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World Elder Abuse Awareness Day

Join the DignityMA Resolution for Sufficient Nursing Home Staffing

Thursday, June 15, 2023 marks the annual observance of WORLD ELDER ABUSE AWARENESS DAY,which was launched more than a decade ago by the International Network for the Prevention of Elder Abuse and the World Health Organization at the United Nations.  Dignity Alliance Massachusetts expresses concern that the staffing shortage and constant turnover among direct care nursing home staff lead to neglect, reduced quality of care, and unsafe conditions which, though not defined in state law, constitutes a form of elder abuse!

Participants in Dignity Alliance and other individuals and organizations advocating for the dignity of older adults, people with disabilities, and their caregivers has adopted a resolution to promote elder abuse awareness by calling on the Massachusetts Department of Public Health (DPH) to vigorously enforce the Commonwealth’s regulations that require nursing homes to meet minimum staffing standards in existence, and to revise those standards consistent with higher hours of health care per resident day to match federal regulations.

In order to achieve these minimum staffing standards, Dignity Alliance and other advocates strongly urge the DPH freeze new admissions to nursing homes until they reach, at least, the current state standards.

Additionally, Dignity Alliance calls on the Attorney General to consider whether a material and ongoing violation of the nursing home staffing requirement as established by DPH licensing constitutes a violation of consumer protection laws in the scenario of private pay consumers (which could conceptually create significant sanctions if nursing homes do not comply, potentially exposing them to triple damages).  Furthermore, MassHealth nursing home rates are based on assumptions of nursing homes operating in a compliant manner with licensing requirements. So if there is routine disregard for the current staffing requirement, then in addition to a skilled nursing facilities being in violation of DPH regulations, it also means MassHealth may be overpaying for services (which should also be a concern for the State Auditor and Inspector General).  Therefore, Dignity Alliance urges the Attorney General to consider whether failure to maintain staffing levels as required by state and federal regulations, could constitute Medicaid fraud.

According to National Consumer Voice for Quality Long Term Care, “The enforcement of a minimum staffing standard would not only protect nursing home residents it would address the long-standing job quality problems that plague nursing homes. On average, nursing home staff turnover is 52% each year, which is the result of low-wages, poor benefits, inadequate training, and little opportunity for job growth. The burden of providing essential and critical care falls largely on women, a majority of whom are women of color, while they are treated poorly by nursing home owners and operators. (Learn more about Inadequate Staffing).

Massachusetts elected and appointed leaders have a responsibility to enforce existing regulations and to support expected new staffing requirements   Such efforts are not only good public policy, but also good politics.  “According to a recent poll, 80% of U.S. registered voters supported candidates who support requiring minimum staffing standards in nursing homes.  Eighty-nine percent of Democrats and 74% of Republicans said they were more likely to vote for candidates who backed minimum staffing standards. The poll conducted by Fabrizio Ward and Impact Research and released by AARP also found wide support for candidates who back proposals that support family caregivers and help seniors live in their own homes.  Seventy-eight percent of voters are current, past, or future family caregivers, and over 70% of voters across the political spectrum said they would be more likely to support a candidate who backed proposals for family caregivers such as a tax credit or paid family leave.  Eighty-nine percent of Democrats and 72% of Republicans support expanding services to help seniors stay out of the nursing home by living at home.” (Read More about Voter Support for Staffing Standards.)

Dignity Alliance asks you to join with us on this June 15th by taking these steps to ensure safe residents staffing on all Massachusetts nursing home in a fitting observance of World Elder Abuse Awareness Day.

Resolution Calling for Sufficient Nursing Home Staffing to Prevent Elder Abuse

June 15, 2023

WHEREAS; Federal law requires all nursing homes to provide enough staff to safely care for residents; and

WHEREAS; Many nursing facilities have fewer direct care staff than needed to meet the care needs of their residents, a problem more common in nursing facilities that serve a high share of Medicaid-covered residents; and

WHEREAS; Since such facilities also have a higher share of Black and Hispanic residents, the low staffing rates in these facilities contribute to health disparities; and

WHEREAS; Insufficient nursing staff negatively impacts all residents in a nursing home and undermines the dignity of both residents and staff. Numerous studies of nursing homes reveal a strong positive relationship between the number of nursing home staff who provide direct care to residents on a daily basis and the quality of care and quality of life of residents. The dangers of understaffing have been common knowledge in the U.S. nursing home industry since the 1980s and culminated with the findings from the 2001 study of Appropriateness of Minimum Nurse Staffing Ratios published by Centers for Medicare & Medicaid Services (CMS)

WHEREAS; The 2001 CMS landmark staffing report identified specific minimum staffing thresholds below which quality of care would be compromised. It recommended a daily minimum standard of 4.1 hours of total direct care nursing time per resident: 2.8 hours certified nursing assistants; 0.75 hours RNs; and 0.55 hours licensed practical/vocational nurses. Research conducted for the report found that staffing levels falling below this minimum put nursing home residents at risk.

WHEREAS; Now, 20+ years after publication of the 2001 report, the CMS standards do not take into account the higher acuity level of the resident population and do not consider quality of life and dignity issues which are important components of the nursing home requirements and rightful expectations for residents and their families.  Consequently, the 2001 standards set a minimum, allowing for increases “to meet resident nursing care needs, based on acuity, resident assessments, care plans, census, and other relevant factors…”

WHEREAS; Research studies provide clear evidence that most nursing homes do not have adequate nurse staffing levels, particularly for RNs.  As nursing staffing (levels and wages) is one of the primary cost components for nursing homes, many nursing homes keep staffing costs as low as possible to maximize profits.   

WHEREAS; Inadequate staffing levels can have devasting consequences, as found in California nursing homes with COVID-19 that had 25% lower RN staffing levels than homes without non-COVID-19 residents. Lower staffing levels in facilities before the pandemic made these facilities more vulnerable to the coronavirus, resulting in more than 28,000 U.S. nursing home resident and worker deaths by May 11, 2020.

WHEREAS; Keeping nurse staffing levels low results in serious quality problems in nursing homes across the country and is not consistent with the 2016 federal regulations that require sufficient nursing staff with the appropriate competencies to assure resident safety and attain or maintain the highest practicable level of resident well-being. Nursing homes are responsible for assuring adequate nurse staffing levels and for complying with federal nursing home requirements, and

WHEREAS; Twenty years after the CMS study found that at least 4.1 hprd of direct care nursing staff time are needed just to prevent poor outcomes, state staffing requirements, with a few exceptions, are nowhere near that recommended level. Despite what is known about the relationship between staffing levels and quality care, staffing standards in almost every state remain severely low. Residents have waited decades for safe staffing around the clock. Every day that passes without sufficient staffing jeopardizes their health, safety and welfare;

WHEREAS; Massachusetts regulation 150 CMR 007 (d) states: “Sufficient nursing personnel to meet resident nursing care needs based on acuity, resident assessments, care plans, census and other relevant factors as determined by the facility. On and after April 1, 2021, sufficient staffing must include a minimum number of hours of care per resident per day (PPD) of 3.58 hours, of which 0.508 hours must be care provided to each resident by a registered nurse. The facility must provide adequate nursing care to meet the needs of each resident, which may necessitate staffing that exceeds the minimum required PPD”, and,

WHEREAS; A minimum nursing care ratio of 3.58 PPD is substantially below the CMS recommended minimum of 4.1 PPD, for safe resident care, and

WHEREAS; Understaffing is a major issue since it is directly related to nursing home resident care and instances of abuse. Nursing home residents can suffer from poor quality of life, and even death, due to less staff than is required; now, therefore, be it

RESOLVED; That Dignity Alliance Massachusetts, together with other advocates, assert that too many Massachusetts nursing homes operate below the Commonwealth’s insufficient minimum regulatory limits, thereby putting residents in great jeopardy and failing to protect the dignity of both residents and staff.  As of Q3, ’22, the most recent available data, 75% of MA nursing homes operate below an average of 3.58 HPRD and, be it further,

RESOLVED; That Massachusetts regulations for nursing home staffing currently appear to sanction a form of elder abuse and on this occasion of June 15, 2023 “World Elder Abuse Awareness Day,” calls upon the Massachusetts Department of Public Health to actively enforce existing staffing regulations until new nursing home staffing regulations can be promulgated consistent with federal policy and regulation, and be it further,

RESOLVED; That a copy of these resolutions be forwarded to the Governor of the Commonwealth, the Secretary of Health and Human Services, the Commissioner of Public Health, and the Clerks of the Senate and House of Representatives.

This resolution has been endorsed by fifty-three members and supporters of Dignity Alliance Massachusetts including the following:

  • Aging Life Care Association New England Chapter
  • Boston Center for Independent Living
  • Center for Living & Working, Inc, Worcester
  • Chelsea Disability Commission
  • COP Amputee Association-COPAA, Wenham
  • Joan Daly, Easton
  • Disability Law Center, Boston
  • Disability Policy Consortium, Boston
  • Lynne Feldman, LifePath, Greenfield
  • Judi Fonsh MSW, Leverett
  • John J. Ford, Esq., Quincy
  • Lachlan Forrow, MD, Newton
  • Wynn Gerhard, Esq., Plymouth
  • Margaret Morganroth Gullette, Newton
  • Lisa Iezzoni, MD, Newton
  • Paul Lanzikos, Beverly
  • LifePath, Greenfield
  • James A. Lomastro PhD, Conway
  • Stacey Minchello
  • Former Senate President Pro Tem Richard T. Moore, Uxbridge
  • Sandy Novack, MBA, MSW, Brookline
  • Anne Porter, Cambridge
  • Janice Philpot, Boston
  • Diane Robie, Pittsfield
  • Susan Rorke, Medway
  • Dr. Ama R. Saran, Good Trouble Collaborative, Georgetown, SC
  • Second Thoughts MA: Disability Rights Advocates against Assisted Suicide
  • Dorothy Weitzman, MA. MSW, Newton
  • Brianna Zimmerman, South Hadley

Download the Resolution Calling for Sufficient Nursing Home Staffing to Prevent Elder Abuse (pdf) (with added footnotes and resource links).