This article was produced by The Maine Monitor, which was a member of ProPublica’s Local Reporting Network in 2022-23. Sign up for Dispatches to get stories like this one as soon as they are published.
In the first major update to assisted living and residential care regulations in more than 15 years, the Maine Department of Health and Human Services has proposed significantly increasing staffing requirements, among other changes.
The proposed updates follow an investigation by The Maine Monitor and ProPublica into the state’s largest residential care facilities. It found dozens of violations of resident rights, including incidents of abuse and neglect, as well as more than 100 cases in which residents wandered away from their facilities and hundreds of medication and treatment violations.
As part of the news organizations’ investigation, one facility owner called the current staffing requirement “scary,” “unsafe” and “completely inadequate.” Experts, advocates and providers said requiring higher staffing levels, better training and more nursing care would help address these problems.
During a public hearing this month, the department proposed doubling the number of direct care workers at residential care facilities overnight and setting stricter rules in memory care units that go beyond the state and federal staffing requirements at nursing homes. DHHS must present its proposed regulations to lawmakers by Jan. 10 in order for them to be considered in the upcoming legislative session.
Assisted living programs serve older Mainers, adults with intellectual and developmental disabilities, and people with mental illness. These facilities offer less medical care than nursing homes, but they have expanded in recent years after the state capped the number of nursing home beds in the 1990s. In the last decade, at least 26 nursing homes have closed in Maine.
That shift has meant that the needs of residents in these facilities have “increased significantly,” said Brenda Gallant, Maine’s long-term care ombudsman, the state’s advocate for residents and their families. “Current regulations for assisted housing have not kept pace with the increasing needs of residents,” Gallant said, citing assessments from the state in recent years that as many as one-third of residents in these facilities could qualify for nursing home care.
Currently, residential care facilities with more than 10 beds require one direct care worker for 12 residents during the day, one for 18 residents during the evening, and one for 30 overnight. Under the proposed regulations, these ratios would be increased to one direct care worker for eight residents during the day and evening shifts and one for 15 residents overnight.
Currently, facilities with 10 or fewer beds must at all times have at least one responsible adult present. That would be increased to two on duty at all times.
For memory care units, the proposed staffing requirements are even stricter — and higher than those currently required in nursing homes: one direct care worker for five residents during the day and evening, and one worker for 10 residents on overnight shifts.
Experts and advocates have told The Monitor that residents with Alzheimer’s disease and other dementias are among the most vulnerable because they have a tendency to wander. The proposed regulations also require assessing residents for risk of elopement, defined as “leaving a secure facility without authorization or supervision.” The Monitor and ProPublica found that there were at least 115 reported elopements at Maine residential care facilities from 2020 to 2022, according to state inspection records and a database of incidents reported to the health department.
“Significant New Costs”
The proposed changes came as “quite a shock,” said Angela Cole Westhoff, president and CEO of the Maine Health Care Association, which represents nursing homes and assisted living facilities across the state.
Westhoff and facility administrators repeatedly asked the state during this month’s hearing to pause the process in order to get more industry input. A DHHS spokesperson did not respond to questions about what would happen if it missed the Jan. 10 deadline for submitting proposals to the Legislature in favor of more discussion.
The staffing requirements will mean adding about 2,000 more direct care workers, according to estimates from MHCA.
“This industry is not financially positioned to incur significant new costs without a corresponding increase in MaineCare spending and private pay pricing,” Westhoff said, referring to Maine’s version of Medicaid. Providers strongly disputed DHHS’ assertion that the rule was expected to have “minimal fiscal impact on licensed providers.”
DLTC Healthcare & Bella Point, a company that owns and operates 17 residential care facilities, estimated the change would cost an additional $108,000 annually for each 30-bed facility.
The director of finance and human resources for Schooner Estates, Schooner Memory Care and Fallbrook Woods estimated the three facilities would need to add 68 full-time-equivalent employees, totaling $4.5 million a year.
Woodlands Senior Living, which operates 16 facilities in Maine, said it would need to hire more than 300 staff members across its facilities, totaling nearly $13 million a year.
Many providers said they would likely have to pass these costs on to residents unless the regulations came with an increase in MaineCare reimbursement from the state.
Facility owners and administrators also warned that increased staffing requirements would be difficult to meet due to workforce shortages. During the hearing, one resident services director in Saco said they have been trying to hire a nurse for more than two years. Another administrator said her facility’s last opening took two months to fill, and when they finally hired, the candidate had “no qualifications” and required months of training.
DHHS spokesperson Lindsay Hammes said the department could not comment about the proposals during the rulemaking process and noted that the proposals could change based on public comments, which were accepted until Nov. 25.
“The Stakes Here Are High”
While facility representatives offered vocal opposition at the recent hearing, others testified in support.
Citing a recent survey of direct care workers, Nicole Marchesi, who works in the ombudsman’s office, said increasing staff ratios could help prevent burnout and turnover.
“Staff continue to express the frustration around caring for residents who are nursing home level of care in assisted living,” Marchesi said. “When staffing is insufficient, resident safety is jeopardized.”
Gallant, the long-term care ombudsman, and Legal Services for Maine Elders also recommended having license renewal and survey inspections completed annually, rather than every two years, and creating a standard practice to follow up on plans of correction when facilities are cited for deficiencies. In their investigation into elopements, The Monitor and ProPublica found that in the vast majority of cases, DHHS never inspects facilities and rarely imposes sanctions.
“The stakes here are high,” wrote John Brautigam on behalf of Legal Services for Maine Elders. “These rules have the potential to prevent neglect, improve health outcomes, and foster environments where residents feel valued and safe. We owe it to them to ensure these protections are as strong as possible.”
