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Iowa GOP lawmakers vow to be ‘proactive’ on nursing home woes
Democrats say more accountability needed following reports of neglect
Jan. 7, 2024 5:30 am, Updated: Jan. 8, 2024 7:43 am
DES MOINES — Iowa House Republicans say they plan on being “proactive” in addressing concerns about staffing shortages, turnover and care at Iowa’s nursing homes, but provided few details ahead of the upcoming legislative session.
Senate Republicans have rejected a request by Democrats for a state oversight meeting to investigate nursing home care in the wake of recent reported deaths, abuse and neglect in Iowa care facilities. Documented instanced include lack of access to food and water, and lack of access to adequate medical care, including medications, wound care and pain management and lack of access to ambulance services.
A Woodbury County care facility recently was cited by the state for retaliating against a woman who reported she was raped by one of her male caregivers, the Iowa Capital Dispatch reported. The woman allegedly was given 30 minutes to pack up her things before a taxi was summoned to drop her off at a homeless shelter.
Sen. Claire Celsi, D-West Des Moines, the ranking member on the GOP-controlled Senate Oversight Committee, said Iowans “want and deserve full accountability and transparency,” calling it “a matter of life and death for impacted Iowans.”
"We have a critical responsibility to ensure state departments are carrying through their legislatively assigned functions," Celsi told reporters last month. "The nursing home crisis is real, and the state has an obligation to investigate and provide workable solutions."
Calling it “a very-regulated industry,” Senate Majority Leader Jack Whitver, R-Grimes, said GOP leaders continue to talk with stakeholders about issues impacting Iowa’s long-term care facilities.
“And we don't necessarily need an actual government oversight meeting just to beat somebody up,” Whitver said. “We want to go find the problem and get the solution. And that's not always what happens in those oversight meetings. A lot of that's just a show to go beat somebody up. We want to get it fixed for Iowans, because that's what I really care about.”
Whitver did not provide details about how that would happen in an interview with The Gazette ahead of the start of the 2024 legislative session Monday. He said Senate Republican “have continued to make investments in our nursing homes … to try to get them on stable footing.”
State lawmakers last year provided an additional $15 million to nursing homes through Medicaid reimbursement funding. He and Sen. Amy Sinclair, R-Allerton, oversight committee chair and president of the Iowa Senate, also pointed to legislative efforts to address workforce shortages in the industry.
"(S)ince 2017, the Senate has increased funding for nursing home care by nearly $75 million, increased incentives for high quality of care to over $111 million, and passed critical tort reforms to ensure nursing homes can continue to provide services in rural Iowa,“ Sinclair said.
Reynolds concerned over staffing mandate
Gov. Kim Reynolds declined to be interviewed for The Gazette’s legislative preview series.
“Gov. Reynolds has increased Medicaid funding every rebase year as governor, leading to $163 million of new funding going to nursing facilities to increase quality of care for residents,” Kollin Crompton, deputy communications director for the governor’s office, said in a statement. Rebasing is the process of adjusting nursing facility rates to use more current cost data.
He said Reynolds has addressed the health care workforce shortage by investing $20 million in apprenticeship programs while allocating more than $4 million to a program to recruit doctors and other health care professionals to rural communities.
“Governor Reynolds believes solving the health care workforce shortage and addressing funding is the path to improving long-term care for Iowa’s seniors,” Crompton said.
The governor's office also raised concerns over a recent proposal from the Biden administration to implement minimum staffing requirements in nursing homes. Reynolds joined 14 other governors who issued a statement opposing the mandate.
Reynolds, in a joint letter signed by other Republican governors, argues the proposal imposes an unfeasible standard because of a nationwide staffing shortage made worse by the pandemic. And it could force more nursing homes to close their doors, ”eroding access to health care for some of our most vulnerable citizens,“ Reynolds wrote.
“Such challenges are especially acute in rural areas,” the letter states. “Despite this, the (Centers for Medicare & Medicaid Services) requirements would force over 80% of facilities nationwide to hire more staff at a time when workers, particularly RNs, have never been scarcer.”
Advocates for older Americans have been calling for such a requirement for more than two decades, arguing that residents are safer and have better care with more staff, but the industry has successfully resisted thus far.
State catches up on overdue inspections
According to federal data, Iowa is responsible for 3 percent of the nation’s nursing facility citations, and 4.1 percent of the nation’s immediate jeopardy and life-threatening situations — despite accounting for just 1 percent of the nation’s 65-plus population.
A report by the U.S. Senate Special Committee on Aging suggests Iowa has one of the nation's worst ratios of nursing home inspectors to care facilities, and that the state's use of private contractors to inspect homes is extraordinarily costly to taxpayers.
A spokeswoman for the Iowa Department of Inspections, Appeals and Licensing argued the report’s ranking of Iowa surveyors to long-term care facilities “isn’t an apples-to-apples comparison.”
Iowa’s 46 long-term care inspectors are dedicated full-time to performing surveys at Iowa nursing homes. The department has additional surveyors to inspect hospitals, assisted living programs, residential care facilities, home health agencies, hospices and other health care facilities. Other states have their inspectors inspect all programs, “which may result in having their nursing home inspectors only dedicate a portion of their time to nursing homes,” said agency spokeswoman Stefanie Bond.
State officials note they have reduced by more than 50 percent the number of Iowa nursing homes that are past due for their annual inspection.
The federal CMS suspended requirements for certain routine inspections as part of its response to the pandemic to prioritize infection control and immediate jeopardy situations and to give health care providers and suppliers time needed to respond to the spread of COVID-19. Starting in fall 2022, CMS required state agencies to reduce the backlog of past-due inspections by 50 percent.
State officials say they met that goal to where only 29 of Iowa’s 407 facilities — or about 7 percent — remained overdue for an inspection.
“DIAL has been in compliance with CMS' performance measurements for recertification surveys and anticipates it will be in compliance this upcoming year as well,” Bond said.
Staffing and funding
Nursing home officials have said workforce challenges, including high turnover rates and worker shortages fueled by low wages, have impacted patient care. Industry officials say they also have felt financial strain from low Medicaid reimbursement that has not kept up with rising costs, making it harder to offer competitive wages.
More than two dozen nursing homes across the state have closed since last June. Iowa currently has more than 28,000 nursing home beds.
Nursing home and hospital nursing staffs have witnessed high turnover as thousands of nurses have quit their staff positions to become contract travel nurses, where the pay is substantially higher.
The rapid turnover has triggered a problematic loop, where hospital administrators, facing nursing shortages, spend large amounts hiring contract nurses, making them less able or willing to increase their staff nurses’ pay. So more staff nurses quit to become contract nurses, exacerbating facilities’ staffing shortages, and driving demand for contract nurses and contract nursing agencies prices higher.
A list of talking points from the Iowa Health Care Association, which represents the state’s long-term care facilities, sent to nursing home administrators to use with state lawmakers in persuading them to increase Medicaid payments to care facilities states staffing shortages are fueling wage inflation.
“We cannot compete on wages because of the reimbursement system,” the IHCA memo states. “At the same time, we are forced to look to staffing agencies, which have leveraged this environment to also drastically increase their pricing.”
Nursing home administrators were instructed to tell legislators: “The long-term care sector in Iowa will be completely insolvent by (date) without a $60 million rebase rate adjustment in 2023.”
Discussions will be ‘amplified’
House Republicans say tackling the issue is among their top priorities for 2024.
“The Iowa House must step up and protect Iowa’s nursing homes and health care institutions from being abused by out-of-state staffing agencies that are lowering quality and increasing costs,” according to a House GOP news release.
Iowa Medicaid patients account for roughly half of Iowa’s nursing home population.
“From the taxpayers’ perspective and quality and continuity of care, we have to be willing to have this conversation,” House Speaker Pat Grassley, R-New Hartford, told The Gazette of “the ability to come in and charge three, four or five, six times more than what traditional wages are for nursing homes.”
Asked what Iowa lawmakers can do about that, Grassley did not provide specifics.
Celsi, the senator from West Des Moines, said Senate Democrats plan to propose legislation that would increase the number of on-staff state inspectors, provide funding for alternatives to institutional care and offer additional training and relocation assistance for those who provide hands-on care for seniors.
She also pointed to a pilot project that’s been underway for a few years, and is now in 44 of Iowa’s 99 counties. The program helps non-Medicaid eligible Iowa seniors maintain their independence by keeping them in their homes following a hospital stay with a comprehensive set of wraparound services and supports. The goal of the project is to reduce nursing home placement and hospitalizations among Iowa seniors.
Lawmakers approved $850,000 to continue to expand the pilot initiative. Celsi said Democrats now want to expand the program statewide. Doing so is estimated to cost $5 million annually, according to state officials.
“The pilot program is working for very little money, keeping seniors out of facilities, keeping them from being rehospitalized,” Celsi told The Gazette.
Grassley said funding to hire more state nursing home inspectors “is a budget question that needs to be addressed through the budget process.” He said that discussion will “probably be more amplified in this session based on some of the things in the news.”
‘Dereliction of duty’
John Hale, a consultant and advocate for older Iowans, called it a “dereliction duty” of lawmakers to not provide oversight of Iowa’s nursing industry in light of recent state citations that display “significant problems in the quality of care in nursing homes that oversight is needed.”
He said about $800 million in taxpayer dollars flow to nursing home owners and operators annually with no expectations for how the dollars are used.
Iowa Health PAC, the political arm of the state’s long-term care industry, is one of the state’s biggest contributors to political campaigns, spending a total of almost $1.5 million on campaign donations and related expenses since 2016, the Iowa Capital Dispatch reported.
“(Lawmakers) have been providing more money to the nursing home industry for decades. It's just a routine process where they just give more money to the industry,” Hale said. “And that hasn't helped improve quality. We still have a quality of care crisis. Department of Inspections and Appeals citations haven't solved the problem. More money to the industry hasn't solved the problem.”
What's missing, Hale said, are state leaders who are “not going to nibble around the edges.” He said Iowa needs to adopt minimum staffing standards to ensure an adequate number of front-line staff per nursing home resident, like what Iowa requires for child-to-staff ratios in child care centers.
Hale suggested lawmakers also:
- Revise nursing home cost reports to ensure more detail and greater transparency in how the industry spends state tax dollars
- Incentivize quality care with a pay-for-performance program, assist facilities that are performing poorly and sanction those that continue to fail
- Budget more dollars to build and sustain a vibrant system of long-term care providers that serve people in their homes and communities
- Approve legislation that allows the installation of cameras in rooms when residents request them
- Ensure the state has adequate resources to quickly and effectively conduct routine inspections and respond to resident complaints.
Brent Willett, president and chief executive officer of IHCA, said in a statement the association “supports a state and federal regulatory system that promotes continuous improvement and timely enforcement.
“We also support new and innovative strategies to grow the permanent direct care workforce, building on important steps recently taken in apprenticeship funding and the regulation of temporary staffing agencies,” Willett said.
He said lawmakers and Reynolds “have demonstrated steadfast commitment to expanding home- and community-based services in Iowa, and we will work to identify ways to fund further investments in Iowa’s home- and community-based services waiver system, as well as its Low Utilization Payment Adjustment program for home health, to improve access to home- and community-based services.”
Legislative previews
In the days leading up to Monday’s start of the 2024 Iowa Legislature session, The Gazette will preview topics of possible discussion by state lawmakers:
Dec. 31: Tax cuts and state budget
Monday: Social issues
Tuesday: Economic development
Wednesday: K-12 education
Thursday: Higher education
Friday: Government transparency
Saturday: Agriculture and environment
Today: Health care
Monday: Hot-button issues
Comments: (319) 398-8499; tom.barton@thegazette.com
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