Published in RINewsToday on March 25, 2024
A few weeks ago, advocates for seniors gathered on Smith Hill, attending a Senate Committee on Health & Human Services hearing to push for passage of S. 2399. The legislation would expand income eligibility for the Medicare Savings Program (MSP), helping many lower income seniors and disabled residents pay their $175/month Medicare Part B premium and covering co-pays and deductibles for those with very low-income.
Thousands of low-income seniors and persons with disabilities on Medicare, but not eligible to participate in the state’s Medicaid program, struggle to pay their Medicare Part B premiums and co-pay costs for services and prescription drugs causing many to forgo needed health care as they cannot afford to pay the co-payments.
S. 2399, introduced by Pawtucket Sen. Sandra Cano (D-Dist. 8, Pawtucket), would expand eligibility for the Medicare Savings Program (MSP) by increasing the income limit to 186% of the federal poverty line and eliminating the strict asset limit. It also increases from 100% to 138% of the federal poverty line a part of the program that covers deductibles and co-payment.
S. 2399 was heard on March 12, 2024 and held for further study. At press time, H. 7333, introduced by Pawtucket Rep. Karen Alzate (D-Dist. 60, Pawtucket, Central Falls), has been referred to the House Finance Committee for consideration. No hearing date has been scheduled.
“With health care costs rising at an alarming rate, it is imperative that we make sure that no one goes without the care they need due to unaffordability. This bill adapts to the significant changes in our society and economy while also ensuring that our most vulnerable senior and disabled residents are able to access the care and medicine that is essential to their daily lives,” said Cano, who champions S. 2399 and in previous legislative sessions introduced legislation to expand the MSP.
“Too many of our low-income seniors and disabled residents are falling through the cracks and foregoing crucial health care services due to rising co-pays and out of pocket costs. This is unacceptable, but thankfully, we can do something about it. By passing this legislation, thousands or more Rhode Islanders will be able to receive the care that they desperately need while also keeping more money in their pockets that’s needed for daily living expenses,” said Alzate, who sponsored the House companion measure.
“We understand this is very important legislation. We had a very informative, thorough hearing on this bill, and I look forward to reviewing all the information we collected.” says Senate Health and Human Services Committee Chairman Joshua Miller (D-Dist. 28, Cranston, Providence).
The Policy Problem and its Solution
Currently, the income limit of $20,331 leaves thousands of older Rhode Islanders and disabled low-income persons on Medicare with significant gaps in coverage and hefty out of pocket costs.
If the MSP income limit is increased to $28,012, as required by the legislation, an estimated 17,000 persons would be newly eligible to have their Medicare Part B covered by being enrolled in MSP. Anyone enrolled in the MSP receives automatic enrollment in Part D “Extra Help,” a federal program which significantly lowers out-of-pocket Medicare prescription costs at no cost to the State. The federal government establishes the minimum income and asset thresholds for the MSP, and states are permitted to increase these limits and many have done so.
Advocates of Cano’s MSP legislative proposal say it also particularly helps Rhode Island’s older woman and minorities. “Since women and people of color and persons with disabilities are disproportionately represented in low-income populations, increasing access to the MSP promotes equity,” finds an advocacy partnership’s analysis of the legislative proposals. “Poverty rates among older adult Hispanic women are two and one-half times that of older Hispanic men and persons age 18 and over with disabilities are twice as likely to live below 150% of the poverty level, said the analysis.
The advocacy partnership’s analysis also noted that significant numbers of older adults and those with disabilities enrolled in Medicare face financial challenges meeting basic needs. The number of older adults living below or near poverty has increased, housing costs have climbed dramatically, food cost have increased and many more rely on food pantries.
Covering the $175/month Medicare Part B premium for 17,000+ Rhode Islanders (at no cost to the State) and additionally covering co-pays and deductibles for thousands of very low-income adults and persons with disabilities on Medicare will give them much needed financial relief. And enrollment in the Extra Help program to reduce drug-related costs provides significant additional financial assistance and improves access to critical medication.
Testimony At the Senate Committee Hearing
Nine organizations either testified at this hearing or submitted written testimony to urge passage of S. 2399. AARP Rhode Island did not testify at the hearing but signed up in support in the committee room. There was no opposition to Cano’s legislative proposal.
“I first became aware of the need to expand the income eligibility for MSP quite a few years ago when an older man in my neighborhood contacted me to tell me he lost out on the program because he was just a few dollars over the income limit. As a result, the Senior Agenda Coalition of RI (SACRI) has advocated for several years to increase the income cap,” says Maureen Maigret, SACRI’s policy Advisor.
It’s a win-win for both older Rhode Islanders and for the Rhode Island General Assembly, says Maigret. “S. 2399 would help Medicare beneficiaries to access care along with putting money back in their pockets to pay for food, rent and their basic needs. By increasing the Medicaid income to $28,012, the federal government will pay the full cost of the newly eligible Medicare beneficiaries,” she told the lawmakers.
Strongly supporting S2399, Karen Malcolm, of Protect Our Healthcare Coalition, noted that the legislative proposal is modeled on the MSP changes enacted in New York last year and approved by the Centers for Medicare and Medicaid Services. “Rhode Island should take advantage of the opportunity to expand access to affordable coverage for seniors and people with disabilities and bring new [federal] revenue to our state.”
H. Phillip West, Jr. lobbyist for the Village Common of Rhode Island, states MSP already makes an enormous difference for many beneficiaries. But, “Rhode Island’s low threshold for eligibility and low allowable assets leaves thousands of our needy neighbors out. The good news is that Senator Cano’s legislation address these defects,” he said.
In submitted written testimony, Heather Smith, MD, president of the Rhode Island Medical Society stated “From our perspective as physicians, we witness firsthand the adverse effects of financial barriers on patient health outcomes. Too often, individuals are forced to forgo or ration medications, delay necessary treatments, or skip preventative care due to concerns of affordability. These delays can exacerbate health conditions, lead to complications, and ultimately result in higher healthcare costs down the road.”
Alex Moore, political director of SEIU 1199NE, stressed the many benefits of passing S. 2399, specifically enhancing access to care, providing needed financial relief, leveraging federal funds, and strengthening the health care workforce. By supporting the legislative proposal, “we demonstrate our commitment to health and well-being of our state’s most vulnerable populations,” he stated in written testimony.
Even with the strong support of the aging community, the state’s Office of Healthy Aging has not yet taken an official position on S. 2399. “As with any other bills at this stage of the session, we are reviewing the impact of H 7333 and S 2399 on Rhode Islanders. We will continue to follow these bills as they make their way through the legislative process,” says Director Maria Cimini.
Samuel Salganik, JD, executive director of RIPIN, which offered testimony in support for S.2399, said, “This is one of the best investments available right now for our state government. At a cost of just over $5 million, the State can draw down more than $40 million in federal support to assist low-income seniors in Rhode Island,” says Salganik. “It’s a great deal for the state. I think that’s a deal that most of us would happily take,” adds Salganik.
Gov. Dan McKee’s recently released FY 2024 Budget does not include funding for to expand the state’s MSP. Now the ball is in House Speaker Joseph Shekarchi’s (D-Dist. 23, Warwick) court as his chamber collaborates with the Senate to hammer out budget resolution to be approved by the Rhode Island General Assembly to be sent for the Governor’s signature. Hopefully, Shekarchi will see the expansion of the state’s MPM as a win-win for lower-income and disabled persons on Medicare and the state. As supporters of S 2399 and H 7333 say, “it’s a no brainer.”
The Advocacy Partners for MSP Expansion was established to push for the passage of S 2399 and H 7333 during this legislative session. They are: the Senior Agenda Coalition of Rhode Island, Rhode Island Organizing Project, RIPIN, the Economic Progress Institute, the Protect Our Healthcare Coalition and the Ocean State Center for Independent Living.
To access the bills under consideration: http://webserver.rilegislature.gov/BillText/BillText24/SenateText24/S2399.pdf – http://webserver.rilegislature.gov/BillText/BillText24/HouseText24/H7333.pdf
Expanding the income eligibility for the Medicare Savings Program (MSP) is one of the legislative priorities of the Senior Agenda Coalition of Rhode Island. These policy issues will be discussed at its upcoming Legislative Leaders Forum scheduled on Wednesday, March 27, 2024, from 10:00 a.m. to 11:00 a.m., at the Crowne Plaza Hotel, 601 Greenwich Ave,, Warwick, RI.
The Senior Agenda Coalition of RI’s Annual Legislative Leaders Forum is this week:
Tag Archives for Centers for Medicare and Medicaid Services
Age beat writer gives us his most important columns in 2023
Published in Blackstone Valley Call and Times, on January 1, 2024
Over the years, like many of the nation’s news organizations, The Pawtucket Times, created an ‘Age Beat’ column in 2002 that allowed this writer for several years to cover a myriad of aging issues, including Social Security and Medicare, ethics, long-term care, consumer issues, spirituality, pop culture, health care and economics. Ultimately, I would return in July, 2012 to resume writing, also picking up other weekly commentaries.
As an ‘age beat’ journalist for over 44 years, I have penned more than 930 stories covering aging, health care and medical issues. These authored and coauthored pieces have appeared in national, state and trade publications.
In 2023, my articles appeared weekly in 52 issues of the Pawtucket Times and Woonsocket Call (now combined in one newspaper called the Blackstone Valley Call & Times), and RINewsToday.com, a statewide digital news publication.
As we celebrate the New Year and look forward to 2024, looking back, here are my top five favorite articles published in 2023:
“In the coming years, generations of older Veterans will be leaving us,” – RINewsToday, Nov. 13, 2023
This commentary published before Veterans Day, had the Department of Veteran Affairs estimate that there will be a couple of hundred World War II veterans, over 1,600 Korean and 14,000 Vietnam veterans still alive in Rhode Island. In the coming years, frailty and health issues will keep these elderly veterans’ from attending Veteran Day celebrations and even at their reunions.
As a generation of Civil War and World War I veterans vanish in 1956 and 2011, this writer urged readers to cherish the surviving older veterans. In the next thirty years, it was stressed that new generations of veterans who fought in World War II, Korea and Vietnam will pass away and these veterans were urged to share their personal stories and oral histories for the sake of America’s future generations. “They have so much to say, and America’s younger generations have much to learn from them,” noted the commentary.
This commentary was dedicated to the writer’s father, Second Lt. Frank M. Weiss, who died in December 2003, in Dallas, Texas at 89 years old.
“Passages – Life and Times of Morris Nathanson,” RINewsToday, Oct. 7, 2023
Over two decades, this writer would visit Morris Nathanson on Saturday afternoons sitting in his living room drinking cups of freshly brewed coffee. We would talk about Pawtucket, world events, and he would reminiscence about his amazing life’s journey from his childhood in Pawtucket, to the international world he lived in later in his life.
My friend, 95-year-old Morris Nathanson, a painter, illustrator and restaurant/hospitality designer died last September. My commentary was written to recognize and honor Morris’s incredible life, detailing his World War II experiences, fighting for civil rights, and his impact on the art and design scene.
Growing up poor during the depression in Pawtucket’s Pleasant View neighborhood, Morris, a spitting image of Mark Twine, or maybe Albert Einstein to me, would ultimately have a major impact on Rhode Island’s art and restaurant design scene.
Morris brought the strategy of adaptive re-use of underutilized and vacant mills to city and state officials, a concept that he picked up from his years of working in New York City, watching the development and transformation of the industrial mills in SOHO.
Witnessing firsthand man’s biases and prejudices motivated him throughout seventy-five years of his long life to fight for the equal rights of all. Morris participated in the Freedom Rides of 1961, Dr. Martin Luther King’s campaigns in Selma and Birmingham, Alabama, and the March on Washington for Jobs and Freedom.
At age 24, Morris, head of the design team at Paramount, developed and designed the first franchise in American history, Dunkin Donuts. While working with Friedman he also designed restaurants in the pavilions of the 1964 World’s Fair in Flushing Meadows, New York.
When Morris left Paramount Restaurant Supply Co, his most notable design projects locally include Hemenway’s, Ruth Chris Steak House, 22 Bowen, restaurants and bars for the Inn at Castle Hill, Capital Grill, Pizzeria Uno, Joe’s American Bar & Grill, Mills Tavern, Waterman Grill, Red Stripe and for those who still remember, the beloved Ming Garden and McGarry’s Restaurant in downtown Providence. He also had clients all over the world.
It would take pages to detail all of Morris’s professional accomplishments while serving on state, city and nonprofit organizations throughout his long-life. Hopefully I whetted your appetite to learn more about his life by reading this commentary.
“Will Magaziner fulfill call to reestablish House Aging Committee,” RINewsToday, Oct. 9, 2023.
As reported, with Congressman David Cicilline retiring from Congress, no House lawmaker has yet stepped up to reintroduce, H.R. 583, the Rhode Island lawmaker’s resolution to reestablish the House Select Committee on Aging (HSCoA). Without receiving a vote in the House Rules Committee at the end of the 117th Congress, the resolution was considered “dead.” On his way out Cicilline was not successful in passing the legislative baton and finding a new original sponsor. The Rhode Island Congressman had introduced this resolution in four Congressional sessions.
The HSCoA was a permanent select committee of the U.S. House of representatives between 1974 to 1992. The committee was initially created with the intent of not crafting legislative proposals, but of conducting investigations and holding hearings to put the Congressional spotlight on aging issues. Its purpose was to push for legislation and other actions, working with standing committees, through regular committee channels.
This writer asks who will ultimately pick up the legislative baton from Cicilline to become Rhode Island’s fiery aging advocate? Will it be Congressman Seth Magaziner, or the newly elected Congressman Gabe Amo, from Rhode Island’s Congressional District 1 to step to the plate?
The article asks why shouldn’t a Rhode Island Congressman follow in the footsteps of former Rhode Island Congressman John E. Fogarty (dec.) and be the original sponsor of legislation that will have a major impact on national aging policy. The lawmaker would become a hero to America’s seniors.
“Unique partnership creates Senior Fellows pilot program,” RINewsToday, Dec. 11, 2023
This commentary announced that the success of a pilot Senior Fellows Program, created by Leadership Rhode Island (LRI) and Age-Friendly Rhode Island (AFRI), the organizations are seeking funding to offer another session in the summer of 2024.
The unique initiative prepared 25 Senior Fellows to advocate for improvements that address age-related challenges in Rhode Island. The initial eight-week program was tuition-free. The first crop of Senior Fellows, residents of 13 different cities and towns in Rhode Island, ranged in age from 62 to 83. Nearly half were retired.
The idea to develop a senior advocates program came from Marianne Raimondo, a graduate of LRI’s Core Program, who made the connection between Leadership Rhode Island and James Burke Connell. Connell is the executive director of Age-Friendly Rhode Island, an initiative at Rhode Island College that represents a coalition of public and private agencies, organizations and individuals committed to healthy aging.
Connell proposed the pilot program because, he says, empowering seniors to become advocates, activists and champions of age-friendly thinking and practices “will result in a Rhode Island where older adults thrive and live their best lives.” He was inspired by similar programs in Maine and New Hampshire.
Age-Friendly RI raised the funds for the pilot program, and relied on LRI’s “talented team” to handle recruiting, participant selection, curriculum planning, and guiding participants in the development of individual community commitments, Connell says.
Most session days were divided into two parts, with half focused on knowledge-building around relevant issues, such as housing, food insecurity, transportation needs, and health care. The other half focused on skill-building, such as writing persuasively, public speaking and network building, to enable the Fellows to develop and eventually execute their own Civic Commitments.
The Fellows took turns describing their Civic Commitments during their final session, held at the RI State House. The presentations, which included several “poignant and pin-drop moments,” were well received.
“Increased funding must be tied to nursing home mandated minimum staffing“, RINewsToday, September 25, 2023
The commentary announced that the Centers for Medicare and Medicaid Services (CMS) had issued a proposed rule to establish comprehensive staffing requirements for nursing homes—including, for the first time, national minimum nurse staffing standards. CMS officials said that the requirement would improve both safety and promote high-quality care in the nation’s 18,700 skilled nursing facilities delivering care to 1.2 million residents each day.
National and Rhode Island nursing home trade groups pushed back on the unfunded mandate requiring more staffing especially during a severe labor shortage forcing hundreds of facilities across the nation to close because of lack of workers.
John E. Gage, President, and CEO of the Rhode Island Health Care Association, reported that six Rhode Island-based facilities have closed since the beginning of the pandemic in March 2020. Three others are currently in receivership. He warns that 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.
James Nyberg, president, and CEO of LeadingAge Rhode Island, with offices in East Providence, sees a staffing ratio mandate as a blunt enforcement tool that does not consider the numerous challenges facing providers, including Medicaid underfunding, lack of workforce, and the diversity of resident needs. Moreover, he charged that fining for being unable to meet a staffing ratio is counterproductive by siphoning off scarce resources that facilities need as they seek to address their workforce and resident care needs.
To review ALL of Herb’s articles published by RINewstoday, go to https://rinewstoday.com/herb-weiss/
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
Herb Weiss 