With elder care in the spotlight this legislative session, lawmakers adopted key reforms aimed at boosting transparency in how nursing home managers spend taxpayer money and increasing oversight of the state’s more than 900 homemaker companion agencies.
But they also passed on several significant proposals that would have raised the mandatory minimum hours of direct care in nursing homes, ensured air conditioning was provided in every resident room, and directed funding to the long-term care ombudsman’s office to substantially increase staff.
“It seems like everything else comes first,” said Debra Ellis, whose wife lived at a Meriden nursing home for two years until her death in 2022. “We get to the nursing home bills and the elderly — it just seems like emphasis is put in other areas.”
Ellis said her wife’s facility was understaffed, and she testified earlier this year in favor of a bill that would have required higher staffing levels. She told legislators about instances of neglect and medical errors she had observed during visits.
“We’ve often said if animals were treated this way, and it was publicized, the public would be enraged,” she said in an interview.
Dozens of nursing home residents and their loved ones complained to the General Assembly this year about subpar staffing levels, neglect, cold food and poor living conditions. Some facility workers said they were stretched so thin they struggled with patient loads and burnout.
Some lawmakers responded by promoting bills aimed at reform and calling for more funding to expand staff in the ombudsman’s office, which advocates for nursing home residents and investigates complaints.
One bill would have raised the mandatory minimum hours of direct care per resident per day in nursing homes to 4.1, up from three. But the measure required substantial funding — an additional $26.6 million during the first year alone — and industry officials opposed it, saying they already were struggling to recruit and retain workers.
Another proposal would have mandated that nursing homes install air conditioning in all resident rooms. Mairead Painter, the state’s long-term care ombudsman, testified that it was “unacceptable” to see residents who are unable to get out of bed for a drink of water go without air conditioning in the summer months. An earlier draft of the state budget proposed setting aside $2 million to help facilities purchase units, but it was stripped out of the final version.
Some advocates suggested undertaking a study of how many facilities now offer air conditioning in resident rooms, and they are searching for an agency to undertake the effort.
“It remains a huge priority of mine. It’s disappointing that we couldn’t make more progress this year,” said Sen. Matthew Lesser, D-Middletown, a co-chair of the Human Services Committee. “It’s important to get better data on the state of things and to really come up with a consensus approach to upgrading our dilapidated facilities.”
Painter also asked the legislature this session for enough money to staff 12 positions in the long-term care ombudsman’s office that will serve home care residents. While those in nursing homes and assisted living centers can access her office, home care residents cannot.
Last year, lawmakers signed off on a state budget that funded one position — a manager to help design and oversee an ombudsman program for the home care sector. But no money was set aside to hire workers who could field complaints.
This year, one additional position was authorized to help home care residents. Painter plans to start by extending services to people on the state’s waiver programs, such as those who participate in the Money Follows the Person initiative or the Connecticut Home Care Program for Elders.
But she hopes to expand. Tens of thousands of people in Connecticut use home care services.
“Although we would have loved to have seen all 12 [positions funded], we’re going to use the one to start to grow the program,” she said. “Hopefully, when we begin to see the number of complaints or intakes that we get, it’ll give us the justification for more positions.”
“That was a huge, huge disappointment,” Rep. Jane Garibay, a co-chair of the Aging Committee, said of funding for Painter’s office. “We’ll be out there fighting for this again, that was one of our priorities.”
Accountability measures
Advocates praised several important reforms that did pass this year, including the transparency mandate and an increase in regulation of home care agencies.
As part of a push for more accountability, the transparency bill requires facility operators to submit narrative summaries of their expenditures along with the annual cost reports they file to the state. Summaries must include profit-and-loss statements, total revenue and expenditures, assets, liabilities, short- and long-term debt, and cash flows from investing and financing.
Nursing home managers would be required to disclose if a private equity company or real estate investment trust owns any portion of the facility. Managers who violate the mandates may be fined up to $10,000 for each lapse.
If the reporting shows nursing home owners and operators are collecting large salaries or administrative fees, lawmakers said they could use that information to inform policy. For example, legislation could be introduced requiring facilities to direct a certain portion of state funds toward direct care only. Similar efforts have succeeded in neighboring states.
“We have to know what’s going on,” said Garibay, a Windsor Democrat. “We don’t really know how much they’re earning. And not just the bottom line of the nursing home — how much are the owners earning? That’s going to be an important piece.”
Another bill that passed transfers oversight of homemaker companion agencies from the state’s consumer protection department to the public health department. It requires the commissioner to revoke a certificate of registration if any agency violates certain provisions three times in a calendar year and mandates that the department create a guide that details how to file a complaint against a homemaker companion company.
Elder care advocates have called the industry the “wild west” because of its lack of oversight, unlike long-term care facilities, which are heavily regulated by the state.
Unlike nursing home employees and home health aides, who must be licensed by the state Department of Public Health, there is no licensing process for homemaker companion workers. Instead, the agencies must register annually with the Department of Consumer Protection.
Managers at those companies are required to conduct criminal background checks on prospective employees but aren’t required to share that information with DCP, which does not track who works at the more than 900 HCAs registered with the state.
CT Mirror reviewed more than 75 complaints against homemaker companion agencies filed with the consumer protection department between 2018 and 2020 and discovered at least half a dozen cases in which HCA employees were arrested for allegedly stealing from their clients, more than a dozen findings by DCP investigators of agencies that routinely mis-advertised the services they provided, and seven complaints of clients being left alone for hours at a time.
Nursing homes
In a separate effort, lawmakers also want to study excess beds in nursing homes. A bill raised early in the session would have slashed funding for facilities whose occupancy dropped below 90%. The industry strongly opposed the measure, and legislators instead opted study the issue.
A working group will be convened to examine licensed bed capacity, occupancy levels and locations of beds not currently in use. The panel will also evaluate the effectiveness of Medicaid payment policies that support efforts to “right size” the nursing home sector.
“The notion of having a thoughtful study and review that really drills down on the excess bed capacity issues is well timed and a smart move in our view,” said Matthew Barrett, president and CEO of the Connecticut Association of Health Care Facilities. “Right sizing, rebalancing and questions of bed capacity are part of the culture or calculus of Medicaid decision making now. … And so with that, the policy of really drilling down on where the excess beds are is a smart move.”
Industry leaders have also expressed support for the transparency measure.
“Connecticut nursing homes have been reporting on third-party-related expenditures for a decade or more,” Barrett has said. “While we are already highly transparent, we are not opposed at all to additional transparency provisions.”
With some significant reforms unresolved, lawmakers pledged to again press for higher staffing, air conditioning and other issues next session.
“This is just a start. We can’t sit back on our laurels and say, ‘Hey, we did this,’” Garibay said. “We have a lot more work to do.”