Interview with Diane Menio


National Citizens Coalition for Nursing Homes

This is the third in a series of interviews with key public officials and leaders in the field of Aging. We hope you will gain a better understanding of the areas and resources that are available to you when they discuss their areas of expertise. We deeply appreciate the interviewee's time and effort since they do not receive any form of remuneration from therubins for taking part in these discussions.

Diane Menio
National Citizens Coalition for Nursing Home Reform
Executive Director
Center for Advocacy for the Rights and Interests of the Elderly

therubins: What exactly does the National Coalition for Nursing Home Reform do? How can individuals help you achieve these goals?

The National Citizens' Coalition for Nursing Home Reform (NCCNHR) emerged out of public concern and community organizing. NCCNHR was founded in 1975 by 12 citizen advocacy groups working at the local and state level to improve nursing home conditions.

NCCNHR's current 21-member board, which includes residents of nursing homes and board and care facilities, represents the grassroots membership of concerned advocates of quality long-term care nationwide. The board is elected by consumer-controlled member groups and meets four times a year to establish policies and direct financial and programming issues.

Two hundred member groups and 1,000 individual members and subscribers from 42 states comprise a diverse and caring coalition of: local citizen action groups, state and local long-term care ombudsmen, legal services programs, religious organizations, professional groups, nursing home employees' unions, providers, national organizations, resident councils, and coalitions of resident councils.

NCCNHR provides information and leadership on federal and state regulatory and legislative policy development and models and strategies to improve nursing home care and life for residents. Ongoing work addresses issues such as:

residents' rights;

quality care and quality of life;

resident empowerment and resident and family council development;

support for the long-term care ombudsman program;

minimizing the use of physical and chemical restraints; and accountability for nursing home expenditures.

NCCNHR is a coalition of individuals and groups. It depends upon many individuals working together to achieve its goals. First, individuals can become members receiving information from the organization and an opportunity to provide input. Help comes in the way of participating in our annual meeting, helping to develop and draft resolutions which help to set policy for the organization, writing letters, making calls, or visiting policy-makers and legislators. Financial contributions that help us to achieve our mission are also valued and put to good use.

therubins:The Quality Care for Nursing Home Patients Act (H.R. 5166) is aimed at strengthening federal standards in nursing homes. What are the estimated costs that the federal and state governments will incur if the legislation is enacted? What do you feel are the biggest impediments to its passage?

Rep. Jan Schakowsky did not ask the Congressional Budget Office to cost out her legislation. HCFA is currently conducting the second part of its study for Congress on the appropriateness of Nurse Staffing Ratios in Nursing Homes. The study will look at the cost of implementing the staffing ratios the report recommends and also at cost savings from increasing nursing staff -- e.g., reductions in unnecessary hospitalizations when there is adequate staff to prevent accidents and avoidable medical conditions. Schakowsky decided to wait for that report.

The greatest impediment to passage of the Schakowsky bill or other staffing legislation will probably be Congress and state legislatures' perception that it will increase Medicare and Medicaid costs too much. NCCNHR stresses that previous research has proved that poor care costs taxpayers millions of dollars a year that could be saved by better staffing.

therubins:What position does the coalition take on the "optimal" ratio of nurses and nurses-aides to residents of nursing homes? What types of educational training must these nurses and aides have, and what provisions need to be made for continuing education?

The following are NCCNHR’s proposed minimum staffing standards for nursing homes as adopted by the NCCNHR Membership in November 1998:

Administration Standard

A full-time RN with a Bachelor's Degree would be the Director of Nursing.
(A provision for grandfathering current RN Directors would be allowed for a specified time period)
A part-time RN Assistant Director of Nursing (full-time in facilities of 100 beds or more)
(This person may also be the MDS coordinator)
A part-time RN Director of In-Service Education (preferably with adult education and gerontology training)
(Full-time in facilities of 100 or more)
A full-time RN nursing facility supervisor must be on duty at all times, 24 hours per day, 7 days per week.

Direct Care Staffing Standard

The minimum number of direct care staff must be distributed as follows:
Minimum Level Direct Care Staff (RN, LVN/LPN, or CNA):
Day Shift 1 FTE for each 5 Residents (1.60 hours per resident day)
Evening Shift 1 FTE for each 10 Residents (0.80 hours per resident day)
Night Shift 1 FTE for each 15 Residents (0.53 hours per resident day)
And Minimum Licensed nurses (RN and LVN/LPNs) providing direct care, treatments and medications, planning, coordination and supervision at the unit level:

Day Shift 1 FTE for each 15 Residents (0.53 hours per resident day)
Evening Shift 1 FTE for each 20 Residents (0.40 hours per resident day
Night Shift 1 FTE for each 30 Residents (0.27 hours per resident day)

The minimum total number of direct nursing care staff would be 4.13 hours per resident day.

These requirements should be in place for all residents, regardless of payment source and no waivers of these standards should be allowed. (Administrative staff would be excluded from the direct care standard except in facilities with 30 or less residents).

Nurses and nurse aides must be counted only once in determining the adequacy of staff in skilled nursing facilities and nursing facilities that operate non-nursing units and home agency services.

Staffing must be ADJUSTED UPWARD for residents with higher nursing care needs. For example, residents classified under the Resource Utilization Groups (RUGs) as being in the category requiring extensive nursing care received an average of 6.2 hours of nursing time per resident day in the 1995-1997 time studies.**

Mealtime Nursing Staff
Direct care staffing standards will take into account specific needs of residents at mealtimes. At all mealtimes, there will be:

1 nursing FTE for each 2-3 Residents who are entirely dependent on assistance.
1 nursing FTE for each 2-4 Residents who are partially dependent on assistance.

Residents must be encouraged to remain as independent as possible in feeding themselves, and this may require more staff time than would be required if residents were fed entirely by someone. Nursing staff who assist with feeding must be certified nursing assistants who are adequately trained in feeding procedures and they must be supervised by licensed nurses.

Education and Training

All licensed nurses in nursing homes must have continuing education in care of the chronically ill and disabled and/or Gerontological nursing (at least 30 hours every two years).

Nursing assistants should have a minimum of 160 hours of training, including training in appropriate feeding techniques (at least 12 hours relevant training every year).

Nurse Practitioners

Each nursing home is strongly urged (but not required) to have a part-time Geriatric or Adult Nurse Practitioner and/or a Geriatric Clinical Nurse Specialist on staff (full-time for 100 beds or more).

Disclosure: Public Right to Staffing Levels

A long-term care nursing facility shall post for each wing and/or floor of the facility and for each shift the current number of licensed and unlicensed nursing staff directly responsible for resident care and the current ratios of residents to staff, which show separately the number of residents to licensed nursing staff and the number of residents to (direct caregivers) unlicensed staff. This information shall be displayed on a uniform form supplied by the licensing agency.

Such information shall be posted for the most recently concluded cost reporting period in the form of average daily staffing ratios for that period.

This information must be posted in a manner that is visible and accessible to all residents, their families, caregivers and potential consumers in each facility.

A poster provided by the licensing agency which will describe the minimum staffing standards and ratios (listed above) shall also be posted in the same vicinity.

A list, in at least 48 point type, showing the first and last names of nursing staff on duty shall be posted at the beginning of each shift prominently on each unit.

** 1995-1997 HCFA time studies found about 8 percent of residents were in the RUGs category that requires extensive nursing care. Approximately 50 percent of the time for the extensive nursing residents in the HCFA 1995-1997 national time studies were for licensed staff and of that 57 percent was for RN time. For residents in the rehabilitation RUGs category, the nursing time spent averaged 5 hours per resident day, of which 50 percent was for licensed staff time and, of that, 50 percent was RN time.) Burke, B. , and Cornelius, B. 1995 and 1997 Staff Time Measurement Study. Baltimore, MD: Health Care Financing Administration Multi-state Case mix Demonstration Project, August 1998.

therubins: Violations of state requirements have been a persistent problem with nursing homes. How do you come down hard on persistent violators without increasing problems for the residents of those homes? Federal standards are minimal for each state. How do states that are strapped for funds insure such services?

It is always difficult to balance the need to protect residents with the rights of those residents. It is important that state and federal surveyors act quickly and appropriately when problems are discovered, giving providers adequate time to correct but not allowing them to continue providing sub-standard care. Alternatives to closing facilities and relocating residents do exist including having state or federally required Monitors and/or temporary management when owners fail to correct deficiencies. It is not only the responsibility of the state, but also the providers to use their resources to the best benefit of residents. Some states, however, have been creative in using Civil Monetary Penalty money and Intra-governmental Transfer monies to help improve quality of care in nursing homes. Closure and relocation should always be a last resort.

therubins: Present pending legislation calls for a restoration of about $36 billion in Medicare payments that were cut under the Balanced Budget Act of 1997. President Clinton has stated that he feels this amount is excessive. Do you favor the full amount of the restoration proposed that will go towards nursing homes, and if so how can we insure that a portion of the restoration goes towards staffing rather than administrative expenses?

NCCNHR has taken a strong position that there should be no increase in Medicare funding for nursing homes without accountability built in. While the nursing home industry blames Medicare cuts for its present inability to recruit and retain workers, nursing staff levels did not increase in Medicare-certified nursing homes during the years when Medicare reimbursement was skyrocketing. We believe the congressional leadership has caught on. The Medicare bill supported by the Republican leadership of both houses increases the Medicare rate for nursing services by 16.66 percent -- but it also calls for the U.S. General Accounting office to audit the impact of the increase and to recommend whether the increased payments should be continued. NCCNHR supported other, bipartisan legislative initiatives in 2000 that would have required nursing homes to provide the government with more frequent and more detailed information about their nurse staffing levels. One provision we supported, requiring nursing homes to post the number of nurses and nursing assistants on duty on each shift for residents and their visitors, was also included in the Medicare package.

therubins: Do you plan to have a rating system in place in the near future that will grade different aspects of a nursing home's operation?

There is more consumer information available than ever on nursing home performance via the Health Care Financing Administration’s web site at and many states have followed in providing this information as well. Placement in a nursing home is a very important decision made for many different reasons. It is important that consumers know how to evaluate and select a facility—one person’s needs may vary from the next. For example, a prospective resident may decide to enter a facility that does not have the best survey record because it is close to home and his/her visitors will be able to visit often. It is important in any case that residents and/or their families be involved throughout the process, particularly after admission. An excellent resource for families is Nursing Homes: Getting Good Care There by Sarah Greene Burger, Barbara Frank, Virginia Fraser, and Sara Hunt. NCCNHR published this widely acclaimed consumer guide on achieving the best possible nursing home experience for a relative or friend. With clarity and compassion, the authors use everyday language and real-life examples to show that care respecting each resident's individuality, dignity and physical and emotional well-being is within reach. Brimming with tips and checklists to help you support a loved one -- and show others the ABC's of advocating for good nursing home care. It is available for a cost of $14.95 and can be ordered when visiting

therubins:. Fewer beds are becoming available in nursing homes which are turning more towards sub-acute care facilities since they are more profitable to the homes. What can be done to encourage an expansion of long term care facilities in the U.S. today?

Consumers repeatedly state that they do not prefer to go into a nursing home. In fact occupancy rates throughout the country are down. This is in part due to consumers making choices to get care in the community, many in assisted living residences that they feel are more like home. All states now have Medicaid Waivers offering in-home and/or assisted living services to nursing home eligible consumers. A recent Supreme Court decision called the Olmstead Decision, has mandated that states have a plan to offer alternatives to institutional care for those needing long-term care and for those already residing in nursing homes if they so wish. One of the major concerns is public financing and oversight of home and community-based alternatives to nursing homes. In short, it does not make sense now to encourage expansion of nursing homes.


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