Tag Archives for skilled nursing facility

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

Dr. Teresa Chopoorian: McKnight’s Women of Distinction Award winner

Published in the Pawtucket Times on February 22, 2021

After reviewing hundreds of submitted entries, an independent panel, composed of two dozen judges, selected 19 women, including Dr. Teresa J. Chopoorian, to be inducted into the McKnight’s Women of Distinction Hall of Honor as part of the program’s third annual class. 

Dr. Chopoorian serves as Vice President and Administrator of the Central Falls, RI-based Mansion Nursing and Rehabilitation Center and is a former Professor of Nursing and Chairs the City of Pawtucket Cancer Control Task Force.     

According to McKnight’s Long-Term Care News the Hall of Honor recognizes executive-level professionals who have made a significant impact in the skilled nursing or senior living industries.  Of the sixty women who have been inducted into the Distinction Hall of Honor since its inception in 2019, Dr. Chopoorian is the only Rhode Islander to receive this prestigious recognition. 

Considered the hallmark of recognition for women leaders in the seniors’ care and living industries, McKnight’s Women of Distinction honors are given in three categories: Rising Stars, Veteran VIPs, and the Hall of Honor. A Lifetime Achievement Award winner will also be announced in March.  The annual awards program is administered jointly by McKnight’s Long-Term Care News and McKnight’s Senior Living. The winners will be recognized in editions of the McKnight’s Daily Update and McKnight’s Daily Briefing newsletters.

All of this year’s honorees, working in the health care industry, will be celebrated during a May 18th virtual awards event.  The ceremony will take place the evening followed by a special McKnight’s educational forum for all professionals in the long-term care and senior living industries the next morning. 

The Life and Times of Dr. Chopoorian

Dr. Chopoorian was hired as an Instructor at Boston University School of Nursing after completing her master’s degree at this university in 1964.  She was promoted to Assistant Professor and recognized as Teacher of the Year in 1968.  

She left Boston University in 1970 to accept a professorship at Boston College to co-direct a Macy Foundation graduate program with Harvard Medical School, a novel initiative to prepare Clinical Nurse Specialists. The program was among the first graduate nursing curriculum in the country and served as a critical role model for forthcoming nurse practitioner programs. 

In 1974, Dr. Chopoorian joined the faculty of Boston State College Department of Nursing and began doctoral studies at Boston University in 1978.  Upon completion of her doctorate in 1982, she accepted a professorship at Northeastern University School of Nursing where she continued to teach and participate in the development of nursing practice.

Coming Back Home to Long Term Care

Dr. Chopoorian joined the Mansion after a 22-year career as a nursing educator.  Her career parallels the transformation of nursing home care as it has undergone generational change.  As nursing homes evolved from custodial care to a case mix of higher morbidities and a greater need to deal with an increasing population of younger residents and residents with mental illnesses, Dr Chopoorian’s career paralleled this transformation in unique ways.

Starting as a teenager working in her family’s business, a 76-bed nursing home on the border of Central Falls and Pawtucket, mill towns emerging from the flight of the textile industry, she was inspired to become a nurse.  She then chose the rigor of enrolling at Classical High School Providence, which laid a strong foundation of scholarship that would serve her well.   More importantly, this earliest choice illustrated a characteristic of always taking on the greater challenge.  

In 1986, Dr. Chopoorian joined the Mansion staff at a time of family crisis.  Her father was retiring as administrator soon after the passing of her mother. At a crossroad of whether to continue the development of a fruitful academic career or apply her clinical knowledge and nursing skills to a family business, she made the critical choice of leading the family’s nursing facility while caring for her father. A daunting choice on every level, leaving the security of an academic career for a business whose nature and regulatory landscape were dramatically different than two decades earlier when she helped her father as a nursing aide.   

Dr. Chopoorian’s family crisis thrust her into the role of Administrator; she led the Mansion as a quality provider of skilled care and rehabilitation services, consistently a 4 and 5-star rated facility.  In 2010, she was recognized as the first recipient of the Nightingale Nurse of the Year Award by the Rhode Island State Nurses Association, as a nurse in the role of nursing home administrator.

Dr. Chopoorian also became active in the greater community and participated in boards such as the Pawtucket YMCA and Samaritans of Rhode Island. But closest to her heart, she has a lifelong commitment to cancer prevention, and has become one of the strongest local voices for cancer prevention in her community.  As chair of the Cancer Control Task Force supported by the City of Pawtucket Mayor’s office, she instituted programs such as a Poetry Slam that has young local school students writing poems competitively on the theme of smoking cessation or prevention.

A Rising Star in the Nursing Profession 

After graduation from the College of Nursing at the University of Rhode Island in 1962, she started as a Staff Nurse at Children’s Hospital Medical Center in Boston. Again, rising to the greater challenge, she enrolled in the Nursing Master’s program at Boston University.  It launched a career that would keep her in the mainstream of nursing education and growth, up to the present day to bring her full cycle to administering a family business and the challenges of passing it on to a third generation.

Dr. Chopoorian shared her pioneering work on education for nursing practice through her teaching, publishing and consulting as these programs became established. She was recognized for her work by the Massachusetts Nurses Association in 1974 – “Recognition of a Nurse Influencing the Directions of Professional Nursing Practice”. 

Perhaps the most prestigious recognition was her selection as the 9th recipient of the International Council of Nursing (ICN) Fellowship in 1978, the first US candidate to be selected from among its 44 member countries.

Among Dr. Chopoorian’s publications, one of special note is her article, “Reconceptualizing the Environment”, which called attention to the social, cultural, political and economic environmental factors that impact the practice of nursing. Published in 1986, it is still heavily cited by scholars in the field and pertinent to the dialog of nursing practice today.

She was appointed Fellow in the National Academy of Practice, Nursing in 1987.

Meeting the Challenges of COVID-19

Dr. Chopoorian is now practicing what she has preached over the years, applying her knowledge and skills to the practical matters of administering a skilled nursing care facility, and doing it in a manner that has earned her the recognition of her peers as Nightingale Nurse of the Year.

Early in March 2020 as it became clear that nursing homes were ground zero in an epic battle; she consulted with her Medical and Nursing Director and decided to close admission of anyone into the facility who was not already in the facility until October of 2020, when community spread overcame the facility staff’s most resolute of defenses. The Mansion is one of only three facilities in Rhode Island with this record in the midst of what was designated as the state’s hot zone. The residents and staff who tested positive have since quickly passed quarantine with no deaths or illnesses. A major practice achievement as we now head into a time of protection with the Pfizer, Moderna, and other versions of the COVID-19 vaccine, and are hopefully home free.

Palliative Care Can Provide Comfort to Dying Residents

Published in Woonsocket Call on May 10, 2015

           A recently published study, by Brown University researchers, takes a look at end-of-life care in America’s nursing facilities, seeking to answer the question, is knowledge and access to information on palliative associated with a reduced likelihood of aggressive end-of-life treatment?

Brown researchers say when a nursing facility resident is dying, oftentimes aggressive interventions like inserting a feeding tube or sending the patient to the emergency room can futilely worsen, rather than relieve, their distress. While palliative care can pull resources together in a facility to provide comfort at the end of a resident’s life, the knowledge of it varies among nursing directors.  A new large national study found that the more nursing directors knew about palliative care, the lower the likelihood that their patients would experience aggressive end-of-life care.

Susan C. Miller, professor (research) of health services, policy and practice in the Brown University School of Public Health and lead author of the study in the Journal of Palliative Medicine, published March 16, 2015, worked with colleagues to survey nursing directors at more than 1,900 nursing facilities across the nation between July 2009 and June 2010.  The researchers hoped to learn more about their knowledge of palliative care and their facility’s implementation of key palliative care practices.

Knowledge Is Power

According to the findings of the Brown study, the first nationally representative sample of palliative care familiarity at nursing homes, more than one in five of the surveyed directors had little or no basic palliative care knowledge, although 43 percent were fully versed.

“While the Institute of Medicine has called for greater access to skilled palliative care across settings, the fact that one in five U.S. nursing home directors of nursing had very limited palliative care knowledge demonstrates the magnitude of the challenge in many nursing homes,” Miller said. “Improvement is needed as are efforts to facilitate this improvement, including increased Medicare/Medicaid surveyor oversight of nursing home palliative care and quality indicators reflecting provision of high-quality palliative care,” she said, noting that besides quizzing the directors the researchers also analyzed Medicare data on the 58,876 residents who died during the period to identify the type of treatments they experienced when they were dying.

When researchers analyzed palliative care knowledge together with treatment at end of life, they found that the more directors knew about basic palliative care, the lower likelihood that nursing facility residents would experience feeding tube insertion, injections, restraints, suctioning, and emergency room or other hospital trips. Meanwhile, residents in higher-knowledge facilities also had a higher likelihood of having a documented six-month prognosis.

The study shows only an association between palliative care knowledge and less aggressive end-of-life care, the authors say, noting that knowledge leads to improved care, but it could also be that at nursing facilities with better care in general, there is also greater knowledge.  But if there is a causal relationship, then it could benefit thousands of nursing facilities residents every year for their nursing home caregivers to learn more about palliative care, the authors conclude.

Progress in Providing End-of-Life Care

Virginia M. Burke, J.D. President and CEO of the non-profit Rhode Island Health Care Association, said, “We were gratified that the authors found that most of the nursing directors who responded to their survey gave correct answers on all (43% of respondents) or most (36%of respondents) of the “knowledge” questions on palliative care.  We were also gratified to see that the number of hospitalizations during the last thirty days of life has declined significantly over the past ten years, as has the number of individuals who receive tube feedings during their last thirty days.  The need for continued progress is clear.”

Burke, representing three-quarters of Rhode Island’s skilled nursing and rehabilitation centers, adds, “It is not at all surprising that greater understanding of palliative care leads to better application of palliative care.”

The states’s nursing facilities are committed to providing person-centered end of life care, says Burke, noting that according to the National Palliative Care Research Center, Rhode Island’s hospitals are among the top performers for palliative care.  “We suspect that our state’s nursing facilities are as well.  We would be very interested in state specific results in order to see any areas where we can improve.”

Says spokesperson Director Michael Raia, of Rhode Island’s Health & Human Services Agency, “We need to provide the right care in the right place at the right time for all patients.”

When it comes to nursing facilities, Raia calls for reversing the payment incentives so that facilities are rewarded for providing better quality care and having better patient outcomes.  He notes that the Reinventing Medicaid Act of 2015 reinvests nursing home reimbursement rate savings into newly created incentive pools for nursing homes and long-term care providers that reward facilities for providing better quality care, including higher quality palliative care.

Bringing Resources to Families

With caregiving one of AARP’s most important issues, it’s no surprise that the organization provides a great deal of guidance on palliative care, stressing that “it involves organizations and professionals coming together to meet a person’s needs both in terms of pain management, along with emotional and spiritual perspectives,” said AARP State Director Kathleen Connell.

Connell says that “It’s is truly a team effort in which nursing home staff become key players. The resources are important to patient with chronic and terminal issues. Their families need help, too. So it is important any time we learn more about ways we can address this very important healthcare need.”

Adds Connell, “In Rhode Island, I’m confident that we have nursing homes that are dedicated to easing the difficulty of this particularly stressful stage of life. They give patients and their families enormous comfort. We certainly applaud their compassion and hope the report is helpful anywhere it identifies a need for improvement,” adds Connell.

AARP’s Caregiving Resource Center (http://www.aarp.org/home-family/caregiving/) includes an End of Life section. Check out a specific palliative care resource at  http://assets.aarp.org/external_sites/caregiving/multimedia/EG_PalliativeCare.html

To read the Brown Palliative Care Study go to http://online.liebertpub.com/doi/abs/10.1089/jpm.2014.0393.

Herb Weiss, LRI ’12 is a Pawtucket writer covering aging, health care and medical issues.  He can be reached at hweissri@aol.com.