Tag Archives for Deb Burton

Advocates, providers on new Nursing Home mandates

Published in RINewsToday on April 29, 2024

In the shadow of Rhode Island’s ongoing staffing shortage, the Center for Medicare and Medicaid Services (CMS) issued its 329-page final rule on Nursing Home Minimum Staffing Standards (CMS 3442-F) on April 22 in the Federal Rule. 

CMS affirmed its commitment to hold nursing homes accountable for providing safe and high-quality care for the nearly 1.2 million residents living in Medicare-and Medicaid-certified long-term care facilities.  

According to CMS, over 46,000 public comments submitted in response to the proposed rule. Central to this final rule are new comprehensive minimum nurse staffing requirements, which aim to significantly reduce the risk of residents receiving unsafe and low-quality care within nursing homes.

Just the Nuts and Bolts

CMS say that central to its final rule are new comprehensive minimum nurse staffing requirements that would significantly reduce the risk of residents receiving unsafe and low-quality care within nursing homes.  The agency is finalizing a total nurse staffing standard of 3.48 hours per resident day (HPRD), which must include at least 0.55 HPRD of direct registered nurse (RN) care and 2.45 HPRD of direct nurse aide care. Facilities are given the flexibility to use any combination of nurse staff (RN, licensed practical nurse [LPN] and licensed vocational nurse [LVN], or nurse aide) to account for the additional 0.48 HPRD needed to comply with the total nurse staffing standard.

CMS is also finalizing enhanced facility assessment requirements and a requirement to have an RN onsite 24 hours a day, seven days a week, to provide skilled nursing care. 

This final rule provides a staggered implementation timeframe for facilities to meet the minimum nurse staffing standards and 24/7 RN requirement based on geographic location as well as possible exemptions for qualifying facilities for some parts of these requirements based on workforce unavailability and other factors. The requirements of this final rule prioritize safety and health care quality while taking into consideration the unique workforce challenges some nursing homes are facing, especially those operating in rural areas. 

CMS will closely monitor and evaluate the provisions of this final rule, including but not limited to, the minimum staffing standards, the 24/7 RN requirement, the exemption process, and the definition of rural, as they are implemented over the next several years to determine whether any updates or changes are necessary in the future. 

Additionally, to increase transparency related to compensation for workers, CMS will also require states to collect and report on the percent of Medicaid payments that are spent on compensation for direct care workers, and support staff, delivering care in nursing facilities and intermediate care facilities, for individuals with intellectual disabilities. 

Provider, advocate positions on new CMS final rule

At press time, the RI Department of Health (RIDOH) had no comments about CMS’s new final rule released last week, say Joseph Wendelken, RIDOH’s public information officer.  The state agency is reviewing the rule and assessing its impact and applicability in Rhode Island,” he says.

With the final rules release, senior advocates and providers are expressing their opinion about its impact.

Former President Donald Trump, who is challenging President Joe Biden for the presidency, has not addressed quality of care in nursing homes with a formal position.  Kathleen Heren, Rhode Island’s Ombudsman, speculates that by releasing the CMS mandate before the upcoming presidential election, President Biden is just trying “to establish a record” of enhancing quality of care in nursing homes.

“Nursing homes cannot find  Registered nurses (RN), and Nursing Assistances to hire,” notes Heren.  The CMS mandate will force nursing homes to downsize, like we have just seen happen at the Scandinavian Home,” she predicts.

According to Heren, the final CMS rules do not include the minimum staffing of LPNs. More important, “it’s an unfunded mandate,” she says.

Gerontologist Deb Burton, MS, executive director of RI Elder Info, is pleased to see a Federal minimum staffing mandate of 3.48 hours of daily nursing care. “It’s important to understand mandates don’t make workers appear and a minimum staffing mandate is only an average amount of time allotted for care across all residents in the facility,” she says, noting that this rule doesn’t mean each resident will receive 3.48 hours of care each day.

According to Burton, the CMS Nursing Home Compare website, as of April 2024, notes there are 6 Rhode Island facilities that would not meet the lower federal minimum staffing mandate if it were enacted today. “The workforce shortage and the dire need to increase Medicaid reimbursements to attract and retain adequate staff with a proper wage are common topics of meetings,” says Burton. 

“When workers say ‘It’s only me on the floor – do I help the resident eat their supper or take the other resident to the bathroom? I can’t do both,’ – we need to listen,” says Burton. “The new federal minimum staffing mandate is a good step forward, but we need more. One day it will likely be us waiting for that workers’ help,” she warns. 

Like other RI senior advocates, Maureen Maigret, policy director for the Senior Agenda Coalition of RI, sees the importance of CMS releasing its final rules.  “It is important that these regulations have been finalized as providing for minimum nurse staffing levels in nursing homes helps  ensure residents across the country will receive quality and resident-centered care,”  she says. 

According to Maigret, Rhode Island has had a provision for 24/7 RN coverage even before the state’s minimum staffing law was passed so that is not a new requirement here. She pointed out the regulations will also promote transparency and accountability by requiring public reporting on how much of the Medicaid payments are spent on direct care staff and that the federal government has committed to invest over $75 Million in an initiative to increase the number of nurses working in nursing homes through such things as financial incentives for tuition reimbursement.   

“We are dismayed that the Biden Administration is moving forward with this one-size-fits-all staffing mandate,” says John E. Gage, President and CEO of the Rhode Island Health Care Association. “In the midst of a historic and deepening caregiver shortage, this unrealistic policy will put access to care at risk for countless seniors in Rhode Island and across the country,” he warns, noting that when nursing homes can’t find nurses and/or certified nursing assistants (CNAs), they will be forced to downsize or, even worse, close their doors altogether, leaving seniors with fewer options to receive the care they need.

New final rule just another unfunded mandate

Like the 2021 RI staffing law, the Federal rule is an unfunded mandate, charges Gage. “Every nursing home wants more workers, but rather than blanket mandates from Washington, we need supportive policies and investments that will help us recruit and retain caregivers, he states.

According to Gage, nationally, the nursing home workforce has declined by 124,200 individuals (-7.8%) since the start of the pandemic. Rhode Island’s numbers are even worse, down 1,495 individuals (-15.3%). Gage calls on Congress to step up and support the bipartisan Protecting America’s Seniors’ Access to Care Act, which would prevent CMS from enforcing this unfunded and flawed mandate.

“Together with our national association, the American Health Care Association (AHCA), we will continue to fight for more common-sense solutions and do everything we can to preserve access to care for Rhode Island seniors,” says Gage.

“The good news about the Biden Administration’s final rule, there are phase-ins over multiple years that will provide an opportunity to challenge the mandates through legislation and/or possible AHCA litigation on the national level,” adds Gage. “The federal mandate highlights how much of an outlier RI’s staffing mandate is.  The RI statute has the highest staffing metrics and the highest fines in the country – 10% above the federal standards.  Without the Executive Actions of Governor McKee, RI nursing homes would be fined $90 million in the first full year of enforcement – devastating facilities and forcing further closures.  RI excludes hours worked by administrative nurses from counting toward the RN metric, yet they are included in the federal standards.  RI also excludes med techs’ and nurse aides in training’s hours from the CNA metric, while CMS includes them,” noted Gage.

Gage adds that the CMS final rules consider Rhode Island to be “urban.” As a result, the state has 2 years to phase-in the 24×7 RN requirement.

Rhode Island regulations and law have required 24×7 RN coverage in nursing homes for many decades, says Gage. “While challenging to maintain compliance given the shortage of registered nurses, this should not be a major concern for RI facilities,” he adds, noting that there will be 3 years to comply with the required 0.55 HPRD for RNs and 2.45 HPRD for CNAs. 

Additionally, Gage says that there are also waiver opportunities in certain circumstances.  “During the implementation phase, facilities and all stakeholders must be laser-focused on building a sufficient pipeline of qualified nurses and CNAs to the nursing home workforce,” he says.  

Like Gage, James Nyberg, executive director LeadingAgeRI, sees the CMS mandate as less onerous than the RI staffing mandate that “fortunately” remains suspended. “We remain concerned about the impact of this national mandate on providers in Rhode Island, and its broader impact on consumers and the health care industry,” he says.

According to Nyberg, the state’s current workforce shortages are already preventing nursing homes from filling open positions, limiting new admissions, and forcing organization closures (six nursing homes have already closed since the COVID pandemic began and two more have embarked on significant downsizing). 

“These challenges are also resulting in backlogs at hospitals, which are unable to discharge patients due to reduced capacity in nursing homes,” says Nyberg, noting that LeadingAgeRI is working with numerous stakeholders on various initiatives to develop a pipeline of workers. “But the simple fact is that it will take time and an infusion of resources,” he adds.

“CMS proposes to spend $75 million on a nursing home staffing campaign.  That amount might help a state like Rhode Island, but that money is national, so it is a drop in the bucket in terms of the support the industry needs, states Nyberg.  “On the home front, we have been working with the Administration and the General Assembly to provide an infusion of funding to try and rescue the homes from their dire financial straits and try to stabilize the industry.  But the federal mandate, and all the related details and requirements embedded in the rule, do nothing to further that cause,” he says.

For the Minimum Nursing Standard final rules, go to https://public-inspection.federalregister.gov/2024-08273.pdf

For the CMS Fact Sheet  on Minimum Nursing Standard final rules, go to https://www.cms.gov/newsroom/fact-sheets/medicare-and-medicaid-programs-minimum-staffing-standards-long-term-care-facilities-and-medicaid-0

Annual retirement survey: Caregivers less likely to save. Support for this critical role.

EBRI Survey Says Unpaid Caregivers Less Likely to Save for Retirement

Published in RINewsToday.com on July 24, 2023

According to the 33rd annual Retirement Confidence Survey (RCS) released last week, caregivers are more likely to have lower levels of assets and more likely to have problems with debt than non-caregivers. Because of this they are also less likely to have saved for retirement, and are more likely to retire earlier than planned for reasons out of their control, which can reduce the lifestyle of caregivers in retirement.

According to the Employee Benefit Research Institute (EBRI), a nonpartisan organization researching health, personal finance and economic security issues, the RCS is the longest-running survey of its kind that measures worker and retiree confidence. The survey is conducted jointly by EBRI and Greenwald Research, a firm specializing in retirement, employee benefits and health care research.

The online survey of 2,537 Americans was conducted from Jan. 5 through Feb. 2, 2023. All respondents were ages 25 or older. The survey included 1,320 workers and 1,217 retirees, and this year included an oversample of roughly 944 completed surveys among caregivers (598 workers and 346 retirees).

“Caregivers can take on many roles and responsibilities when taking on the care of a relative or friend. Unfortunately, what we found is that caregiver retirees are more likely than non-caregivers to say that their overall lifestyle in retirement is worse than they expected it to be before they retired,” said Craig Copeland, director, Wealth Benefits Research, EBRI in a statement released on July 18, 2023.

Key findings in the 2023 RCS Caregivers Report

The RCS’s findings also indicate that caregivers are more likely to have little financial cushion in retirement, having virtually no financial assets and are more likely to have a problem with debt than non-caregivers.  Twenty five percent of caregivers have less than $1,000 in savings and investments compared with 15 percent of non-caregivers. At the same time, caregivers are less likely to say that debt is not a problem — 36% compared with 48% among non-caregivers.

The researchers found that 55% of caregivers who work, and 37% of retired caregivers reported that they provide financial assistance to the recipients of their care. Over one-third of working caregivers (35%) and retired caregivers (37%) say they provided $5,000-$14,999 in financial support to their caregiving recipient in the past 12 months.

RSC’s study also found that the unpaid caregiver’s role and responsibilities are more likely to have a negative impact on their mental and physical health, than in doing specific financial tasks. Among working caregivers, 66% say their mental health is negatively impacted by the caregiving they provide, and 57% say their physical health is negatively impacted. Fifty four percent of the working caregivers reported that they had difficulty saving for emergencies and could not work the hours they wanted or needed to work.

According to RSC’s study there are no significant differences between caregivers and non-caregivers strongly or somewhat agreeing that they feel knowledgeable about managing their day-to-day finances.  Additionally, there are also no significant differences in the likelihood of caregivers and non-caregivers strongly or somewhat agreeing that they feel knowledgeable about managing savings and investments for the future.

Caregivers in many instances have less confidence in their finances than non-caregivers, say the researchers, noting that when it comes to preparing for retirement, caregivers are just as likely as non-caregivers to have done various retirement preparation tasks. These include having tried to figure out how much money they will need to have saved by retirement, thought about how much money to withdraw from their retirement savings and investments, and planned for how they would cover an emergency or big expense in retirement.

The distributions of the ages at which both caregivers and non-caregivers retired are not different, say the researchers, noting that the likelihood of retirees having retired earlier, later, or when planned are also not different between caregivers and non-caregivers. However, the findings say that the top reason caregivers were most likely to have retired earlier than planned was because they had to care for a spouse or another family member. 

Finally, RSC’s survey found that caregiver retirees are more likely to say that their overall lifestyle in retirement now, compared with how they expected it to be before they retired, is worse than non-caregiver retirees. Specifically, 31% of caregiver retirees say it is worse, compared with 20% of non-caregiver retirees.

A call for Congress and state policies to assist Caregivers

“EBRI’s study further confirms that America’s 53 million unpaid family caregivers are experiencing harsh financial effects due to caregiving. From taking on debt to spending down savings, too many family caregivers are sacrificing their financial health to fulfill their care responsibilities, says Jason Resendez, President & CEO of the National Alliance for Caregiving. “Without federal policies such as paid family and medical leave, family caregivers will continue to risk their financial security to provide essential care for their loved ones,” he says.

According to Maureen Maigret, Chair of the Aging in Community Subcommittee of the Long-Term Care Coordinating Council, the findings are no surprise to her. They mirror findings from the 2020 National Alliance for Caregiving and AARP report, Caregiving in the U.S. which found 61% of family caregivers were women, 45% had seen a financial impact due to caregiving, and an increase in family caregivers reporting fair or poor health since 2015.

“It’s estimated that 121,000 Rhode Island caregivers provide an economic value of $2.1 billion for the care they provide,” says Maigret. 

“The fact that women represent a larger percent of unpaid caregivers is significant in looking at differences in financial situation of caregivers vs. non-caregivers,” says Maigret, who serves on the board of the Senior Agenda Coalition and Village Common of RI.

“There continues to be a wage gap for women workers which impacts them in their retirement years”, she says, noting that U.S. Census data shows there is a 21% difference in average Social Security benefits for Rhode Island women and a 43% difference in pension income.

“Women are also over-represented in a number of paid caregiving jobs with depressed wages such as nursing assistants and childcare workers, and this impacts them in retirement,” says Maigret, calling on state lawmakers to pass legislation to expand the Temporary Caregiver Insurance law paid leave program funded entirely by workers from 6 to 12 weeks as most states with such programs have done. They could also increase state funding for the caregiver respite program to allow greater amounts of respite for family caregivers to work or address their own needs.  

“The Rhode Island General Assembly can also consider a tax credit program to help offset the costs incurred by family caregivers as several states have done,” adds Maigret, suggesting that they could consider lowering the age for the Office of Healthy Aging @Home Cost Share program from 65 to 60 years to allow more caregivers of seniors with disabilities to access this program thus relieving some of their financial burden.

Deb Burton, Executive Director of RI Elder Info, notes that Rhode Islanders are disproportionately impacted by the cost of caregiving because in comparison to other states, “We have a higher per capita ratio of individuals over the age of 85 in the state. Many people in their 60’s and 70’s retired to care for their parents who are in their 80’s, 90’s and 100’s,” says the gerontologist. 

“There are also disparities in financial strain among caregivers based on race, ethnicity and age of the caregiver which must be considered in light of the EBRI study,” says Burton, citing an article penned by Richard Eisenberg. According to Eisenberg’s article in AARP. “The Family Caregivers Feeling the Most Strain” Hispanic family caregivers, spend an average of 44% of income on caregiving, African Americans spend 34% and White caregivers spend 14% on caregiving costs. Caregivers ages 71 to 91 pay more than twice the amount of caregivers ages 51 to 70. 

“We urgently need to create a Statewide Plan on Aging to address the multiple ways our added longevity is intersecting with our financial, familial and community roles,” she says.

“The House commission on older adults will begin meeting in September and we will begin by looking at a broad set of policies and programs.  We haven’t established what our agendas will look like, as of yet, but issues raised within this new report may be part of the conversation,” says Rep. Lauren Carson (D-District 75, Newport) who chairs the new study commission to take a look at funding, coordination, and deliver of state programs and services to seniors. 

“Over the next 10 years, we’ll likely have 15 to 20 percent more seniors in Rhode Island, and we need to be prepared,” says Carson, noting that the commission will take a look at all the challenges and issues at the outset.” We’ll develop more specifics as we move forward. I’m very interested in this retirement confidence survey, and I think it could really be useful to our commission as we look at the myriad of issues facing our older Rhode Islanders,” she says.

The RCS report focusing on caregivers can be viewed by visiting www.ebri.org/rcs-caregivers.  

Caregiving in the US found at https://www.caregiving.org/research/caregiving-in-the-us/

For estimates of #of RI caregivers: https://www.aarp.org/content/dam/aarp/ppi/2023/3/valuing-state-estimates.doi.10.26419-2Fppi.00082.009.pdf

For caregiver data, go to US Census Age Group Gender Gap data @ https://www.census.gov/library/visualizations/interactive/exploring-age-groups-in-the-2020-census.html

Advocates on aging issues review their priorities for Gov. McKee’s policy agenda

Published in RINewsToday on Nov. 14, 2022

Over 3 months ago, the Senior Agenda Coalition of Rhode Island (SACRI) invited the six Gubernatorial candidates to give the details of their aging policy positions to hundreds gathering at East Providence High School, and watching virtually. With the dust settling after the Nov. 8 midterm elections, aging advocates are asking the winner, Gov. Dan McKee, to place a high priority on enacting aging policies that he supported during SACRI’s 143-minute forum.

McKee goes on the record

McKee addressed the issue that Rhode Island nursing home and home care providers can’t provide sufficient and sustainable wages to attract and retain workers because of low state reimbursement. When questioned about how he would rebuild and sustain a viable workforce to provide services to seniors and persons with disabilities, the Governor stated he has addressed staffing issues at home health agencies and nursing homes by expanding the Wavemaker Fellowships to include healthcare workers and increasing reimbursement rates for home health agencies by $900,000 annually.

More seniors prefer to age in place at home in their community rather then enter nursing homes. McKee gave his thoughts about Medicaid rebalancing and expanding the program to keep seniors at home. He touted the $10 million invested this year to rebalance the long-term care continuum, announcing his plans to soon issue an Executive Order to direct state agencies to review existing policies through

At the forum, McKee stated he will also direct all state agencies to appoint a representative to a task force, also including municipalities and community-based nonprofits, that will create a Statewide Aging Plan to determine where federal monies and grants can be utilized to support older Rhode Islanders.

During the mid-1990s the Department of Elderly Affairs (DEA) had a staff of 65. Demoted to the Office of Healthy Aging within the state’s Department of Health and Human Services, Gov. McKee went on record that he will support legislation next year to make the state’s Office of Healthy Aging a full cabinet department. He pledged to provide an adequate budget and staffing to oversee its programs and services to Rhode Island’s growing senior population.   

Gov. McKee also supported a yearly cost-of-living increase to the state Supplemental Security Income payment in the 2024 proposed budget. He also supported the increasing of eligibility for the Medicaid Savings Programs for seniors and people with disabilities in the proposed 2024 budget by eliminating the asset test and increasing eligibility to at least 185% Federal Policy Level. 

With the state passing $250 million in funding for housing, Gov. McKee agreed to provide an adequate amount to support senior housing.  He stated: “we’re off and running”, noting that he recently announced an investment of $80 million to construct 825 units in 17 communities.  The Governor noted that his 2030 plan speaks specifically on the issue of senior housing.

Make aging policy a priority

“With the growing needs of seniors throughout the country and within our state it is time to return to a function of government which “had teeth” to enact change for elders who were at risk,” says Bob Robillard, LMHC, President of Rhode Island Senior Center Directors Association, representing 34 Senior Centers, noting that his aging group is pushing for the passage of bipartisan legislation next session that will elevate the Office of Healthy Aging to a full department – cabinet – status. 

According to Robillard, having a seat at the table as a cabinet position, the Director would directly advocate with the Governor’s Office to address unmet needs and seek creative solutions for our seniors. 

Robillard also urged the Governor to continue efforts to develop secure and affordable housing that meets the need for increased  homelessness of Rhode Island seniors. ”Their income level and having to make difficult choices to survive each month is seen in our interactions with seniors every day, and they are increasingly utilizing food banks, emergency services, and our centers, and funding these basic services needs to be a top priority,” he says.

While some federal funds have been used to address this issue, Robillard says there is a “global need for a full and comprehensive Aging Plan for Rhode Island including the voices of direct service providers like the Senior Centers, senior advocates, caregivers and, of course, seniors, themselves.” 

Finally, Robillard believes that there should be a strong focus on transportation for seniors to access their community. “Safe, respectful and person-centered transportation in our rural areas throughout our state needs to be a focus,” he says, noting that if you cannot access your community in these ways then you cannot participate in them either.

With Rhode Island experiencing a critical shortage of homecare workers, Maureen Maigret, chair of the Long-Term Care Coordinating Council’s Aging in Community Subcommittee, calls on Gov. McKee to provide funding in the FY2024 budget to increase wages for CNAs working in home care. “The current budget includes $10 million to rebalance long term care. These funds should be used for wage increases for homecare direct care staff as an initial step to bring these invaluable workers fair wages,” says Maigret.

“It is also important to provide more resources to the Office of Healthy Aging and support for local senior services. Governor McKee started to increase funds for local aging services in the current budget and the Office of Healthy Aging has requested funding to provide each community ten dollars per person aged sixty-five and over next year,” adds Maigret, urging the Governor to include this in the budget he presents to the legislature for FY2024 as well as other funding requested by the Office including $.5million to support the state’s Aging and Disability Resource Center known as THE POINT. 

Gerontologist Deb Burton calls for the Governor to move forward to pass an Olmstead Plan to create opportunities for individuals to live in the least restrictive environments. “The Olmstead Plan would fit hand in glove with providing resources for individuals to age in the community, and not in institutions,” says Burton, who serves as Executive Director of RI Elder Info.  

Finally, Vincent Marzullo, well-known aging advocate who served as a federal civil rights and national service administrator, suggests that McKee direct the RI Commission for National/Community Service to identify AmeriCorps (national service) opportunities that would help build capacity and service delivery for our local senior centers and human services offices.  “Their needs have grown considerably during COVID,” says the West Warwick resident.

Editor’s Note: During the COVID weekly press conference time, Gov. Raimondo noted that changes need to be made in how people live in Rhode Island’s nursing homes, both from a communicable disease point of view, and from a humanity point of view. She announced a fund of $5 million to be put aside to support nursing homes transitioning their physical “plants” to be single room – single bathroom accommodations. Since Raimondo left office, there has been acknowledgement that this fund was set aside, but no action taken to address the mandate moving forward.