Dignity Alliance will take positions on issues which most of the Alliance agrees on. We are a broad coalition, and expect to rarely get 100% agreement!

Why Did So Many In Our Nursing Homes Die from COVID-19? What Lessons Did We Learn? And Are We Prepared For A Second Surge? – October 13, 2020

The hearing was held on October 13. For more information, including video testimony, visit: https://malegislature.gov/Events/Hearings/Detail/3580. Paul Lanzikos can be seen and heard around the 30 minute mark in the first video. Unfortunately, closed captions are not included.

From State Senator Becca Rausch: “As the Senate Vice-Chair of the Elder Affairs Committee, on Tuesday I participated in a hearing entitled: Understanding the Tragedy: Why Did So Many In Our Nursing Homes Die? What Lessons Did We Learn? And Are We Prepared For A Second Surge? We heard from many critical stakeholders, included Massachusetts Secretary of Health and Human Services Marylou Sudders, about our very concerning COVID-19 case and death rates in nursing homes across the state, state actions taken in the spring to reduce cases/deaths, and lessons we learned that we can implement should we see another outbreak in nursing homes. Thank you to the Chairs Senator Pat Jehlen and Representative Ruth Balser for convening this important hearing.

Paul Lanzikos Testimony

Download Paul’s Testimony: https://dignityalliancema.org/wp-content/uploads/2020/10/Dignity-Alliance-Testimony-Oct-13-release.docxhttps://dignityalliancema.org/wp-content/uploads/2020/10/Dignity-Alliance-Testimony-Oct-13-release.docx

Good afternoon, Senator Jehlen, Representative Balser, and Members of the Committee. My name is Paul Lanzikos and I am representing Dignity Alliance Massachusetts, a statewide coalition of aging and disability service and advocacy organizations and individuals. I have included the roster of our current members who have endorsed this testimony.

Every one of us deserves to live a full life with dignity. No matter what our circumstances may be; what our care and support needs are; how young or old we are; or healthy or infirm we may be, our choices and decisions ought to be honored. As disability rights activists proclaim, “Nothing about us, without us”.

However, Covid-19 has robbed many of that right — more than 6,000 people have already died in Massachusetts nursing homes – one of every six – in just eight months and the toll increases daily. Hundreds more have succumbed to the dangers of extended isolation. Nursing home residents account for two out of three Covid-19-related deaths in the Commonwealth. All of them were mothers, fathers, grandparents, friends, or neighbors. For perspective, that is more than the total population of 116 individual communities in Massachusetts. Imagine walking through Boxborough, Essex, or Provincetown, entirely devoid of any people.

Dignity Alliance Massachusetts has been formed to address the structural and systemic deficiencies which have been exposed by this public health crisis. Dignity Alliance Massachusetts members are committed to advocating the implementation of essential care improvements and the expansion of access to living alternatives that will make the Commonwealth a model of care and living choices, as well as mitigating harm from future communicable disease crises.

There can no longer be any doubt about the urgent need for comprehensive change to the nursing home model as the predominant option of long-term care for older adults and people with disabilities. Not only is a fundamental restructuring of facility operations necessary, but as a coalition of advocates with first-hand experience and well-established expertise, we proclaim that it can be done.

New public policies are urgently required to promote community-based services and housing options while also improving the conditions inside existing nursing homes. Too many residents are vulnerable and at risk while the threat of Covid-19 resurgences remains high. Months of visitation restrictions have made residents de facto inmates, imprisoned for nothing done wrong by them.

Moreover, for many, if not most nursing facility residents, continued, unnecessary institutionalization in a nursing facility is illegal. The Supreme Court has made clear that, under Title II of the Americans with Disabilities Act (ADA), the unnecessary segregation of persons with disabilities is a form of prohibited discrimination. As a result, state governments must provide meaningful access to community services for those unnecessarily confined in, or at serious risk of being admitted to, a nursing facility. ADA cases have already been brought and settled by the Commonwealth on behalf of nursing facility residents with brain injuries and those with intellectual/developmental disabilities, which have resulted in thousands of disabled individuals successfully transitioning to the community. Similar cases could be brought on behalf of nursing facility residents with other disabilities, a significant portion of whom could benefit from integrated community settings.

In response, and to ensure that these conditions are not perpetuated, Dignity Alliance Massachusetts is organized as a broad-based group representing a wide range of stakeholders, including nursing home resident advocates, disability rights organizations, legal service entities, mental health organizations, health policy experts, and many individuals amplifying the voices of frail older adults and persons with disabilities. Our aim is to advance policies that revolutionize long-term care, putting the dignity of individuals – both care receivers and caregivers – first, ensuring privacy and effective infection prevention measures for congregate living situations, affordable options for community living, and providing living wages and benefits for caregivers and service workers in facilities and home and community-based settings.

Dignity Alliance is advocating four actions in the near term.

Dignity Alliance Position: Single-Occupancy Rooms

First, we urge the immediate creation of an initiative to demonstrate the efficacy of nursing facilities operating primarily with single-occupancy rooms. This addresses consumer demand and expectations for privacy, dignity, and choice as well as optimizes infection control protocols. While Governor Baker’s proposal to eliminate three and four bedded rooms is a positive step, we strongly feel it is only the first step and not sufficient. We are not aware of any person who willingly opts to live with a stranger.

Dignity Alliance Position: Determine Why and How Residents and Workers Incurred the Worst Impact of Covid-19

Second, we call for further legislative inquiry to determine why and how residents and workers disproportionately incurred the worst impact of the Covid-19 pandemic and to identify and develop strategies, policies, and procedures to address any resurgence of Covid-19 or the spread of influenza and other infectious diseases in nursing homes and other congregate living settings.

Dignity Alliance Position: Universal Availability of Frontline Worker Supports

Third, we strongly advocate appropriations to ensure the universal availability of necessary supports, including, but not limited to, sufficient and appropriate personal protective equipment (PPE) and of livable wages and benefits for frontline workers confronting the current coronavirus outbreak as well as anticipating future needs.

Dignity Alliance Position: Expand Availability of Home and Community Services

And, our fourth immediate objective is the expansion of the ability of older adults and persons with disabilities to receive comprehensive services, support, and care in their own homes or other locations in the community of their choice. This can occur through changes to Medicaid waiver programs, enhancement of eligibility rules and the scope of benefits in state-supported service programs, and the development and operation of more affordable, service supported housing options. If the Health Care Conference Committee, which is meeting right now, included in its final bill, Section 38 of H4916, the House Health Care bill, this would quickly and easily make community based care more financially possible for many seniors. One other specific option for consideration is the development of a program to stimulate and support the conversion of nursing facilities which cease operations to become supportive housing for persons with various needs. We believe significant involvement of the legislature’s Joint Committees on Housing, Health Care Finance, and Elder Affairs, the Department of Housing and Community Development, and the Executive Office of Health and Human Services—including the Executive Office of Elder Affairs—is essential.

Dignity Alliance Massachusetts members are committed to work with legislators, public policy makers, regulators, and providers with the goal of ensuring that the systems of long-term services, support, and care available in the Commonwealth to older adults and persons with disabilities are ones of quality, affordability, and are committed to honoring their dignity and choices.

Applications for Determination of Need from Long-Term Care Facilities – October 6, 2020

Testimony to the Massachusetts Department of Public Health Determination of Need Program relative to its Memorandum on Applications for Determination of Need from Long Term Care Facilities dated October 6, 2020.  This response is being presented on behalf of the members of Dignity Alliance Massachusetts.

Download the written testimony: DignityAllianceDPHDON.docx or scroll down for the information.

note: DON – Determination of Need

The Need for Skilled Nursing Facilities

Given the tragic loss of so many residents of long-term care facilities in Massachusetts far above the national average there is, in our opinion, NO need for any additional beds to serve the traditional general population of older adults or people with disabilities.  Even prior to the pandemic, the census in nursing homes was on the decline.  Additionally, Mass Senior Care, the nursing home industry trade organization, testified to the Legislature on April 19, 2019 that “lack of stable financing would result in 35 homes projected to be at risk of closure this year (2019), on the heels of 20 homes that shut their doors in recent months”.

We believe that the closing and consolidation of skilled nursing facilities and the lower bed census resulting from the tragic loss of residents to COVID-19, will produce a savings to the Commonwealth that should be re-invested in home and community-based supports and services, including affordable housing vouchers.  Older adults and people with disabilities deserve the dignity and respect of remaining in their home or their community and have demonstrated a clear preference for maintaining as much independence and choice as their health condition permits. Dignity Alliance strongly supports such a reimagining of long-term care.

In fact, there needs to be an independent assessment of all current nursing home residents, to determine their suitability for living in the community with adequate supports and services in keeping with Governor Baker’s Executive Order 576 advancing the concept of an “age-friendly Commonwealth.” This independent assessment should occur prior to granting any new or amended licenses to serve any of the specialized populations mentioned in the Memorandum of October 6, 2020.

We recognize, however, that while there is no demand for traditional congregate nursing facilities for most frail older adults, there may be current and future need for certain specialized facilities such as those envisioned in the Memorandum.  We propose that the conditions for permitting such facilities need to be strengthened to provide the best possible service to residents with the special needs that the Department has outlined and avoid the expense of unnecessary capacity.

Issue #1: Specialized Populations

Population with Substance Use and Mental Health Disorders.

According to a May, 2017 report by Margaret Mattson, Ph.D, Rachel N. Lipari, Ph.D., Cameron Hays, M.A., and Struther L. Van Horn, M.A.,  “Although the percentage of people with substance use disorder (SUD) reflects the decline in use as people age, more than 1 million individuals aged 65 or older (“older adults”) had an SUD in 2014, including 978,000 older adults with an alcohol use disorder and 161,000 with an illicit drug use disorder. Research suggests that substance use is an emerging public health issue among the nation’s older adults. Illicit drug use among adults aged 50 or older is projected to increase from 2.2 percent to 3.1 percent.  There is a cohort of older adults who may experience the negative consequences of substance use, including physical and mental health issues, social and family problems, involvement with the criminal justice system, and death from drug overdose. Older adults are more likely than people in other age groups to have chronic health conditions and to take prescription medication, which may further complicate adverse effects of substance use.”  As the general population of older adults continues to increase through 2030, it is reasonable to expect that the specialized population with substance abuse is likely to grow at least as fast. While the need for this type of facility for older adults in this specialized population is clear, the applicant must be evaluated based on their history of misuse of anti-psychotic drugs in any conventional care facility for which they are licensed.  According to the Long-Term Care Community Coalition, the 2019Q3 federal report on inappropriate use of anti-psychotics, a significant number of Massachusetts licensed skilled nursing facilities reflect misuse well above the national average use of such substances.  Therefore, those licensees with significantly above average misuse of anti-psychotic drugs in their current facilities should not be considered a suitable applicant for a new DON to treat substance use and mental health disorders.

Population at Risk of Homelessness

The National Health Care for the Homeless Council reports in 2019 that “older adults comprise a growing proportion of the homeless population, and indeed homelessness causes premature aging.  The health care and homeless services systems are bracing for more older adults with increasingly complex needs.  Older adults who are experiencing homelessness have three to four times the mortality rate of the general population due to unmet physical health, mental health, and substance use treatment needs. The combination of issues typically associated with homelessness among older adults, such as reduced mobility and a need for assistance with daily activities associated with behavioral and substance use concerns,  is resulting in the demand for housing and services providers to develop an array of creative solutions. This population is typically experiencing poverty and unable to find safe, affordable housing.

New long-term beds dedicated to older adults at risk of homelessness may not be the best solution for this population.  Homeless adults often resist going to shelters that lack privacy and safety, however a specialized skilled nursing facility might not be the best option.  Independent living options are, with support services, such as HEARTH offers – housing specifically for people who have been homeless, or at least at-risk of homelessness.  They provide wraparound services to support these residents to keep them living independently.  Traditional nursing homes, rest home, and assisted living residences are not able to provide this.

Given the prevalence of substance use among an older homeless population, if the Department accepts applicants for a specialized program, the applicants must be evaluated based on their history of misuse of anti-psychotic drugs in any conventional care facility for which they hold licenses. 

Population with Cultural or Linguistic Needs

A 2018 article in FORBES stated that “now the oldest boomers are entering their 70’s, which means they’re starting to enter the nation’s independent living, assisted living and skilled nursing homes. However, these facilities have lagged the diversification trends. Many are not prepared to provide welcoming environments to residents from a variety of orientations, religions, and ethnic backgrounds. Simply demonstrating compliance with federal, state, and local fair housing laws does not guarantee that the environment inside senior residences will be welcoming for all people. Creating an inclusive environment requires the will to do so.”  It is important for providers to recognize that specialized, culturally-sensitive dietary services and the availability of non-traditional medical care practices are important aspects of the services to be provided.

“The National Gay and Lesbian Task Force estimates that 3 million LGBT elders live in the United States, and that number will double by 2030. Clearly, this signals a demand for LGBTQ-friendly senior housing. Add to that, the growing number of people in other diverse demographics, such as Muslims, Hindi, Buddhists and people from China, India, the Middle East and Latin America, and it becomes clear that America’s independent living, assisted living and skilled nursing homes need to step up their diversity competency to meet the needs of today’s retirees.”

Cultural competency and multi-language proficiency are among the issues which Massachusetts nursing facilities traditionally serving an English speaking, non-diverse population must address.  Increasingly, immigrants with limited English language fluency are serving English-speaking older adults in skilled nursing facilities.  This can frequently create miscommunication resulting in mismanagement of prescribed medications, rejection of various foods, and anxiety and tensions between caregiver and care receiver.  There is a heightened and immediate need to address cultural and linguistic requirements in many currently operating Massachusetts nursing homes.  Specialized nursing homes serving distinct population with specific cultural or linguistic characteristics is less desirable than setting expectations for current nursing homes to provide welcoming environments and to remove culture and / or language barriers.  Problems arise not so much because of the differences, but due to insufficient efforts to enable people from varying perspectives to live harmoniously together. Staff must be well-trained in multi-cultural awareness and practices to reduce unconscious bias tendencies.  Direct care, support, and management staff should be provided information and guidance in multiple languages.  Segregating residents of specific, relatively homogeneous sub-groups could very well violate existing federal and state fair housing laws in fact if not in spirit.  We advocate that the availability of a specialized DON for cultural and linguistic needs be dropped from the DON categories listed in the Memorandum.

Population with COVID-19

New facilities, or additions to existing facilities, to serve those recovering from COVID-19 or the needs of so-called “long haulers” who experience other mental or physical issues resulting from the virus, may be needed.  However, any facility must expressly document that management has learned the lessons that COVID-19 is teaching us.  An affected population must be housed apart from any general population of older adults that have not experienced the virus.  The characteristics of these specialized units should be comparable to those which serve persons with dementia and cognitive issues to maintain separation of the population with the disease from those without infections.  Providers must enforce visitation policies that are designed for safety while maximizing socialization. Operating plans must optimize the deployment of staff to specific populations to minimize spread of infection and ensure enough testing supplies, PPE, and appropriate medications are always available. Staff must be well-trained and supervised in infection prevention and control.

In any such specialized facility, there must be special attention to the care of both staff and residents.  Facilities serving this population must have a close, active affiliation with an acute care hospital or health system.  A DON application for a specialized COVID-19 skilled nursing facility must have a conversion and operating plan for activation when the need for such a specialized facility has dissipated.  The issuance of a DON should require a periodic full review of continuing need for the specialized services.

There must also be a requirement that should a resident require to be re-admitted to an acute care facility, the bed shall be held as long as necessary to enable the patient to return when appropriate and as desired by the patient.  Frankly, this should be a requirement in all skilled nursing facilities for residents who require hospitalization.

Dignity Alliance Position on Issue #1:

Dignity Alliance supports lifting the DON moratorium for specialized skilled nursing facilities for substance use/mental health issues and COVID-19 rehabilitation. Any applicant which proposes to serve this population should demonstrate that it has the skills, expertise, appropriate programming, and trained staff to adequately meet the needs of the population.

We question the need for special facilities for homeless elders who should be helped to remain in their community as much as possible through rental assistance and support services from organizations such as PACE providers, Senior Care Organizations (SCO), Independent Living Centers (ILC), and Aging Service Access Points (ASAP).

We believe that the cultural and linguistic issues exist in many conventional nursing homes should be addressed through new policies and enhanced programming rather than issuing a DON for a specialized services facility

Issue #2: Enhanced Infection Control

The Department deserves commendation for requiring responsible infection prevention and control of any new or amended DON serving one of the specialized populations identified in the Memorandum dated October 6, 2020.

In addition to the conditions listed in the Memorandum, we believe that the applicant must be required to report infections as they occur to the Department of Public Health and to the Centers for Disease Control and Prevention through the CDC’s National Health Safety Network (NHSN).

All staff in a specialized facility must be trained in infection prevention and control and work toward certification through programs such as InfectionControlsTraining.com that offer training and certification on infection prevention and control for individuals as well as organizations. A wide range of infection prevention and control topics should be specified to be covered through training such as chain of infection, prevention and control, hand hygiene, personal protective equipment, environmental controls, sharps and injection safety, occupational health, sepsis, etc. Case studies are also important to apply principles learned to real world situations.  The infection prevention and control program must be supervised by a full-time infection preventionist who is a registered nurse.

The specialized facility must commit to maintaining an adequate supply of PPE and testing materials and operationalize a policy of regular testing of staff and residents.  In addition, all staff must be vaccinated for influenza, pneumonia, and – when available – COVID-19.

Dignity Alliance Position on Issue #2:

Dignity Alliance generally applauds the Department’s attention to infection control and believes this should be a priority for ALL skilled nursing facilities, not only in some new specialized facility.

Issue #3: Dedication of New Beds for MassHealth Recipients

This requirement is too vague when is states, “some of the new capacity is reserved.”  We recommend that a minimum percentage of the capacity for patients supported through MassHealth such as stating that not less than eighty percent (80%) of the new capacity beds must be reserved. 

In addition, we recommend that the applicant demonstrate that every resident will be offered and placed in a single-occupancy room with their own bathroom unless they, or their care representative, request a two-person room which has sufficient space to meet social distancing guidelines issued by the Department.

Dignity Alliance Position on Issue #3

Dignity Alliance applauds the Department’s recognition that older adults and persons with disabilities who qualify for MassHealth have the right to be treated with dignity and respect as any other individuals. This can be best demonstrated in every person’s ability to choose to live in single-occupancy rooms in any skilled nursing facilities whether specialized or not.

Issue #4: Performance Scores

An eligible applicant, in addition to being in the top quartile performance as measured in and reported to the Commonwealth’s Nursing Home Survey Performance Tool, must demonstrate that it has been in the top quartile for the three (3) years preceding the DON application.  In addition, all deficiencies reported to the Department, the Long-Term Care Ombudsman, or the Attorney General must be evaluated and considered in the determination.  Prior to granting any DON under this Memorandum, an independent financial and performance audit should be completed to assure the financial capacity of the facility to maintain performance in the top quartile even during any public health emergency.  Notwithstanding the immunity provisions of Chapter 64 of the Acts of 2020, the applicant must demonstrate that it has not been the subject of litigation relative to quality of care and safety of patients during the previous three years prior to the DON application.

Dignity Alliance Position on Issue #4

Dignity Alliance agrees that quality measures and past performance of applicants are vital to offering long-term care services.

Issue #5: Compliance with DON Health Priorities

Rather than require an applicant to address at least one of the DON Health Priorities, we recommend that an applicant be required to address how they are addressing priorities a through f, in addition to any other long-term care priorities. In addition to requiring that the applicant be in compliance with applicable federal and state laws and regulations, we believe that this review of compliance apply to the three years preceding the application for the specialized DON provided in the Memorandum dated October 6, 2020.

Dignity Alliance Position on Issue #5

Dignity Alliance urges the Department to set the bar high and suggests that all the listed priorities are important. Applicants should be required to state what they will do to support each of the priorities listed in the Memorandum and any others required by the Department..