Brenda Gallant, RN Maine Long-Term Care Ombudsman

Consumer Voice 38th Annual Conference

November 16 ,2014

PL 1999, Chapter 731, part BBBB

Direct Care Staff ◦ 1:5 ratio days

◦ 1:10 ratio evenings

◦ 1:15 ration nights

Includes RN’s, LPN’s, CNA’s

Direct Care means hands-on care provided to residents, including but not limited to feeding, bathing, toileting,

dressing, lifting and moving residents

Licensed nurse coverage shall be provided according to the need of the residents as determined by their levels of care.

1 DON RN full time included

1 RN 8 consecutive hours, 7 days/week on Days

1 RN/LPN Charge Nurse 7 days/week on Days

For 20+ beds DON may not be the Charge Nurse

For 100, 150, 200, etc., beds add 1 LN for each increment of 50

For 100+ : for each multiple of 100, the additional LN shall be an RN

1 RN/LPN Eve on duty 8 hours every evening

1RN/LPN for multiples of 70 beds

For 100+: one additional LN shall be an RN and 1 RN/LPN Night and 1 RN/LPN for multiples of 100

For 100+: an RN shall be on duty at night

The requirements for licensed staff existed before our legislation for staffing ratios was passed.

Ch. 110 Regulations Governing the Licensing and Functioning of Skilled Nursing Facilities and Nursing Facilities: Chapter 9 Resident Staffing http://www.maine.gov/sos/cec/rules/10/chaps10.htm

Maine’s minimum staffing provides:

◦ (RN .32)

◦ LN.56

◦ DC 2.93

◦ 3.49 HPPD

Maine nursing homes provide an average of 4.23 HPPD (cost reports DHHS, Division of Audit 2013)

PL 1999, Chapter 731, PART BBBB required changes in the principles of reimbursement:

◦ The department shall reconsider the provision that

allows retention of 25% cost savings in the direct care component.

◦ This was important in removing an incentive to reduce staffing

◦ In 1997, 48 % of nursing homes had direct care savings

◦ In 1996, 35% of nursing homes had direct care savings

(source: DHS Division of Audit)

Legislation passed in 1994 led to: ◦ Initiative to reduce the number of nursing home

beds by 2,000

◦ Expansion of home and community based services

◦ Establishment of statewide assessing agency

◦ Significant change in eligibility standards for nursing home care

◦ A requirement that nursing facilities participate in Medicare and establish a minimum number of skilled nursing facility beds

◦ Must have a skilled nursing need 7 days/week or ◦ Need skilled therapy 5 times/week or ◦ Need extensive assistance with 3 of the following:

bed mobility, transfer, locomotion, eating and toileting or

◦ One or two skilled needs/week with limited assist with 1 or 2 ADLs

◦ Cognitive impairment with limited assist with 1or 2 ADLs or

◦ Behavior screen triggered Ch.II-Section67:Nursing Facility Services

http://www.maine.gov/sos/cec/rules/10/ch101.htm

◦ MLTCOP received an increased number of complaints from family members, residents and nursing home staff

◦ Representative David Etinier, Health and Human Services Committee and I met with CNAs employed in a nursing home

◦ They shared their stories about having too many residents to take care of and the adverse impact on resident care

◦ They asked for our help in requiring more staffing in nursing homes

December 1996 – Public meeting with CNAs, DHS

Commissioner, State Unit on Aging Director, Licensing and Regulatory Services staff, families of residents and MLTCOP to discuss inadequate staffing in nursing homes

Work group formed to discuss and study current staffing

1997 MLTCOP drafted legislation: Chapter 34 Resolve (H.P. 828 LD 1133, Resolve to Ensure Quality Care to Residents in Nursing Facilities through the Establishment of a Task Force on Minimum Staffing (sponsored by Representative Etinier)

Resolve required the Task Force to: review current rules concerning staffing minimums of 1:8 days, 1:12 evenings and 1:20 nights

Consider the appropriateness of increasing the minimum staffing to identify and discuss other issues relevant to the study

Make recommendations to change department rules concerning minimum staffing

Activities of Task Force; On site visits made by Task Force members to 11 nursing homes to examine staffing patterns, case mix data, resident needs, and determine staffing methodologies

Residents, families and staff interviewed Residents, families and CNAs recommend improved staffing ratios

Task force could not come to consensus regarding a proposal to change minimum staffing

The 118th Maine Legislature established the Commission to Examine Rate Setting and the Financing of Maine’s Long-Term Care Facilities in 1997 with the passage of Resolve of 1997, Chapter 81 and the amendment to it passed in Resolve of 1997, Chapter 129

The Commission considered the setting of rates for nursing facility services, levels of profits, comparison of rates among the states, advisability of rate equalization, case mix, salaries and management of facilities

The relationship between staffing levels and quality of care and maintaining high quality care

Mechanisms for providing consumer participation in decisions on reimbursement for nursing facility care

Collaboration among advocates serving on the commission made the difference in keeping a focus on residents:

MLTCOP staff, AARP volunteer, Senator Chellie Pingree ,

Citizen Advocate and Consumer

RATE SETTING COMMISION RECOMMENDATIONS

Remove any reimbursement incentives that have unintended adverse impacts on resident care. (reference to the 25% savings allowed in direct care )

Minimum staffing requirements: The commission recommends that the Legislature direct the DHS to replace its current minimum staffing ratios with minimum staffing requirements that :

◦ A) are tied to the level of acuity of residents and to the other needs of residents that effect the quality of their lives and

◦ B) that ensure that adequate numbers of direct care staff are available at all times to meet resident needs

Legislation submitted by MLTCOP 1999

LD, 1408 “An Act to Increase Reimbursement for Hands-on Care to Nursing Home Residents”

To appropriate $ 2,100,000 for each of the fiscal yeas 1999-00 and 2000-01 for direct care to allow nursing facilities to hire and retain staff

LD 1432, “An Act to Improve Care to nursing Home Residents by Requiring Adequate Staff to Provide to Provide Hands–on Care”

Defined direct care, required ratios of direct care providers of 1:5 Days, 1:8 Evenings, 1:12 Nights, in addition ratios for licensed staff of 1:15 Days, 1:20 Evenings and 1:30 Nights and a ratio of 1 : 3 at mealtimes, and posting of staffing information

Both bills voted ONTP and instead, the concepts were incorporated into LD 42, “An act to Implement the recommendations of the Commission to Examine the Rate Setting and Financing of Long-Term Care”

PL1999, Chapter 731, Part BBBB

PL 1999, CHAPTER 731, PART BBBB also required: Medical Supplies included as a direct cost component Regional variations in labor cost Performance standards, measurable outcomes and Consumer and family satisfaction surveys Supplemental payment of 3-4% for all positions in direct

care component excluding administrative salaries If supplemental payment not used for wage increases,

funds to be recouped at audit Establishment of the Long-Term Care Implementation

Committee to review quality of care and implementation of the provisions of the law, and make recommendations to DHS and the legislature

MLTCOP served on the committee

◦ CNAs, residents, family members, stakeholders and legislators worked with us to get legislation passed

◦ Champions for quality care: ◦ Representative Etinier, Representative Thomas Kane

and Senator Chellie Pingree as well as members of the Health and Human Services Committee and Appropriations

◦ Networking with CNAs to hear their concerns and provide information about legislation

◦ CNAs provided testimony consistently and contacted legislators

◦ Ombudsman Volunteers had lunch with legislators in the Hall of Flags

Summary of Volunteer Ombudsmen observations about responses to call bells and comments made by residents about staffing

Student nurses wrote letters to the editor and met with members of the Appropriations Committee to discuss MLTCOP’s staffing legislation

Press conferences with family members and stakeholders MPBN radio covered the savings facilities had in direct care Active MLTCOP participation with HHS Committee during

their meetings on long-term care before the legislative session

MLTCOP Hired the retired Director of DHS Division of Audit to help with reimbursement issues and questions

We made sure MLTCOP had a seat on every Commission

Maine providers do not want regulation regarding staffing

Maine providers say ratios do not allow “flexibility”

Some see the ratios as an optimal level for staffing rather than a minimum

When unemployment was low, some providers opposed changes in the minimums because they had difficulty recruiting staff

2012- LD 1700, “An Act to Provide an Alternative Method of Calculating Minimum Staffing Levels- voted ONTP ◦ Resulted in a DHHS led work group to amend its minimum

staffing rules to provide flexibility in staffing by setting standards based on the 24 hour day.

◦ MLTCOP suggested that the issue was reimbursement not ratios and that there should be a rate setting commission.

2013 - LD “An Act to Promote Greater staffing Flexibility without Compromising Safety or Quality of Care in Nursing Faculties”- voted ONTP ◦ Adopt acuity based staffing standards over a 24 hour

period ◦ MLTCOP insisted that the 24 hour standard would have to

be a minimum of 4.1 HPPD

2013 LD 986, Resolve to Establish the Commission to Study Long-Term Care Facilities

Resolve 2013, chapter 78 to address issues related to reimbursement , staffing and access

MLTCOP served on the commission

Commission voted unanimously not to change staffing ratios

Facilities received funding increase

Commission recommendations enacted in Public Law 2013, chapter 594

Letters to the Commission ◦ Nursing home resident ◦ Charlene Harrington, R.N., PhD ◦ Consumer Voice ◦ Maine Alzheimer’s Association ◦ Legal Services for the Elderly ◦ Home Care for Maine

Testimony ◦ CNAs, Family member, Worker advocate

Phone calls to Legislators serving on the commission Facility Visit: Commission Chair made a visit to

nursing home along with Ombudsman volunteer

Activity Definitions Time Estimates Avg. Minutes

Bed Mobility

How person moves to and from lying position, turns side to side and positions body while in bed.

0 0

Transfer

How person moves between surfaces-to/from: bed, chair, wheelchair, standing position (EXCLUDE to/from bath/toilet).

5 times, 5 minutes each=

25

Locomotion

How person moves between locations in his/her room and other areas on same floor. If in wheelchair, self-sufficiency once in chair.

6 times, 5 minutes each=

30

Dressing & Undressing

How person puts on, fastens and takes off all items of street clothing, including donning/removing prosthesis.

15 minutes each, 2 x per day=

30

Eating How person eats and drinks. 30 min per meal, 3 x per day=

90

Toilet Use

How person uses the toilet (or commode, bedpan, urinal); transfers on/off toilet, cleanses, changes pad, manages ostomy or catheter.

60 minutes per day= 60

Personal Hygiene

How person maintains personal hygiene, (exclude bath and showers) add shampoo and nails.

30 minutes per day= 30

Walking

How person walks for exercise, how person walks around own room, how person walks within home.

20 minutes per day= 20

Bathing

How person takes full-body bath/shower, sponge bath (EXCLUDE washing of back, hair), and transfers in/out of tub/shower.

15 minutes per day= 15

TOTAL=5 HOURS PER DAY

Time Study done by DHHS for Residential Care

Provnum Facility State Group Chain RN LPN Aide Total Defics G+Defs

205031 ORONO COMMONS ME Selected for Profit Chain GENESIS 1.00 0.74 2.69 4.43 5.0 0.0

205060 CEDAR RIDGE CENTER ME Selected for Profit Chain GENESIS 1.26 0.17 2.82 4.25 5.0 0.0

205065 RIVER RIDGE CENTER ME Selected for Profit Chain GENESIS 1.80 0.90 3.44 6.14 13.0 0.0

205068 SPRINGBROOK CENTER ME Selected for Profit Chain GENESIS 1.17 0.42 2.53 4.12 3.0 0.0

205069 SANDY RIVER CENTER ME Selected for Profit Chain GENESIS 1.01 0.56 2.81 4.39 2.0 0.0

205070 PINE POINT CENTER ME Selected for Profit Chain GENESIS 1.21 0.65 2.39 4.24 7.0 0.0

205072 MARSHWOOD CENTGER ME Selected for Profit Chain GENESIS 1.28 0.51 3.12 4.91 5.0 0.0

205091 OAK GROVE CENTER ME Selected for Profit Chain GENESIS 1.27 0.19 2.73 4.19 3.0 0.0

205122 HARBOR HILL CENTER ME Selected for Profit Chain GENESIS 1.26 1.02 3.17 5.46 16.0 1.0

205159 SEDGEWOOD COMMONS ME Selected for Profit Chain GENESIS

205180 WINDWARD GARDENS ME Selected for Profit Chain GENESIS 1.76 0.52 3.03 5.32 3.0 0.0

Genesis State average 1.30 0.57 2.87 4.74 6.2 0.1

Genesis US averages 395 0.83 0.73 2.16 3.72 8.3 0.4

205062 BREWER CENTER FOR HEALTH & REHABILITATION, LLC ME Selected For Profit Chain Kindred 1.26 0.22 2.32 3.79 4.0 0.0

205077 AUGUSTA CENTER FOR HEALTH & REHABILITATION, LLC ME Selected For Profit Chain Kindred 0.87 0.57 2.14 3.58 1.0 0.0

205078 WINSHIP GREEN CENTER FOR HEALTH & REHAB, LLC ME Selected For Profit Chain Kindred 1.21 0.34 2.13 3.67 4.0 0.0

205079 BRENTWOOD CENTER FOR HEALTH & REHABILITATION, LLC ME Selected For Profit Chain Kindred 0.84 0.46 2.11 3.42 3.0 0.0

205094 FIELDCREST MANOR ME Selected For Profit Chain Kindred

205095 KENNEBUNK CENTER FOR HEALTH & REHABILITATION, LLC ME Selected For Profit Chain Kindred 1.22 0.84 2.12 4.18 2.0 0.0

205096 SHORE VILLAGE REHAB & NURSING ME Selected For Profit Chain Kindred

205097 NORWAY CENTER FOR HEALTH & REHABILITATION, LLC ME Selected For Profit Chain Kindred 1.33 0.47 4.33 6.13 0.0 0.0

205105 KINDRED NURSING AND REHABILITATION-WESTGATE ME Selected For Profit Chain Kindred 0.72 0.63 2.91 4.26 4.0 0.0

205106 EASTSIDE CENTER FOR HEALTH & REHABILITATION, LLC ME Selected For Profit Chain Kindred 0.89 0.52 2.07 3.48 2.0 0.0

Kindred State average 1.04 0.50 2.52 4.06 2.5 0.0

Kindred US average 265 0.85 0.74 2.15 3.74 7.8 0.5

Total US Nuring Facilities 15,005 0.937 0.904 2.618 4.459 7.6 0.4

CMS CASPER Data 2012-all US Nursing Facilities