This article is prepared Maine Monitorwhich was a member of the ProPublica Local Reporting Network in 2022-23. Subscribe to Dispatches to receive such stories as soon as they are published.
In the first major update in more than 15 years to nursing and residential care regulations, the Maine Department of Health and Human Services has proposed significantly increased staffing requirements, among other changes.
The proposed updates stem from an investigation by The Maine Monitor and ProPublica of the state’s largest inpatient facilities. Dozens of violations of residents’ rights were found, including cases of abuse and neglect, as well as more than 100 cases of residents wandering out of their facilities and hundreds of violations of medication and treatment.
In an investigation by news organizations, one facility owner described current staffing requirements as “horrendous,” “dangerous” and “completely inadequate.” Experts, advocates and providers said requiring higher staffing levels, better training and more care would help address these issues.
At a public hearing this month, the department proposed doubling the number of direct care workers in nursing homes overnight and imposing stricter rules on memory care units that go beyond state and federal nursing home staffing requirements. DHHS must submit its proposed rules to lawmakers by Jan. 10 for consideration in the upcoming legislative session.
Assisted living programs serve older Mainers, adults with intellectual and developmental disabilities, and people with mental illness. These facilities offer less medical care than nursing homes, but they have expanded in recent years after the state limited the number of nursing home beds in the 1990s. At least 26 nursing homes have closed in Maine in the past decade.
That shift has meant the needs of residents at these facilities have “increased significantly,” said Brenda Gallant, Maine’s long-term care ombudsman, the state’s advocate for residents and their families. “The current housing regulations are not meeting the growing needs of residents,” Gallant said, citing state estimates in recent years that about one-third of residents in these facilities may qualify for nursing home care.
Currently, inpatient facilities with more than 10 beds require one direct caregiver per 12 daytime residents, one per 18 evening residents, and one per 30 overnight residents. Under the proposed rules, those ratios would increase to one direct caregiver per eight residents on day and evening shifts and one per 15 residents at night.
Currently, facilities with 10 beds or fewer must have at least one responsible adult present at all times. This will be increased to two on duty at all times.
For memory care units, the proposed staffing requirements are even tougher — and higher than what is currently required in nursing homes: one direct worker per five day and evening residents and one worker per 10 residents at night changes.
Experts and advocates told The Monitor that residents with Alzheimer’s and other dementias are among the most vulnerable because they have a tendency to wander. The proposed rules also require residents to be evaluated for escape risk, which is defined as “leaving a secure facility without authorization or supervision.” The Monitor and ProPublica found that at least 115 escapes were reported at Maine inpatient facilities between 2020 and 2022, according to state inspection records and a database of incidents reported to the health department.
“Significant new costs”
The proposed changes came as “a big shock,” said Angela Cole Westhoff, president and CEO of the Maine Healthcare Association, which represents nursing homes and assisted living facilities across the state.
Westhoff and facility administrators repeatedly asked the state during a hearing this month to suspend the process to get more information from the industry. A DHHS spokesman did not respond to questions about what would happen if it misses a Jan. 10 deadline to submit proposals to the Legislature in favor of more discussion.
MHCA estimates that staffing requirements will mean adding about 2,000 more direct care workers.
“This industry does not have the financial capacity to incur significant new costs without a corresponding increase in MaineCare spending and private pay pricing,” Westhoff said, referring to Maine’s version of Medicaid. Providers strongly dispute DHHS’s assertion that the rule should have “minimal financial impact on licensed providers.”
DLTC Healthcare & Bella Point, which owns and operates 17 inpatient facilities, estimated the change would cost an additional $108,000 annually for each 30-bed facility.
The director of finance and human resources for Schooner Estates, Schooner Memory Care and Fallbrook Woods estimated that the three facilities would need to add 68 full-time employees at a total cost of $4.5 million annually.
Woodlands Senior Living, which operates 16 facilities in Maine, said it will need to hire more than 300 employees at its facilities, a cost of nearly $13 million a year.
Many providers said they will likely have to pass those costs on to residents if the rules don’t come with an increase in MaineCare reimbursement from the state.
Facility owners and administrators also warned that increased staffing requirements would be difficult to meet due to labor shortages. During the hearing, one director of resident services in Saco said they had been trying to hire a nurse for more than two years. Another administrator said her facility’s last opening took two months, and when they finally did hire, the candidate had “no qualifications” and required months of training.
DHHS spokeswoman Lindsay Hams said the department cannot comment on proposals during the rulemaking process and noted that the proposals could be modified based on public comments received through Nov. 25.
“The stakes are high here”
While representatives of the agency spoke against it at a recent hearing, others spoke in support.
Citing a recent survey of health professionals, Nicole Marchesi, who works for the ombudsman’s office, said increased staffing could help prevent burnout and turnover.
“Staff continue to express frustration with the level of care nursing home residents receive,” Marchesi said. “If staffing is insufficient, the safety of residents is at risk.”
Gallant, the long-term care ombudsman, and the Maine Elder Law Service also recommended annual, rather than biennial, license renewal inspections and surveys, and creating standard practices for implementing remediation plans when facilities are cited for deficiencies. When investigating the escapes, The Monitor and ProPublica found that in the vast majority of cases, DHHS never inspects the facilities and rarely imposes sanctions.
“The stakes here are high,” wrote John Brautigam for Elder Legal Services of Maine. “These rules can prevent neglect, improve health outcomes, and create an environment where residents feel valued and safe. We have to do this in front of them to ensure that this defense is as strong as it can be.”
