will be reviewed for FY 2003 (including Kentucky), and 7 states will be reviewed in 2004.† Safety outcomes include: (1) children are, first and foremost, protected from abuse and neglect; (2) children are safely maintained in their own homes whenever possible and appropriate.† Permanency outcomes include: (1) children have permanency and stability in their living arrangements; (2) continuity of family relationships and connections is preserved for children.† Well-being outcomes include: (1) families have enhanced capacity to provide for their childrenís needs; (2) children receive appropriate services to met their educational needs; and (3) children receive adequate services to meet their physical and mental health needs.
Representative Burch asked how programs are checked out.† Ms. Pike said states submit proposed sites they want to have checked out.† The largest metropolitan area is always one of the sites in each state.† During the statewide assessment, Kentucky gathers information, and looks at their program.† Then, they submit information to the federal office about proposed counties. The choice of counties is negotiated between the state and their office.
Representative Burch asked if they are making suggestions to the states on how to expedite the adoptions.† Ms. Pike said they are, and the states are responding to those suggestions.† They also offer technical assistance to states.
Senator Thayer asked if there is something Kentucky can do in terms of legislation that would help achieve higher adoption rates, and strengthen the rights of adoptive parents.† Ms. Pike said there is some federal legislation that has time frames that states will have to meet.† Some states are putting that into legislation.† Also, some states have looked at the time between termination of parental rights and the time the parents have to make an appeal.†
Representative Nunn reminded the members that in 1998, the SWIFT adoption legislation was passed, which has helped to some extent, but Kentucky continues to have 300 children ready for adoption at any time.† Kentucky† needs more parents willing to accept more children that are struggling within the system.
Ms. Pike said Kentucky is doing a good job assuring that childrenís physical health needs are being met, but mental health needs for children are not adequate. Representative Marzian noted that funding for substance abuse is not there in Kentucky, due to the fact that Medicaid does not cover substance abuse unless the woman is pregnant.†
Representative Westrom asked if there are sanctions if the states donít meet the challenges of the federal government.† Ms. Pike said there can be sanctions.† Once Kentucky was presented with the final report and the findings, every state is given an opportunity to do a program improvement plan.† By implementing this plan, the sanctions are delayed.† Kentucky will put a plan in place, and have two years to implement it.
Ms. Pike went on to say that they† look at the following systemic factors for states: (1) statewide information system; (2) case review system; (3) quality assurance system; (4) training; (5) service array; (6) agency responsiveness to the community; and (7) foster and adoptive parent licensing, recruitment, and retention.†† She said in every state there has been a trend to do a good, comprehensive assessment of families and with that information, link them to the services that will make positive outcomes for families.† Case planning is also a major area states are struggling with.† The engagement of families, working with them, and helping them to receive the right services is also an area that states need to do a lot of work in.† Child welfare canít do this job alone.† It has an impact on all the other systems, including: (1) courts; (2) education system; (3) health providers; and (4) mental health providers.
Representative Nunn said Kentucky has a lot of work to do in many areas.† Ms. Pike said Kentucky is not alone in areas that need improvement.† One thing they saw was that Kentucky has a lot of good procedures, policy and training.† One of the major areas is consistency.† Kentucky is addressing that.†
Ms. Hommrich said in terms of the statewide review, it is a true, random pull of cases.† The Cabinet believes that if more recent cases were pulled, different results would have been seen.
Representative Nunn asked for confirmation that there are 6000 kids in the foster care system, and the sample was 50.† Ms. Hommrich said that is correct, but 25 of the cases were foster care, and 25 cases were of children receiving services in their home.
Senator Thayer said that 50 cases seems like a very small sample, and thought the results could be skewed to look worse than they are, due to the small amount of cases looked at.† Ms. Pike said the Childrenís Bureau stands behind the findings with the 50 cases.† Senator Thayer said he is skeptical.
The next item on the agenda was a discussion regarding Long-Term Care Quality by Bernie Vonderhide, advocate for nursing home reform, Tim Veno, President, Kentucky Association of Homes and Services for the Aging, Mary Haynes, RN, Administrator, Nazareth Home, and Ed Wilson, Cabinet for Health Services.† Mr. Vonderhide stressed that inadequate staff has led to dehydration, bed sores, malnutrition, and simple abuse by negligence of some residents in long-term care facilities.† He said that Certified Nursing Assistants are underpaid, undertrained, and overworked.† He suggested that a solution to solve these issues would be to implement legislation that would tie future increases in Medicaid reimbursement, over and above any inflationary adjustments, to the quality of staffing.† He also reported that 90 percent of the nursing homes in the United States do not have enough staff.
Tim Veno said he has been talking to legislative committees since 1990 regarding staffing ratios.† He said if he believed that staffing ratios would improve quality, his agency would be the first to support that, but he does not believe that.† He said a key component of quality care is linked to reimbursement.† Currently, 75 percent of the residents in long-term care facilities in Kentucky are Medicaid recipients.† Instead of looking at minimum staffing ratios, look at nursing home quality in another way, by examining the adequacy of reimbursement as it relates to the ability to recruit and retain high quality staff.
Mary Haynes said since 1974, a large part of her job has been to assess patients and to delegate assignments and work with licensed and non-licensed personal to not only meet the needs of patients, but exceed those needs.† She said a policy that would mandate a set standard would be a barrier to the service that everyone expects, and that she is committed to provide.† There is no way that a set standard could ever keep up the pace of a dynamic busy operation.† A staffing pattern takes into account the needs of residents for that period as well as the skills and the abilities of the staff that are present in the mix.†
Ed Wilson said the Inspector Generalís office will enforce whatever the law is relative to nursing homes.† Prior to considering staffing ratios, he asked if the minimum becomes the maximum and if it is quantity versus quality.† Those are two issues that need to be addressed.† He said they have an investigative protocol concerning staffing, and it is being investigated in nursing homes and being cited.
Representative Burch asked if the salaries are a factor in the reason people are coming and going in nursing homes.† He asked if the Cabinet had recommendations to overcome that.† Mr. Wilson said the pay is not sufficient, and the people that stay are people dedicated to working with the residents, that really care for the elderly and that type of work.†
Next, Betty Higgins of the Alzheimerís Association commented about her experiences with the nursing home her mother was in, and her experiences with wonderful workers she encountered at† the facility.† She said as far as interviewing the residents and coming to a consensus about the care they are getting, the numbers must be looked at.† The current number of people with Alzheimerís disease is over 67,000.† The percentage of residents with moderate to severe cognitive impairment is 49 percent; while the percentage of residents with very mild to mild impairment is 24 percent.† She noted that with those figures, you couldnít get very good information about their experiences in the facilities.
The meeting was adjourned at 11:45 a.m.