‘System in Crisis’: US Senate Hearing Calls for More Funding, Staffing for Nursing Home Inspections

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.

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‘System in Crisis’: US Senate Hearing Calls for More Funding, Staffing for Nursing Home Inspections

Senate panel looks to fund Alzheimer's research and resources

WASHINGTON – Public health leaders and caregivers coalesced Tuesday behind an effort to focus attention and funding on Alzheimer’s disease.

There was no dissent among the witnesses or the members of the Senate Special Committee on Aging about the need for more resources such as those called for in legislation introduced by U.S. Sens. Susan Collins, R-Maine, and Catherine Cortez Masto, D-Nevada.

Their bill would authorize $37 million annually to establish resource centers across the country, to enhance public-private partnerships, and to improve data collection on the incurable brain disease.

The Building Our Largest Dementia Infrastructure for Alzheimer’s Act – or BOLD Act – is an important step toward finding a cure, said U.S. Sen. Bob Casey of Pennsylvania, the committee’s ranking Democrat. He said the centers will particularly help rural Americans who need better access to resources.

Although there is no cure for Alzheimer’s, early diagnosis and intervention can be cost-effective and can help patients and their caregivers live better lives, testified Pennsylvania Secretary of Aging Teresa Osborne.

Better investment will afford Alzheimer’s patients “the opportunity to age in place in the setting of their choice with their friends and family with the dignity and respect that they deserve,” she said.

She also asked Congress to fund training and resources for first responders who can assist disoriented Alzheimer’s patients like the one another witness described.

Cheryll Woods-Flowers of Mount Pleasant, S.C., whose father died of Alzheimer’s in February, said his diagnosis came at age 70, shortly after he disappeared from home. Seven hours later he was found hungry, lost and crying.

He lived 16 more years with the disease, said his daughter, who is grateful for the early diagnosis that gave her and her five siblings time to talk through decisions, understand his wishes and get him on medication that reduced the severity of his symptoms.

Actress Marcia Gay Harden, whose mother, Beverly, has Alzheimer’s disease, said coping would have been easier if the BOLD Act already were in place.

“I wish we’d had BOLD,” because it would have provided specific resources directing them where to turn for resources about everything from finances to dietary needs of patients.

“Alzheimer’s becomes a stealthy thief, robbing families of their finances and security and forcing its victims to live only in the moment,” she said because it causes memories to evaporate.

Witnesses said they want Congress to pass the BOLD Act along with additional investments in Alzheimer’s research and education.

The current year’s appropriation is $1.8 billion – an increase of $414 million over last year, according to Aging Committee staff. Mr. Casey would like to see that funding reach $2 billion.

“Alzheimer’s disease and related dementias are among the greatest public health challenges facing older Americans,” Mr. Casey said. “As our population ages, the number of people living with the disease and their caregivers will only grow.”

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Senate panel looks to fund Alzheimer's research and resources

Bergen OKs aid for needy seniors facing foreclosure

HACKENSACK — The Bergen County Board of Freeholders on Wednesday approved $20,000 in funding for legal assistance for low-income seniors facing foreclosure on their homes.

The new program builds on a counseling service that the county has provided for more than a decade to homeowners older than 62 who are interested in a reverse mortgage.

It will assist those homeowners in cases where they are later unable to pay taxes or homeowners insurance after the reverse mortgage money has dried up.

"As we’ve been doing this more and more, some of these people are really in that financial crisis," said Lorraine Joewono, director of county senior services. "Even with a reverse mortgage, they’re going to use that money up within a few years."

A reverse mortgage allows a homeowner to draw down the home’s equity value for cash, typically for living expenses. The homeowner can take the money in a lump sum, line of credit or monthly payments and the withdrawals, plus interest, are repaid when the house is sold.

"The addition of legal counseling to our existing Reverse Mortgage Counseling Program will help protect our seniors, and will be another tool in Bergen County’s continuum of services that helps our residents age in place," said Freeholder Vice Chairwoman Tracy Zur.

The program complements multiple county initiatives such as Meals on Wheels, home repair and maintenance programs that aim to help seniors "age in place" and put off entering a nursing home or having to sell their homes and leave the area, said Joewono.

"We know that many of our seniors want to stay in their homes, which is why it’s so important to support and expand our programs that let our residents continue to live independently and comfortably," said Freeholder John A. Felice.

Although borrowers are not required to repay the reverse mortgage until they leave the home, they must still pay all property taxes and homeowner insurance premiums.

The program will help homeowners who fall behind by first trying to negotiate a repayment plan between the homeowner and lender.

If that plan fails or if the lender rejects it, then homeowners can also tap legal services during the foreclosure process.

Ron Romano, county reverse mortgage counselor, said that he works with people in their 70s all the way up to centenarians who want to remain in their homes and are interested in a reverse mortgage.
Low-income seniors on average have an annual income of $15,000 or less, Romano said. And a reverse mortgage can help someone with a limited income to continue to live in their home.

The reverse mortgage isn’t for everyone, he said. Often if the homeowner is seeking the money for home upgrades or repairs, he can direct them to other county or state assistance programs.

Over the past decade the program has assisted 2,000 county Bergen County homeowners.

Until 2014, 85 percent to 95 percent of those who sought reverse mortgage counseling eventually obtained the mortgage.

But Romano said that the U.S. Department of Housing and Urban Development instituted more stringent requirements for the loans last year, and the portion of those who get counseling on the mortgages and then obtain them has dropped to about 70 percent.

Romano said that the county program is the only HUD-certified face-to-face counseling service focused on reverse mortgages in New Jersey, Joewono said.

The $20,000 approved Wednesday will pay up to $900 per client through Northeast New Jersey Legal Services.

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Bergen OKs aid for needy seniors facing foreclosure

Elder Abuse Prevention Gets Big Boost From New York Budget

Prevention of elder abuse received a considerable boost as New York state not only restored funding but increased money for education and outreach.

The recently passed budget brought back $245,000 for existing contracts with the Office for the Aging, and allowed $500,000 for additional services.

Lifespan of Rochester will administer the contract that covers intervention, training for professionals, and education for seniors and families about the signs of abuse.

“People don’t believe elderly abuse exists,” said Ann Marie Cook, president and chief executive officer of Lifespan. “Even when it’s happening right under their nose, they don’t recognize it as abuse.”

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Elder Abuse Prevention Gets Boost From New York Budget