On February 2, several DignityMA members met with Secretary Kate Walsh of the Executive Office of Health and Human Services and Dr. Robert Goldstein, Commissioner of the Department of Public Health.
DignityMA presented their thoughts and recommendations regarding various issues affecting the delivery of long-term services and care in the Commonwealth especially those involving nursing homes. Hoping that this is the beginning of ongoing communication with DPH and EOHHS about these vital issues, Dignity Alliance participants throughout the state are prepared to offer their observations, experience, and expertise.
Recommendations
For Immediate Attention (i.e. now through June 30, 2024)
Masking and vaccination
- Review current compliance rates with directives and guidance regarding masking and vaccinations in nursing homes and other congregate settings.
- Following the review, issue update directives and guidance to ensure optimal compliance.
Conduct an “After Action” review of the closure the four Northeast Health nursing homes in western Massachusetts which closed in the winter / spring of 2023. Among the questions to address:
- Where were residents discharged to?
- How many residents were discharged to other facilities? How many residents were discharged to home and community services?
- What is the status of residents currently?
- What monitoring and support services were available to residents and families?
- How many deaths have occurred?
- How many hospitalizations occurred?
- How do residents and their family members feel about the transfer process? About their present situation?
- Were Spanish speaking residents transferred to other facilities which had Spanish speaking staff?
- How many residents were transferred to lower rated facilities, i.e., from 4- or 5-star facilities to 3-star of lower rated facilities?
- How compliant were the discharges with requirements imposed by the Department of Public Health, e.g., abiding by the timeline; limiting discharges to no more than five daily; identifying receiving facilities within a 25-mile radius, etc.?
- How could nursing home management have conducted the closure process better?
- How effective were the actions / oversight of state entities, e.g., Department of Public Health, the Nursing Home Ombudsman Program?
- How accommodating were public housing authorities and other service providers in the community?
Board of Nursing Administrator Compliance with directive contained in FY 2024 state budget (line item 510-0721)
- Ensure that a report is compiled according to the directive:
For the operation and administration of the boards of registration for health professions licensure; provided, that funds shall be expended for the operation and administration of the boards of registration in nursing, pharmacy, dentistry, nursing home administrators, physician assistants, naturopathy, perfusionists, genetic counselors, community health workers and respiratory care; provided further, that the board of registration of nursing home administrators shall review facilities closed between January 1, 2023 and July 31, 2024, inclusive, for compliance with 105 CMR 150; and provided further, that not later than September 1, 2024, the board shall submit a report to the house and senate committees on ways and means and the joint committee on elder affairs that shall include, but not be limited to, accounts of compliance issues and violations of the regulations. [Emphasis added.]
Strengthen nursing home change of ownership vetting and transfer process
- Review current process and requirements to ensure compliance.
- Identify elements to strengthen process including:
- Timely public notification via the DPH website at a minimum.
- Ensuring transparency throughout the process including public access to applications and supporting documentation.
- Involving the Public Health Council via public hearings and obtaining Council review and approval.
Short-term Actions (FY 24 / FY25)
Develop and promulgate regulations relative to the quality and safety of specialized services in nursing homes, especially if they are statutorily authorized in H.4193.
We recommend the following provisions be considered:
- Explicit certification criteria for each specialty should be established.
- There should Board certified medical direction for each specialty provided in a facility.
- The Public Health Council should review and approve all proposals for specialty services. There should be some type of determination of need criteria to ensure that there is appropriate geographical distribution of approved services,
- Approval of specialty services should be limited to facilities rated 4 and 5 stars.
- There should be comprehensive training and continuing education requirements for personnel working with specialty services.
- No temporary workers should be assigned to specialty services unless appropriately trained.
- State surveyors for specialty services should have specialized training.
- Twice annual public reporting should be required including at least these data: volume, length of stay, referral sources, outcomes, incidents.
- State level external advisory / oversight panels for each specialty service should be established.
- Existing programs can have a one-year waiver in order to become certified.
- Promotion / advertising of specialty services should require approval by DPH.
- Accreditation by appropriate external organizations should be required for each specialty service.
Maximum room occupancy
- Take actions to ensure that the policy establishing a maximum room occupancy of two residents is implemented by December 31, 2026.
- By December 31, 2028, create and implement a plan to optimize the use of single resident rooms with the objective of improving infection prevention and promoting privacy.
Marsters v. Healey
- Develop options with input from advocates to promote fiscally responsible solutions to address issues raised in Marsters v. Healey.
Staffing requirements
- Enforce compliance with state staffing regulations (3.58 HPRD [hours per resident day]) and develop consent agreements with providers to reach compliance in a timely manner.
Care transitions
- Review EOHHS memo Strategies to Address Healthcare Capacity (January 9, 2024) to ensure that priority is given to returning patients home or out-patient settings before nursing home placement.
Medium-term Actions (FY25 through FY27)
Nursing home resident rights
- Conduct review of rights currently delineated in DPH regulations.
- Develop proposal to update regulations to equalize the rights of nursing home residents with those for clients served by the Department of Mental Health and the Department of Development Services (Draft sent to Commissioner Goldstein).
Data collection and analysis
- Direct the Center for Health Information and Analysis (CHIA) and other relevant agencies to present data in more use-friendly and accessible formats.
- Streamline current data collection requirements to ensure that the most relevant is collected and presented and incidental information is minimized. Currently, over 2,000 data elements are collected and presented.
- Take steps to post collected data more expediently. (The data 2021 has only been recently posted.)
- Conduct and post meaningful analysis of the data annually.
Nursing home survey process
- Review DPH’s nursing home surveying process.
- Take steps to stabilize staffing and reduce turnover.
- Develop a plan to reduce the number of nursing homes covered by each surveyor.
- Ensure that there is sufficient clinical expertise among surveyors to survey specialty programs.
Anti-psychotic medication
- Review options to reduce over-use and mis-use of anti-psychotics, etc. with nursing home residents.
- Evaluate potential for a monitoring system comparable to that in use with opioid prescriptions.
Informed consent
- Clarify by regulation the procedure to comply to the Massachusetts informed consent law, including greater reliance on supported decision-making.
Social service staffing
- Review and update social worker staffing requirements which have not been modified since the 1970’s.
Nursing home medical directors
- Review and expand nursing home medical director requirements including the possibility of requiring certification by the American Board of Post-Acute and Long-Term Care Medicine.
Long-term Action (Before FY30)- Private equity
- Develop strategies for addressing the impact of private equity interests, real estate investment trusts, and similar entities in the acquisition and / or control of nursing homes and health care facilities and enterprises.