Elder Justice Coordinating Council 

Remarks of Lori Smetanka, Executive Director 

National Consumer Voice for Quality Long-Term Care 

June 21, 2022 

Good morning, Chairwoman Barkoff and members of the Elder Justice Coordinating 

Council. I am Lori Smetanka, Executive Director of the National Consumer Voice for Quality 

Long-Term Care. The Consumer Voice is a national non-profit advocacy organization that works 

with and on behalf of individuals receiving long-term care and services to achieve quality care, 

quality of life, and protection of rights. We also are proud to host and operate the National 

Long-Term Care Ombudsman Resource Center through a grant from the Administration for 

Community Living, where we provide training, technical assistance, and support to State and 

local Long-Term Care Ombudsman Programs. Through their work, Ombudsman Program 

representatives provide critical advocacy, support, information and resources to long-term care 

facility residents and their families. Thank you for inviting me to speak today, and for including 

this panel focused on nursing home issues. 

For more than 25 years I have worked in this field, where I have had the opportunity to 

talk with many residents, families, ombudsmen, facility staff, and others about the experiences 

of residents. A recurring theme, which research and data clearly show, is that the single most 

important element for ensuring that residents receive the care and services they need is having 

the necessary staff in a facility. Adequacy of staff includes numbers of staff, skills mix, and 

training. 

When there are not enough staff to provide care, residents may not get out of bed for 

hours, or even days. They have long wait times to be helped to the bathroom – often resulting 

in the person urinating or defecating themselves, and then waiting longer for someone to help 

clean and change them. Antipsychotic drugs are inappropriately given to residents to control 

behavior or for the convenience of staff. Teeth aren’t brushed, and residents who need 

assistance moving and turning often develop pressure sores as they lie in the same position for 

countless hours. Residents tell us that showers are regularly skipped due to short staffing – so 

instead of receiving two showers a week, she may receive one, sometimes none. 

At the end of her life, my grandmother lived in a nursing home and needed help with 

eating. When I would visit and would help feed her, it would take 20-30 minutes, or more, for 

her to finish her plate of food. A staff member caring for 20 residents – a common occurrence 

in today’s nursing homes – would be hard pressed to spend that amount of time helping one 

resident eat. We learned during the pandemic that many facilities are highly dependent on the 

informal care that families provide when onsite. 

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Short staffing also puts great stress on the staff themselves, who are at increased risk of 

injury, and often have to make the difficult choice of deciding which residents to assist and 

what kinds of assistance they can provide. Short-cuts get taken and mistakes are more 

frequently made. Staff also don’t have the opportunity to connect on a personal level with the 

residents, because they are rushing to get on to the next task. 

The critical shortage in staffing that currently exists in many areas today is part of a 

longer, systemic problem. Low wages and benefits, poor working conditions, and inadequate 

training and support are some of the factors that lead to high turnover and difficulty attracting 

new workers into this field. 

We cannot allow this broken system to continue. Immediate changes need to be made 

that include minimum requirements for staffing and increased accountability and transparency 

for facilities – both to meet quality standards and to account for the use of public dollars. We 

commend the Biden Administration for the bold set of reforms proposed in late February that 

would begin to address these issues and we support their implementation. 

Despite well-established research showing that nursing homes with higher averages of 

nursing care per day have higher overall ratings, better health inspection ratings, and fewer 

instances of abuse, we continue to have weak federal policies around nursing home staffing. 

Facilities are required to have “sufficient staff” – a standard that is vague, subjective, and 

difficult to measure. As average daily staffing decreases, so does a facility’s overall rating and 

performance in health inspections, and instances of abuse rise. 

In the nursing home reforms proposed by the Biden Administration on February 28, 

2022, a key element is the creation of a federal minimum staffing standard, based on the 

findings of a new study being commissioned. Any staffing standard must include a baseline, or 

minimum, below which a facility cannot go, and must also include adjustments for resident 

acuity to assure higher staffing levels when residents have higher care needs. 

Facilities must also be held accountable for meeting minimum quality standards. 

Penalties for not complying must be meaningful and appropriate for deficiencies cited; and we 

cannot allow chronic bad actors to continue owning and operating facilities. There could and 

should be better federal agency coordination around facility and corporate monitoring, data 

sharing and analysis, and referrals of cases and complaints. Increased collaboration, including 

among agencies on this Council and the programs you oversee, would leverage the power and 

resources of the federal government to both systemically and individually address bad actors in 

the system, and would improve conditions for residents. 

Additionally, we must insist on greater transparency and accountability for the billions 

of dollars of public funds nursing homes receive. The nursing home industry claims that it does 

not receive enough money to hire the necessary staff, nor to provide high-quality care to which 

residents are entitled. The truth, however, is that shell games such as submission of 

incomplete and inaccurate cost reports, and strategies such as the use of related-party 

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transactions, have been employed to divert attention from how money is really spent, and to 

make financial accountability more difficult. Information that is available, however, reveals a 

profitable industry that diverts resources away from direct care to profits and other expenses. 

It is essential, then, for the Administration’s proposed reforms around transparency be 

implemented. CMS should implement sections of the Affordable Care Act, passed more than 

ten years ago still not fully implemented, which require transparency in nursing home 

ownership and finances. Additionally, facilities should be required to submit audited, 

consolidated cost reports, that are reviewed by CMS. We would also encourage the 

administration to require that a minimum percentage of facility revenue be spent on direct care 

to residents. 

One resident who has lived in a nursing home for more than a decade told me that she 

sees the changes that occur when her facility is bought and sold. She said suddenly there are 

fewer staff working on the floor, fewer supplies available, and lower quality items, especially in 

the food department. Billions of our tax dollars are given to nursing homes each year, but little 

to no scrutiny is placed on how those dollars are spent. Essential to a minimum staffing 

standard is ensuring that dollars go where intended – towards patient care. 

There has been much rhetoric from the nursing home industry that they view 

implementation of a minimum staffing standard as an unfunded mandate. The law is clear, 

however, that the Secretary of Health & Human Services has full authority to set standards that 

ensure nursing homes provide each resident with high quality care and that Medicare and 

Medicaid payments are spent on resident care. That would include the setting of a minimum 

staffing standard. 

Instead, what we have is a long-standing unfulfilled mandate for residents – one that 

entitles each resident to attain or maintain his or her highest practicable level of physical, 

mental, and psychosocial well-being. Nursing home owners and operators voluntarily agree to 

meet this standard in return for federal funding. While the providers have received the 

funding, nursing home residents have largely not received the care and services to meet this 

promise. 

I thank you for the opportunity to be here today and share these remarks. I also thank 

and commend the Administration for prioritizing these issues and putting forth their important 

reforms that, when implemented, can make a critical difference for residents. 

Next, in a short video, we’d like you to hear directly from residents about their 

experiences when there are not enough staff available. These residents participated in a 

dialogue in late 2021 hosted by the Consumer Voice. 

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