Legislative package targets fiscal oversight, inspections and quality of care improvements
Legislative leaders are fast-tracking a new nursing home reform package that combines key elements of proposals already before the General Assembly, including tighter fiscal controls, more targeted inspections, a triage system for complaints, and new quality standards.
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The five bills, introduced May 26 as the “Long Term Care Reform Act of 2005,” were heard last week by committees in both the state House and Senate.
They have the support of state Health Director David R. Gifford, who called them “an excellent package,” and of Lt. Gov. Charles J. Fogarty, a leader on the issue whose own proposals are the basis of one bill.
The support is not universal, however. Attorney General Patrick C. Lynch, who had sought stronger powers to force nursing homes into receivership, as well as criminal penalties for violators, called the package “a step in the right direction,” but one “that doesn’t go far enough.”
The response from the industry was also mixed. Alfred Santos, president of the Rhode Island Health Care Association, said he was meeting with nursing home operators to go through the details of the five bills, but after an initial reading, he saw items he believed they’d support – such as quality improvement measures – but also some fiscal rules he called “illogical.”
The bills could still be revised as they move through both legislative chambers. But if the fast progress of the Jobs Growth Act, another fast-tracked item backed by legislative leaders, is any indication, a consensus on the major issues has already been reached. The package was also created by the leaders of the committees in charge of reviewing it, further reducing the likelihood of significant changes.
Several other nursing home regulation bills before the General Assembly are now considered dead. The five bills alone, however, cover a vast amount of ground, even including recent recommendations from state Auditor General Ernest A. Almonte, who audited the Department of Health’s Division of Facilities Regulation at legislators’ request and found it generally met federal standards for oversight of nursing homes, but routinely fell short of state requirements for inspections and response to complaints.
Part of the problem, Almonte found, was that the office had far too few resources to conduct the mandatory minimum three annual inspections, for example – and it wasn’t clear that there was any point to inspecting well-functioning facilities so often.
The first bill in the package addresses that issue directly, requiring only one annual inspection for all, but at least two more visits for any facility with patterns of deficiency, and inspections every two months for those where “substandard care” occurred.
The bill would also align the state’s standards for triaging complaints with the federal government’s, and require investigation within 24 hours for any situation in which a resident is in “immediate jeopardy.” It would also allow the state to make a facility hire, at its own expense, an outside “quality monitor” to assess its efforts to correct problems and comply with state and federal regulations.
Finally, in line with many officials’ view, in the wake of the Hillside Health Center collapse, that the quality of patient care is closely tied to a home’s finances, the bill would require detailed financial reports to be filed with the Department of Human Services, which in turn would share them with the Department of Health. The bill also sets standards for what financial conditions would trigger state intervention, as well as standards for reporting, to residents, their families and the public, about problems found in a home.
The second bill, dubbed the Germaine Morsilli Act, after an 87-year-old woman who was found lying in her own waste, with a severe bedsore, at Hillside Health Center, is based on Fogarty’s proposal. It would define the responsibilities of nursing home administrators and nursing home medical directors in oversight of quality of care, require facilities to annually post and report staffing levels, require quality improvement programs within each home, require health officials to develop a system to identify homes in need of intervention, and allow family councils to be created at each facility.
The third bill, based on legislation submitted by Gov. Donald L. Carcieri, would tighten controls on licenses issued to nursing homes, establishing a “probationary status” as a first step before health officials limit admissions to a nursing home or removes its license, defining a “controlling person” at each facility who is responsible for its operations, and requiring license-holders to disclose all partnerships and management relationships.
The fourth bill, adapted from legislation submitted by Lynch, would establish a process for the health department to ask the attorney general to seek a receiver to run a poorly operating nursing home, and allow the receivership process to be used to keep a facility open while necessary improvements are made, or so residents can be moved with minimal disruption.
The final bill is a resolution requiring the Department of Human Services to study the need for home care, adult day services, respite care, assisted living and nursing home care, with recommendations for financing community-based long-term care.
All five bills were developed by the Permanent Joint Committee on Health Care Oversight, a team of leaders of key House and Senate committees who held hearings on nursing homes over several months. Last year, the same group developed sweeping reforms to tighten oversight of Blue Cross & Blue Shield of Rhode Island.
“This committee of dedicated senators and representatives worked very hard for months and dug deep into the problem in an effort to understand why these recent tragedies have occurred in our nursing homes,” House Speaker William J. Murphy said. “Their effort and expertise have provided the General Assembly with what we can confidently say is a very comprehensive response that will improve the care that nursing home residents receive in Rhode Island, and help families feel secure about the safety and comfort of their relatives who are in nursing care.”
Fogarty, who stood with the legislators as they unveiled the five bills, said they will “go a long way to ensuring that Rhode Island is the quality state” when it comes to nursing homes. But noting that Rhode Island had tough rules before that just weren’t enforced, he stressed that only with “the proper enforcement and the proper resources” would this package be effective.
State Rep. Steven M. Costantino (D-Providence), co-chairman of the health care committee, agreed with that assessment. He noted that Carcieri’s 2006 budget provides for six new nursing home inspectors, but said he believes the health department might need more.
Gifford, for his part, said if his department “can do things in new and creative and innovative ways,” he is “confident that we will be able to do the work” with just six more people, and he would consider it a “misuse of government funds” to request more.
Gifford said he also expects to use technology to better use the data the state gathers on nursing homes, and while “it’s not going to happen overnight,” in the long run, his department will be able to do a much better, more targeted job.
Asked whether the bills missed any key issues, Gifford said they don’t.
“I think it’s a pretty comprehensive package,” he said. “I feel that all the necessary things are in there. We may discover that nursing homes or others are able to exploit a loophole or two that we are unaware of, but only time will tell.”
