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North Carolina Regional Long-Term Care Ombudsman Association
2008 Legislative Priorities

The North Carolina Regional Long-Term Care Ombudsman Association is a subcommittee of the North Carolina Association of Area Agencies on Aging.

State Issues

1. Support a bill that would increase Medicaid nursing home residents’ personal needs allowance in nursing homes from $30 per month to $50 per month. 

Federal law requires a Medicaid personal needs allowance of at least $30 per month.  A Medicaid Personal Needs Allowance Increase bill was introduced in the 2004 – 2005 legislative session that would increase the Medicaid personal needs allowance from $30.00 per month to $50 per month for residents in skilled nursing facilities.  The bill was referred to Appropriations, where no action was taken.  The following information is taken from the bill.

The personal needs allowance of residents in NC nursing homes has not been increased since 1988.  Thirty dollars per month is not sufficient to cover the cost of personal needs of residents.  In December 2004, over 25% of states paid $40.00 - $49.00 in Medicaid personal needs allowance for skilled nursing facility residents, and protocols for automatic annual increases in the personal needs allowance are in place in five states.  Furthermore, the Medicaid personal needs allowance paid by the State draws down the federal match to these funds.

2. Continue to support efforts to address concerns related to mixed populations in adult care homes.

Studies conducted in N.C. indicate that over 40% of persons residing in adult care homes have a diagnosis of mental illness.  These persons are often younger and placed in facilities designed and staffed to serve an older, frailer clientele.  Mixing of younger persons with mental illness with older, frail adults creates less than optimal situations for both groups, often impacting the well-being and safety of residents.  A lack of viable housing options often forms the basis of placement in residential care facilities.  Persons with mental illness or developmental disabilities often lack appropriate services and supports.

3. Support a study of the need for requiring air conditioning in adult care homes due to changing weather patterns.  The study should include a determination of the number of facilities across the state currently without air conditioning, as well as the medical implications and impact on quality of life associated with exposure of residents to increasingly hot temperatures.

Currently in adult care homes, if the temperature in the main center corridor exceeds 80 degrees, the facility is required to have air conditioning or a fan for each resident bedroom.  The rules do not require that the temperature then be maintained below 80 degrees

4. Support the enhancement and provision of new dental services in long term care facilities.

There is no consistent access to dental care for the more than 200,000 North Carolinians who are homebound or live in nursing homes or group homes. North Carolina has no statewide oral health system to serve patients with special care needs. Long term care facilities have few qualified community dentists to care for their residents and are challenged to meet each resident’s daily oral hygiene needs.  Local dental providers are reluctant to treat the medical and behavior needs of patients with special care needs. There are no specialty training programs for providers wanting to serve this population. Uncontrolled oral infections result in more costly infections such as aspiration pneumonia, uncontrolled diabetes and endocarditis. Medicaid rates do not keep up with inflation.  The two non-profit programs that serve these individuals (Access Dental Care/Carolinas Mobile Dentistry) are stretched to the financial breaking point.  These organizations provide comprehensive care to 6400 residents in 13 piedmont counties with an 80% Medicaid/20% Private Pay mix.
(*Source: Access Dental Care)

5. Support labor enhancements for direct care workers in long term care facilities to improve recruitment, retention, development and job satisfaction, thereby improving the quality of care, continuity of care and quality of life of long term care facility residents.  Labor enhancements include but are not limited to enhanced wages, benefits, shift differentials, career ladders and child care options.

According to the NC Study Commission on Aging, on 02/15/06, the Commission heard a presentation on the NC NOVA project.  The presentation highlighted the high turnover rates for direct care workers in N.C., with average annual turnover rates in 2004 being 106% in adult care homes and 107% in nursing homes.  The presentation also shared that direct care jobs are among the occupations with the largest projected job growth, with N.C. anticipated to need 30,590 additional direct care workers from 2002 to 2012.  Furthermore, as of November 2004, the median hourly wage for direct care workers defined as nurse aides, orderlies and attendants was $9.59.
(Source: NC Study Commission on Aging draft recommendations, April 4, 2006)

Federal Issues

1. Support the need to increase the minimum number of direct care nursing staff in Nursing Facilities to the following ratios:

Minimum Level Direct Care Staff (RN, LPN, or CNA)

(*FTE - Full Time Equivalent)

Minimum Licensed Nurses (RN and LPNs) providing direct care, treatments and medications, planning, coordination and supervision at the unit level:

(*FTE - Full Time Equivalent)

The National Citizens Coalition for Nursing Home Reform (NCCNHR) Staffing Standards.

 In 1998, NCCNHR members voted to support these minimum nurse-staffing ratios developed in consultation with long-term care experts over a period of years.  Since then, these standards have been used, as intended, as “a model framework for state and federal action”, introduced in several congressional bills, and used as a basis for debate in a number of state legislatures that have enacted state staffing standards.

2. Support future Reauthorizations of the Older American Act that extend current provisions for Long-Term Care Ombudsman programs and require that any changes related to the Ombudsman Program enhance program effectiveness.  Support the need to increase appropriations for Ombudsman Programs under title VII.  

This item has been a priority issue for both the National Citizens Coalition for Nursing Home Reform and the National Association of State Ombudsman Programs.

3. Support the Elder Justice Act of 2008 (S. 1070, H.R. 1783)

The bill before the Senate is an important step towards ensuring the safety of vulnerable elders.  If passed, the new law among other things would:

• establish an Elder Justice Coordinating Council to foster coordination throughout the federal government on elder abuse topics;
• establish an Advisory Board to the Coordinating Council of experts on elder abuse, neglect and exploitation;
• require the issuance of regulations to guide researchers in the area of elder abuse relating to human research;
• authorize funds for the federal elder justice system;
• require the Secretary to carry out activities that provide incentives for individuals to train for, seek, and maintain employment in long term care facilities, and require all adjudications of criminal violations by nursing facilities or employees to be reported on the official Nursing Home Compare Website;
• provide grants to improve ombudsman capacity, conduct pilots, provide support and improve training;
• provide and improve the training of surveyors with respect to investigating allegations of abuse, neglect and misappropriation of property in programs and long term care facilities that receive payments under Medicare and/or Medicaid.
• require immediate reporting to law enforcement of crimes in a long term care facility.

More information

4. Support the effort to ensure maximum consistency in enforcement of the National Nursing Home Reform Law.  (OBRA 87)

On July 9, 2006 Senate Finance Committee Chairman Charles Grassley of Iowa sent a letter to CMS Administrator Mark McClellan on the results of interviews between his staff and approximately 20 state surveyors, who charged that their hands were tied in agencies that required them to overlook or downgrade deficiencies.  Grassley conducted the interviews after years of hearings and government reports showing that some of the inconsistency in the survey process appears to be related to differences in the way states cite and code deficiencies and to political pressure in some states to cite harmful deficiencies at a non-harm level.  (Grassley’s letter is posted on the NCCNHR website under “Washington Update”). 

5. Support efforts to increase transparency and accountability of owners of chain-operated long term care facilities.

Although strong federal and state laws exist to protect residents in long term care facilities, more protection is needed.  On September 23, 2007, the New York Times published an article entitled, "At Many Homes, More Profit and Less Nursing", which focused national attention on the lack of quality care being provided by owners of chain-operated nursing homes.  The recent buyout of Manor Care by the Carlye Group also exposed concerns by advocates regarding operations of long term care facilities by private equity groups.  Efforts to increase transparency and accountability may include but are not limited to increased disclosure of ownership and expenditures; inspection findings and enforcement actions; and increasing nursing staff to resident ratios.

In February, 2009, Sen. Charles Grassley (R-IA) and Sen. Herb Kohl (D-WI), introduced S. 2641, the Nursing Home Transparency and Improvement Act.

This legislation would:

• strengthen accountability requirements, including requiring independent audits for nursing home chains and providing more transparency in nursing home expenditures;
• provide more information about the ownership of facilities and include a standardized complaint form and online inspection reports;
• strengthen available enforcement actions by enabling the Secretary of Health & Human Services to impose a higher range of civil monetary penalties of up to $100,000 for a deficiency resulting in death and up to $25,000 for deficiencies at the level of actually harm or immediate jeopardy, and equipping the Secretary with tools to address corporate-level problems in nursing home chains by giving the authority to develop a national independent monitor program;
• provide greater protection to residents of nursing homes that close by requiring advance notice of the closure, along with the development of a transfer, and relocation plan for residents.
  (See NCCNHR’s February, 2008 press release)     

The North Carolina Regional Long-Term Care Ombudsman Association, a subcommittee of the North Carolina Association of Area Agencies on Aging, will continue to be supportive of the appropriate efforts of other advocacy groups that pursue legislative action on issues of importance to older adults. This is consistent with our mandated responsibilities as outlined in Section 306 of the Older Americans Act that states “the area agency on aging will serve as the advocate and focal point for older individuals within the community by (in cooperation with agencies, organizations, and individuals participating in activities under the plan) monitoring, evaluating, and commenting upon policies, programs, hearings, levies, and community actions which will affect older individuals.”