New Jersey relies too heavily on nursing homes to care for its frailest senior citizens and does not hold the worst operators accountable as they repeatedly fail to meet staffing and safety standards, according to a long-awaited, post-pandemic analysis of the long-term care industry.
The report, commissioned by the state, called for tougher sanctions against nursing homes that persistently fail to meet standards of care. And it urged policy makers and lawmakers to make it easier for seniors to receive support and remain in their own homes.
The findings in the 74-page report were released Friday by the New Jersey Task Force on Long-Term Care Quality and Safety, created in 2020 to examine the reasons behind the staggering loss of life in nursing homes during the COVID-19 pandemic. It is not clear why the Murphy administration took about 10 months after the task force completed its work to make its study public.
The report lands in the midst of state budget negotiations for the fiscal year beginning July 1. Although there are no estimates of what its suggestions would cost to implement, the dramatic changes suggest a hefty price tag.
“It calls for radical transformation of the system in New Jersey,” said Gwen Orlowski, a task force member and Executive Director of Disability Rights New Jersey.
It comes after two other inquiries into the state’s nursing home crisis sparked in part by the arrival of COVID. In March, a law firm and a consulting firm issued a 910-page post-mortem on New Jersey’s entire pandemic response, including the shortcomings in care for nursing home residents that made it easy for the virus to spread rapidly. About one in four of the 37,000 confirmed and probable COVID-19 death were nursing home residents.
And in June 2020, the consulting firm Manatt — hired after more than 5,400 long-term care residents died in the first three months of the pandemic — also recommended the state Health Department flex its muscle more by suspending admissions and levying steeper fines for habitual bad actors. Manatt also recommended creating the task force, which issued the most recent analysis.
The task force in its report Friday took particular aim at those nursing home operators repeatedly cited for violations.
“There is a group of chronically poor performing facilities that consistently fail to provide high-quality, safe care, in some cases for many years,” it said, pointing to recent reports by the New Jersey Office of the State Comptroller that found a number of long-term care owners lacking. “The task force finds this unacceptable and believes that more resources dedicated to oversight and intervention, along with more assertive and coordinated enforcement, are needed.”
It called on state regulators to more frequently take aggressive action — such as halting admissions, appointing a monitor and imposing hefty fines — when operators violate New Jersey’s landmark minimum staffing law and accumulate health and safety code violations.
Doug Struyk, the CEO of the nonprofit home and nursing facility provider Christian Health who chaired the task force, said the bad actors in the industry are fortunately “in the minority, but seem to get the majority of the attention. We all want those bad operators to be addressed.”
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The task force suggested changing the way nursing home rates are paid based on how much care a resident requires — what is known as acuity adjustments. Rates should be higher for residents on ventilators to keep them alive, or those with health problems that require more nursing care.
New Jersey has not adjusted Medicaid nursing home payments by acuity for eight years, according to the report. That lack of acuity adjustment reduces the incentives for providers to admit residents with more serious needs and creates disincentives for providers to invest in technology to provide more clinically complex care, the report said.
The state also suggested making the nursing home industry more accountable for how it spends its money. “Cost reports” — detailed breakdowns of expenses that were recently revived by the state — should include detailed and verifiable ownership information about any person or group that owns any part of a nursing home, the report said.
Investing in the workforce
The task force stressed the state’s need to be more aggressive in reducing the national shortage of direct-care professionals willing to work with the disabled and elderly at home or in state-licensed facilities. The panel suggested ways to get more workers into the pipeline, including scholarships, loan forgiveness and training programs, and targeting high-school students to encourage this caregiving career path.
“In New Jersey, the working age population is expected to decline by 1.3 percent over the next five years, while the age 65+ population is expected to grow by 14 percent, worsening the imbalance between supply and demand,” according to the report.
The task force’s report also said the state does not have enough nursing home inspectors, also known as surveyors. The Department of Health reports that there are 53 surveyors and estimates a need for an additional 30 to 40 so-called “full-time equivalents” to fill the shortfall. New Jersey is one of seven states with a surveyor vacancy rate greater than 50 percent.
“The federal expectation is that all nursing homes should receive a recertification (standard) survey between 9 and 15.9 months from the previous survey exit date. In New Jersey, 42% of nursing homes have not had a standard health survey in over 15 months,” the report said. That compared with 35% nationwide, according to the report.
In addition, the task force urged the state to devote more money and effort to keep seniors in their own homes. In 2019, New Jersey ranked 37th in the country for the percentage of Medicaid funding — 47% — spent on home and community-based services. The national average is 59%, the report said.
The task force also encouraged the development of much smaller nursing facilities — such as ones in a handful of other states known as “Green Homes” — that serve about two dozen to three dozen people with live-in staff.
“Our nursing homes are often large, hospital-like spaces, but today’s consumer prefers smaller, homelike settings that offer greater levels of person-centered care,” the report said.
Orlowski, the Disability Rights New Jersey executive director, said the state may need to offer financial incentives to nursing home operators to embrace the smaller-home model to make them financially feasible, but it would be well worth it for the quality of services and home-like atmosphere they provide.
“The consensus was the report was meant to recommend a radical shift” in how long-term care is delivered in New Jersey, Orlowski said. Keeping people home longer and scaling back the size of nursing homes and eliminating room sharing when people can no longer live independently “is what people want and a reaction to COVID.”
Laurie Facciarossa Brewer, New Jersey’s Long-Term Care Ombudsman, said New Jersey has historically relied too heavily on institutional care such as nursing homes.
“We must change long-held mindsets and investment priorities. We must incentivize the people who own and operate long-term care facilities to create welcoming, home-like environments,” she said, endorsing the report’s recommendations of fundamental changes to Medicaid to ensure people can get timely care at home rather than being placed in a nursing home.
“When given the option, 80% of older adults would prefer to receive care at home,” she pointed out. “We should ensure that New Jersey’s long-term care system honors these preferences and prioritizes people’s dignity as they age.”
In a statement, Health Commissioner Kaitlan Baston thanked the task force member for its work but did not endorse any specific proposal.
“I am grateful for the effort and expertise of the Task Force members who volunteered their time to produce this report,” Baston’s statement said. “I’m impressed by the scope and depth of the recommendations, and I especially appreciate the willingness to tackle some of the industry’s most long-standing problems. Among the most critical issues we’ve faced since I joined the Department are the quality of care and acute financial concerns in our long-term care facilities.
“We will carefully review the report, which I believe can help to inform both strategic and day-to-day priorities,” Baston’s statement said. “I look forward to continuing our work to strengthen infrastructure and adopt policy changes to support long-term care facilities and the residents who call them home.”
The 19-member task force included nursing home residents and relatives, nurses, doctors, union leaders, industry professionals, advocates including Disability Rights New Jersey and the AARP and policy experts. State government representatives from the departments of Military and Veterans Affairs, Health and Human Services also served.
The task force believes that a key lesson from the pandemic is “you get what you pay for,” Struyk said.
“Early on in our process we said that we were not going be limited to the status quo. It’s very easy to say there is never enough money so we have to be limited in what we are going to recommend,” Struyk said. “We chose not to be limited by the status quo and to listen to consumer interest and choices and on what our own experiences were. If we want a top-notch, quality and safe long-term care delivery system in New Jersey, these are our recommendations to get there.”
“There are some key choices for the Legislature and the governor to make,” he said.
State Director for AARP-NJ Chris Widelo said state leader have “no time to waste... to act swiftly to implement the report’s recommendations, and protect New Jersey’s 39,000 nursing home residents.”
“Tragically, thousands of residents and staff lost their lives as a result of COVID wreaking havoc on our nursing home system,” Widelo said.
“We applaud the New Jersey Task Force on Long-Term Care Quality and Safety for providing a clear framework for transforming our long-term care system. This report prioritizes home and community-based care so more New Jerseyans can age in place and avoid nursing homes, and ensures that we will not see a tragedy of this scale in the event of another public health emergency.”
But Andrew Aronson, president and CEO of the Health Care Association of New Jersey, which represents the state’s long-term care industry, said the task force consisted of advocates who set forth “an aspirational vision” of what long-term care could be if we were not limited by workforce and funding constraints.
“But indeed, we are limited by real shortages in workforce and funding, and we need to focus on how to best care for vulnerable seniors in the context of those real-world constraints,” he said. “The report’s failure to focus on the current underfunding of our existing system undermines all of its recommendations.”
Aronson said the state cannot delay making a significant investment to serve its most vulnerable population.
“It’s not a choice, it’s an obligation,” he said.
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Susan K. Livio may be reached at slivio@njadvancemedia.com. Follow her on Twitter @SusanKLivio.
Ted Sherman may be reached at tsherman@njadvancemedia.com. Follow him on Twitter @TedShermanSL.
