Michigan Nurses Association
Testimony on 2000-090 CI - Homes for the Aged
(Consumer and Industry Services Bureau of Family Services)
November 3, 2003
Good morning, my name is Cynthia Beel-Bates, RN, PhD and today
I am speaking on behalf of the Michigan Nurses Association (MNA).
I serve as the Chairperson of the Michigan Nurses Association's
Congress on Public Policy, but my full time responsibilities are
as a Lecturer and Research Associate for the University of Michigan
School of Nursing. In addition, I have direct clinical work experience
from part time employment as a staff nurse in an assisted living
facility caring for persons with dementia, and from having served
as an assisted living patient advocate for 13 years. My many years
of caring for the elderly, and extensive experience with conducting
focused research on elder care, clearly position me to address the
proposed changes to the rules for Homes for the Aged.
The Michigan Nurses Association, representing almost 9,000 Registered
Nurses, commends the effort to update the Homes for the Aged rules,
but we believe that the changes proposed are not sufficient. In
support of this statement, back in 1997 the Michigan Department
of Consumer and Industry Services convened an Assisted Living Task
Force to review the need for consumer protections within unlicensed
ALFs. A set of task force recommendations was developed, and supported
by MDCIS, but it is unclear if this endorsement remained solely
as an internal document. Six years later, the term assisted living
remains a vague term. There is an unknown number of unlicensed ALFs
providing care to vulnerable elders with physical and/or mental
impairments, potentially subjecting these residents to the risk
for abuse, neglect and exploitation. According to a study by Mickus'
2002 , in Michigan the social model of care in an ALF is often provided
with no health care personnel on staff, or even available. This
raises critical questions given the advanced age and health needs
of most ALF residents.
The MNA opposes the proposed rule changes for Homes for the Aged,
as currently written. We strongly recommend that the following comments
be incorporated into the final HFA rules, which might allow the
MNA to consider a change in our formal position to that of support.
PART 1. GENERAL PROVISIONS:
R325.1901 Definitions:
ADD a definition of continuous nursing care. Continuous nursing
care is referred to several times in the proposed rules without
a definition. In 1997 at the request of the Michigan Department
of Consumer and Industry Services the Michigan Nurses Association
convened nurse experts who developed a definition of continuous
nursing care that was adopted as a MNA position statement. The MNA
gladly offers to revisit the definition developed in 1997, make
any appropriate revisions, and submit it for inclusion in the definitions
section of the rules.
ADD a definition of medication error. The Michigan Nurses
Association has previously analyzed complaints issued to the state
on behalf of residents in Homes for the Aged, and the majority of
the complaints focused on medication issues. At a minimum, Homes
for the Aged should document, report, and take corrective action
on medication issues with medication error having a standardized
definition established in the rules. This is especially important
if non-licensed personnel employed by a Home for the Aged administer
and/or withhold medications.
REVISE the definition of elopement to read "absent
without notice for more than one hour." The proposed definition
of "absent without notice for more than 12 hours" is unacceptable.
The profile of ALF residents suggests that 50-72% of the residents
are mildly cognitively impaired. Their vulnerability is too great
to allow 12 hours to pass before notifying the police.
Subsection (12):
DELETE "licensed practical nurse." PA 368 of 1978
MCL 333.17201 (b) defines LPNs as a sub-field of nursing and requires
that LPNs practice only under the supervision of a Registered Professional
Nurse, physician or dentist. The Michigan Public Health Code prohibits
LPNs from supervising or delegating nursing acts, tasks or functions
to non-licensed personnel.
R325.1901 Definitions;Rule 1
Subsection (14):
DELETE "as prescribed by a licensed health care professional."
The listing of health care professionals in R325.1901 Definitions;
Rule 1
Subsection (12) is not consistent with laws related to prescribing
in this subsection.
PART 2. STATE ADMINISTRATION:
Any licensed Home for the Aged must be required to clearly disclose
the qualifications of the employees related to care of elders, specifically
whether or not a professional Registered Nurse is available for
health care consultation. Homes for the Aged must be held accountable
to statutory requirements that it is illegal to employ LPNs without
the LPNs being under the supervision of a professional Registered
Nurse; as specified in the Michigan Public Health Code (being PA
368 of 1978, sections 333.1101 through 333.25109). Such disclosure
should occur when a contract for residency is signed. Additionally,
a daily posting of the staff-to-resident ratio, and staff credentials,
must be an expectation of a Home for the Aged.
PART 3. ADMINISTRATIVE MANAGEMENT OF HOMES:
R325.1921 Definitions;Rule 21
Subsection (2) (c):
ADD "Professional Registered Nurse" as the health
care professional that is the most knowledgeable, capable, and appropriate
licensed health care professional to assess a resident's health
related to modifying and implementing a resident's service plan.
A Professional Registered Nurse is credentialed to evaluate a resident's
care, and can best analyze any resident reports of medication error,
accident or incident. Furthermore, elders have multiple diagnoses,
medication changes, and chronic illnesses, so a professional registered
nurse (employee or consultant) should review a resident's service
plan and assess the resident on a quarterly basis.
PART 4. RESIDENT CARE
R325.1932 Resident Medications:
There are well-developed standards of care related to medication
administration, however this section lacks many of the basic standards
that protect vulnerable elders. The Michigan Nurses Association
offers to submit the standards developed by professional Registered
Nurses to address medication administration in this section of the
rules.
The MNA requests that MDCIS convene another Task Force with Registered
Nurse representatives to: 1) revisit the recommendations in the
MDCIS report titled "Assisted Living Initiative;" 2) review
the recommendations of the Senate Special Committee on Aging report
of April 2003 titled "The Assisted Living Workgroup: Assuring
Quality in Assisted Living: Guidelines for Federal and State Policy,
State Regulation and Operations" for potential development
of policy in Michigan regarding ALFs; and 3) produce a set of draft
rules that have the potential to ensure full protection for Michigan's
frail and vulnerable elders.
In closing, the proposed rule changes represent a beginning effort,
but much work still needs to be done to protect and to provide adequate
and appropriate care for the increasing number of Michigan citizens
who will need services such as those provided by Homes for the Aged.
The Michigan Nurses Association thanks you for the opportunity to
testify, and we stand ready to assist in the finalization of rules
for the Homes for the Aged.
Reference:
Mickus, M. (2002). Complexities and Challenges in the Long Term
Care Policy Frontier: Michigan's Assisted Living Facilities. Michigan
State University.
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