[Senate Hearing 118-027]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 118-027

                    RESIDENTS AT RISK: THE STRAINED
                   NURSING HOME INSPECTION SYSTEM AND
                     THE NEED TO IMPROVE OVERSIGHT,
                    TRANSPARENCY, AND ACCOUNTABILITY

=======================================================================

                                HEARING

                               BEFORE THE

                       SPECIAL COMMITTEE ON AGING

                          UNITED STATES SENATE

                    ONE HUNDRED EIGHTEENTH CONGRESS


                             FIRST SESSION
                               __________

                             WASHINGTON, DC
                               __________

                              MAY 18, 2023
                               __________

                           Serial No. 118-04

         Printed for the use of the Special Committee on Aging
         
         
                  [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]         
         

        Available via the World Wide Web: http://www.govinfo.gov
        
        
                               __________

                    U.S. GOVERNMENT PUBLISHING OFFICE
                    
52-564 PDF                 WASHINGTON : 2023         
        
        
        
        
                       SPECIAL COMMITTEE ON AGING

              ROBERT P. CASEY, JR., Pennsylvania, Chairman

KIRSTEN E. GILLIBRAND, New York      MIKE BRAUN, Indiana
RICHARD BLUMENTHAL, Connecticut      TIM SCOTT, South Carolina
ELIZABETH WARREN, Massachusetts      MARCO RUBIO, Florida
MARK KELLY, Arizona                  RICK SCOTT, Florida
RAPHAEL WARNOCK, Georgia             J.D. VANCE, Ohio
JOHN FETTERMAN, Pennsylvania         PETE RICKETTS, Nebraska
                              ----------                              
               Elizabeth Letter, Majority Staff Director
                Matthew Sommer, Minority Staff Director


                         C  O  N  T  E  N  T  S

                              ----------                              

                                                                   Page

Opening Statement of Senator Robert P. Casey, Jr., Chairman......     1
Opening Statement of Senator Mike Braun, Ranking Member..........     2

                           PANEL OF WITNESSES

Erin Bliss, Assistant Inspector General for Evaluation and 
  Inspections, Department of Health and Human Services, Office of 
  Inspector General, Washington, D.C.............................     4
Shelly Williamson, President of the Board of Directors for the 
  Association of Health Facility Survey Agencies (AHFSA), 
  Administrator for the Section for Long Term Care Regulation 
  with the Missouri Department of Health and Senior Services, 
  Jefferson City, Missouri.......................................     6
Leah McMahon, M.A., Director, Colorado State Long-Term Care 
  Ombudsman Program, Denver, Colorado............................     7
Susan Feng Lu, Ph.D., M.A., Gerald Lyles Rising Star Professor of 
  Management, Mitchell E. Daniels, Jr. School of Business, Purdue 
  University, West Lafayette, Indiana............................     9

                                APPENDIX
                      Prepared Witness Statements

Erin Bliss, Assistant Inspector General for Evaluation and 
  Inspections, Department of Health and Human Services, Office of 
  Inspector General, Washington, D.C.............................    31
Shelly Williamson, President of the Board of Directors for the 
  Association of Health Facility Survey Agencies (AHFSA), 
  Administrator for the Section for Long Term Care Regulation 
  with the Missouri Department of Health and Senior Services, 
  Jefferson City, Missouri.......................................    45
Leah McMahon, M.A., Director, Colorado State Long-Term Care 
  Ombudsman Program, Denver, Colorado............................    50
Susan Feng Lu, Ph.D., M.A., Gerald Lyles Rising Star Professor of 
  Management, Mitchell E. Daniels, Jr. School of Business, Purdue 
  University, West Lafayette, Indiana............................    55

                        Questions for the Record

Erin Bliss, Assistant Inspector General for Evaluation and 
  Inspections, Department of Health and Human Services, Office of 
  Inspector General, Washington, D.C.............................    63
Shelly Williamson, President of the Board of Directors for the 
  Association of Health Facility Survey Agencies (AHFSA), 
  Administrator for the Section for Long Term Care Regulation 
  with the Missouri Department of Health and Senior Services, 
  Jefferson City, Missouri.......................................    67
Leah McMahon, M.A., Director, Colorado State Long-Term Care 
  Ombudsman Program, Denver, Colorado............................    73
Susan Feng Lu, Ph.D., M.A., Gerald Lyles Rising Star Professor of 
  Management, Mitchell E. Daniels, Jr. School of Business, Purdue 
  University, West Lafayette, Indiana............................    78

                       Statements for the Record

AMDA Statement...................................................    83
California Advocates for Nursing Home Reform Statement...........    85
California Long-Term Care Ombudsman Program Statement............    87


                         C  O  N  T  E  N  T  S

                              ----------                              

                   Statements for the Record (cont'd)

Indiana Long-Term Ombudsman Program Statement....................    89
LeadingAge Statement.............................................    92
Michigan Long-Term Care Ombudsman Program Statement..............    96
Minnesota Office of Ombudsman Program Statement..................    99
Mississippi Long-Term Care Ombudsman Program Statement...........   102
Tennessee Long-Term Care Ombudsman Program Statement.............   103
Texas Long Term-Care Ombudsman Program Statement.................   105
West Virginia Bureau of Senior Services Statement................   107

 
                 RESIDENTS AT RISK: THE STRAINED NURSING HOME 
             INSPECTION SYSTEM AND THE NEED TO IMPROVE OVERSIGHT, 
                     TRANSPARENCY, AND ACCOUNTABILITY

                              ----------                              


                         Thursday, May 18, 2023

                                        U.S. Senate
                                 Special Committee on Aging
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 9:32 a.m., Room 
366, Dirksen Senate Office Building, Hon. Robert P. Casey, Jr., 
Chairman of the Committee, presiding.
    Present: Senator Casey, Gillibrand, Blumenthal, Warren, 
Kelly, Braun, Rick Scott, Vance, and Ricketts.

                 OPENING STATEMENT OF SENATOR 
                 ROBERT P. CASEY, JR., CHAIRMAN

    The Chairman. Good morning, everybody. The Senate Special 
Committee on Aging will come to order.
    Today, the Special Committee on Aging will examine 
troubling problems, and that is an understatement, in the 
Nation's nursing home inspection system and receive testimony 
about the urgent need to invest in oversight to protect nursing 
home residents, health and safety.
    Last year, I directed my staff and the Committee to 
investigate the capacity of State inspection agencies to 
enforce health and safety standards in the Nation's 15,000 
federally certified nursing homes.
    Today, I am releasing the findings of that investigation in 
a report entitled, I will hold it up just for illustrative 
purposes "Uninspected and Neglected", and the subheading is, 
"nursing home inspection agencies are severely understaffed, 
putting residents at risk". This is based upon 2,000 pages of 
documents and data provided by every State in the Nation.
    The report paints a picture of a system in crisis. 
Underfunded and understaffed State agencies have fallen behind 
on the basic duties that they are charged with executing on. 
For example, conducting annual nursing home inspections and 
responding to resident complaints in a timely manner, as 
nursing home residents and their families should have a right 
to expect.
    As we will hear from our witnesses, the result is that 
nursing home residents are at risk because of this problem. 
Just imagine the horror of an 84-year-old woman whose leg was 
broken at a nursing home in Pennsylvania, but a full week 
passed before she was taken to a hospital where she later died.
    The county coroner cited negligence as a contributing 
factor in this woman's preventable death that occurred one day 
before her 85th birthday. Often such stories aren't the subject 
of public attention due to inadequate oversight. Federal data 
shows that one out of nine, one out of every nine nursing homes 
in the Nation, has not received a comprehensive annual 
inspection in two years.
    Infrequent annual inspections have led more residents and 
families to file complaints, which States are failing to 
investigate in a timely manner. Time is of the essence when 
State inspectors need evidence to prove serious deficiencies 
like physical abuse, sexual assault, or inadequate medical care 
in circumstances like we have all read about.
    My fear is that the trail is going very cold for too many 
residents before nursing home inspectors can arrive at the 
scene. The findings of this investigation should serve as a 
wakeup call to Congress, both the House and the Senate.
    The investigation found that 32 States survey_State survey 
agencies have vacancy rates of 20 percent or more, 20 percent 
or more among nursing home inspectors, and nine of those 
agencies have vacancy rates of 50 percent or higher.
    States directly linked staffing shortages to inspection 
delays and said flat lined Federal funding over the last decade 
is making these problems much worse. Simply put, Federal 
dollars are not keeping up with the growing workloads and the 
need for States to offer comprehensive, I am sorry, the need to 
offer competitive salaries to attract workers.
    Today, the Federal Government is spending tens of billions 
of dollars on nursing homes, but Congress appropriates less 
than $0.80 per resident per day on nursing home oversight. Not 
even enough to buy a cup of coffee. For too long, Congress has 
failed to invest in strategies to protect the health and safety 
of the Nation's 1.1 million nursing home residents.
    If we as Americans claim that ours is the greatest country 
in the world, we must insist upon, and invest in, and ensure 
that we have the best long term care system in the world. That 
should be our goal, and we are not fulfilling that goal right 
now, and I will now turn to Ranking Member Braun for his 
opening remarks.

                 OPENING STATEMENT OF SENATOR 
                   MIKE BRAUN, RANKING MEMBER

    Senator Braun. Thank you, Mr. Chairman. For the first time 
in U.S. history, older adults are expected to outnumber 
children by 2034. As our population ages, we are facing growing 
health care workforce shortages. I have dealt with that before 
I came to the Senate in a different arena. Indiana has 4,300 
job openings for nurses and is projected to need 5,000 more--
5,000 more by 2031.
    Nursing homes have not been spared from these shortages, 
leading to issues with patient care and overall quality. My 
home State has worked to address this issue. A law championed 
by Ivy Tech Community College and the Indiana Hospital 
Association removed limits on nursing school enrollment.
    Ivy Tech partnered with nursing homes to offer paid 
apprenticeships. Last month, I went to a rural high school, and 
they have a program for students to earn a CNA. We need to do a 
lot more of that in high school where the education is the best 
value we get, and before they get outside of the system, we 
need to have programs there, career and technical education 
that leads you, into places that may not need more time and 
more money.
    I have also introduced a Prioritizing Evidence for 
Workforce Development Act, which prioritizes funding for 
evidence-based workforce programs. The Federal Government 
should make it easier for people who are looking to work not 
more complicated, especially in health care. Instead, excessive 
Federal rules and regulations pose barriers.
    We got to have regulation, some guardrails, but not to 
where they become oppressive, and I have witnessed that in 
running a business over the years, and being aligned with the 
State Government that I think finds a little better balance.
    President Biden is expected to propose an overtime rule, 
for instance. In my own company, that was 35,000. At one point 
I think it was adjusted up a little bit, but taking it up to 
80,000, that will dislocate so many jobs and the people that 
would want something at a lower level, but yet you got kind of 
a crazy Federal recommendation there, and that is what goes 
above and beyond.
    This would make nursing home workers subject to overtime 
regulations, reducing staff flexibility, and quality of care. 
As an employer, I dealt with the Administration, the Obama 
Administration's overtime rule myself, and know the obstacles 
it created in my own business. As we work to buildup health 
care workforce, we must do more to improve transparency and 
accountability.
    In 2021, we spent $181 billion on nursing home care. 
However, nursing home cost data is not readily available. 
Transparency is lacking in so many places in commerce 
throughout our country, and a lot of it has to do with 
Government regulations or at least their being for it. More 
transparency is never bad.
    I sent a letter to the National Center for Health 
Statistics asking to improve an important long term care survey 
that runs every two years. Currently, the survey does not ask 
about nursing home costs.
    I have asked to add new questions to that to bring that out 
into the forefront. Federal Government is required to conduct 
annual surveys of nursing homes, which is vital. It just needs 
to be done, I think, more thoroughly and with full 
transparency. CMS incorporates survey data and developing five-
star quality ratings which are displayed on the website, Care 
Compare. I am developing a Bill that would make Care Compare 
more accessible. I would like to recognize the majority's 
report. I think they are for that as well. Over the past two 
years, nursing home inspection rates have been unacceptable.
    COVID policies contributed to some of these delays. 
Nevertheless, we have got to do better, so much of health care 
comes at that stage in life. I agree with some of the 
recommendations in the majority report. We need to improve Care 
Compare and expand the health care workforce. I look forward to 
working with the chairman to accomplish these goals.
    The Chairman. Thank you, Ranking Member Braun. Now, we will 
turn to our witness introductions. I want to start with Erin 
Bliss. Ms. Bliss is the Assistant Inspector General for 
Evaluation and Inspections at the Department of Health and 
Human Services Office of Inspector General. She has been with 
the OIG's office since 2000.
    Our second witness is Shelly Williamson. Shelly Williamson 
is the President of the Board of Directors for the Association 
of Health Facility Survey Agencies, which represents State 
survey agencies across the country. She is also the 
Administrator for the Section for Long Term Care Regulation 
with the Missouri Department of Health and Senior Services.
    Our third witness is Leah McMahon. Leah McMahon is the 
Director of the Colorado State Long Term Care Ombudsman 
Program. Ombudsmen work to resolve problems related to the 
health, safety, welfare, and rights of individuals in long term 
care facilities. Now, I will turn to Ranking Member Braun to 
introduce our fourth witness.
    Senator Braun. Dr. Susan Lu is the Gerald Lyles, rising 
star, Professor of Management at Purdue University's Mitch 
Daniels School of Business. She is also affiliated with the 
Regenstrief Center for Health Care Engineering at Purdue 
University.
    Her research centers on health care operations and 
analytics, with an emphasis on nursing home operations.
    She received her Ph.D in managerial economics and strategy 
from the Kellogg School of Management at Northwestern. Dr. Lu's 
work has been widely recognized by a number of popular media 
outlets, including Nature News, Vox, Freakonomics, and 
Barron's, and we are delighted to have you here today.
    The Chairman. Thank you, Ranking Member Braun. Now we will 
turn to Ms. Bliss for her opening remarks.

      STATEMENT OF ERIN BLISS, ASSISTANT INSPECTOR GENERAL

         FOR EVALUATION AND INSPECTIONS, DEPARTMENT OF

              HEALTH AND HUMAN SERVICES, OFFICE OF

              INSPECTOR GENERAL, WASHINGTON, D.C.

    Ms. Bliss. Good morning, Chair Casey, Ranking Member Braun. 
Thank you for the opportunity to discuss the strains to the 
nursing home inspection system and the impacts on nursing home 
residents.
    Decades of OIG work has found that alarming numbers of 
nursing home residents are subject to low quality care or 
unsafe conditions. The bottom line is this, people in nursing 
homes need a robust and effective inspection system to protect 
their health and safety. In some cases, their lives depend on 
it.
    OIG has identified lapses in that system that put residents 
at risk. State survey agencies' responsibilities are vast and 
consequential. They are on the front lines, conducting 
inspection surveys for more than 15,000 nursing homes. State 
agencies assess nursing home quality and safety, investigate 
complaints, identify deficiencies, and verify that nursing 
homes correct those deficiencies.
    However, State agencies too often fall short in fulfilling 
those responsibilities. A predominant issue is that many States 
fail to conduct timely surveys. This is a decades old problem 
worsened by the COVID-19 pandemic. States are required to do 
comprehensive surveys for each nursing home at least every 15 
months, but nationally, about a quarter of nursing homes are 
overdue for these vital surveys. States must also do surveys to 
investigate the most serious complaints about nursing homes 
within a certain number of days, but many States have 
repeatedly missed those deadlines to. Backlogs in routine and 
complaint surveys can have real consequences for residents.
    On average, States cite almost nine deficiencies in health 
standards per survey, so delays in surveys mean delays in 
identifying and fixing risks to resident and even actual 
resident harm. This is very concerning, as serious complaints 
commonly involve allegations of poor care. In one example, a 
complaint alleged that a resident with known high blood sugar 
did not have glucose testing strips available and then died.
    Other serious complaints involve allegations of patient 
abuse and neglect, poor conditions at the facility, and 
infringements of residents' rights, but States face some real 
challenges. States have pointed to staffing shortages as a 
driving cause for survey delays. Similar to the chairman's 
report findings, we have heard going back for years that States 
struggle to attract and retain surveyors who are typically 
nurses.
    For example, in 2018, Colorado cited its vacancy rate of 32 
percent as a cause for its late surveys. States have pointed to 
long hours and not being able to offer high enough salaries to 
compete for nurses. State agencies have also faced increasing 
numbers of complaints requiring onsite investigations.
    The persistence of State agency performance problems raises 
questions about the Centers for Medicare and Medicaid Services, 
known as CMS, which oversees State survey agencies. How 
effectively is CMS able to drive improvements? They have relied 
primarily on corrective action plans and training to try to 
improve State agency performance, but these efforts often did 
not resolve the problems.
    CMS's processes for validating survey results reported on 
the public Care Compare website are also inadequate. Last 
month, OIG reported on inaccuracies in State survey results 
showing on Care Compare for an estimated two-thirds of nursing 
homes. In conclusion, an effective survey process and 
transparency into its results is crucial for protecting nursing 
home residents.
    OIG is committed to driving improvements in this safety 
system, as well as other aspects of nursing home performance, 
resident well-being, and oversight. We have recommended ways 
for CMS to strengthen nursing home oversight and are engaging 
with them to drive positive change.
    Thank you for the Committee's support of OIG's work, and 
the resources that we need to protect people in nursing homes 
and other HHS programs. Thank you and I will welcome your 
questions.
    The Chairman. Thank you, Ms. Bliss. Ms. Williamson, you may 
begin your statement.

        STATEMENT OF SHELLY WILLIAMSON, PRESIDENT OF THE

           BOARD OF DIRECTORS FOR THE ASSOCIATION OF

            HEALTH FACILITY SURVEY AGENCIES (AHFSA),

          ADMINISTRATOR FOR THE SECTION FOR LONG TERM

          CARE REGULATION WITH THE MISSOURI DEPARTMENT

                 OF HEALTH AND SENIOR SERVICES,

                    JEFFERSON CITY, MISSOURI

    Ms. Williamson. Good morning, Chairman Casey, Ranking 
Member Braun. I am here today representing the Association of 
Health Facilities Survey Agencies, or AHFSA, the organization 
that represents survey agencies across the country. I am also 
the Administrator of the Section for Long Term Care Regulation 
in Missouri, which oversees 511 certified nursing homes in the 
State. Like many survey agency managers and directors, I have 
spent most of my working life dedicated to protecting our 
country's most vulnerable citizens.
    For me, my grandparents were a driving force, from the day 
I decided to pursue a graduate degree in social gerontology to 
becoming a nursing home surveyor, a manager, and to my role 
today. Four of my grandparents have relied on nursing home 
care. This work is personal to me. I understand firsthand why 
the work of a surveyor is so important to residents and 
families.
    Protecting health and safety is the cornerstone of survey 
agency work. Our work is important and rewarding, and our work 
is hard. Our surveyors are the face of our work. They talk to 
families upset with care, to facilities concerned with the 
citations they receive, and they see the joy on resident and 
family faces when our work creates real, meaningful change. An 
example of this dedication is a recent survey at a nursing home 
in Missouri.
    Our surveyor started their day early one morning and 
identified deficiencies that could have likely resulted in 
serious injury or death, if we had not intervened, what Federal 
regulations call immediate jeopardy.
    The surveyors remained in the facility until midnight that 
night, ensuring they had an acceptable plan from the facility 
to remove the immediate jeopardy. Surveyors were back onsite to 
continue the survey the very next morning. Our work is not 9:00 
a.m. to 5:00 p.m., Monday through Friday.
    Surveyors spend many nights, weekends, and holidays away 
from their families and loved ones. Across the Nation, this is 
the type of protection survey agencies provide every single 
day. With workload increases, including a 102 percent increase 
in the number of immediate jeopardy complaints since 2015, and 
increases in the severity of deficiency cited, survey agencies 
are reacting to alleged noncompliance rather than being 
proactive by conducting recertification surveys.
    Vacancies in nearly all survey agencies are having an 
impact on the ability to respond timely to complaints and to 
complete recertification surveys. Nearly 70 percent of survey 
agencies have surveyor vacancy rates over 10 percent, with many 
reporting closer to 20 or 30 percent. Registered nurse salaries 
in over 80 percent of survey agencies are not competitive with 
the health care market.
    An increase in the Federal budget is necessary for survey 
agencies to rebalance, to improve retention of existing 
surveyors, and to recruit new surveyors, and with a growing 
number of Americans expected to need nursing home care in the 
coming years, it is imperative to increase the Federal budget 
now and to sustain that increase.
    Nursing home residents are our parents and grandparents, 
aunts and uncles, brothers and sisters, friends and loved ones. 
They are the generation that molded many of us today. They 
deserve our respect, our compassion, our dedication, and our 
protection.
    Thank you for the opportunity to provide this testimony and 
for your support in ensuring nursing home residents receive the 
care they deserve. I welcome any questions you may have.
    The Chairman. Thank you, Ms. Williamson, and thanks for 
sharing your own story about starting as a surveyor. Ms. 
McMahon.

           STATEMENT OF LEAH McMAHON, M.A., DIRECTOR,

            COLORADO STATE LONG-TERM CARE OMBUDSMAN

                   PROGRAM, DENVER, COLORADO

    Ms. McMahon. Good morning, Chairman Casey. Ranking Member 
Braun. I am the Colorado State Long Term Care Ombudsman and 
thank you for the opportunity to appear before you today. Last 
year, my office received a call from a family member who 
reported concerns about their loved one living in a nursing 
home.
    The Ombudsman met with the resident and the resident 
reported regularly waiting hours to receive assistance after 
requesting help from the nursing home staff. The Ombudsman 
observed the resident crying while they reported that the 
nursing home staff yelled at the resident often, refused to let 
them out of their room, and physically shoved their wheelchair 
while forcing them back into their room and then slamming the 
door shut.
    The resident also reported an instance of a staff person 
who pulled their hair, took away their phone, physically shook 
them, and left the resident in the bathroom after assisting 
them to the toilet. The resident requested the Ombudsman to 
file a complaint to the State survey agency.
    A year later, the Ombudsman received a call from the 
surveyors stating they were investigating the complaint. The 
Ombudsman informed the surveyor that the resident moved out due 
to abuse and neglect. It was too late. The family later 
informed the Ombudsman the resident suffered from night terrors 
due to post-traumatic stress disorder.
    This is unconscionable and one example of many my office 
has received over the past couple of years. This person lives 
with a disability and suffered abuse at the most vulnerable 
time in their life, with the greatest need at this time in 
their life. Imagine if this was your family member, your 
sibling, or you. It takes courage for residents and family 
members to file a complaint.
    The fear and real threat of retaliation by nursing home 
staff is a concern on the minds of residents. Therefore, when a 
resident or family member finds that courage to file a 
complaint, it is critical that there is timely followup. The 
nursing homes have their equity firms, their trade 
associations, their lobbyists, their attorneys. The residents, 
the lucky ones, have family, and the rest of them have us.
    As the Colorado State Long Term Care Ombudsman, I represent 
the interests of approximately 45,000 vulnerable adults and 
people with disabilities who reside in licensed assisted living 
homes and licensed nursing homes in Colorado. My role is to 
coordinate and oversee the Ombudsman Program and provide 
systemic advocacy for residents.
    The nationwide Long Term Care Ombudsman Program authorized 
by the Older Americans Act is an independent health oversight 
agency that advocates for the interests of long-term care 
residents.
    We are in nursing homes at residents bedsides every day, 
listening to the concerns of residents and their families, and 
advocating on their behalf. I would like to highlight to the 
Committee my concern about the impact of the staffing shortages 
among long term care surveyors.
    The State agency is responsible for licensing, surveying, 
and regulatory oversight of long-term care facilities. In 
Colorado, nursing home surveyors have incredibly challenging 
jobs, which are made more demanding by agency staffing 
shortages. I have great appreciation and respect for surveyors 
and the survey process. I know from speaking with the Colorado 
State Survey Agency, there are difficulties in maintaining 
adequate survey staffing levels.
    The State agency needs to offer competitive wages to hire 
surveyors, and training new surveyors is time intensive and can 
take up to a year. I see firsthand the impact these shortages 
have upon nursing home residents and their families. Residents 
and family members have complained to my office about waiting 
long periods of time for a response after filing a complaint, 
and at times have not received a response.
    Additionally, the Ombudsman Program has filed complaints 
with similar experiences. In March 2021, a local ombudsman was 
in a long-term memory care nursing home and observed several 
instances of abuse and neglect. This included a staff member 
yelling at a frail elderly resident, and residents laying in 
their own urine and feces.
    This is a clear violation of residents' rights. The 
ombudsman called the State agency's complaint line, and they 
did not report back for one year after the complaint was filed. 
This delay can have a negative impact to the health, safety, 
not for just one resident, but all residents.
    I know surveyors are working as hard as they can to be 
responsive to resident complaints and concerns, but it appears 
there is just not enough survey staff. These shortages place 
residents at a significant risk of harm and even death. The 
survey agency is the only entity with the authority to enforce 
standards that facilities meet regarding the quality of care 
and services residents receive.
    Thus, it is important for CMS and State survey agencies to 
have the necessary staff and resources to conduct annual 
surveys and to respond to complaints in a timely manner. The 
Colorado Office of the State Long Term Care Ombudsman Program 
recommends increasing funds to assist State survey agencies to 
hire and retain nursing home surveyors to meet the workload.
    Offer competitive salaries for required nursing surveyor 
positions, which could be the most difficult positions to fill 
and maintain within the regulatory agency. Create dedicated 
recruitment and training positions to hire and train new 
surveyors.
    I appreciate the opportunity to appear before the Committee 
and for your time and attention regarding vulnerable adults who 
live in long term care nursing homes. I look forward to 
answering your questions.
    The Chairman. Ms. McMahon, thanks very much. Dr. Lu, you 
may begin.

     STATEMENT OF SUSAN FENG LU, PH.D., M.A., GERALD LYLES

         RISING STAR PROFESSOR OF MANAGEMENT, MITCHELL

           E. DANIELS, JR. SCHOOL OF BUSINESS, PURDUE

              UNIVERSITY, WEST LAFAYETTE, INDIANA

    Dr. Lu. Thank you, Chairman Casey and Ranking Member Braun, 
for granting me this invaluable opportunity to testify on the 
regulations and operations of nursing homes. My name is Susan 
Lu from Purdue University. As the only child in my family, I 
have always pondered, how can I provide the best care to my 
aging parents?
    In my quest, I recorded the--an older saying from my 
cultural background that emphasizes treating the elderly with 
the same respect and care as if they were my own parents, so 
hence this motivated me to focus my dissertation on nursing 
homes, dedicating nearly two decades of research of this 
industry, and over time, helping the elderly to receive high 
quality health care became the very mission of my life.
    My expertise lies in the fields of economics and operations 
management, where I was trained to maximize social welfare, 
minimize cost, and optimize resource allocation by 
understanding the impact of policies and of technological 
advancements on nursing home behavior. I am pleased to provide 
my expertise in three key areas, quality disclosure, staffing, 
and ownership.
    First, publicly disclosing quality information of 
individual nursing homes is crucial for the elderly to find a 
home where they would love to stay. The Center for Medicare and 
Medicaid Services have made commendable efforts in making 
quality information transparent, and that these actions have 
proven to be effective. Going forward, we aim to increase 
public awareness of those disclosed quality information, and to 
find an efficient way of communicating those valuable data to 
consumers, helping them to make informed decisions.
    Second, the ongoing challenge of staffing shortages 
significantly affect nursing homes' operations. To effectively 
tackle the shortage, it is important to explore innovative 
ideas and have access to comprehensive data on individual 
nurses.
    Third, there has been increasing concern about the 
potential downsides of ownership change, including the 
acquisition by private equity firms. However, rigorous research 
in this area is limited. It is critical for us to recognize the 
potential risks associated with ownership changes and implement 
targeted oversight to protect the well-being of nursing home 
residents.
    Today, I stand before you as an expert in nursing homes, 
ready to offer insights into potential strategies that could 
incentivize nursing homes to improve the quality of care they 
provided. I would like to extend my sincere appreciation for 
your leadership and unwavering commitment to address the needs 
of older adults.
    In conclusion, I express my utmost gratitude for the 
opportunity to be here, and I hope that we can work together to 
create an environment where nursing homes not only provide 
excellent care, but also serve as compassionate and reliable 
sources of support for our aging population. Thank you.
    The Chairman. Dr. Lu, thanks very much. I think our panel 
set a record for time used in their opening statements. Well 
below the time you had, and I appreciate your efficiency. I 
would start my questions for--I have a question_I will go right 
down the panel. The Committee's investigation found that 
severely understaffed survey agencies are falling behind on 
nursing home inspections and complaint investigations.
    Ombudsman provided examples of serious complaints involving 
abuse, neglect, and poor health care going months or longer 
without being investigated. I will start with Erin Bliss and go 
down the panel, and this is kind of a basic yes or no question. 
Are you concerned that understaffed survey agencies and delayed 
inspections negatively affect both health and safety of nursing 
home residents?
    Ms. Bliss. Yes, very concerned.
    Ms. Williamson. Yes, absolutely.
    Ms. McMahon. I agree. Absolutely.
    The Chairman. Doctor--thanks very much. I will next turn to 
Ms. McMahon. Your testimony highlighted examples of nursing 
home residents suffering when complaints went unanswered by 
strained survey agency staff, and our report shows that 
ombudsmen across the country similarly identified how 
residents, the care of residents, I should say, suffered as 
State surveyors were unable to respond to complaints in a 
timely way.
    How do nursing home residents benefit from improved survey 
agency staffing, as well as more regular annual inspections, 
and third, faster response to complaints?
    Ms. McMahon. More oversight. More regulatory eyes on the 
conditions of the nursing home and the residents' care.
    The Chairman. What do you think is the best way to 
effectuate that?
    Ms. McMahon. To make sure that the survey agencies have 
enough surveyors to do the work. It is a heavy workload. It is 
long, exhausting days, and they need help so that they have 
competent surveyors who are trained and skilled to do this 
exhaustive work.
    The Chairman. Thanks very much. Ms. Williamson, I wanted to 
turn to you. According to the report that we have released this 
morning, more than 30 States expressed concern to the Committee 
about Federal funding levels for nursing home oversight.
    Three Presidential Administrations, the Obama 
Administration, Trump Administration, and Biden Administration 
have proposed increasing funding for these survey agencies in 
their budgets.
    However, Congress has not kept--has not had enough of a 
focus on this funding, effectively freezing much of the funding 
for the last decade. How would more funding help survey 
agencies better protect both health and safety of nursing home 
residents?
    Ms. Williamson. Thank you for that question, Chairman 
Casey. An increase in funding would allow survey agencies to 
recruit new staff, retain existing surveyors to be able to 
respond to both complaints that we receive, and to conduct 
recertification surveys. State agencies are finding themselves 
now utilizing many of their resources to respond to complaints 
that we received.
    Overall, since 2015, complaints have increased by 45 
percent, and as I highlighted in my testimony earlier, the most 
serious complaints have increased by 102 percent, so we are 
spending a lot of resources responding to complaints. The 
recertification surveys are very, very important.
    Those are a comprehensive look at all of the regulatory 
requirements, and that often creates or results in identified 
issues before they become so severe that they harm residents, 
so more funding would allow us to both respond to complaints 
and to conduct those recertification surveys in a timely 
manner.
    The Chairman. I wanted to highlight that number that you 
made a reference to in both your opening and then just a moment 
ago, the 102 percent increase in immediate jeopardy complaint, 
and that is just since 2015, correct?
    Ms. Williamson. That is correct. Yes.
    The Chairman. That is very alarming, and in order to keep 
the streak going--of going within our term, I will turn now to 
Ranking Member Braun.
    Senator Braun. Thank you, Mr. Chairman. I want to start 
with Dr. Lu, and it has to do with the overtime rule.
    I would like Ms. Bliss to weigh in on it as well, so that 
is a tricky way, in terms of compensation for anyone, yet it is 
generally an agreement between an employer and employee that 
seems to be the best working model. Under the Obama 
Administration, it was $23,000, and simply, if you had any type 
of arrangement that was over, or not at least there, you had to 
take in overtime into consideration.
    Their idea was taking it up closer to $50,000. During the 
Trump Administration, it actually moved to $35,568. Biden 
Administration, and a lot of the stuff coming out of the Labor 
Department, is actually proposing that it is $80,000, so across 
almost all disciplines that would disrupt tons of relationships 
between employers and employees where they both mutually agree 
that's okay on whatever that amount is, as long as it meets 
that minimum threshold.
    What do you think would happen in the nursing home business 
if for those that are on salary, all of a sudden you had to 
take that up to $80,000 from $35,000, how many jobs would be 
lost? I think that would cut both ways.
    Employers may not be able to afford it. Employees may not 
even demand it, so give me your take on how it would apply to 
nursing homes.
    Dr. Lu. Thank you, Senator Braun. Regarding the payment on 
the overtime issue, actually, it is beyond my study--the scope 
of my study, but I do have a paper to investigate the impact of 
mandatory overtime loss on nursing home quality, so initially I 
actually really liked this policy. Hence we want to do--
evaluate this policy.
    However, to our surprise, we find it that this well-
intentioned policy leads to quality decline in nursing homes, 
and it took us more than half a year to figure out why, and 
eventually we find out that such type of overtime regulation 
leads to undesirable staffing changes, and a nursing home 
substitute the full-time nurse's overtime hours with those 
hours from temporary nurses, from outsiders.
    Those contract workers actually are not very familiar with 
the nursing homes they are going to work for. They even don't 
know the names of the elderly, so hence it caused the problem, 
so that is the research finding in my work. Yes, thank you.
    Senator Braun. Thank you. Ms. Bliss.
    Ms. Bliss. Thank you. Unlike Dr. Lu, we have not directly 
studied the impacts of overtime policies, so I don't have a 
basis to comment on that directly, but what I can say is that 
understaffing in nursing homes is a dire concern.
    We have seen some nursing homes not even meeting the barest 
minimum of requirements of having eight hours of registered 
nurse staffing in a day, and that is extremely alarming, so 
certainly, any policies that support getting sufficient numbers 
of staff, sufficient quality of staff into nursing homes.
    We have heard some concerns from nursing homes that Dr. Lu 
referred to regarding challenges around contracted nursing and 
will have forthcoming reports speaking to those.
    Senator Braun. I think that this is probably something you 
need to all have on your radar because every particular 
component of our economy has some degree of it, and remember 
that if it is too low, you are not going to get people there. 
If you take it too high, you are going to shed jobs, so as 
tough as it is to get people to work in the arena, your concern 
with, just be aware of that.
    Ms. Bliss, I will stick with you on this. When it comes to 
training, I am a big advocate that we are wasting time in high 
school to direct parents and kids into career and technical 
education avenues. Indiana, 135,000 jobs, double what it was 
pre-COVID. Need no further training.
    They need better life skills. What is the best way to get 
more people interested in working at a nursing home? Does it 
have to have something postsecondary, or can we do better? It 
may be doing some things when they are crafting what they want 
to do after they get out of high school.
    Ms. Bliss. Thank you for that question. The pipeline of 
nurses and other clinical support staff going into the field to 
be able to even staff these jobs is a huge issue that comes up, 
so there are questions of low pay, long hours, longevity, but 
there is also questions of, are there even enough people to 
hire if we can offer those things.
    The pipeline is really important to keep building. We have 
heard from nursing homes that challenges involve both staffing 
of nurses, registered nurses themselves, as well as nursing 
aides, which may require, you know, lower degrees of----
    Senator Braun. What I was asking, though--that is a symptom 
of the system. Would it be better, and do you think there is 
adequate attention to the place, where as a CEO in a play and a 
company, where I never had any issue hiring four year degree 
slots to fill--in fact, we have gotten rid of most of those 
requirements--the place I found most lacking would be life 
skills taught in high school that would apply to a broad array 
of jobs.
    Apprenticeships, part time jobs, summer jobs, even where 
you might need a little additional training--so I think we are 
out of time here. We may come back to that, and I can expound 
on that in the next--okay.
    You want to look at it from that point of view. What about 
using those years where you are wondering, are you going to go 
AP, are going to go into something that maybe needs a little 
bit of training? When I went to school, you had all those 
skills being built and we have pretty well gotten away from 
that, so do you want to come back and offer any more on it?
    Ms. Bliss. Sure. Certainly, starting early, you know, 
reaching out to people in high school and even before--you 
know, or in that early education, seems like it could be very 
important to building that pipeline, attracting them to go into 
the health professions, nursing and otherwise, providing 
opportunities for those skills.
    It is not something that we at the HHS, OIG have directly 
studied, but I think, you know, all options need to be on the 
table to deal with the workforce crisis.
    Senator Braun. I can tell you that in a State like Indiana 
with one of the lowest unemployment rates in the country, 
biggest manufacturing State per capita, how we are dealing with 
this is not necessarily from here.
    It is through our States and getting the industry, these 
sectors that are struggling with people coming into whatever 
they need, they are starting in middle school, trying to have 
stuff in high school so that you are not so dependent 
postsecondary on how you get employees. Thank you.
    The Chairman. Thank you, Senator Braun. As many of you 
know, you have heard me say this before, that with Thursday 
mornings is a busy morning around here, lots of competing 
hearings and that command the time of Senators.
    I just wanted to mention Senators have been here and then 
some who have been here and then returned. Senator Blumenthal 
was here. Senator Warren was here and is back. Senator Kelly, 
Senator Rick Scott, and Senator Vance, and I think in terms of 
just going back and forth, I will turn to Senator Warren, and 
then Senator Vance.
    Senator Warren. Thank you very much, Mr. Chairman, and 
thank you both for holding this hearing today. It is a very 
important hearing. Nursing homes are where the most vulnerable 
members of our communities live.
    It is our duty to ensure that they are safe, but some of 
these facilities are in horrendous condition due to the greed 
of their corporate owners, and it is families that end up 
paying the price. Private equity firms have targeted nursing 
homes for decades, and now new investment vehicles, real estate 
investment trusts, or REITs, are in the game, too, snapping up 
nursing homes as lucrative investments.
    For these profiteers, their interest in nursing homes has 
less to do with providing care to those in need and a lot more 
to do with money. Now, research shows that private equity and 
REIT owned nursing homes are associated with higher Medicare 
costs, increased emergency department visits and 
hospitalizations, fewer registered nurses, and 40 percent 
higher COVID mortality rates.
    Regulators need to be able to hold nursing homes 
accountable for patient safety, but corporate owners use all 
kinds of tricks to avoid identity. Ms. Bliss, it is the job of 
the Inspector General's Office to investigate waste, fraud, and 
abuse in nursing homes to make sure that residents are safe and 
taxpayer money is being used wisely.
    How easy or hard is it for your investigators to identify 
the owner of a private equity or REIT owned nursing home?
    Ms. Bliss. Thank you for that important question. It can be 
very difficult to identify nursing homeowners and management, 
and really uncover who are the responsible parties to be held 
accountable when something goes wrong. That is something that 
comes up in our oversight and our enforcement cases.
    Senator Warren. Okay, so hard to enforce the law if you 
can't figure out who is on the other end of this, so the way 
this gets so tangled up is that private equity and REIT owners 
set up these complex legal arrangements to avoid transparency 
and to try to evade responsibility when something goes wrong.
    Also, by the way, to make money. One trick is that when the 
company that owns the nursing home also has a stake in another 
company that sells supplies and services to the nursing home.
    Now, Miss Bliss, the Inspector General's Office is looking 
into this issue, which is known in Government language's as 
related party payments. If a nursing homeowner is making money 
on both sides of a transaction like this, do you have concerns 
about whether or not taxpayer money is being used wisely?
    Ms. Bliss. We do. We have concerns about the use of 
taxpayer funds, and we have concerns about the impact on the 
residents in those nursing homes. As you noted, we do have 
ongoing audit work that is looking into these arrangements and 
payments.
    They are often called related party transactions, where 
that nursing home is making payments to contractors with whom 
it may have some financial stake, and we are looking at whether 
those payments may be inappropriately inflated and potentially 
diverting funds away from patient care.
    Senator Warren. Okay, so it is really important that 
taxpayer funds be protected. I appreciate your work on that, 
but of course, the main thing, too, is we want to make sure 
that patients have a safe, healthy place to live.
    Ms. McMahon, you are a State Ombudsman, which means you are 
on the front lines when it comes to identifying and preventing 
problems in nursing homes, so can you tell us what trends you 
have noticed when a for profit company, such as a private 
equity firm or a REIT, purchases a nursing home?
    Ms. McMahon. Thank you, Senator Warren. I have observed 
firsthand over the years, and typically what we see is staffing 
cuts, in particular nursing staff, which are critical to the 
health, safety, and welfare of residents.
    The Ombudsman Program will see an increase in complaints 
from families who report the inadequacies of care and their 
concerns when they visit their loved ones in nursing homes. 
Residents who are bedridden and develop open wounds because 
staff are not changing protective undergarments.
    They are languishing. They are not receiving their 
medications timely or as prescribed. They are not getting basic 
needs such as food or water. Due to these types of concerns, 
residents become dehydrated, they lose weight, endure painful 
bedsores, oftentimes the size of your hand that can happen.
    This can lead to hospitalization and in worst cases, death. 
We see a fast deterioration and systematic stripping down of 
the operations of the facility to the bare bones to make a 
profit at the expense of residents' lives. Residents go from 
thriving to just surviving.
    Senator Warren. That is a terrible list, and I just want to 
say to both of you, to all of you, I appreciate the work you 
are doing in trying to keep nursing home residents safe.
    The Affordable Care Act requires facilities to disclose 
ownership and related party information, but the nursing home 
industry lobbied furiously to make sure that these provisions 
were never implemented.
    In February, the Biden Administration took a step to change 
that. I urge CMS to finalize its proposed rule on ownership 
disclosure to ensure that consumers can make informed choices 
and so that regulators have the information they need to hold 
these owners accountable and to keep patients safe. Thank you, 
Mr. Chairman.
    The Chairman. Thank you, Senator Warren. Senator Vance.
    Senator Vance. Thank you, Mr. Chairman. Thanks to you and 
the ranking member for holding this Committee hearing. 
Elizabeth, or Senator Warren said it is a very important 
hearing, and any of us who have known or love someone in a 
nursing home knows that while the care that they get when it is 
good can be quite exceptional, that when things do suffer, it 
really, really affects the quality of life for those who are 
sometimes languishing in our nursing homes.
    To your point, Ms. McMahon, surviving instead of thriving, 
and that is not what we should want for any of our elderly 
folks, so I would--sort of two lines of questioning I would 
direct at Ms. Williamson here. One, just on, my understanding 
here is that staffing shortages play a major role in what is 
driving the lack of inspections, and probably driving a lot of 
other issues in our nursing homes as well.
    We sort of understand the basic qualifications here, so 
when we talk about the people doing these inspections, what 
qualifications do they need to have before applying to a job 
with your particular agency?
    Ms. Williamson. Thanks for that question, Senator Vance, so 
there are several different disciplines of surveyors, but the 
primary thing I would like to talk about is that when we do a 
recertification survey, and many of our complaint 
investigations are recertification surveys, and those require a 
registered nurse.
    Every survey team has to have a registered nurse as part of 
that team, and then if the complaints are about quality of 
care, where a nursing assessment needs to be conducted, a 
registered nurse has to conduct those investigations as well. 
We do utilize other disciplines. Part of our survey process is 
also a life safety code survey or a fire safety survey.
    We have to have surveyors who are trained and have that 
background in order to assess compliance with those 
regulations. Many other disciplines are social workers or 
physical therapists, and other disciplines outside of that 
registered nurse, but the primary struggle States are having is 
in the registered nurse.
    Senator Vance. I see, and how big are the survey teams 
normally? You mention that each one needs to have at least one 
registered nurse. I mean, are these teams of ten, or five, of 
less or more?
    Ms. Williamson. The team size depends on several factors. 
How large the home is, how many residents are in care at the 
home. The numbers of complaints that we may have to investigate 
during that survey, and then, you know, how much travel we have 
to do, how many resources we have to take. Normally a team of 
three or four over a work week is average for a recertification 
survey.
    Senator Vance. Got it, so moving on from there, I just want 
to ask about maybe possible COVID hangover effect. I am right 
that a lot of the backlog here is because we effectively 
stopped doing inspections for a few months during the COVID 
pandemic, is that correct?
    Ms. Williamson. That is certainly a contributing factor.
    Senator Vance. Okay. You seeing any evidence of sort of a 
potential COVID hangover effect? What I mean, of course, is 
that, you know, we just declared an end to the emergency, I 
think far too late, but at least the declaration happened a 
week or two ago.
    Is there any sense that the people who would be doing the 
inspections were maybe a little exhausted, a little 
overwhelmed, certainly by the pandemic, but also even well 
after the pandemic, had it reached its emergency phase end, or 
affected by a lot of the requirements and a lot of the 
regulations that existed on caretakers and inspectors related 
to the pandemic rules?
    Ms. Williamson. While the pause certainly was a 
contributing factor, we have also seen a significant increase 
in number of complaints that have been reported to us. I 
mentioned earlier the number of immediate jeopardy complaints 
since 2015 has increased by 102 percent.
    Those are the complaints where residents and allegations of 
residents are being harmed, severely harmed, so investigating 
those complaints day after day does lead to exhaustion and burn 
out, and stress on surveyors.
    Senator Vance. Sure. I suspect, just to close here, that 
the caregivers themselves are probably exhausted, and as you 
lose the best caregivers, it probably increases the complaints 
you are going to get because the underlying quality of care 
deteriorates.
    The final point I would make here, and I appreciate, Ms. 
Williamson, your answers, and I appreciate the four of you for 
being here with us is, look, COVID was obviously a very 
terrible pandemic. I don't mean to make light of it or make 
light of the fact that it killed a lot of people.
    I also think that we have to balance the public health 
response with the incredible stresses that we place on a lot of 
our public health and hospital and nursing home caregivers, 
because a consistent theme that I get is that COVID was 
miserable, but also all of the surrounding things that were 
placed on us because of COVID, or at least allegedly because of 
COVID, were also miserable.
    I think we lost a lot of good people in our health care 
industry, so we are going to have a pandemic, God forbid, but 
we will eventually, hopefully, it is many, many years from now. 
I hope we learn the lessons and don't overstress our health 
care system again, because I think you all, and certainly other 
parts of our health care system, are dealing with the 
consequences. Thank you.
    Senator Braun. Senator Ricketts.
    Senator Ricketts. Great. Thank you very much. I want to 
thank our witnesses for being here today.
    Obviously, we have got a lot of people across the country 
that are in skilled nursing facilities, and we have got to be 
able to make sure that we protect them. Everybody probably has 
a family member that is going to be impacted by this, if not 
currently, at some point in the future.
    In my home State of Nebraska, I know that one of the issues 
we have had has been with regard to staffing and making sure 
that our nursing facilities are staffed appropriately.
    There is a lot of different issues, especially in rural 
areas, that can impact that. As Governor, we actually provided 
a 15 percent increase in funding for nursing facilities to be 
able to, which was like the most significant increase they had 
in probably a decade, to be able to help fight that.
    We also put a tax credit in place for caregiving expenses 
designed to improve the financial and workplace security of 
family caregivers, but this continues to be an issue we have 
had, and as we have skilled nursing facilities and assisted 
living facilities close, one of the issues they relate to is 
the staffing.
    Dr. Lu, you know, could you--I know you have got a lot of 
data and research that you have done with regard to staffing on 
this. What sorts of conclusions and recommendations can you 
give us around effectively be proactively combating nursing 
shortage?
    What are some of the things that States can do, or are 
there models that you would suggest, or is somebody who is 
really getting it right that we could look at and say, here is 
a good model, something we should be replicating?
    Dr. Lu. Thank you for reading this staffing question to me. 
I firmly believe that we needed to rely on technology 
advancement, so we have the staffing shortage issue. I know, I 
understand to say raising salary, increasing the working 
environment, they are good ideas, but they have other 
consequences.
    I am aware of two types of technology advancements that may 
help, according to my research. The first one is the adoption 
of healthcare information technology, so according to the 
research, we find that in a 12 shift--in a 12-hour shift, the 
hours are not spent at the bedside, patient at bedside--only 
two and half hours. The remaining huge amount of hours are 
wasted in walking on the hallway and something else, but health 
care information technology could help to improve the 
utilization of nurse hours.
    The second the technology I am aware is kind of nurse 
sharing platform, which is something like Uber car sharing, so 
our team now is working with those type of platforms. They try 
to match nurses with those healthcare facilities and improve 
the efficiency of using the idle time of the nurses.
    I hope that in the near future, we could rely on the 
technology to help to solve the staffing shortage.
    Senator Ricketts. Are there any regulations or red tape 
that the Federal Government puts in place that would enable CMS 
to dedicate more attention and resources to oversight of 
nursing homes?
    Dr. Lu. Of course, more resources are better. I, as a 
person training in economics, I care more about how to optimize 
the allocation of resources. In other words, how we can use the 
resources efficiently and effectively. That is a more important 
issue in my mind.
    Senator Ricketts. Yes. I have got just about a minute left, 
but I am going to ask every one of you just if you have got 
something that--to talk about this. One of the things I am 
concerned, it gets back to what Senator Vance was talking about 
with the pandemic, is one of the things we saw in Nebraska was 
having the residents be isolated.
    That, you know, there was a lot during COVID wearing masks. 
You couldn't see people's faces. They were--they used to have, 
you know, meals together, and then that got discouraged because 
we didn't want to--and then I am not sure we have gone back to 
getting people back together again. I am really concerned about 
the loneliness of our residents of skilled nursing facilities.
    I mean, the other thing, Ms. McMahon you were talking about 
are obviously very important, too, but here is one I think is 
maybe not getting enough attention, which is our residents in 
skilled nursing facilities getting enough social interaction.
    It is not just about taking care of their physical well-
being, but also, you know, their mental well-being, and, you 
know, having a life where they actually have interaction with 
other people. Just--these are just real quickly--Ms. Bliss, we 
are going to start with you.
    Just give me a comment real quick on what do you think 
about what I am talking about here in regards the loneliness 
and personal interaction, and what we can do, and just how we 
might address it.
    Ms. Bliss. Sure. Yes. Wellbeing of residents in all 
dimensions, including social and mental health, is critically 
important. I think that is a challenge worth focusing on.
    Ms. Williamson. Thank you for the question. You know, 
during the pandemic, one of the things that I didn't say in my 
response to Senator Vance was our staff went into nursing homes 
with outbreaks going on to do focused infection control 
surveys.
    We did see the isolation that was there and just the 
struggles that the residents and their families, because they 
couldn't visit, were experiencing. I think things are slowly 
getting back to what our new normal is.
    There are still some areas where people need to be mindful, 
but communal dining and activities and those things are 
starting. Visitation is much more open now. Those are all very 
good things that are happening. Did the isolation and 
loneliness take a toll? Yes, it did.
    Senator Ricketts. Are there things that we can be doing to 
encourage the facilities getting back to more normal, to 
encourage that--those activities, the meals, all that?
    Ms. Williamson. I think the ending of the public health 
emergency and some of the restrictions that were in place being 
relaxed is a good first step, and I think more groups meeting 
and talking about the importance of those social and 
interpersonal relationships.
    Yes, care is very important, the physical care, but those 
other things are just as important. I think the more we can 
highlight that, and talk about that, and encourage that, that 
will only improve.
    Senator Ricketts. Okay.
    Ms. McMahon. Thank you, Senator Ricketts. Residents 
suffered helplessness and loneliness to the highest degree 
during the pandemic, and folks were locked in their rooms all 
alone, and it is time for us to get back to having social 
opportunities for residents, in particular around meals.
    That is where they come together every day to see their 
friends and to visit and talk over a meal, and I think one of 
the things that we continually need to address are the nursing 
home staffing shortages so that we can get back to those 
activities and facilitating that for the residents. The 
Ombudsman have seen firsthand that the activities are still 
lacking and are not quite what they should be. Thank you.
    Senator Ricketts. Dr. Lu, do you have any comment?
    Dr. Lu. I do not have comment on this issue. Thank you.
    Senator Ricketts. Thank you.
    Senator Braun. Thank you, Senator Ricketts. We are going to 
have some other Senators roll in here, I think, soon. I will 
fill the gap. Got a question for Ms. Williamson. I ran a 
business for 37 years in a place like Indiana. Senator Ricketts 
was in charge of a State.
    There is this constant dialog about where do we craft the 
best solutions for issues like this, and who pays for them? 
Since I have been here, this place is going the wrong direction 
in terms of running its own kind of finances in a way that 
would be sustainable, for all the places that look to it.
    You know, we are running $2 trillion deficits currently, up 
from $1 trillion, and it has been on both sides of the aisle 
that have not managed the Federal Government in a way that puts 
so much in peril. With these issues, and I am pretty certain on 
staff shortages, that is probably something better addressed by 
States because they are going to know what they can do. It 
doesn't necessarily mean they would be the only ones, but where 
do we craft the solutions best in your mind, and how do we pay 
for them best over the long run? And should we be looking at a 
difference in, you know where the relative emphasis has come 
from to date?
    That is a kind of a broad question, but I think it is 
really relevant because we are dealing with that same question 
on so many issues in the country.
    Ms. Williamson. Thank you for that question, and yes, 
nursing home residents are our most vulnerable citizens, so I 
think they deserve adequate protection, and that is what survey 
agencies do. Survey agencies do receive a combination of 
Federal and State funds, so it is a combination, so I think it 
is imperative that both----
    Senator Braun. Which form of Government, though--from here 
down to the grassroots are States and not all of them 
necessarily get it right. Where do you think the relative 
emphasis ought to be shifted to if we are going to actually 
solve these problems and pay for them in a way that is going to 
be sustainable?
    Ms. Williamson. I think it is a combination. Federal has to 
allocate resources and States have to allocate resources.
    Senator Braun. Do you think it should move one direction or 
the other, or just stay the way it is?
    Ms. Williamson. I think it is both, because when survey 
agencies go do an inspection, it is for certification purposes, 
Medicare and Medicaid certification purposes, and it is also 
for State licensure purposes, so there is that share there. 
States recently have increased their budgets to fund survey or 
salary increases because of the shortage, so that is falling on 
States now because we don't have that increase in Federal 
funds.
    Senator Braun. Dr. Lu, would you want to weigh in?
    Dr. Lu. Yes. First of all, I like the idea to increase the 
annual income for surveyors because they provided the 
fundamental information for quality disclosure. However, I 
think there are lots of ways to increase their income, in 
addition to raising pace, so here I proposed to one potential 
idea from my own perspective.
    I think we can collaborate with those colleges with nursing 
education programs and give the money to them and let them to 
hire some State surveyors to train or mentor those 
undergraduate students or graduate students as a part time 
surveyor or provide exponential learning on those survey 
courses, and the students can be allocated with those tasks 
which do not require specified, or say, high skills. For 
example, they can check whether the floor is cleaned, whether 
nurses wash their hands between care. These are the dimensions 
in those data, surveyor programs, so by doing so, students 
could get a greater learning experience and open the new door 
to them. Let them get interested in the health care system.
    Maybe potential surveyors will be there in the future, and 
also, surveyors can get more pay by teaching. They can earn the 
extra money by helping those students doing mentoring services, 
and those education programs also can benefit from it, at least 
so they can increase the quality of their program by providing 
such kind of exponential learning, and our Federal Government 
and a State Government could also benefit from it. It can help 
to solve the severe shortage issue and also, I would say, 
efficiently allocate the resources so each party can be better 
off. That is my idea. Thank you.
    Senator Braun. Thank you.
    The Chairman. Ranking Member Braun, thank you for filling 
in as I was running between committees. Appreciate that work 
and thank our witnesses. We will now turn to Senator 
Blumenthal.
    Senator Blumenthal. Thank you. Thank you so much, Mr. 
Chairman, and thank you to the Ranking Member, Senator Braun, 
as well, and thank you for all of the input that you are 
providing today. I am very, very grateful to the Chairman and 
Ranking Member, and also the staff of this Committee, for the 
work that it is doing on this really critically important 
topic.
    With all of the issues that are facing us today that are in 
the headlines, sometimes the most important work doesn't get 
the attention that it deserves, and this work is among our most 
important.
    Uncovering the need and the consequences of oversight and 
scrutiny in this area is very important, and I look forward to 
reading the investigative report that uncovers staffing 
shortages, high turnover rates, and flat Federal funding for 
the last decade that has resulted in insufficient oversight of 
the Nation's nursing homes and threatened the health and safety 
of their residents.
    Yesterday, the Permanent subcommittee, the subcommittee 
on--Permanent Subcommittee on Investigations, held a hearing on 
Medicare Advantage, another area of health care where there is 
a need for greater scrutiny, and I think that some of the facts 
that have been uncovered by this investigation will be relevant 
to the work done there, and again, the Office of Inspector 
General, Ms. Bliss, has been very, very instrumental in that 
area as well. I would like to ask Ms. McMahon, beyond health 
care, beyond Care Compare, what do you advise families 
searching for a nursing home to do to ensure that they have all 
the relevant information they need to make an informed decision 
on what nursing home is best for them?
    Ms. McMahon. Thank you, Senator. I would say call my 
office. We certainly can direct folks to other resources as to 
where--as to what they should look into. We oftentimes will 
tell folks to go to the survey agency and look at the most 
recent survey, and we will talk about the things that, as the 
Ombudsman Program, the things that they can ask of specific 
facilities as they are looking to provide the best quality of 
care and life for their loved one.
    Senator Blumenthal. Let me ask you, just for you and maybe 
for the other witnesses, when families regret what has happened 
to a loved one, what do they wish they knew before choosing a 
facility? In other words, you know, regret is probably one of 
the most important emotions that we have with respect to loved 
ones when it comes to health care. What do they wish they had 
known?
    Ms. McMahon. Thank you, Senator, and we are talking about 
transparency. We are talking about potentially wanting to know 
staffing levels, how many nurses are in the building at any 
given time, who is the medical director that is overseeing and 
coordinating the overall care? Maybe any instances of abuse and 
neglect that have happened prior to. I think those are really 
important things to know.
    Senator Blumenthal. Ms. Williamson--and thank you for that 
answer. Ms. Williamson, your testimony touched on the issue of 
contractors, and I wonder if you can tell us, first of all, 
maybe elaborate a little bit on which States do well with 
contractors, which do not, and what lessons State, and 
particularly State officials ought to learn from the experience 
you have had.
    Ms. Williamson. Thanks for that question. I did touch on 
contractors because more and more States are relying on them to 
complete, particularly recertification surveys and some focused 
infection control surveys.
    Each state's contracts are a little bit different, and the 
work that they have contractors do can vary. I can speak on 
behalf of Missouri. We do have contracts for contract surveys. 
Primarily for us, those are the recertification surveys, the 
health care portion of the recertification survey.
    We have used them not as extensively as other States. They 
have done about 15 or so surveys for Missouri. We have had 
pretty good luck with the surveys that they have done. We have 
ongoing communication with the contractors when they are doing 
the survey, particularly if they are finding issues that are 
serious, just to make sure that they are thoroughly 
investigated, that the State agency agrees with the citations 
that they are issuing. We also do a review on the back end of 
their survey to make sure that they are applying the regulatory 
requirements consistently with what we would do.
    Each state's experience is a little different. I can't 
speak to other States and their experience. I know the report 
highlights some different experiences. I don't have firsthand 
knowledge of that. I can just speak from Missouri, but I do 
know more and more States are relying on contract surveyors 
just because of the staffing shortages.
    Senator Blumenthal. I think more than half the States now 
rely on private contractors to do this kind of oversight and 
certification.
    Ms. Williamson. That is correct.
    Senator Blumenthal. Connecticut actually is considering 
hiring a contractor because we have been unable to fill our 
vacant positions that were created during the pandemic, but it 
is a critical job, and it is kind of going to be garbage in, 
garbage out if we don't kind of oversee the quality of the 
contractors who do the certification--we don't certify the 
certifiers, so to speak.
    That is a vastly over simplistic way of looking at it, but 
I think it is a very important area, and thanks for your input. 
Thanks, Mr. Chairman, for letting me run over my time a little 
bit.
    The Chairman. Don't worry about it. Senator Blumenthal, 
thanks very much, and we will turn next to Senator Gillibrand.
    Senator Gillibrand. Thank you, Mr. Chairman and Ranking 
Member. This is an excellent hearing and one very needed for my 
State of New York. The Centers for Medicare and Medicaid 
Services require every nursing home to designate a medical 
director as responsible for resident care coordination of 
medical care.
    CMS does not have a compliance mechanism for this legal 
requirement, however, and nursing homes are not required to 
submit the identities of their medical directors to CMS. Ms. 
McMahon, if nursing homes were required to report their medical 
directors to CMS and State survey agencies, would this be a 
helpful tool for ombudsmen to hold nursing homes accountable 
and effectively advocate for residents?
    Ms. McMahon. Thank you, Senator Gillibrand. I do believe 
that requiring nursing homes to report their medical directors 
to CMS and State survey agencies could increase quality of care 
in nursing homes.
    As you noted, the regulations place great emphasis on the 
role of the medical director and requiring them to implement 
resident care policies and coordinate care. Often, medical 
directors are absent from the nursing home for long periods of 
time. It is rare that you will see a medical director 
physically in a nursing home.
    This is sometimes due to the medical director overseeing 
several nursing homes in the chain. By increasing 
accountability for medical directors, it could ensure they are 
fulfilling their critical obligations under the regulations, 
and when that doesn't happen, ombudsmen have another tool to 
take to the survey agency as a concern, and again, this ties 
back to increasing the surveyors for the State Survey Agency.
    Senator Gillibrand. Well, it doesn't sound right, though, 
that a medical director would have to oversee eight facilities. 
Don't you think they should have to limit how many facilities 
they have under their care?
    Ms. McMahon. I absolutely agree with you.
    Senator Gillibrand. What limit would you put on it?
    Ms. McMahon. I think it would be hard to pick a number 
because you have to take into consideration how many residents 
are in a specific facility in each building----
    Senator Gillibrand. Maybe no more than a hundred residents 
for a medical director. Like, would you do it by that basis?
    Ms. McMahon. I think that is a good way to approach it.
    Senator Gillibrand. Well, we--you know, to the extent any 
of you have a recommendation on that, please submit it by 
letter to the Committee, if you have some thought about it, 
because I think some individual responsible for eight 
facilities obviously is not doing a good job. It is impossible 
to have that level of oversight if you are spread that thin.
    I would like your recommendations there, and are there any 
ways that medical directors can increase transparency and 
accountability within nursing homes? Off to anyone. Go ahead, 
Dr. McMahon--or Ms. McMahon.
    Ms. McMahon. Yes. Thank you, Senator Gillibrand. In my 
experience, again, this is a rare situation where residents 
even know the medical director who the--of the nursing home, 
and further what the role is of the medical director that they 
play actually in the nursing home.
    By increasing transparency, residents will be able to 
interact better with the people who are responsible for 
implementing the policies and care. Increasing the 
participation of the medical directors in the facility 
operations would add additional safeguards and protections for 
nursing home residents.
    Senator Gillibrand. Thank you. In 2021, New York Attorney 
General reported that the number of nursing home residents who 
died from COVID-19 was undercounted by as much as 50 percent 
compared to data from the New York Department of Health. The 
investigations reveal that facilities that had lower pre-
pandemic staffing ratings had higher COVID-19 fatality rates.
    Ms. Williamson, the New York State Attorney General report 
revealed a lack of compliance with infection protocols led to 
increased risk of harm for nursing home residents. How could 
better compliance with standard surveys improve outcomes in 
nursing homes? How can increased staffing standards improve 
compliance with surveys?
    Ms. Williamson. Thanks for that question, Senator. As far 
as increased compliance and infection control, infection 
control is one of the most frequently cited deficiencies that 
survey agencies cite, pre-COVID and since COVID.
    That regulatory requirement has a lot of different elements 
to it, but it is one of the most frequently cited deficiencies. 
During the pandemic, our staff focused on conducting focused 
infection control surveys to assess compliance with infection 
control standards, and we continue those today.
    I think increasing our ability to do recertification 
surveys will catch some of those lapses in infection control 
before they harm residents, so that is very important to us, 
and one of the things that we are struggling doing with the 
increased volume in the surveyor vacancies that we have. That 
is a very important aspect of our work, that we hope to be able 
to do more of with an increase in resources to do so.
    Senator Gillibrand. Thank you very much. Thank you, Mr. 
Chairman. I have a question for the record based on investments 
at home and community-based services, I will submit.
    The Chairman. Senator Gillibrand, thanks very much. I just 
have one more question, and then I think we will close, and I 
appreciate our witnesses' testimony today.
    Ms. Bliss, I wanted to go back to kind of the basic 
function of the office you are a part of--the independent 
watchdog function, which is so vital in Government as it is and 
any other endeavor. That work has never been more important or 
under--frankly, under more pressure in recent years.
    Last week, I met with the Nation's Inspectors General to 
discuss how oversight can improve accessibility for people with 
disabilities under Federal information and services. Today, you 
have highlighted how your office's critical work on nursing 
homes is so essential for us to examine, and it is an issue I 
know that Inspector General Grimm considers a top priority.
    How can Congress best help your efforts on a number of 
fronts, but in particular to help improve nursing home care, as 
well as to tackle other pressing issues?
    Ms. Bliss. I really appreciate that question, and in fact, 
improving nursing home care and safety is the number one 
priority for Inspector General Grimm. We are investing heavily 
into this area, but our resources are really strained.
    We have about $0.02 for every $100 spent by the Department 
of Health and Human Services, so we have a vast and incredibly 
complex mission that is-incredibly important to the people that 
the programs serve.
    We make difficult decisions every day about what oversight 
work we can and can't get to, what enforcement cases we can and 
can't investigate, and the President's budget request for 
Fiscal Year 2024 includes an increase of $52 million, 
specifically for our Medicare and Medicaid oversight.
    Certainly an increase like that would expand our ability to 
better protect nursing home residents, and to expand our work 
looking at care for residents of nursing homes with 
disabilities, and people with disabilities outside of nursing 
homes and across other HHS programs.
    The Chairman. Well, thanks very much, and in the interest 
of time, we will move to our close. I just have a closing 
statement, then I will turn to ranking member Braun. 37 years 
ago this week, the Aging Committee held a hearing to examine 
the State of nursing home oversight, which was chaired by a 
Pennsylvania Senator, John Haynes, who was then the chair and a 
leader on this issue.
    At that hearing in May 1986, the Committee heard about the 
critical need to adequately fund nursing home inspection 
agencies and how not doing so would have, ``grave 
consequences'' for quality care. We heard similar warnings 
today, and these warnings must not be ignored.
    Here is just four steps the Committee should work on going 
forward, and I would argue not just this Committee, but 
multiple committees in both houses of Congress. First is, of 
course, funding. Congress must prioritize the Nation's 1.1 
million nursing home residents by investing in oversight, as I 
will say it again, the last three Presidential Administrations 
have proposed. Second is transparency.
    The investigation makes clear that CMS needs to track and 
report survey agency staffing, given that staffing is a leading 
indicator of a state's performance. Third, protecting 
taxpayers. States, CMS, and independent watchdogs need to 
closely examine the use of contract inspectors and make sure 
that proper guardrails are in place, and finally, fourth, 
workforce.
    The investigation shows that expanding the health care 
workforce will help health care providers deliver better care 
and ensure that States conduct better oversight. The Aging 
Committee's oversight in the 1980's paved the way for landmark 
nursing home reforms that President Reagan signed into law.
    Today's hearing and the Committee's investigation provide 
another opportunity to find common ground to make sure nursing 
home residents are kept safe and receive the care that they and 
their families deserve and have a right to expect. I would like 
to thank the witnesses for their thoughtful and expert 
testimony today.
    You have helped us to diagnose the problem and to set forth 
those problems, as well as solutions that we will examine going 
forward. I will now turn to Ranking Member Braun for his 
closing remarks.
    Senator Braun. Thank you, Mr. Chairman, and again, we have 
had a good discussion. You can't legislate through this 
Committee, but a lot of discussions happen here that then do 
get legislated through other committees.
    I think it is clear, from what I have heard, we need to 
improve transparency and accountability. I look forward to 
working with Chairman Casey to do this. Both of our officers 
have had a knack for, I think, finding common sense solutions 
and putting them into law. I stressed earlier, don't make 
things worse by Federal rules and regulations. Overtime rule 
was one.
    We had a discussion on it. I can tell you that in almost 
all other arenas, you have got to be careful there because it 
went from just $27,000, which was too low during the Obama 
Administration, they wanted to change it. It went to a level 
where it was an uproar in terms of the number of jobs that 
would have been lost or places just couldn't probably afford to 
do it, and now the current Administration is talking about 
going up nearly to $80,000, and it would be great, I guess, if 
you could afford to do it, but it would completely disrupt 
employer, employee relations across the country. How we sort 
that out remains to be seen. On other extreme Federal 
overreach, we have had to weigh in as a freshman Senate office.
    When we do, it was generally on an issue that made sense 
because something was fixed on account of it. We had a lot of 
discussion earlier too. Do these solutions get crafted here in 
a place that has not evidently ever taken finance 101? Many 
places depend on it, and we increasingly borrow more and more 
money to support the programs that so many people look to. It 
is not a good long term business plan.
    Something has got to change, and I think until we actually 
start doing budgets and doing things that would give more 
confidence to the American public that we are going to craft 
solutions and pay for them sustainably, maybe look to the rest 
of the Government marketplace, which would be States that 
actually have to live within the regimen of not borrowing from 
future generations, and have an equal responsibility and might 
be in better place to actually affect them and do it in a 
sustainably long run basis.
    The one thing I think we can agree on is this is a big 
issue. I am going to be here as a partner with Chairman Casey 
to see what we can do, and again, thank you all for weighing in 
today. Much appreciated.
    The Chairman. Thank you, Ranking Member Braun. I wanted to 
note for the record the scale of a report like this, as you can 
imagine, takes many, many months of work. Peter Gartrell right 
behind me, over my left shoulder, and his team put untold 
numbers of hours into this report. It gets to page 89, the 
footnotes, Peter goes over 440, something like that, so it is a 
pretty big report.
    We had a stack of documents here which I won't lift up to 
show you, but it requires a maximum effort by our staff, and we 
are grateful for that, and grateful that Ranking Member Braun 
and his team are here with us today to talk about this.
    I want to once again reiterate our gratitude to each of the 
witnesses for bringing not just your testimony and the answers 
to questions, but in many of your--in each of your cases, a 
lifelong, or more significant period of your life's commitment 
to these important issues. Nothing could be more important. No 
work could be more important than making sure that we are 
providing the best care to seniors.
    If any Senators have additional questions for the witnesses 
or statements to be added to the record, the hearing record 
will be kept open for seven days until next Thursday, May 25th. 
Thank you all for participating today. We are adjourned.
    [Whereupon, at 11:04 a.m., the hearing was adjourned.]

      
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                      Prepared Witness Statements

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                        Questions for the Record

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                       Statements for the Record

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