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Father points out the personal impact of our neglect of adequate wages for caregivers
While the state provides almost $2 billion a year to privately run corporations to deliver a wide range of services to people with developmental disabilities, policy makers and legislators have historically been reluctant to fund even small increases in wages to actual caregivers.
In the case of parents of children with disabilities, the state provides no financial remuneration at all. At least one of those parents would like to see that changed.
We’ve written before about John Summers and his efforts to care for his non-speaking, autistic son Misha. In an opinion piece in The Boston Globe on May 18, Summers talks about the difficulty he has had in finding Personal Care Attendants (PCAs) to come to his home to help him provide daily care to Misha.
That difficulty Summers is facing is due to an ongoing staffing shortage that has afflicted virtually every facet of the state’s human services system since the start of the COVID pandemic some three years ago.
But there’s more to it than the lack of available staff. Summers, as a caregiver himself to his disabled son, receives no financial help from the state to do that work even though caring for Misha required him to leave his job and has dropped his income below the poverty line.
We have on many occasions called for adequate wages, benefits, and training for direct caregivers in the provider-run group home system funded by the Department of Developmental Services (DDS). The same neglect of the caregiver role exists when it comes to the funding of services to people living in their private homes, which is ostensibly where the state wants disabled people to live.
As Summers notes, “the concept (of PCA services) reflects a policy consensus that sustaining disabled people in their homes beats the alternative of institutional care.” Yet Summers contends the system as practiced today “cheats “ caregivers like himself.
Parents should be paid as caregivers
MassHealth allows consumers to hire just about anyone they want, including friends and relatives, to provide personal care services to themselves or others in their homes. But so-called “legally responsible relatives,” particularly parents, are barred from receiving state funding for caregiving.
As Summers points out in his article in the Globe, payment to legally responsible relatives is prohibited by the federal Medicaid law. But the state’s Home and Community Based Services (HCBS) waiver allows for the development of state programs that don’t meet specified Medicaid requirements. Payment of parents as caregivers is one such practice that can be permitted under the waiver. So far, however, MassHealth has not sought such permission from the federal government.
According to Summers, state legislators have filed bills since 2015 to allow legally responsible relatives and guardians to be paid for caregiving services. One such bill, S.775, is now before the Legislature’s Health Care Financing Committee.
Governor Healey, however, could act as well to seek such a waiver. Given the ongoing staffing shortage among PCAs and other caregivers, it would make a lot of sense to do so.
Governor labels PCA staffing shortage a priority
Summers points out that Governor Healey has pledged to place the “crisis-level” staffing shortages in the MassHealth Personal Care Attendant Program at the “top of her list.”
It is currently unknown, however, how many of the tens of thousands of persons who are enrolled in the state’s PCA program aren’t receiving PCA assistance due to the staffing shortages. The Healey administration needs to get a handle on that number for a number of reasons.
State funding for PCAs unspent
Summers, for instance, provided us with data he received from MassHealth on May 23, after he had filed a Public Records request for it. The data show the state appropriated more than $432 million in funding for personal care attendant services between 2012 and 2022 that was never spent, apparently because of a lack of available PCAs.
There is a keen irony here. More PCAs would become available if they were paid a living wage for their work. Instead, they are paid just $18 an hour, pursuant to a recent collective bargaining agreement.
The irony is that the $432 million in unspent funds implies there is enough money to boost the pay of caregivers in the human services system. While we have called for a raise to $25 an hour, Summers has suggested $50. So far, no one seems to have information on how much money is available or actually needed to fully address the direct-care wage problem.
Bureaucratic, privatized structure
What the state has done has been to perpetuate a privatized bureaucracy to administer the PCA program, just as it has built a largely privatized group home system funded by DDS. Summers believes the bureaucratic hurdles that the state has imposed have further discouraged people from applying to become PCAs and have led many to leave that profession.
As Summers points out, PCAs are paid though Tempus Unlimited, Inc., a private “fiscal intermediary.” Those workers will soon have to submit to a potentially intrusive process called Electronic Visit Verification, which is administered by Optum, another private firm.
It seems the state and federal governments are using the Electronic Visit Verification system to target PCAs for potential fraud. But are individual PCAs really committing most of that fraud, or does PCA fraud primarily take the form of improper billing by managers of the PCA provider companies? As usual, the direct care workers get few of the benefits of the system in which they work, but incur most of the blame. It’s apparently good politics.
Misplaced priorities
In sum, it appears the state has over-funded the PCA line item each year for the past 10 years, apparently due to continuing staffing shortages. Yet, the state could have used that funding each year to raise the hourly wages of the PCAs, which might have helped solve the staffing shortage problem.
There is also clearly more than enough funding available to pay parents such as Summers to enable them to care for their disabled children so that those parents are not forced into poverty.
It is not clear that the state has a handle on the extent of the PCA staffing shortage either or on the extent of potential fraud in the system. Yet, the state has created a privatized, bureaucratic administrative process for its PCA program that appears intended to inconvenience and place the blame on the very people who are the key to making the system work – the parents and caregivers.
We hope that in placing the PCA problems at the top of her list, Governor Healey will recognize and work to correct these misplaced priorities.
Mass Arc echoes our concern that DDS faces ‘systemic failure’ in providing services
Almost two years ago, we first reported that direct care staffing shortages were causing a potentially serious deterioration in residential and day program services in the Department of Developmental Services (DDS) system.
We have also reported repeatedly that the ongoing staffing shortages have caused worsening conditions in the group home system and a lack of meaningful activities in community-based day programs.
Now, the Arc of Massachusetts — an organization that lobbies for DDS residential and day program providers — is echoing our concerns. GBH News, citing the Arc, reported on April 27 that “up to 3,000 Massachusetts residents are waiting for a placement in these much-needed day programs, which are facing the same staffing shortages seen in other social service fields.”
The public radio news outlet quoted Maura Sullivan, a senior Mass Arc official, as saying:
There are thousands of adults with developmental disabilities that are not being served or we consider them underserved — very, very few services…
I think of it as really a systemic failure. And we’re really waking up to the fact that, you know, human services is a workforce that has been neglected in terms of rate increases. (my emphasis)
We would emphasize that we believe that thousands of Massachusetts residents are waiting not only for day program services, but for residential placements as well. In her remarks, Sullivan did not refer specifically to day program services, but to a lack of services in general.
The resources may be there
What the Arc isn’t saying is that the corporate providers are well funded in the state budget. The provider residential line item will have grown from $847 million, ten years ago, to more than $1.7 billion, under Governor Healey’s Fiscal Year 2024 budget proposal.
We think there is sufficient funding in the DDS system to provide needed services. It’s just that DDS isn’t using the resources in an optimal way. An example of that is DDS’s neglect of the ICFs and state-operated group homes as potential resources.
We have suggested to families whose loved ones are either receiving substandard services or are waiting for services that they ask DDS for placements in either the state-run Wrentham or Hogan ICFs, or in state-operated group homes. In the vast majority of those cases, however, we have heard that DDS has either not responded or pushed back on those requests.
While the state has continued to pour money into the corporate provider system, the number of residents in the state’s state-operated group homes and state-run ICFs have continued to drop.
As of the fall of 2021, we heard that state-operated group homes were being closed, and last month, we received records from DDS indicating that those closures were the result of insufficient staffing of corporate provider-run group homes. Yet, the records also indicated that the state-operated group homes continued to have vacancies.
Poor pay of direct care workers not the result of a lack of resources
We agree with the Arc that the human services direct care workforce continues to be grossly underpaid, and that this is a primary reason for the continuing staffing shortages.
Where we disagree with the Arc is that it once again doesn’t appear to us that the problem of low pay for direct care workers is necessarily due to a lack of resources.
The increases in state funding to the providers over the past decade have resulted in continuing increases in the pay of the provider executives. The increased state funding, however, hasn’t been passed through by the providers to their direct care employees.
We hope the Healey administration is open to a new approach to this problem. The new administration needs to redirect more of the state’s resources to state-run programs, and needs to ensure that those resources get to those who underpin the entire system — the direct care workers.
DDS emails show concern that governor’s COVID vaccination mandate could worsen staffing shortage in state-op group homes
Department of Developmental Services (DDS) Commissioner Jane Ryder and at least one other top DDS official were concerned last September that Governor Baker’s COVID vaccination mandate for state employees could worsen an already existing staffing shortage in the Department’s state-operated group homes.
Those concerns were expressed in a handful of emails, which COFAR received from DDS late last month after a nine-month battle for internal records relating to closures and consolidations of the homes.
On July 8, the state’s Public Records Supervisor ruled that DDS must produce the records because the Department had not met its burden of proof that the emails were exempt from public disclosure. DDS provided the emails to us on July 29.
The internal emails confirm that there had been closures of some state-operated group homes in Massachusetts due to an executive order issued last August by Governor Baker requiring all state employees to be vaccinated by October 17 or face termnation.
That vaccination mandate applies only to staff of state-run residential facilities. It does not apply to the much larger network of DDS-funded group homes that are run by corporate providers.
As of October 21, we had received unconfirmed reports that up to seven state-run homes in the southeastern region of the state had been closed because staff in them had not been vaccinated for COVID.
In an email, dated September 24, Gall Gillespie, the DDS Metro Region director, stated that she wasn’t sure whether Baker was aware of the impact his vaccination mandate might have on the state-operated group home system. Her email, which was sent to a DDS consultant, stated:
I am not sure the governor knows about the impact (of his vaccination mandate). Jane (Ryder) is briefing the secretary (Health and Human Services Secretary Marylou Sudders).
We have had homes consolidate and close, staff taking individuals home with them, and administrative staff working shifts. Some agencies are asking about the National Guard… We may be asking area and regional staff to fill in shifts if staff get terminated around the vaccine mandate. We cannot ask staff if they are vaccinated; so only know a percentage based on a cross check with DPH.
In an email earlier that same day to the same consultant, Gillespie described “a major crisis looming with the staff shortage…I think it is a problem that is almost too scary to address and it seems not in our control. It also does not directly affect some of our senior staff. Some of us are meeting and trying to come up with plans if we lose 20-40% of our direct care staff on October 17.”
But while those emails show a concern within DDS over the staffing shortages in the group home system and the potential impact of the vaccine mandate, no concerns were expressed in the emails about other potential causes of the staffing shortages such as the problem of low direct-care wages. One email from Gillespie said only that DDS would pay overtime to staff willing to work shifts in state-operated group homes after their regular work week was completed.
We have reported that a key cause of the staffing shortages has been low direct-care wages that have plagued the entire DDS system.
No discussion about future of state-run group homes
Administration officials have declined to comment to us on the staffing shortages or closure reports regarding either state-operated or provider-operated homes. The emails provided to us on July 29 confirm the Department’s concerns about those issues, at least regarding the state-run homes.
But the emails don’t contain any discussions about any plans or concerns DDS might have had regarding the future of the state-run group home system, which was one of the reasons we sought the internal documents.
We view the state-operated group home system to be a crucial backstop for care in the DDS system as a whole. Yet DDS has been allowing the number of residents in the state-operated group home network to drop in the past several years.
Overtime offered to staff willing to work in state-ops
In an email on October 13 to DDS state-operated group home personnel, four days before the October 17 vaccination deadline, Gillespie again referred to the staffing shortage that DDS anticipated “will get worse after the deadline for the vaccine mandate passes.”
Gillespie said that while some staff had volunteered to work in Metro Region homes the previous week, DDS was now offering to pay overtime for staff willing to work shifts in those homes beyond their regular work week. She added that the Central West Region was also looking for volunteers to staff group homes.
In an October 12 email to all of the DDS regional directors, a DDS official listed clinics around the state at which state employees could get vaccinated.
As noted, none of the emails addressed the issue of long-term DDS policies concerning closing or consolidating state-operated group homes. As a result, it’s not clear why DDS fought so hard against releasing these emails to us.
No clear plan for addressing the staffing shortage or direct-care wages
It’s also not clear from the records that DDS has a systematic plan to address the staffing shortage or direct-care wage problems in either the state or provider-run group home networks.
The one thing that the internal DDS documents appears to show is that DDS offcials were, and potentially still are, concerned about staffing shortage in state-run group homes.
But it doesn’t appear DDS has done more to address that issue than to issue appeals for volunteers and offer to pay overtime to staff willing to work beyond their regular work week.
Late last month, Governor Baker signed the Fiscal Year 2023 budget, which includes a provision requiring DDS and other human services agencies to direct up to $173 million in state funding to boost wages of their direct-care workers, But to date, there has been little or no information available as to when that money will start flowing, or even what the impact will be on worker wages.
We think a plan is urgently needed from the administration that includes details on how the administration intends to deal with these issues.
Critically needed federal stimulus money still hasn’t come through for DDS residential providers facing staffing shortages
Shannon Guenette still hasn’t seen any of the money even though Congress and the Biden administration released $8.7 billion in federal stimulus funds to Massachusetts last March.
“We’ve received some guidance (from the state regarding the funding), but we haven’t received any additional funds,” Guenette, executive director of Almadan, Inc., said five days prior to Thanksgiving. Almadan is a group home provider in the western part of the state to the Department of Developmental Services (DDS).
In August, Guenette told us her agency and other DDS providers throughout the state desperately needed the additional federal funding to retain workers in light of a worsening shortage of direct-care and clinical staff.
The Baker administration in Massachusetts has targeted hundreds of millions of dollars of the federal American Rescue Plan Act (ARPA) funding for human services workforce retention and recruitment.
But the state Legislature took months to come up with its own plans for distributing the funding after at least one legislative leader said they didn’t see a need for hurry.
Earlier this month, state legislators went home for their Thanksgiving recess without having reconciled Senate and House bills (S.2564 and H.4234) that specify differing distribution plans for the money.
Meanwhile, other than noting there will be three rounds of ARPA funding distribution, the administration itself has provided little clear information about the details of its distribution plan such as how many workers and which agencies would receive the money, and how much of that funding would go toward higher wages.
Under the administration’s plan, the first round of funding was supposed to augment provider rates by 10% from last July through December of this year. But, as noted, no money has reportedly been distributed for residential programs.
Repeated queries by COFAR to DDS Commissioner Jane Ryder and to Health and Human Services Secretary Marylou Sudders about the DDS staffing shortage and how to address it have gone unanswered.
Even when the ARPA money is finally distributed, we are concerned about a potentially low limit set on the amount of funding per worker under the Senate and House bills. Also of concern is a lack of clear oversight of the distribution of the funding.
And it appears at least some of the funding is intended to be used to move residents out of the state’s two remaining developmental centers and into the already overburdened privatized group home system.
A $2,000 limit per worker
Language in both the Senate and House bills would limit funding for higher wages to $2,000 per worker. It’s not clear how effective such a payment would be in recruiting and retaining workers, particularly if it is only a one-time payment.
The Senate bill would also establish an advisory panel to make recommendations to the administration regarding the “Essential Employee Premium Pay Program.” The panel’s report is due with its recommendations by March 31, 2022.
The advisory panel sounds like a potential recipe for further delay without necessarily providing a structure for ensuring that the funding goes to the workers.
The distribution of funding to workers may not have sufficient oversight
Information posted online by the administration requires DDS providers to attest or essentially promise that 90% of the additional ARPA funding they receive will be used for “compensation for their direct-care workforce.” That could include, “among other things,” hiring and retention bonuses.
While the providers will be required to submit spending reports, it isn’t clear that the administration has dedicated sufficient resources to auditing such reports and ensuring that the money is going in all cases to front-line staff.
State Auditor Suzanne Bump’s office reported in 2019 that increases in state funding to DDS and other providers resulted in surplus revenues for the providers, but that those additional revenues led to minimal increases in wages for direct-care workers.
According to Bump’s audit, while the increased state funding was at least partly intended to boost direct-care wages, it “likely did not have any material effect on improving the financial well-being of these direct-care workers.”
Some ARPA funding may be used to “divert” residents from developmental centers
According to the administration’s distribution plan, at least $44 million of the ARPA funding will be used starting in Round 2 to “divert” clients “towards community living … and away from facility-based settings.”
We are concerned that while at least some of this funding would reportedly be used to prevent the inappropriate placement of DDS clients in hospitals or nursing homes, a portion of the funding may be used to further reduce the population of facilities such as the Wrentham and Hogan developmental centers. As such, this funding would only further reduce choices in residential care for DDS clients.
The residential population at both Wrentham and Hogan have been declining in recent years, and admissions to both facilities were zero in 2020.
Providers cite need for funding and higher pay for direct-care workers
In September, a provider-based “Collaborative” provided written testimony to the state Legislature’s Ways and Means Committee chairs seeking $174 million per year for five years in ARPA funding for human services organizations. The money was being sought “to provide recruitment and retention incentives to workers to help combat the workforce crisis in the sector.”
The Provider Collaborative testimony said the $174 million would affect about 34,800 staff earning less than $60,000, and nurses and clinicians earning less than $90,000.
The Collaborative noted that low wages paid to direct-care workers are a problem. “The low rates of pay for direct-care staff… coupled with complex, difficult jobs have led providers to struggle with recruiting and retaining workers even before the COVID-19 pandemic impacted programs,” the testimony stated.
The Collaborative blamed those low wages on the state’s “rate-setting process.” We think, however, that many providers, as the state auditor noted, could afford to pay more to their workers.
Shannon Guenette told us that Almadan is currently only able to pay its staff $15.25 an hour. The Collaborative stated that the median salary for direct-care workers is $16.79 an hour. According to the Collaborative, the MIT Living Wage calculator notes a living wage for a single person in the area is $17.74 an hour.
All of this points to the need for quick action to distribute the ARPA funding. It’s unfortunate that legislative leaders don’t appear to recognize that there is, and has been, a need for hurry. There is also a need for effective oversight of the funding to make sure it gets to those workers.
DDS state-operated group homes facing a staffing and possible closure crisis
State-operated group homes for persons in Massachusetts with developmental disabilities appear to be facing a perfect storm of staffing shortages, potentially unvaccinated staff, and a possible departmental effort to shut at least some of the residences down.
The staffing shortages are also affecting the much larger network in the state of corporate provider-operated group homes funded by the Department of Developmental Services (DDS). But we are increasingly concerned that the critically important state-run DDS group home network could be facing a crisis that could threaten its long-term existence.
We often advise families whose loved ones are experiencing poor care in provider-run residences to ask for placements in available state-run group homes. Staff in the state-run network generally receive higher pay and benefits and more training than their counterparts in the provider system.
Resident moved without notice
This week, we received a report that a state-run group home in western Massachusetts was being closed and that at least one of the residents was moved without written notice as of Thursday (October 21) to a location in another town.
Earlier this month and this week, we received reports from a COFAR member that up to seven state-run homes in the southeastern region of the state had been closed because staff in them had not been vaccinated for COVID-19.
We have not been able to confirm those reports about closures of homes in southeastern Massachusetts. A DDS official privately told a COFAR member that no state-operated group homes had yet been closed in the region as of mid-October, but that some closures could happen after October 17. The official referred to the possibility of “temporary consolidations” of group homes around the state.
In August, Governor Baker issued an executive order requiring all state employees to be vaccinated by October 17 or ultimately be terminated. While the executive order apparently applies to staff in state-operated group homes and the Wrentham and Hogan Developmental Centers, the separate provider-operated DDS group home system is apparently not subject to the vaccination mandate.
It is not clear how many staff in the DDS group home system remain unvaccinated. As of last April, the last time EOHHS apparently tracked staff vaccinations, less than 50% of staff in state-operated DDS group homes were fully vaccinated, and only 51% of staff in provider-run group homes were fully vaccinated.
Administration officials not commenting
On October 14, we emailed DDS Commissioner Jane Ryder and the press office at the Executive Office of Health and Human Services (EOHHS) with questions about the reports of closures and consolidations in the state-operated group home network.
To date, Ryder has not responded to our query. A spokesperson for EOHHS said we would have to file a Public Records Request for that information. On October 15, we filed a Public Records Request, and EOHHS responded that same day that that agency did not have any records relevant to our query.
DDS regulations may be violated by sudden closures
Under DDS regulations (115 CMR 6.63), DDS clients cannot be transferred without a 45-day notice and the opportunity for a hearing unless the the Department determines that the transfer is “an emergency involving a serious or immediate threat to the health or safety of the individual or others.”
Western Mass DDS staff urge Ryder to address staffing shortages
Meanwhile, on Wednesday (October 20), the Massachusetts Nurses Association, a union that represents nurses in the DDS system as well as hospitals around the state, reported that several DDS employees in western Massachusetts had sent a letter in late September to Commissioner Ryder “imploring her to intervene in a growing patient-care crisis that is unfolding in many of the region’s DDS group homes.”
The letter stated that staffing shortages in both state-operated and provider-operated group homes were causing “significant increases” in client injuries requiring emergency room treatment, and in the placement of untrained staff in homes.
The MNA letter said some staff were being forced to work overtime due to staffing vacancies, and that one staff worker was reportedly required to work 48 hours straight.
The MNA letter to Ryder was dated September 21. The union said that as of October 20, Ryder had not responded.
COVID rates in the DDS group home system continuing to climb slowly
In the midst of the continuing staffing and apparent vaccination problems, the latest online COVID testing report from EOHHS shows a slow, but continuing increase in individuals testing positive in DDS state and provider-run group homes. In state-operated group homes, the number of residents testing positive rose from 3 to 6.
Among staff in the state-operated group homes, the number of those testing positive rose from 11 to 12 between September 7 and October 5.
In provider-run homes, the number of residents testing positive jumped from 31 in September to 49 in early October. The administration, however, does not report the number of staff testing positive in the DDS provider-run system.
Census in state-ops and ICFs declining
Whether or not there are plans to close state-operated group homes or the Wrentham or Hogan Developmental Centers, the administration has nevertheless been letting the residential populations or census drop in these facilities. In addition, funding for these facilities has dropped or has remained flat for years. (See here and here.)
Documents provided by DDS on September 21 in response to a Public Records Request for records on the number of admissions to state-operated group homes, confirm that the census in those facilities has been declining since Fiscal Year 2015. We previously received information from DDS showing a decline in the census and virtually zero admissions in 2019 and 2020 at the Wrentham and Hogan Centers.
The census in DDS provider-operated group homes grew by an average of 124 residents per year between Fiscal Years 2008 and 2021. However, the census in state-operated group homes grew by an average of only 3 residents per year.
Moreover, since Fiscal 2015, the census in state-operated group homes has actually dropped by an average of 18 residents per year while the census in provider-operated group homes has continued to grow by an average of 83 residents per year. The number of residents in state-run group homes was almost 10% lower in Fiscal 2021 than in 2015.
The data show there have been admissions each year to the state-operated homes. But those admissions have apparently been more than offset by deaths in those residences.
Future is concerning
In sum, all of these numbers and trends are concerning, as is the administration’s policy not to respond to questions either from us or from unions such as the Mass. Nurses Association.
We may learn a little more if DDS does provide records relevant to our Public Records Request concerning the reported state-operated group home closures. But in the meantime, we are left to wonder what the administration is planning to do – or is actually doing — to address the staffing shortages in the DDS system.
At the very least, we hope the administration doesn’t view the staffing shortages and the problem of unvaccinated staff as opportunities to further downsize the state-operated group home system.
COFAR blog 