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Healthy Maine Talks
Stories from people across Maine working to make their communities healthier and safer. Hosted by Maine Public Health Association.
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Healthy Maine Talks
Rose Lundy: Investigating Maine's long-term care system
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Rose Lundy, a public health reporter at the Maine Monitor, walks Matt through her groundbreaking series that investigated Maine's long-term care facilities. Tune in to hear about the problems that Rose uncovered, and how we can potentially move forward to improve long-term care for people in Maine.
*This Healthy Maine Talks episode is supported by the New England Public Health Training Center*
Hey everybody, thanks for jumping in to another episode of Healthy Maine Talks. This is your host, Matt Wellington, and also Associate Director of the Maine Public Health Association. For this episode, I chat with Rose Lundy, a public health reporter at the Maine Monitor, about a series of stories that Rose wrote about long-term care facilities in Maine and some serious issues that she uh uncovered in her series and uh how we can potentially move forward in our state to improve long-term care. So please stay tuned after the break for my uh interview with Rose, and thanks again for tuning in. Hey everybody, welcome to another episode of Healthy Main Talks. I am here with Rose Lundy from the Maine Monitor. Hey Rose, how are you?
SPEAKER_00Good, how are you?
SPEAKER_01Very good. Thanks for jumping on and doing this with me. We are gonna dig into a series of stories that you've put out over the course of the last year, more than a year.
SPEAKER_00Yeah, more than a year now.
SPEAKER_01More than a year on long-term care facilities in Maine. And uh I I won't give anything away. I want you to walk us through your series. So uh I'll stop there. And then can you just share a bit more of your background with our listeners and some information about the main monitor before we dive into your series on long-term care? So can you tell us more about yourself?
SPEAKER_00Absolutely. Yes. I so I am a public health reporter with the Maine Monitor. I've been here for about four years. And before that, I was spent three years at a local newspaper in in Washington State near Mount St. Helens, uh, covering local government there. So um, but yeah, I so I've been at the Maine Monitor and for the last four years. And we are a nonprofit, nonpartisan investigative news outlet covering the whole state of Maine. And um all of our content is free on our website, the main monitor.org. And we let all um publications in the state pick up our stories for free. So even if you haven't heard of us, you might have read some of our stories uh in any of the newspapers or on some of the TV websites and um the radio station. So you can look for us going forward. We'll have the byline the main monitor under it.
SPEAKER_01Yeah, I didn't know that you let other outlets pick up your stories for free.
SPEAKER_00And also a huge part of our oh, sorry.
SPEAKER_01No, you go ahead.
SPEAKER_00I just isn't going to say a huge part of our mission is making all of our journalism and our investigative reporting free to anybody in the state. So it's very important.
SPEAKER_01Yeah, key word for me is investigative reporting. I think you do such a great job of the deep dive stories on issues that are really important that I think other outlets certainly do. But um, you know, it's a it's a hard landscape right now for media to be able to do those long-form investigative stories. And so I just really appreciate you doing that. And and kudos to the main monitor for making it happen. So, yes, please uh to our listeners keep an eye out for the main monitor, check out the story, share their content. And you said you're a nonprofit. So, does that mean you take donations?
SPEAKER_00We do, yes.
SPEAKER_01Okay, well, there you go. Support the main monitor. Um, okay, so let's jump into long-term care in Maine, long-term care facilities. So, like you said, more than a year investigating this story. You came out with a series of three articles about it. And let's start from the beginning. So, why did you decide to start looking into Maine's long-term care facilities? What piqued your interest there?
SPEAKER_00Yeah, absolutely. Well, I started at the monitor as a public health reporter in June 2020. So immediately was thrown into COVID-19 pandemic coverage. And uh as people probably know, um the pandemic hit nursing homes really hard. So I was writing a lot about nursing homes from the get-go. And then it's especially important here, we're the oldest state in the country. So um I think I just became really interested in issues that impact older mainers and the systems that care for older Mainers. So I'm a public health reporter, but I have a special interest in aging issues and older adults. So I already was interested in that. And then I got an anonymous, anonymous news tip from someone saying you should look into two incidents that happened at a residential care facility. So that's uh refers to what is commonly known as an assisted living facility, but here in Maine we call them residential care facilities. So the the two incidents involved first, a gentleman who had a very serious peanut allergy was given a peanut butter and jelly sandwich for lunch, and he went into anaphylactic shock and ultimately went to the hospital and died a couple of days later. And then the second incident was a woman who got into a locked courtyard at night in the middle of winter and was there for two hours before anybody found her. And she was in the snow when she was found, and she ultimately died a couple of days, a few days later as well. So I when I looked into the cases, I got the inspection reports from the state, and they confirmed that they had investigated them for these cases and that they had looked into it and that it had happened. So I did a story at the time, but it made me think, well, I only knew about these cases because somebody brought it to my attention. You know, how many more are out there, even if there are inspection reports and we don't know about them? And so I wanted to think how could I be looking into this more proactively rather than waiting for someone to bring it to my attention? And so when I started to look into it, I learned that residential care is kind of a different beast from nursing homes. You know, nursing homes are federally regulated, and there's actually a lot of information out there that you can find as someone as a member of the public. There's this really incredible database called Nursing Home Compare. And so that's where you can look up all the nursing homes in the state, and you can look at individual facilities and find out how they rank on quality measures and if they've been fined, and what the latest investigation and inspection report said. So anybody who's looking into nursing homes, I encourage you to look up that database. It's called nursing home compare. You can just Google it. But assisted living facilities, what is known as assisted living, you know, commonly, are state regulated. So it's really different from state to state. There's not the same kind of information available. They're regulated really differently. And, you know, in a lot of ways, Maine has much better regulations than other places, but as we'll talk about, there's, you know, there's still quite a few gaps that are important to look into. So that's a long way of saying I discovered that there's just not a lot of information out there about these residential care facilities. And so I decided to get the inspection reports for all of the facilities for the last three years and just read them myself and find out what's going on. So at that same time, I applied for a fellowship with ProPublica, which is a nonprofit national investigative news outlet. They do a lot of really incredible work that's won a lot of awards. And they have this program where they partner with local reporters like me and they help you tackle a bigger investigation. So I pitched this story and they helped me kind of tackle this story that involved hundreds of documents and a pretty comprehensive database with, you know, eight, I think eight hundred lines of data in the database. So um stop.
SPEAKER_01Yeah, I was gonna say if I can jump in and ask. So, first off, that is a Herculean undertaking, three years of inspection reports, probably not the most uh relaxing reading material for you. No, so yep, acknowledging that. And then what were you looking for? So as you're sifting through these inspection reports, what were you trying to find? What were you keeping an eye out for?
SPEAKER_00Well, it's a good question because I don't think I knew what I was trying to find. I I went in with an open mind. I would, I was, I wasn't sure what I what I wouldn't cover. I mean, um, so we took an open-ended approach, which is each each inspection and investigation could have multiple citations within it. So we we started building the spreadsheet that said, you know, this facility, this inspection report, here's here's the here are the different citations. And we broke it out by citations to see what was happening the most frequently. And what we ended up finding were a couple of different buckets of types of violations. The first was we were surprised by um, you know, there were 200 out of 700 citations that involved medication and treatment errors. And so that was surprising because these facilities are technically non-medical facilities. And so that first piqued our interest and started to we started to look into that. And that was my first story. And then we also noticed a number of resident rights violations, which are can be the most serious that can include abuse and neglect. And so that was another pocket that we um looked into for my second story. So we didn't know going in what we would find, but then based on what appeared in those inspection reports, we started to follow those trails.
SPEAKER_01So you you cover this in the in the articles, but can you share that what you mean by those residents are supposed to be non residences are supposed to be non-medical? What does that mean?
SPEAKER_00Yes. So a nursing home is a medical facility. You have to you have to um qualify medically to get into the into those facilities. And um residential care facilities are intended to be more home-like alternatives. So you get some medication management assistance, and they are required to help you get to doctor's appointments, and then they help you with things called activities of daily living. So they help you if you need help walking or bathing and things like that. So it's intended to be a little bit more independent with some assistance still.
SPEAKER_01So you were surprised when you saw the volume of medication violations because they're supposed to be non-medical facilities. Like you said, there's some assistance with medication, but did that just flag for you that there's more medical treatment happening in these facilities than there potentially should be? Was that the issue when you saw 200 violations?
SPEAKER_00Well, ultimately what I learned is I think that the demand for the medical need in these facilities is so much higher than it was intended to be. So people are ending up in these facilities with higher needs than the um intent of the of the facilities. And and part of that is this decision that dates back 30 years in the 90s, which was to move away to reduce the reliance on nursing homes in Maine. And that was for a couple of reasons. The first one was people don't want to live in nursing homes, they don't want to be um in institutional settings if they can avoid it. So in the mid-90s, Maine lawmakers tried to shift away from nursing homes and encourage these other more independent, more home-like settings as a result. It also was a financial decision, too, because nursing home care is very expensive and um assisted living services and these residential care facilities is not as expensive. So it was a financial decision as well. And what we've seen since then is that Maine's nursing home beds have decreased significantly over that time, and residential care has expanded very dramatically. So there's been a shift in where people are served, but the result is that people have much higher needs in residential care than they did 20 years ago, 30 years ago when the shift started.
SPEAKER_01Yeah, so it sounds like the intent of that policy change in the 90s, it was there was positive intent there, but this is a very unfortunate, unnecessary concept, or sorry, unfortunate, unintentional consequence of that policy change. So this is it is a good segue into the question I had for you next, which is just what were the major problems you found? You talked about some of the violations and what are some of the gaps out there? So let's stay on that thread for a little bit here. So you talked about the policy change in the 90s, nursing home beds decreasing, residential care beds increasing. So what would come? Well, I guess before I ask what comes next and potential solutions, what other gaps did you find in your reporting? What other problems came up as you were looking into this?
SPEAKER_00Yes. So we found a number of um violations and citations that we've talked about. We also looked at the state's response to those violations. And what we found is that the state has the power to impose a fine up to $10,000. And it could also issue something called a conditional license, which can include a pause on um new admissions. So those are two sanctions that they could use in very serious cases, but overwhelmingly, it the state opts to do something called a plan of correction. So they they issue a document saying here's all of the errands that we found. They call them deficiencies. And then the facility is supposed to fill out this document called a plan of correction, saying specifically how it's going to address each of the issues. And the state says that most often the plan of correction is sufficient to correct any errors going forward. But what we found some pretty serious cases in which it the only result was a plan of correction. So, you know, the the incident where the gentleman with the severe peanut allergy was given a peanut butter and jelly sandwich, that resulted in a plan of correction. And the woman who got into the courtyard in winter, that resulted in a plan of correction. There were other um pretty serious medication errors where residents had to go to the hospital. There's one serious case in which one resident sexually abused another resident multiple times, and the facility didn't report it, and that resulted in a plan of correction. So there's oversight, but it um in most cases the state opts for the lowest level of oversight.
SPEAKER_01Yeah, and so this is um, you know, I I'm trying to see this from an impartial lens, which I know you are as well as a journalist. Your job is to report the facts and what you find. But why do you think there's not more discipline? Is it because of the sit, you know, the bigger picture situation we have in the state where we just don't have enough resources available to care for older people? And so is the more you know, more severe disciplinary measures, is that seen as actually harming that bigger or contributing to that bigger picture problem? Or I don't know, what what what did you take away from the interviews you did and and your reporting about why, you know, why there isn't more oversight, more severe discipline?
SPEAKER_00It it's hard to say without speculating. Um it's a very good question. And I would I would hate to put any intent uh or assign any intent to the state. I think the concerns that I've heard about it is certainly we do um we have a lot of demand. We have a lot of older people who need help with services in the state, and we do need places to provide those services. Um, and certainly nursing homes, but also residential care facilities have really struggled in recent years, particularly in the pandemic.
SPEAKER_01Um I might be asking you to speculate unfairly. So it's totally fine to leave it there if you want. Like I said, I understand your your job as a journalist is not to speculate. So taking things in a slightly different direction, I you know, and I do want to get back to the some of the issues around staff shortages, which I know you've written about recently as well. Um well, let's just do that now. Yeah. So the staff shortages, there's a new federal mandate to increase staff in is it nursing homes or across long-term care? Is it just nursing homes?
SPEAKER_00It's only nursing homes, yeah.
SPEAKER_01Okay. So yeah, what can you share some more detail on that? And I I don't think that was part of your series here, right? That was a separate story, but it's it is related. So how does that what is that mandate for nursing homes? And then how does how does the staffing shortage relate to residential care facilities as well?
SPEAKER_00Yes, so the the federal government um at the end of last year rolled out some new requirements for minimum staffing in nursing homes. So it's only for nursing homes. Um, and it had minimum care hours for um registered nurses and nurses, nursing assistants. And so, and those just went into effect recently this year. And Maine already has pretty high requirements in nursing homes already. So the it's not a huge increase in Maine. So we're pretty well positioned here. The challenge I've heard from providers is that there's now a requirement to have a registered nurse on duty 24-7. And that can be the hardest, especially in rural areas, to make sure that it's hard to have somebody there at all times. But um, my story looked at it, it analyzed payroll data from the the year prior to look at how close our nursing homes are to actually already meeting the the requirement that's going into place. And we we did better than most other states. We're we're way better, but we're still pretty far off. Um, my analysis found that um in in the second quarter of last year, 8% of Maine nursing homes met both of the new requirements on every single day. But the national average was 1% of nursing homes met it on every single day. So we're doing better than most states, but it still is a challenge. And providers and advocates here are worried about the staffing shortages and nursing homes struggling. I think the the debate with that issue is that well uh high having higher staffing standards is it has been found to be related to to better quality of care. And so it's you know, the advocates um applauded this new initiative because, or these new regulations because they think it will bring up the standards of care and it's what we need to be doing to care for people. There's a concern about finding the people to to to provide that care.
SPEAKER_01Yeah, I I read that story and saw both both sides there about how doing this again, unintentional consequences, right? So making sure it doesn't affect the overall number of nursing homes out there. And so how does how does this relate to the residential care services? Because the problem, again, unintentional problem coming from that policy change in the 90s was less people are going into nursing homes, so there's less nursing home beds, more people are in residential care facilities. So are there similar pushes to increase staffing in residential care facilities? And what does that look like? Is the intent to reverse some of that trend and have more people going into the nursing home settings if it's appropriate given their medical needs? Can you share some information about that?
SPEAKER_00Yeah, so um the there are staffing ratio, minimum staffing ratios in residential care facilities as well. And the result is it's um it's roughly um direct care workers have to care for roughly twice as many people as they would in a nursing home. So just to get into the nitty-gritty, in a nursing home, it's one direct care worker to five residents in the in the morning, one to 10 in the during the the day in the evening, and one to 15 overnight. And for residential care facilities, it's one to 12 in the morning in the day, and one to 18 in the evening and afternoon in the evening, and one to 30 overnight. So we are um ahead of some other states and even having staffing requirements in in residential care. A lot of states just say you need to have staffing sufficient to meet the needs. So we're better than some places, but um a lot of the people I talked to said that those ratios are not enough. I I talked to the owner of one of these residential care facilities, and she used the words scary and completely inadequate because the need is just so much higher. So I haven't heard people saying we need to reverse the trend and send people back to nursing homes. I've heard people say we need to increase the standards in residential care facilities. We need to have more training for people, and we need to have stricter staffing standards that um have more people on duty to care for these residents.
SPEAKER_01Yeah, and that gets to the violations you saw. And was it your when you spoke to people and looked into the inspection reports? Was it I guess I'm trying to tease out how much of this is intentional neglect versus a product of what you just shared, just not enough training, not enough staff, not enough oversight. So what do you is that the am I characterizing that properly? That really it's not the problems you found in your reporting could be solved by better staffing, better oversight, better training. It's not necessarily that there's some, you know, intent there to some of the neglect or horrible circumstances you saw. I imagine not, but you tell me what you what you think.
SPEAKER_00Absolutely. I I don't think there's intentional, nefarious intent there. And I want to be very clear. I talk to a lot of people who work in long-term uh care and in aging services, and overwhelming, they say people who do this work, they really love it and they really care about it and they really want to take care of people. And so certainly don't want to demonize the people doing this really important work with my reporting. I think it's a systemic problem. These facilities, you know, there could be some bad apples, but I think they're kind of set up to fail by the current system here because they are providing care for people who have higher needs than what they are they were intended to care for. And so um they can go above the requirements, but that's kind of at a cost. And so, on one hand, you should absolutely care for the people that are in your service and you should be held accountable for if you're going to accept somebody, you should care provide the care for them in order to keep them safe and and healthy. But I also think it's incumbent upon the rest of us to set up a system that um makes that possible.
SPEAKER_01Well, and I think you're you've set the the the spark, right? Because without your reporting, we just wouldn't have known the scope of these problems in the first place. So I think that's really important that you took the time and read through the hundreds of inspection reports and did the legwork here. So thank you for that. Um thanks for saying that. No, of course. And so to move forward here, so can you summarize the three stories that you wrote in the series and encourage folks to check them out? So I'll pass it to you to give that quick summary. Here are the three stories, each topic area, and then we can end by talking about what so other solutions you uncovered as you spoke to people, interviewed, you know, advocates, people in long-term care about how to move forward and solve some of these problems.
SPEAKER_00Absolutely, yes. So my first story looked at the increasing demand for medical need and sort of the historic factors from the 90s that set up this current system that we're in. And uh looked at one case in particular in which a gentleman had rising needs and uh didn't feel like they were being met in his facility. And um his sisters were really concerned about the care that he was getting. My second story looked at cases of abuse and neglect and how the state responded to them. So it outlined some of those cases that I mentioned before and looked at what the state did in response and um overwhelmingly was plans of correction. And then my third story that just came out um is about incidents in which residents wandered away from their facilities. The technical term is elopement, um, but it's it's common for residents with dementia to um wander. And so there were 115 cases in which these facilities had residents leave their premises um without anyone noticing. Um the state defines that as unsafely wanders from the facility. So there were 115 of those cases, and um in 98 of those cases, investigators did not even visit this the facility to look into it um and rarely sanctioned the facilities at all for them. So those are the the three stories that I wrote, and um you can find them all on the the main monitor.org. And then in terms of solutions that I've heard from people, I've I what I've heard the most is that we need to increase the staffing standards, um, just have more people providing the care. That would prevent people, residents from leaving without anyone noticing. It would um improve the quality of care in these facilities. Um, and the need is right, the medical need is higher. So we need to have more people who um are caring for them. And you also need to have more training, is what I've heard. So, in particular with my recent story on elopements, there's just a dearth of training on dementia. You only have to have eight hours of initial training for dementia care if you have um if you are a memory care facility. So there's no requirement for the rest of the residential care facilities. But you know, we have a lot of people with dementia in this state. And so the people I spoke to said you need to know how to care for the people that are in your facility. And so we need more training.
SPEAKER_01Um I ask really quick, you said there's training requirements for memory facilities, but um, I think you were implying there are lots of folks with dementia who are not in those types of facilities, they're just in res normal residential care. And is that a failure in diagnosis, or are they supposed to be in those more specialized facilities? What what what's the wrinkle there?
SPEAKER_00I mean, frankly, we we have a lot of people with dementia in Maine. I think the number is 35,000 people with dementia. There's also a lot of studies that find that up to 50% of people with dementia are never diagnosed. So there's just a lot of people out there. And memory care issues just come along with aging. Uh, you know, the people I talked to say that you're going to have people with dementia in your population, kind of no matter what. Um, I talked to somebody who owns one of these level four facilities. She is not a memory care facility, but she's estimated that 95% of her residents had some memory issues. So she's not held to the same requirements as the other places, but um chooses to staff higher and um thinks there should be more training across the board because of the population that she serves in her non-memory care residential care facility.
SPEAKER_01Right. And I want to pull out a statistic you share in your in this latest article. So you say the number of people in the state with dementia is projected to grow by 20% between 2020 and 2025. So this is a problem that will in seems to potentially be increasing. Um, so yeah, definitely I think lights a fire under advocates and and other folks in the state who are working with these facilities to figure this out. So we will wrap up there, and I'll just encourage folks check out Rose's stories, check out all of her stories at the Main Monitor, but especially this series, which again took a lot of legwork and um really solid reporting. So themainmonitor.org is where you can find them. And thank you so much for lending your time here, Rose. I appreciate it.
SPEAKER_00Thank you so much for having me.
SPEAKER_01Of course.