By Zahida Siddiqi
The nursing home inspections system is underfunded and understaffed and needs federal assistance for alleviating inspection backlogs, or residents will remain in peril, experts and legislators said at a U.S. Senate hearing on Thursday.
Officials from the long-term care ombudsman program as well as leaders from state inspections and regulatory bodies were among those who testified before the U.S. Senate Special Committee on Aging, following the release of its investigative report.
“The report paints a picture of a system in crisis,” said Sen. Bob Casey (D-Penn), who blamed a shortage of inspectors and low funding as factors that are jeopardizing the annual nursing home inspections process. “The result is that nursing home residents are being put at risk because of this problem … My fear is that the trail is going cold for too many residents before nursing home inspectors can arrive on the scene.”
The report titled, “Uninspected and Neglected,” was commissioned by Sen. Casey to investigate the efficacy of state inspection agencies across the nation.
“My investigation reveals unacceptable rates of vacancies at state survey agencies, threatening the safety and health of nursing home residents as their complaints collect dust while inspectors struggle to meet the demand,” Casey said.
Inspection backlogs
As a result of fewer inspectors, most states have nursing home inspection backlogs.
The report found 31 states and the District of Columbia had inspection staff vacancy rates above 20% on average, and nine were short-staffed by 50% or more. Meanwhile, the highest vacancy rates were in Kentucky at 83%, Alabama at 80% and Idaho at 71%.
Severe staffing shortages and high turnover rates driven by inadequate salary compensation for state inspectors hampered the annual survey process and prompt reporting of complaints, the report found. Given this scenario, the report called into question the timeliness and accuracy of the Care Compare tool used by prospective residents to evaluate nursing homes.
Since inspectors are registered nurses, pharmacists, social workers and dieticians, competition with jobs in the private sector impacts their recruitment and retention rates.
Meanwhile, much of the funding for inspections is aided by federal dollars, and while the last three administrations have requested this funding, it has yet to be approved by Congress.
“Survey agencies have not received a meaningful increase in federal funding to complete these critical oversight responsibilities since 2015, yet the cost to recruit and retain survey staff, the volume of work and additional work expected of survey agencies has significantly increased,” said Shelly Williamson, president of the board of directors for the Association of Health Facility Survey Agencies (AHFSA). “These factors have resulted in many survey agencies being unable to complete recertification and complaint surveys timely, leaving nursing home residents at risk of substandard care.”
Williamson is also administrator of the Section for Long-Term Care Regulation at Missouri Department of Health and Senior Services.
Since 2015, Congress increased that spending by a meager 2.5%, while the budget for inspections will need to be increased 30% to keep up with inflation.
Williamson said that since states have recently increased their budgets to fund surveys and salary increases for inspectors, the federal government will need to step up funding for these endeavors.
The Senate report also suggests that the Biden administration’s proposed nursing home regulations might not succeed unless the problems in the inspections process are addressed.
Greater visibility of staffing roles, numbers
During the hearing, staffing shortages at nursing homes were also cited by experts as being important for better health outcomes, especially as they relate to mental health concerns of residents.
“I think one of the things that we continually need to address are the nursing home staffing shortages, so that we can get back to those [social] activities … The ombudsmen have seen firsthand that the activities are still lacking and are not quite what they should be,” said Leah McMahon, director at Colorado State Long-Term Care Ombudsman Program in Denver. Ombudsmen are authorized by federal and state law to settle disputes and resolve resident problems.
To improve the process of choosing a nursing home, McMahon said it was important to enforce more transparency on quality of staffing.
“We’re talking about potentially wanting to know staffing levels. How many nurses are in the building at any given time? Who is the medical director that is overseeing and coordinating the overall care, and maybe any instances of abuse and neglect that have happened?” McMahon said. “I think those are really important things to know.”
Improving the visibility of the activities of the medical director, and perhaps putting limits on how many residents can be overseen by each medical director should be an important goal, McMahon said.
“I do believe that requiring nursing homes to report their medical directors to CMS and state survey agencies could increase quality of care in nursing homes,” McMahon said.
Sometimes medical directors are spread too thinly as they oversee several nursing homes within a chain, she said.
“Often medical directors are absent from the nursing home for long periods of time. It is rare that you will see a medical director physically in a nursing home,” she said. “By increasing accountability for medical directors, it could ensure they’re fulfilling their critical obligations under the regulations. And when that doesn’t happen, ombudsmen have another tool to take to the survey agency as a concern.”
Other experts who testified at the Senate hearing sought to improve the pool of inspectors by increasing training and recruitment efforts at colleges.
Advocates’ push against staffing mandate
Advocacy groups for nursing homes said the Senate committee’s work underlines a widespread staffing crisis within the sector. They renewed calls to resist the forthcoming proposed minimum staffing mandate and improve funding.
“We appreciate the Senate Committee on Aging’s focus on this important issue and share concerns surrounding the backlog of nursing home surveys. Conducting timely surveys of nursing homes is important for consistency in the regulatory process,” said Holly Harmon, senior vice president of Quality, Regulatory, and Clinical Services at AHCA/NCAL, in a statement. However, Harmon also said, “The shortage of state surveyors is indicative of a larger workforce crisis facing the entire long term care profession. As the committee’s report signals, addressing this labor crisis requires significant investments, not mandates. We need a concerted, supportive effort to help recruit more individuals to serve our nation’s seniors.”
Moreover, Harmon said the oversight process needs to be more resident-driven.
“We need to focus on the science of quality improvement by recognizing good faith efforts, leveraging continuous learning, and effectively remedying identified issues,” Harmon said. “Enforcement alone will not transform America’s nursing homes.”
Need for consensus
In closing, Sen. Casey compared the current findings to work of the Senate committee on nursing home oversight almost four decades ago, and said, “We heard similar warnings today and these warnings must not be ignored.”
Aside from more funding, Casey recommended adding more transparency to the survey process and scrutiny of independent contractors as well as boosting the health care workforce.
“The [Senate] Aging committee’s oversight in the 1980s paved the way
for landmark nursing home reforms that President Reagan signed into law.
Today’s hearing and the committee’s investigation provide another
opportunity to find common ground to make sure nursing home residents
are kept safe and receive the care that they and their families deserve
and have a right to expect,” Casey said.
Full Article & Source:
‘System in Crisis’: US Senate Hearing Calls for More Funding, Staffing for Nursing Home Inspections
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