Tag Archives for Alliance for Better Long Term Care

Increased funding must be tied to nursing home mandated minimum staffing

Published in RINewToday on Sept 25, 2023

The Centers for Medicare and Medicaid Services (CMS) issued a proposed rule to establish comprehensive staffing requirements for nursing homes—including, for the first time, national minimum nurse staffing standards. The proposed rule seeks to would ratchet up the quality of care in the nation’s 18,700 skilled nursing facilities, delivering care to 1.2 million residents each day.

“Establishing minimum staffing standards for nursing homes will improve resident safety and promote high-quality care so residents and their families can have peace of mind,” said HHS Secretary Xavier Becerra in comments on Sept. 1, 2023. “When facilities are understaffed, residents suffer. They might be unable to use the bathroom, shower, maintain hygiene, change clothes, get out of bed, or have someone respond to their call for assistance. Comprehensive staffing reforms can improve working conditions, leading to higher wages and better retention for this dedicated workforce,” says Becerra.

The Nuts and Bolts of CMS’s proposed ruling

Under CMS’s proposal, nursing homes participating in Medicare and Medicaid would be required to meet specific nurse staffing levels that promote safe, high-quality care for residents. Nursing homes would need to provide residents with a minimum of 0.55 hours of care from a registered nurse per resident, per day, and 2.45 hours of care from a nurse’s aide per resident, per day, exceeding existing standards in nearly all states. CMS estimates approximately 75% of nursing homes would have to strengthen staffing in their facilities. As the long-term care sector continues to recover from the COVID-19 pandemic, the proposed standards take into consideration local realities in rural and underserved communities through staggered implementation and exemptions processes.

In addition, nursing homes would also be required to ensure a registered nurse is on site 24 hours a day, 7 days per week, and to complete robust facility assessments on staffing needs. Facilities would continue to be required to provide staffing that meets the needs of the individual residents they serve, which may require higher levels of staffing above the proposed minimum standards.  

CMS also proposed to require states to collect and report on compensation for workers as a percentage of Medicaid payments for those working in nursing homes and intermediate care facilities. These policies build on CMS’ recent proposals to support compensation for direct care workers in home and community based settings and to publish Medicaid data on average hourly pay rates for home care workers. This enhanced transparency will aid efforts to support and stabilize the long-term care workforce across settings strengthening access to high-quality long-term care both at home, in the community as well as in nursing homes and other facilities.

Attracting and supporting Nursing Home staff

Additionally, CMS announced a national campaign to support staffing in nursing homes. As part of the HHS Workforce Initiative, CMS will work with the Health Resources and Services Administration and other partners to make it easier for individuals to enter careers in nursing homes, investing over $75 million in financial incentives, such as scholarships and tuition reimbursement. This staffing campaign builds on other actions by HHS and the Department of Labor to build the nursing workforce.

More than 500,000 direct care workers provide care in nursing homes, assisting residents with daily tasks, such as bathing, dressing, mobility, and eating. This work, often performed primarily by women of color, is significantly undervalued. Direct care workers across long-term care settings earn low wages, rarely receive health and retirement benefits, and experience high injury rates. Improving working conditions and wages will lead to improvements in the recruitment and retention of direct care workers and enable nursing staff to provide safer care.  

CMS and the HHS Office of the Inspector General called for increased transparency and enhance enforcement of existing standards. This would result from increased audits of nursing homes’ staff, improving nursing  home inspections, oversight as to how nursing homes spend taxpayer dollars and cracking down on prescribing inappropriate antipsychotic drug prescribing practices.  The proposed rule would also undertake new efforts to improve resident safety during emergencies. 

Mandating more staffing during a severe labor shortage – pushback on an unfunded mandate

“It is unfathomable that the Biden administration is proceeding with this federal staffing mandate proposal. Especially when just days ago, we learned that CMS’ own study found that there is no single staffing level that would guarantee quality care, says Mark Parkinson, President and CEO of the American Health Care Association, a national nursing home trade group representing 14,000 nursing homes and other long-term care facilities across the nation taking care of five million residents each year.

“At the very same time, nursing homes are facing the worst labor shortage in our sector’s history, and seniors’ access to care is under threat. This unfunded mandate, which will cost billions of dollars each year, will worsen this growing crisis, warns Parkinson, noting that the proposed rule requires nursing homes to hire tens of thousands of nurses that are simply not there and then penalizes the facilities and threatens to displace hundreds of thousands of residents.

“Already, hundreds of nursing homes across the U.S. have closed because of a lack of workers,” states Parkinson. 

​John E. Gage, President, and CEO of the Rhode Island Health Care Association, with offices in Warwick, agrees with Parkinson’s assessment of the harm such proposals will trigger and its devastating impact on nursing homes and residents. “The federal staffing proposal is unfunded and is being implemented at a time when additional staff is simply not available,” he said.  

According to Gage, six Rhode Island-based facilities have closed since the beginning of the pandemic in March 2020. Three others are currently in receivership. Arbitrary federal staffing mandates will result in more closures, and residents will be displaced from their homes just as they were most recently when Charlesgate Nursing Center in Providence was forced to close because of skyrocketing costs, a scarcity of staff and chronically inadequate Medicaid funding. 

Unintended consequences of mandating minimum staffing

James Nyberg, president, and CEO of LeadingAge Rhode Island, with offices in East Providence, views see a staffing ratio mandate as a blunt enforcement instrument that does not consider the numerous challenges facing providers, including Medicaid underfunding, lack of workforce, and the diversity of resident needs. Moreover, the imposition of severe financial penalties on homes that are unable to meet a staffing ratio is counterproductive: fines siphon off scarce resources that providers need as they seek to address their workforce and resident care needs,” he says. 

“Our state’s experience illustrates the numerous challenges and unintended consequences of a staffing ratio mandate: the severity of fines, how compliance is measured and calculated, compliance costs, backlogs of people in hospitals waiting for skilled nursing care after admissions have been reduced due to a lack of staff and other access-related issues,” notes Nyberg, noting that even those homes that are currently able to comply with the staffing ratio are doing so at an unsustainable cost. 

While Kathleen Heren, executive director of the Alliance for Better Long-Term Care and the state’s Long-Term Care Ombudsman, supports HHS’s minimum staffing standard, the administration must adequately fund to train recruited workers and to pay a livable wage to retain them. “Rhode Island doesn’t have an issue with its nursing home inspection process as other states do, she says, noting that newly hired RI Department of Health surveyors are “doing a great job.” 

“RIDOH surveyors only cite facilities, when necessary,” says Heren, noting that administrators can challenge any cited deficiency if they view it as unfair, and she doesn’t see a problem in the use of antipsychotic medications in Rhode Island facilities “but acknowledges that there’s always room for improvement.”

Direct Caregivers, mainly women, undervalued despite significant work demands

“Almost 80 percent of nursing home care is paid for with government programs (Medicare and Medicaid), so it is hugely important that those dollars provide quality care,” says Maureen Maigret, chairperson of the aging in community subcommittee for the Long Term Care Coordinating Council.  She noted that studies show a clear relationship between staff levels and quality care but there is tremendous variation across the states in hours of direct care staff provided in nursing homes. 

“Rhode Island has required 24/7 RN staffing for many years and a 2021 state law requires minimum direct care staffing levels although implementation has been challenging due to the critical workforce shortage. Importantly, the proposed federal regulation would require states to report on compensation for workers as a percentage of Medicaid payments. For too long our direct care workers, mostly women, have been undervalued despite the significant demands of their work. It is time for them to receive a living wage and  shedding light on where our Medicaid dollars are going will help advocate for better wages helping to recruit and retain these essential workers,”  she says.

There will be a 60-day comment period for the notice of proposed rulemaking, and comments must be submitted to the Federal Register no later than November 6, 2023.  

For a copy of the federal register detailing CMS’s proposed rules on minimum staffing issued on Sept. 6, 2023, go to 

https://www.govinfo.gov/content/pkg/FR-2023-09-06/pdf/2023-18781.pd

For a copy of a CMS Fact Sheet on CMS’s proposed rules on minimum staffing, go to https://www.cms.gov/newsroom/fact-sheets/medicare-and-medicaid-programs-minimum-staffing-standards-long-term-care-facilities-and-medicaid

Real Heroes Need to Be Recognized   

Published in Pawtucket Times on November 3, 2003

Sometimes the actions of real heroes are not reported by newspapers, radio or television newscasts. While stories of poor care and abuse in the state’s nursing facilities quickly make headline news in local media outlets, the good deeds oftentimes go unreported.

Here’s a story about a fire in an East-Providence independent living facility that made the local news one evening in October, but the real story was left untold.

Although the Rhode Island Chapter of the Red Cross ultimately go the ink for being on the scene, there were others – nursing facility administrators, firefighters, police officers and the Alliance for Better Long-Term Care – who also came to the assistance of the elderly tenants that fall night.

On Friday, Oct. 3, a boiler fire at Taunton Plaza forced 117 elderly and handicapped residents from their heated apartments into the chilly night. The elderly tenants residing in this independent living facility  were ultimately not allowed to return until Monday, because of a power outage, smoke damage and concerns regarding environmental contamination by polychlorinated biphenyls (PCBs).

Although the Santa Maria Club, on Broadway, offered a brief respite from the cool fall weather that evening, these residents needed overnight accommodations because they could not immediately return to their apartments. For that weekend, the majority of the elderly tenants went to the homes of family and friends, while others slept on cots at a temporary shelter site.

Roberta Hawkins, state ombudsman and executive director of the Alliance for Better Long-Term Care, remembered getting a phone call while watching a local television newscast about the fire.

“We really could use your help,” the Red Cross official said, asking her to immediately come to East Providence.

Ultimately, Hawkins and Kathy Heren, her agency’s staff nurse, quickly arrived at the Portuguese club and got down to the business of interviewing residents to learn about their medications, special needs and current health status. Some of the displaced elderly tenants were diabetic on insulin, while others were taking high blood pressure and heart medications.

Nursing home administrators, along with their directors of nursing, were also summoned to the fire site after receiving phone calls from Hawkins and Heren. These facilities would ultimately provide free accommodations for 18 elderly tenants whose health status required medical care  monitoring until they could return to their apartments.

Meanwhile, with information provided by Hawkins and Heren, East Providence firefighters and police officials entered smoke-filled apartments to retrieve prescription drugs. “Some of these seniors need to take their medications at the time of the fire,” said Hawkins.

Responding to a visibly shaken woman, an East Providence policeman even went into a smoke-filled apartment to rescue her cockatoo, a pet that might have died from smoke inhalation.

“The sobbing woman was so grateful that one would have thought the policeman had just rescued her child,” Hawkins said.

Administrator Orlando Bisbano Jr., of Orchard View Manor, came to Taunton Plaza that night of the fire with his director of nursing. He ultimately would take seven elderly tenants  back to his East Providence-based facility.

“We were willing to help in any way we could,” said Bisbano, noting the uncompensated care his facility provided totaled $ 2,300.

According to Bisbano, nursing assistants with wheelchairs were positioned outside Orchard  View Manor for more than a half an hour in the chilly night after the fire, waiting for the arrival of the traumatized elderly tenants.

“We called staff back to the facility who would later help to get them settled down and ready for bed,” he said. Management staff even came back to the facility to process the necessary paperwork that included a list of the new admission’s medications.

Ultimately, administrator Donna Amaral, of Eastgate Nursing and Recovery Center, along with administrators from Waterview Villa Nursing and Rehabilitation Center and Hattie Ide Chaffee Home, responded to Hawkins pleas for help for facilities to temporarily admit the displaced elder tenants.

“This was the first time in my 22 years as an administrator that I opened up my facility to help out in a crisis,” Amaral told All About Seniors, estimating  her East Providence-based facility provided at least $ 2,500 in free care, food and lodging, to six elderly residents.

Besides getting the residents fed and ready for bed, Amaral stressed how her staff had to locate medications for one of her unanticipated guests. One of her newly admitted tenants came without his insulin, and she quickly made arrangements with a local pharmacy for replacement insulin.

Hawkins recounted one elderly man was ultimately too confused to return to his apartment at Taunton Plaza and was late admitted to Amaral’s facility, Eastgate Nursing and Recovery Center.

Upon arriving with no shoes or jacket, Jack Heren, the facility’s food manager, took off his brand-new  sports jacket and gave it to a shivering man. “He sept wearing his new jacket that first night,” said Hawkins, who noted the man treasures the gifted jacket and has not taken it off since his admission to the facility.

Although the R.I. Red Cross and Picerne Management Group, the owners of Taunton Plaza, along with some of the elderly tenants and their families thanked the Alliance and nursing facilities for their assistance, local media did not report the acts of kindness.


It is disappointment the local press did not recognize the local nursing facilities were there and ready to take all of the residents, if necessary,” said Bisbano. “While it ultimately does not matter that we weren’t recognized, nursing facilities are here to serve the community and are prepared to deal with disasters like that fire.”

Hugh Hall, president of the R.I. Health Care Association, a trade group representing a majority of the state’s nursing facilities, added, “I don’t think that there is much positive news in general as we would like to see including positive articles about nursing facilities.

“When this type of crisis [fire] happens, the long-term care community rises to the occasion, to assist, and always will,” says Hall.

Hawkins weighted in on the issue of positive news coverage of nursing facilities, too.

“While local television stations covered this fire, they never really identified the real heroes, that is the nursing facilities, the police and firefighters, who in times of disaster help people they don’t even know,” she said.

“Couples fall in love and even get married in facilities with the assistance of staff. Nursing assistants oftentimes become family to residents, comforting them when they are sad, frightened or dying. We hardly read about these good deeds either,” said Hawkins.

For this columnist, hats off to the East Providence police and firefighters, the nursing facilities and their dedicated staff who briefly provided quality of care for the displaced traumatized elderly tenants and to the Alliance for Better Long-Term Care. Positive news and acts of kindness will be reported and real heroes recognized in this column.

Alliance for Better Long-Term Care Celebrates 25th Anniversary

Published in Pawtucket Times on October 20, 2003

Next Friday, nursing home advocates, state officials, residents and their families and friends along with long-term care providers are invited to North Kingston to celebrate the 25th anniversary of the Alliance for Better Long-Term Care.

With its emergence on the advocacy scene in 1988, the Alliance for Better Home Care (later renamed the Alliance for Better Long-Term Care) has effectively defended the rights o those who can no longer speak for themselves – the elderly who receive care in the state’s nursing homes. Later in the late 1990s, the nonprofit group expanded its advocacy role into the assisted living, home care and hospice sectors. (This would result in the above-mentioned organizational name change).

Back in 1986, a thirty-something Roberta Hawkins had just raised her two daughters, Robin and Cindy. The former facility worker with 15 years’ experience under the belt working at Warwick-based Levitons Manufacturing Co., sought out a new career in human services.  Hawkins enrolled at Rhode Island College to become a  social worker.

At this time, she joined the federally funded program, Volunteers in Service to America (VISTA) “to make a difference.”

Hawkins would later be assigned to assist low-income Rhode Islanders in applying for eligible federal and state benefits. However, poor nursing home care provided at the Rhode Island Nursing Home in Providence would later lead to refocusing of the nonprofit group’s mission, one that would aim to protect the health and dignity of the Ocean State’s growing nursing home resident population.

With VISTA funds and small grants drying up at the beginning of the Reagan years, around 1888, Hawkins’ nonprofit group received funding from the Department of Elderly Affairs to refocus her group’s new advocacy role in the state. The Alliance for Better Nursing Home Care was born.

Hawkins, along with six fellow VISTA volunteers, would later form the staff of the newly created statewide, advocacy group.  Three years later, Hawkins would take over the helm of the group.  Three years later, Hawkins would take over the helm of the group. Ultimately, she would become the sole staffer, with an organizational budget of $ 8,000.  Volunteer staff, consisting mostly of family members of nursing home residents, would help Hawkins formulate advocacy strategy, recruit new members, write and disseminate a newsletter and organize fundraisers.

Twenty-five years later, Hawkins Alliance for Long-Term Care has an operating budget of $ 770,000 with a staff of 14 people and a core group of 40 volunteers.  Several years ago, the Department of Elderly Affairs (DEA) out-sourced ombudsman duties to this non-profit group.

Since its inception, the Alliance for Better Long-Term Care has assisted families in both understanding and choosing the most appropriate care setting to place their loved ones, said Hawkins, in a multiple of care settings – from assisted-living nursing homes or to their own homes, through the provision of home care services.

As the state’s official ombudsman agency, Hawkins and her staff work to educate family members and residents of their state and federal rights.  Care complaints are investigated a resolution mediated between residents and the long-term care providers.

As an advocate, Hawkins testifies on behalf of nursing home residents at legislative and regulatory hearings.

Where does Hawkins go from here?

Hawkins said she looks forward to making  bigger changes in the Ocean State’s long-term care delivery system.

“When delivering services, state agencies sometimes cut people off from the services when they reach a certain age,” like rehabilitation and mental health services, she said.  “That’s totally inappropriate,” she adds.

Hawkins also told All About Seniors she will continue to work toward “putting the home back into nursing homes.” The facility must truly become are a resident’s home, she urged.

Rhode Island’s most visible nursing home advocate also wants to see facility staff adequately paid for the valuable work they perform.

“We must get rid of the staff that do not care about providing good care to the elderly and keep those who really do, by paying them livable wages and providing a good working atmosphere,” she said.

Hawkins has gained the respect of a wide variety of state officials, aging advocates and providers in her 25 years of advocacy.

Lt. Gov. Charles Fogarty, who worked with Hawkins when he was a state senator and as chair of the state’s Long Term Care Coordinating Council (LTCCC), said Rhode Island is fortunate to have such a dedicated and committed advocate.

“We all sleep better at night knowing that she is there for us to advocate on behalf of the thousands of frail and vulnerable elderly in long-term care settings,” he said.

Lucille Massemino, administrator of Charlesgate Nursing Center, a Providence-based 160-bed skilled nursing facility and a former m ember of its board of directors, said she sees Hawkins as a passionate advocate pushing for the quality of life of nursing home residents.

“She is very assertive with administrators, knowing the needs of residents and prodding facilities towards fulfilling those needs,” she said.

Meanwhile, Hugh Hall, president of the Rhode Island Health Care Association has seen Hawkins in action over the past 18 years, working tirelessly for the improvement of Rhode Island’s long-term care services.

“She has lobbied the state legislature for better care in nursing homes [urging lawmakers to pay facilities an adequate reimbursement rate and calling for the state to address a nurse staffing shortage],” he said.

Hawkins said she plans to stay around as long as she is effective and as long as her passion to fight for nursing home residents remains. For the sake of the tens of thousands of Ocean State seniors and young disabled people who need long-term care services, hopefully we’ll see her around advocating on their behalf for a long time to come.