Time to resolve RI’s ongoing Nursing Home staffing crisis

Published in RINewsToday on April 18, 2021

The latest release of AARP’s Nursing Home COVID-19 Dashboard shows that both cases and deaths in nursing homes declined in the four weeks ending March 21. Although these rates are improving, chronic staffing problems in nursing homes—revealed during the COVID-19 pandemic—continue. In Rhode Island, 30% of nursing homes reported a shortage of nurses or aides, which is only fractionally better than the previous reporting period. 

AARP has come out swinging to fight for enhancing the quality of care in Rhode Island’s 104 nursing homes.

AARP Rhode Island, representing 131 members, calls for the General Assembly to ensure the quality of care for the state’s nursing home through minimum staffing standards, oversight, and access to in-person formal advocates, called long-term care Ombudsmen. The state’s the largest aging advocacy group has urged lawmakers to create a state task force on nursing home quality and safety and has pushed for rejecting immunity and holding facilities accountable when they fail to provide adequate care to residents.  It’s also crucial that Rhode Island ensures that increases in nursing homes’ reimbursement rates are spent on staff pay and to improve protections for residents, says AARP Rhode Island. 

Last December, AARP Rhode Island called on Governor Gina Raimondo to scrap Executive Order 20-21 and its subsequent reauthorizations to grant civil immunity related to COVID-19 for nursing homes and other long-term care facilities. The aging advocacy group warned that these facilities should be held responsible for providing the level of quality care that is required of them for which they are being compensated.

Rhode Island Lawmakers Attack Nursing Home Staffing Crisis

During the legislative session, the state’s nursing home staffing crisis caught the eye of Senate Majority Whip Maryellen Goodwin is a policy issue that needs to be addressed. They knew that Rhode Island ranked 41st in the nation in the number of the average hours of care nursing home residents receive, according to data from the Centers for Medicare and Medicaid Services.  The state also has the lowest average resident-care hours per day of any New England state.

On Feb. 2, the Rode Island Senate approved S 0002, “Nursing Home Staffing and Quality Care Act” sponsored by Goodwin and nine Democratic cosponsors to address an ongoing crisis in staffing nursing homes that has been exacerbated by the COVID-19 pandemic.  The bill had passed unanimously in the Health and Human Services Committee, and ultimately, the full Senate gave its thumbs up to the legislative proposal by a vote of 34 to 4.  Only one Republican senator crossed the aisle and voted with the Democratic senators.

“There is a resident care crisis in our state. Staffing shortages and low wages lead to seniors and people with disabilities not receiving the care they desperately need. The pandemic, of course, has exponentially increased the demands of the job and exacerbated patients’ needs. We must confront this problem head-on before our nursing home system collapses,” said Sponsor Senator Goodwin (D-Dist. 1, Providence).

The legislation would establish a minimum standard of 4.1 hours of resident care per day, the federal recommendation for quality care long endorsed by health care experts including the American Nurses Association, the Coalition of Geriatric Nursing Organizations, and the National Consumer Voice for Quality Long-Term Care. The bill, which the Senate also approved last year, has been backed by Raise the Bar on Resident Care, a coalition of advocates for patient care, and the Rhode Island’s Department of Health (RIDOH).

The bill would also secure funding to raise wages for caregivers to recruit and retain a stable and qualified workforce. Short staffing drives high turnover in nursing homes. Not only does high turnover create undue stress and burnout for remaining staff, but it also diverts valuable resources to recruit, orient, and train new employees and increases reliance on overtime and agency staff.  Low wages are a significant driver of the staffing crisis. The median wage for a CNA in Rhode Island is less than $15, and $1/hour lower than the median wage in both Massachusetts and Connecticut.

The legislation would also invest in needed training and skills enhancement for caregivers to provide care for patients with increasing acuity and complex health care needs.

At press time, the companion bill (2021-H-5012), sponsored by Reps. Scott A. Slater (D-Dist.10, Providence) and William W. O’Brien (D-Dist. 54) was considered by House Finance Committee and recommended for further study.

RIDOH’s Director Nicole Alexander-Scott, MD, MPH says the state agency “supports the thoughtfulness of the provisions included in the legislation and welcomes dialogue with its sponsors, advocates, and the nursing home facility industry regarding methods to sustain the necessary conditions associated with the intent of the bill.”

Alexander-Scott states that “RIDOH takes its charge seriously to keep nursing home residents and is supportive of efforts to update standards of care to better serve Rhode Islanders in nursing facilities, as well as increase resident and staff satisfaction within nursing facilities.”

Scott Fraser, President and CEO of the Rhode Island Health Care Association (RIHCA), a nonprofit group representing 80 percent of Rhode Island’s nursing homes, says that “staffing shortages are directly traceable to the chronic lack of Medicaid funding from past governors. Period.” 

According to Fraser, state law requires Medicaid to be funded at a national inflation index, usually averaging around 3%. “Up until this year, previous governors have slashed this amount resulting in millions of dollars in losses to our homes.  Thankfully, Governor McKee is proposing to fully fund the Medicaid Inflation Index this year,” he says.

RIHCA opposes the mandatory minimum staffing the legislation now being considered by the Rhode Island General Assembly, says Fraser, warning that its passage would result in facilities closing throughout the state. “No other state has adopted such a high standard,” he says, noting that the Washington, DC-based American Health Care Association estimates that this legislation would cost Rhode Island facilities at least $75 million to meet this standard and the need to hire more than 800 employees. 

Fraser calls for the “Nursing Home Staffing and Quality Care Act” to be defeated, noting that the legislation does not contain any provisions for funding.  “Medically, there is no proof that mandating a certain number of hours of direct care results in any better health outcomes.  This is an unfunded legislative mandate. If homes are forced to close, not only would residents be forced to find a new place for their care, but hundreds of workers would also be forced out of work,” he says.

Goodwin does not believe that mandating minimum staffing requirements in nursing homes will force nursing homes to close. She noted that the legislation is aimed at ensuring nursing home residents receive adequate care and that Rhode Island is the only state in the northeast without such a standard.

“There is an un-level playing field in nursing home staffing in Rhode Island,” charges Goodwin, noting that many facilities staff 4.1 hours per day, or close to it, while others only provide two hours of care per day. “In either case, the overwhelming majority of well-staffed and poorly-staffed nursing homes remain highly profitable,” she says. 

According to Goodwin, the lack of staffing and certified nursing assistants (CNAs) is due to unreasonable workloads and low pay. “RIDOH’s CAN registry makes it clear that retention of these workers is a big issue. This is in part because they can make as much money – or more – in a minimum wage profession with much less stress,” she adds, stressing that “The Nursing Home Staffing and Quality Care Act” directly addresses these staffing challenges.

One quick policy fix is to provide nursing home operators with adequate Medicaid reimbursement to pay for increased staffing.  Lawmakers must keep McKee’s proposed increase of nursing home rates pursuant to statute, requiring a market-based increase on Oct. 2021, in the state’s FY 2020 budget. The cost is estimated to be $9.6 million.

With the House panel recommending that Slater’s companion measure ((2021-H-5012) to be held for further study, Goodwin’s chances of seeing her legislation becoming law dwindles as the Rhode Island Assembly’s summer adjournment begins to loom ever closer. There’s probably no reason to insist that a bill be passed in order to have a study commission, so this could be appointed right away if there is serious intent to solve this problem.

Slater’s legislation may well be resurrected in the final days of the Rhode Island General Assembly, behind the closed doors when “horse-trading” takes place between House and Senate leadership.  If this doesn’t occur, either the House or Senate might consider creating a Task Force, bringing together nursing home operators, health care professionals and staff officials, to resolve the state’s nursing home staffing crisis. 

The Best Of…Seniors Can follow Steps to Avoid Heat-Related Illnesses

Published July 5, 2002, Pawtucket Times

            On July 3rd, it was so hot you could fry an egg on the pavement outside of McCoy Stadium.

             Although more than 10,500 fans had bought tickets to watch the PawSox game against the Ottawa Lynx, which concluded with a 45-minute fireworks display, only 8,300 fans showed up, according to Ken McGill, co-chair of teh Pawtucket Fireworks Committee.

             There were even smaller crowds who set up chairs in the parking lots and on sidewalks in the surrounding neighborhoods around McCoy Stadium to watch the much-awaited fireworks display, McGill said.

              But despite the searing heat that evening it was clear that some just like it hot.

              As the PawSox game was winding down, Ray Ethier, 60, a former union electrician, chatted with his friend, George Panas, 59, of Spumoni’s Restaurant.

             “I don’t mind the heat.  I just don’t like this humidity,” he candidly admitted.  However, Ethier acknowledged that the heat has slowed him down a bit, because “it’s too hot to play golf.”

            Panas doesn’t mind the searing outside heat either, or even working in a hot kitchen.

            “When people are sweating buckets in the kitchen, I feel as cool as a cucumber,” he said.

            Fifty-seven-year old Stan Lachut, a retired Pawtucket school teacher, waited with his wife Beverly, for darkness and for the fireworks show to begin. Standing by the barbecue tent and surrounded by more than 200-plus guests of the Pawtucket Firework’s Committee, the Cumberland residents said the heat’s not a problem for him, either.

            “Being outside in summer is a time you can spend with your family and friends,” he said, whereas “colder temperatures force people to stay inside buildings.”

            On the other hand, not everybody like summer’s hot days

           Ttemperatures in the mid-90s, combined with high humidity, can become uncomfortable and a serious health hazard for seniors.  And many are heeding the advice of experts gleaned from radio, television, and local newspaper articles about how to cope with the scorching summer heat.

           Patricia A. Nolan, M.D.,  the state’s top health official, gave her advise on surviving Rhode Island’s current heat wave.

            Seniors, small children and the mentally ill are the most susceptible to health problems from searing summer heat waves, said Nolan, who serves as the director of Rhode Island’s Department of health.  High temperatures can be especially dangerous to persons’ with cardiac and respiratory probems and to mentally ill patients taking psychotropic medications, she said.

            She noted that psychotropic medications make it harder for an individual to cool down.

            According to Noran, the early symptoms of heat-related illnesses include muscle cramps in the arms, hands, abdomen and legs.  Muscle cramps are a result of dehydration and salt loss, primary problems associated with heat stress.  Additionally, Nolan said that fainting in the heat is another early symptom

           If someone faints because of the heat, take the person into a cool place and cool them off by using a wet, cool cloth, Nolan recommends.

          “You want to sponge people down and fan them to reduce their body heat,” she says.

          Heat exhaustion, or heat-stork, is a more serious problem related to dehydration caused from high temperatures Nolan stated.  “Feelings of complete exhaustion, confusion, nausea or vomiting are real danger signs,” she said, adding, “If this occurs, you must get the body temperature down by addition fluids through intravenous methods.”

          To successfully beat the heat, seniors should cut back on outside physical activities and drink plenty of water, Nolan recommends.

          While water is the best fluid to drink on a hot day, fruit juice can also be considered a viable substitute.

          “Cooling off with a cold beer is not the best plan,” Nolan said, noting that alcohol coffee, tea and soda are loaded with caffeine, which can increase the changes of dehydration.

           “Seniors who tend to be most vulnerable to heat are those who don’t have a way to get cool for a part of the day,” Nolan said.  “One of the reasons heat waves affect the elderly more than the general population is because seniors are isolated, can’t get to a cool place, don’t have air conditioning and are afraid to open their windows at night when it finally cools down.”

            Nolan warned that with temperatures in the mid-90s, staying indoors in a really hot house or apartment is not the best thing for seniors to do.

           “Go to an air-conditioned shopping mall, see a movie, visit a restaurant, or get yourself into an air-conditioned space,” she recommended.  “If you can do this for an hour on a really hot day, you can protect yourself from serious health-related problems.”

          Sometimes seniors get into trouble during days with high temperatures because they just don’t realize the danger,” Nolan noted.

          During these days, it becomes important to monitor elderly parents or older friends, she says.

           “Call on them every day to make sure they are coping with the heat.  Take them out to a cool place, like a shopping mall, a library, or a restaurant to let them cool off.”

           In Rhode Island, some seniors tend not to adjust their behaviors to the heat because it’s only going to be hot for a few days,” Nolan says.

           However, adjustments are fairly easy to make, she noted, stating that not making them can be hazardous to their health, and perhaps even deadly.

          Herb Weiss is a Pawtucket-based freelance writer who writes about aging, health care and medical issues. He can be reached at hweissri@aol.com.

The Best of…Nationally Elder Abuse and Neglect on the Increase

           Published June 25, 2001, Pawtucket Times

           Although numerous federal studies and Congressional hearings have put the public spotlight on elder abuse and neglect over the years, a Special Senate on Aging panel calls for the nation to get serious to tackle this all-to-common tragedy, called by some “the dark side” of aging. 

           “With the senior population skyrocketing, incidents of elder abuse will only continue to rise,” warned Democratic Chairman John Breaux of Louisianato his panel colleagues at the June 14th hearing.   At the hearing Senator Breaux took over the reins of the Aging  Committee from the former Chairman Republican Larry Craig ofIdaho, with the Senate majority tipping to the Democrats.  Initially it was Senator Senator Craig who had planned and put the hearing on the Senate schedule.      

           At the  hearing, Chairman Breaux estimated that more than 820,000 older and developmentally disabled individuals are subjected to abuse, neglect and exploitation.  Meanwhile, throughout  the hearing “Elder Abuse, Neglect, and Exploitation: A Hidden National Tragedy,” several witnesses testified that this number is too low because of underreporting and there are no universal definitions of what is elder abuse and neglect.  To combat abuse, Chairman Breaux and the witnesses called for more funding to be provided to adult protective services, better training for medical personnel to identify the problem early and more resources for caregivers to help them with their caregiving responsibilities.

            Despite the fact that many believe that elder abuse and neglect take place in nursing facilities and assisted living facilities, most often times it occurs in a person’s home where nearly 95 percent of all domestic long-term care is being informally provided by family members and community-based caregivers, noted Chairman Breaux.

            Summing up testimony from hearing witnesses, a Senate Aging Committee staffer told The Times that elder abuse can be caused by social, medical and legal factors.

             “We are expecting families to provide a large amount of long-term care and we give only minimal assistance and support to them,” the Senate staffer said.  To deal with social factors causing elder abuse and neglect, “we need more respite care and training in care giving skills.” he added.   

             As to medical factors, the Senate staffer added, “it is crucial that better training be made available to physicians and nurses to recognize the early signs of elder abuse itself.”  If this occurred there could be much quicker interventions, he said.  

             Finally, legal factors, specifically the lack of funding for elder protective services, reduce the effectiveness of prosecuting persons who financially exploit elderly.

                 So what’s happening inRhode Island?

             According to Wayne Farrington, Chief of Facilities Regulation,Rhode Island’s Department of Health, elder abuse is on the increase in nursing facilities and assisted living facilities across the state.  “This year we have had about a 15 percent increase in reports of abuse, neglect or mistreatment,” he says.  Farrington speculates that the rise in reporting is a result of a better informed public who know where to register complaints combined with increased publicity over the staffing shortage in nursing facilities and community-based provider agencies.  The shortage of nursing assistants, who provide most of the direct patient care, along with nurses oftentimes results in the facility not being able to provide the needed care.

            “Because neglect abuse and mistreatment are criminal matters they are turned over to the Rhode Island Office of the Attorney General for further investigation and prosecution, Farrington says.  “If we find that facilities have violated regulations that have resulted in the abuse or neglect we will cite the facility with deficiencies that may be tied to civil monetary penalties.

           According to Medicaid Fraud Unit Chief Bruce Todesco, of the state’s Office of the Attorney General, there are really no accurate statistics or numbers that tell the incidence of elder abuse and neglect inRhode Island.  “A lot of information comes from different sources,” he said, stressing that it would take a lot of work to pull together meaningful statistics.

           Adds, Genevieve  Allair-Johnson, Special Assistant Attorney General who serves as Elderly Affairs Liaison for Criminal Division, in the Attorney General’s Office, elder abuse and neglect cases may be under reported because the elderly person does not want to proceed against the child and competency issues often times come into play.

           “We work closely with the Department of Elderly Affairs and local police departments and provide them with legal assistance in their investigations, Allair-Johnson says.  “When discussing a case sometimes it comes up that additional inquiries will have to be made to bring about charges.”   

            Allair-Johnson states “Many times criminal charges will not be filed in cases because high standards must be met.”   Rather than filing criminal charges for elder abuse or neglect other options are in place like removing the elderly person from a home, or seeking a court ordered guardianship.

          Over the last few years the Office of the Attorney General has developed effective partnerships with the local police departments, Department of Elderly Affairs, and the Alliancefor Better Long-Term Care,” Allair-Johnson says.  “There are a host of state agencies and resources that are beginning to pull together to resolve this elder abuse issue. We’re going in the right direction.”

          To obtain materials on elder abuse, including the pamphlet “The Elder Victims Guide to the Criminal Justice System,” or to seek information about consumer issues or to report elder abuse, neglect and financial exploitation, call the Attorney General’s Senior Line at 888-621-1112. 

          If one has a reasonable knowledge and suspects an elderly person has been abused neglected or mistreated in a nursing facility call the Division of Facility Regulation at 222-2566.

          Herbert P. Weiss is a Pawtucket, Rhode Island-based  free lance writer covering aging, health and medical care issues,  This article appeared in the June 25, 2001 in the Pawtucket Times.   He can be reached at hweissri@aol.com.