Waterloo, Iowa August 25, 2017

The Board of Supervisors of the County of Black Hawk, in the State of Iowa, met in special adjourned meeting at the Courthouse in Waterloo, County Seat of said County, at one-thirty o’clock (1:30) a.m., pursuant to law, to the rules of said Board, and to adjournment.  The meeting was called to order and on roll call there were present: Frank Magsamen, Chair; Linda Laylin, Tom Little, Chris Schwartz and Craig White. Absent:  None. Unless otherwise noted, all actions were approved unanimously. Moved by Little, seconded by White that the AGENDA be received and place on file with the County Auditor as approved.  Motion carried.WORK SESSION – Board action will not be taken for items in this work session to discuss options for the future direction of Country View Care Center. The following individuals have been invited to provide information and participate in the discussion:  Bob Lincoln, Director of County Social Services; Jeff Steggerda, President of Brighton Consulting Group; Kathy Kieler, Bureau Chief, Medicare/Medicaid Bureau III with Iowa Department of Inspections and Appeals; Linda Kellen, Bureau Chief with Iowa Department of Inspections and Appeals. Magsamen announced that the purpose of this meeting is to gather information to help the Board make decisions.  Finance Director Susan Deaton said that the County has been reviewing the financial concerns including the discussions during the FY2018 budget process that Country View would likely run out of money in FY2018.  The decision was made to use general fund reserves to subsidize Country View in FY2018 and we have recently transferred $500,000 from the General Fund.  As we approach the FY2019 budget, we need to have information to help determine if we should continue with tax payer support or look at the variety of other options that have been reviewed.  One option that hasn’t been explored closely yet is the possibility of closing Country View by gathering information to see what that process would be like.   Another is to look at continuing operations of Country View if changes in Medicaid reimbursement were granted. Kieler said facility closures can be for any number of reasons and she brought a Closure Book that explains the process including letters and notifications that would need to be sent.  If the decision is made to close, you would contact the Iowa Department of Inspections and Appeals and a closure crisis team would be established. A 60 day notice to both IDIA and the Iowa Department of Human Services is required and closing a facility doesn’t happen overnight.  A family and resident meeting would be held to let them know of your decision.  The process can take some time until every resident is placed somewhere.  IDIA would have crisis meeting with representatives of DHS, Disability Rights of Iowa, the Office of Ombudsman, any attorneys that may be involved, Board members etc. to review the process in the Closure Book to help identify how to provide food and supplies for residents, staffing, etc. while residents are being transitioned to new homes.  Residents have the right to pick where they go.  The Black Hawk County area has lots of nursing facilities.  White said there aren’t many beds available in the local facilities.  Kieler disagreed as she covers Black Hawk County and there are long term nursing facility beds available.  For the residents with mental illness needs it may be more difficult.   Deaton asked what costs are involved in closing and what happens if the facility just doesn’t have the money to stay open.  Kieler said she isn’t involved with the funding side of the process, but would refer the County to DHS for civil money penalties that are kept for things just like this situation to help move residents. Staff will need to be on hand, including from temporary agencies if necessary to provide all of the needs for any residents that remain through the process. Our experience in past closures has been that staff took a lot of responsibilities for the residents during the transition.  Steggerda said some staff will leave once the announcement is made, but he has seen where many of the key care givers stay to help.  Until you dip down below 50% resident levels, your current level of costs will continue.  He sees the County having a very difficult time placing 25-35 residents and 15 of those could be very very difficult.  Magsamen asked if a resident once moved doesn’t like where they went, will we have to take them back.  Kieler said no, once you have announced you are closing, you will not be allowed to take residents.  The new facility would have to find a different placement.  Deaton asked if the long term residents were placed elsewhere and we were down to the more difficult placements could we open a new facility for them or would we just finish the process through the current facility.  Kieler said the latter because to open a new facility you would have to go through a certificate of need and Keller added that right now Iowa Medicaid Enterprise is not allowing new ICF/ID facilities to open, but some current facilities are adding ICF/ID beds.  Lincoln said Community Social Services has had a long partnership with Country View providing care coordination.  There is no question that there is the need for a facility like Country View to provide the services for the residents with these needs. Magsamen ask that if Black Hawk County can’t provide the funding to sustain the facility due to the Medicaid funding covering only 80% of costs, how will anyone else be able to do it.  Why would another facility take them?  Steggerda said Country View is not an average nursing home.  The level of Medicaid utilization residents is close to 90% while the state wide average is closer to 50%.  Also in the most recent fiscal year, the state did not adequately fund Medicaid.  Alternate sources of funding are sought to make up the difference.  ICF/ID can limit the loss because it is cost based and costs are updated each year.  He said the last information he had on ICF/ID beds in the state is that 99.4% of them are occupied leaving only 22 beds available across the state. Magsamen asked if the Medicaid reimbursement of 80% would go up.  Steggerda said there would be an increase in the base effective 7/1/17 with a rough estimate of an annual amount of $540,000 for Country View, but that amount won’t be known until end of December.  Cost growth and the state’s underfunding of Medicaid by 10% are the issues for the County.  As your consultant (at the board’s request) we filed an exception to policy for ICF/ID and Skilled Nursing.  No formal response has been received, but informally we have received a communications that they are reviewing the request.  We have requested a more frequent rate reset based upon current costs for all three service programs at the facility.  If that is resolved favorably, the shortfall could decrease by 15%.  Then the next issue would be working with the managed care organizations (MCOs) to pass through that rate.  Current contracts between the state and the MCOs state that the MCOs don’t have an obligation to follow any exception of policies directed by the state.  Lincoln said that if all of that happened, the remaining 5% would be more manageable for Community Social Services to help with. Deaton said that this doesn’t address capital improvements?  Steggerda said there are two types of capital expenditures. One is those that could possibly be included as expense in current budget and larger purchases that would have to be depreciated.  Deaton said one concern is that Country View is an aging outdated facility without private rooms or baths.  Steggerda said you could look at downsizing as well or putting cap on how much you are willing to subsidize, but capital money would be needed.  Some parts of the facility could be updated but other parts are very aged and it may not be worth updating. Discussion was held on survival rate of residents after being moved.  Kellen said that some did pass away shortly after moving, but others also were very content in their new homes.   Kieler added that some of them have difficulty making new friends or have trouble adjusting for other reasons.  The Ombudsman  and Disability Rights people do follow up on the residents.  Steggerda said this is referred to as transfer trauma and a statistic that has been used for a number of years is that 75% die within 180 days of being transferred.  He later qualified this statement to statistics from two emergency closures that happened in 2006-2007 after Deaton asked if the age of the resident also played a part.  Lincoln added that Community Social Services also plays the role of a safety net or a gap filler to make sure residents are connected to their support sources.  Kellen added that in other closures staff accompanied residents to the new facilities and some even stayed in town for a couple of days.  The time you take and the plan you have will have a big part in it being successful. Frank said he appreciated the folks that participating in today’s meeting.  We will soon be working on the FY2019 budget and today’s meeting was strictly for fact finding and no decisions have been made. On motion and vote the meeting adjourned.  2:52 pm

Frank Magsamen, Chair, Board of Supervisors                             Helen R. Steffen, Systems/Real Estate Tax Manager