2022 Tennessee Disability Scorecard

 From the Tennessee Disability Coalition

Yesterday, with the expertise of our members and Policy Team, the Tennessee Disability Coalition released our inaugural Tennessee Disability Scorecard.   Inspired by the tremendous amount of phone calls we receive from current and future Tennesseans, as well as policy priorities voiced by our membership; the 2022 Scorecard outlines eight policy priority areas for working Tennesseans with disabilities.   Across these priorities, letter grades were given to the State of Tennessee based on primary and secondary research compiled by the TDC, and will be reviewed and released annually to ensure the lived experiences of our community are at the forefront of all policy decisions made by state leaders including lawmakers, appointed commissioners, and municipalities.   Overall, the State of Tennessee received a grade of D+ for working adults with disabilities, and was comprised from the following:   Priority: Housing Grade: F 80 of Tennessee’s 95 counties do not have affordable housing for working people with disabilities.   Priority: Employment Grade: D+ 33% of Tennessee workers with disabilities are employed, compared to 78% of workers without disabilities. This ranks Tennessee 44th out of all 50 states.   Priority: Transportation Grade: C- Tennessee ranks 39th in the US for quality of public transportation.   Priority: Medical Debt Grade: F Tennessee has the 5th highest percentage of adults with medical debt in the country.   Priority: Home Healthcare Worker Crisis Grade: F Tennessee ranks 43rd in the US for the availability of home healthcare workers, with only 13 workers for every 100 Tennesseans needing care.   Priority: Sales Tax Burden Grade: A Like nearly all states, Tennessee does not tax the sale of durable medical equipment, prescriptions, and mobility devices.   Priority: Affordability of Care Grade C+ The AARP ranked Tennessee 35th in the affordability of care for people with disabilities based on relatively low home health care costs, but 49th in consumers’ ability to access these home healthcare services.   Priority: Support for Family Caregivers Grade: F Given the critical shortage of home healthcare workers across the country, AARP ranked Tennessee 49th in supporting family members caring for loved ones with disabilities based on state policies.   We hope you will share this report with your communities, stakeholders, and people of influence. In a spirit of coalition, we look forward to working together to improve these outcomes on behalf of all Tennesseans both present, and future.   More information can be found in the full Scorecard including citations and graphics, and is available on the TDC’s website using the following link: https://www.tndisability.org/tennessee-disability-scorecard.   -TDC Policy Team

Voting Rights

Your Civil Rights and the Election

From the Department t of Justice:

The Civil Rights Division’s Disability Rights Section enforces the Americans with Disabilities Act (ADA), which prohibits discrimination in voting based on disability. The ADA applies to all aspects of voting, including voter registration, selection and accessibility of voting facilities, and the casting of ballots on Election Day or during early voting, whether in-person or absentee.

The Civil Rights Division’s Criminal Section enforces federal criminal statutes that prohibit voter intimidation and voter suppression based on race, color, national origin, or religion.

On Election Day, the Civil Rights Division will implement a comprehensive program to help ensure the right to vote that will include the following:

• The Civil Rights Division will conduct monitoring in the field to observe compliance with the federal voting rights statutes.

• Civil Rights Division attorneys in the Voting, Disability Rights, and Criminal Sections in Washington, D.C., will be ready to receive complaints of potential violations of any of the statutes the Civil Rights Division enforces. Attorneys in the division will coordinate within the department and will take appropriate action concerning these complaints before, during, and after Election Day.

• Individuals with complaints related to possible violations of the federal voting rights laws can call the Justice Department’s toll-free telephone line at: 800-253-3931, and also can submit complaints through a link on the department’s website at: https://civilrights.justice.gov/.

• Individuals with questions or complaints related to the ADA may call the Justice Department’s toll-free ADA information line at 800-514-0301 or 833-610-1264 (TTY), or submit a complaint through a link on the department’s ADA website at ada.gov.

ADAPT's Consistency in Advocacy

ADAPT’s success in the case MR v Dreyfus was spectacular; but did you notice some similarities with an earlier ADAPT campaign?

Editor's Note: This is a look back Ten Years Ago Today at the issues of the disability community. Ten years ago the state of Washington ended its appeal of MR v Dreyfus; More than ten years before that, ADAPT was successful in getting the state of Washington to remove their support for Olmstead. 

By Tim Wheat

ADAPT and our allies' success in making Washington Governor Christine Gregoire end the appeal of MR v Dreyfus was a terrific grass-roots success. Some long-time ADAPT activists however may be reminded of a similar campaign in late 1998 and early 1999 to convince US states to remove their names from an amicus brief in support of the state of Georgia that was going to the US Supreme Court.

Back in 1998, Tommy Olmstead, Commissioner, Georgia Department of Human Resources, struggled to keep two women locked away in institutions even though the state’s professionals had found them more suited for the community. Georgia lost in the 11th US Circuit Court and was appealing the case to the US Supreme Court. Commissioner Olmstead argued that forcing citizens to live in institutions does not constitute discrimination because non-disabled people do not receive such services. No "discrimination" in service delivery can take place if no comparable services exist. The ADA gives no protection to individuals with disabilities, Georgia argued, who receive services designed only for people with disabilities.

Georgia was successful in getting over half the US States to support their appeal to the US Supreme Court by signing on to a friend-of-the-court brief that argued home and community services would become a “new entitlement." The amicus brief of the states also perversely contended that even though home and community services were less costly than expensive institutionalization, the ADA’s requirement for integration would be a financial burden to states and would be an “unfunded mandate” from the federal government impeding state sovereignty.

But ADAPT was clear. This was an issue of Civil Rights and ADAPT led the grassroots campaign to ensure the US Supreme Court did not overturn our right to live in the community. Twenty-six states signed onto the amicus brief supporting Georgia. ADAPT could have little direct impact on how each of the nine justices would rule, but the grass-roots group could change the minds of the states that supported Georgia.

One by one ADAPT struck in the US states that had signed on in solidarity with Georgia’s appeal. By April, when the Supreme Court heard the oral arguments in the case, the number of supporting states was down to 11.  Although judges say they make decisions based on facts and issues of law, ADAPT and our allies had reduced the support for Georgia from over half of US states, to just a handful. The ADAPT campaign was truly a tremendous grass-roots success.

On March 9, 1999 Governor Gary Locke and the Attorney General of Washington wrote a letter to explain why they had removed their state from the Georgia amicus brief:

"The Governor and I have each affirmed our strong support for better services and choices for persons with disabilities.  We do not want our signature on this amicus brief to call that commitment into doubt and create unnecessary fear and anxiety."

On June 22, 1999 the court released its decision in Olmstead. The ruling upheld the ADA “integration mandate” and called inappropriate institutionalization discrimination. ADAPT has called it our community’s “Brown v Board,” because it requires integration.

"Today's decision is a critical step in changing how and where people with disabilities receive services necessary for everyday life," said Mike Auberger, a national organizer with ADAPT, back on the day the Olmstead decision was announced.  "It tells states that segregated services will no longer be tolerated.  But our fight for REAL choice continues."

The fight for REAL choice has continued. The Attorney General who signed the letter removing the state of Washington from the Georgia amicus brief was Christine Gregoire. Now, thirteen years later: Governor Gregoire; the Governor who was the target of a grassroots campaign to protect the gains of Olmstead by not appealing MR v Dreyfus.

One very powerful aspect of ADAPT that is often hard to see is our consistency. People looking for immediate results and instant gratification may not understand the importance of the ADAPT action opposing Tommy Olmstead’s case against two women in Georgia. But the consistency of ADAPT’s fight for almost 30 years has amplified the power of our community. FREE OUR PEOPLE!

A New Direction for Independent Living

Looking back 20 years on thoughts about the Independent Living movement. 

Editor’s Note: This is an unpublished and unfinished article from twenty years ago. Tim Wheat had just completed a cross-country bicycle trip visiting Centers for Independent Living and disability rights demonstrations. Tim Wheat has highlighted his current thinking in italics while the original text is not italicized. 

September 23, 2002

September 23, 2022

By Tim Wheat

Twenty years ago I believe I had a lot to say about the direction of Independent Living, but I never finished or explained what I had found on my cross-country visit to other Centers for Independent Living. I re-examine some of my thoughts in the paragraphs below.

The Independent Living (IL) movement does not lack direction because it has been unsuccessful, on the contrary, the IL movement seems to make good sense in a wide variety of disability related areas. It is because of this wide-spread appeal of IL rhetoric that the “direction” of the movement is hard to gauge. 

PHOTO: Tom Kirby at the Roswell Center for Independent Living in New Mexico. One of the Centers I visited on my six month bicycle adventure across the country.

Twenty years ago, I visited several Centers for Independent Living on a special assignment from MCIL’s Executive Director Deborah Cunningham. What I was attempting to point out in this opening paragraph was that I was able to see the Independent Living movement reflected in all parts of the disability community, and not unique to CILs.

Social workers spoke of client choice, person centered planning and independent living. Apartments, especially for older Americans, were adopting the moniker: Independent Living. Larger, older and better funded agencies switched from “case managers,” who may be involved in every aspect of a “case,” to only being the gatekeeper for a particular funding stream or program. 

Twenty years ago I thought I was viewing the great success of the IL movement, but now, twenty years later and more than forty years since the beginning of federally funded CILs, I do not see the same success. In 2002 I saw Centers that were diligently working to include people with disabilities in a variety of ways, but what they did not do was to make themselves the center of Independent Living and faithfully promote and defend the Independent Living movement. 

The historical components of the IL Center have become unnecessary because of the ADA and a change in social attitudes. Many CILs talk about the “four core services,” yet these services no longer are effective at meeting the needs of people with disabilities attempting to live independently. Please examine these core services when Title VII was written as compared to today. 

Twenty years ago there were four core services: Information and referral, Independent Living skills training, peer counseling and advocacy. Now CILs have a fifth core service that can be described as transition. Transition from a nursing home or institution into the community and transition from school-age youth to an independent adulthood. 

If you are not familiar with Independent Living, the idea of core services sounds pretty basic. The movement was progressive at the time and was similar to the Vocational Rehabilitation system that had developed. “Cases” moved, progressed and were tracked in a system that was centered on a file and a counselor, case worker or social worker. 

The federal regulations that make up CILs and the reporting were before the 1990 Americans with Disabilities Act and lacked a lot of clarity. The “services” that IL Centers offer are broadly defined. There are a list of 17 services and yet the four core services are not the backbone of that list. 

One problem with the long list is that it is never clear what a CILs is to do. Everything will fit under advocacy. I cannot see how each thing that we do is either systems advocacy, self advocacy or individual advocacy. The CIL working with people with disabilities to improve the system, build on disability rights and promote community inclusion all are system advocacy. Teaching an individual with a disability to navigate barriers because of their disability is self-advocacy and advocating for someone with a disability issue is individual advocacy. I believe CILs could do their work with advocacy as the only service category. 

Teaching someone to ride the bus can be IL Skills Training, while providing transportation can be a service that directly interferes with a person’s independence. If someone learns to depend on the CIL for transportation, they are less independent. I believe Centers for Independent Living were originally designed to advocate and help sustain reliable accessible transportation for people with disabilities. 

Many CILs got funding to provide transportation and the IL focus of the Centers changed to providers who talked about inclusion, yet profited from a segregated system. 

Thirty-two years ago when the ADA was signed, public transportation was to become accessible and include people with disabilities. Paratransit systems were to provide transportation for people with disabilities who could not access the main-line public transportation system because of their disability. 

The concept was that as fixed-route public transportation became accessible, paratransit would become unnecessary or less necessary. Now in 2022, paratransit in Memphis is as large as it was in 2002. MCIL has not only experienced push-back from local people with disabilities who do not wish to have an integrated public transit system, but we have dual advocacy of supporting accessibility of the fixed-route, while we promote the use of the segregated paratransit system. 

PHOTO: Crossing the Continental Divide on my way to visit two CILs in Utah and the ADAPT National Meeting in Salt Lake City. Notice the ADAPT t-shirt hand painted by Sher Stewart.

The Administration for Community Living News

Department of Homeland Security Finalizes “Public Charge” Immigration Rule

By Alison Barkoff, Acting ACL Administrator and Assistant Secretary for Aging, and Melanie Fontes Rainer, Acting Director of the HHS Office for Civil Rights

 

The Department of Homeland Security (DHS) has finalized a rule defining the criteria it uses when determining whether a person can be denied a visa and/or legal residency because they are likely to become a “public charge.” The final rule comes on the heels of the proposed rule, published February 24, 2022, and is the latest chapter in a long series of regulatory and legal actions surrounding the public charge policy. It includes several provisions that directly affect older immigrants and immigrants with disabilities, their families and caregivers.

For more information and background on the history of the public charge policy, see ACL's March 2022 blog post on the Notice of Proposed Rulemaking and the July 2021 blog post on the history of public charge rulemaking as well as resources from the Department of Homeland Security. 

What’s most important for older immigrants and immigrants with disabilities to know?

Someone may be considered a “public charge” if they are likely to become primarily dependent on the government for subsistence. This is evaluated by looking at prior and current use of certain public benefits as well as other factors such as age, health, and financial resources.

Participation in most public benefits, including ACL’s programs, will notadversely impact a citizenship or residency determination under the new rule. The ONLY public benefits considered in a public charge determination are:

• Long-term institutionalization funded by the government (for example, Medicaid-financed care in a nursing facility). Receiving Medicaid Home and Community-Based Services (HCBS) or other Medicaid health care benefits will not affect a public charge determination.
• Direct cash assistance programs, including Supplemental Security Income (SSI) and Temporary Assistance for Needy Families (TANF).

This is a codification of DHS’ 1999 Field Guidance (the policy that is currently in place). It solidifies DHS’ long-standing position on which public benefits will be considered in a public charge determination and which will not. 

What are the major provisions of the final rule?

DHS received 233 comments on the proposed rule, including many from the aging and disability community. The final rule provides responses to many of those comments, explaining why policy changed or remained the same. The final rule closely mirrors the proposed rule with a few exceptions. The major provisions include:

• Receiving Medicaid Home and Community Based Services (HCBS) will not factor into any public charge determination. Medicaid HCBS, as well as acute care benefits, will not be considered. 
• Long-term institutionalization at government expense will be factored into a public charge determination and while “long-term” is not explicitly defined, the rule includes guardrails. While the rule did not define what constituted “long-term” institutionalization with a hard threshold or day limit, it did specify that short-term residential care for rehabilitation or mental health treatment would not be considered. Long-term institutionalization also does not include imprisonment for conviction of a crime. DHS will collaborate with the Department of Health and Human Services to develop sub-regulatory guidance to help guide DHS agents’ evaluation of past or current institutional stays.
• Evidence may be presented to show unjustified institutionalization in violation of federal law. DHS recognizes that some people are forced to live in institutions due to the unavailability of HCBS and in violation of their rights under the Americans with Disabilities Act and Section 504 of the Rehabilitation Act (as interpreted by the Supreme Court in Olmstead v. L.C.). As a result, an applicant for admission to the United States or an immigration status change may present evidence to show their institutionalization was in violation of federal law, thus mitigating negative weight that may be put on that period of institutionalization during a public charge determination. 
• No single factor alone is determinative of whether someone may be deemed a “public charge.” DHS will perform a “totality of the circumstances test” considering both past and current use of publicly funded institutional care and cash assistance. The test also includes an evaluation of five statutory factors: health, age, family status, assets/resources/financial status, education/skills to determine likelihood of primary dependence on the government for support. No single factor is determinative, however. Thus, past or current institutionalization, receipt of cash benefits, poor health or advanced age alone is not sufficient to render someone a public charge.
• Disability alone is not sufficient for a determination that individual is likely to become a public charge. Disability, as defined in Sec. 504 of the Rehabilitation Act of 1973, cannot be the sole basis for a determination that an that individual is in poor health, is likely to require long-term institutionalization at government expense, or is likely to become a public charge due to any other factor. 
• DHS will consider the medical evaluation performed by a physician when evaluating a non-citizens health: In the proposed rule, DHS did not specify evidence it would consider as a part of the statutory minimum factor evaluation. In the final rule, DHS clarifies it will accept information submitted via forms it is already gathering as a part of the admission, citizenship, or naturalization process. The standard medical report and vaccination record  will be considered as evidence for the health factor. This report captures information on a non-citizens chronic health conditions and/or disabilities and will be used by DHS agents in the “totality of the circumstances” analysis. DHS will work with HHS on guidance to agents to ensure disability competency when evaluating medical conditions or disabilities that appear on the medical report.

What does this mean for immigrant communities moving forward?

Non-citizens should apply for and use the public benefits to which they are entitled, with the understanding that: 

• Long-term institutionalization paid for by Medicaid (or another public source) or cash benefits like SSI or TANF may, but will not necessarily, adversely affect immigration decisions under the public charge rule. 
• Using other services – such as Medicaid HCBS, services provided through ACL’s programs, or the Supplemental Nutrition Assistance Program (SNAP) – will not affect immigration decisions under the public charge rule. 

The final rule will be effective on December 23, 2022, and will be published in the Federal Register on September 9, 2022. 

Read more:

Release from the U.S. Department of Health and Human Services: New Rule Makes Clear that Noncitizens Who Receive Health or Other Benefits to which they are Entitled Will Not Suffer Harmful Immigration 

If you believe that you have been discriminated against because of your race, color, national origin, disability, age, sex, or religion in programs or activities that HHS directly operates or to which HHS provides federal financial assistance, you may file a complaint with HHS at: https://www.hhs.gov/ocr/complaints/index.html.
 

Remembering Justin Dart

Justin Dart 

Memorial Service and Celebration of the 12th Anniversary of the Americans with Disabilities Act. 

EDITOR'S NOTE: Twenty years ago today was the public memorial service for the "Father of the ADA," Justin Dart. This piece was in the MCIL Journal archives.

By Tim Wheat, MCIL

(WASHINGTON DC July 26, 2002) A memorial and celebration of the life of Justin Dart was held today on the twelfth anniversary of the singing of the 1990 Americans with Disabilities Act. 

“Justin Dart was truly the father of the ADA and a great humanitarian,” said Dick Thornburgh the former US Attorney General and a featured speaker at the memorial, “but most of all, he was our friend.” 

The service was held at the New York Avenue Presbyterian Church in Washington DC and drew dignitaries and grassroots civil rights activists from around the world. The church was filled with signs from the Disability Rights movement and memento’s of Justin’s life. 

“Hillary and I were just nuts about Justin,” said President Bill Clinton. “He stood by anybody big or small that he thought was the victim of arbitrary discrimination . . . I was profoundly honored to give him the Medal of Freedom.” 

The highlight of the service was the reading of Justin Dart’s final message. His granddaughter, who Marca Bristo reported was the “light of his life,” read the powerful final communication of Justin. 

“Justin Dart always identified himself as an ADAPT member. He believed in direct action,” said Bob Kafka the national organizer for ADAPT. “Justin, we will free the two million people in institutions, we will free our people.” 

Much of the tribute was directed at Yoshiko Dart who had a long and special relationship to Justin. She and members of the Dart family sang the song “Sakura,” a song in Japanese. 

“I will remember the boots, I will remember the hat, but most of all Yoshiko,” said Ralph Neas of People for the American Way, “I will remember you (and Justin) side by side.” 

“He loved with premeditated passion,” said Joe Washington for the Dart family. 

Following the Memorial Service there was a celebration at Union Station that featured music by the Dart family. Hundreds of people came to the gala where Senator Tom Harkin made a toast to Justin Dart. 

“In the 16 years I knew Justin he never talked about yesterday,” said Sen. Harkin. “Justin Dart’s tomorrow is MiCASSA ... Here is to Justin Dart’s tomorrow.” 

Washington, DC 

Safety and Quality of Care in the Nation’s Nursing Homes

FACT SHEET: Protecting Seniors and People with Disabilities by Improving Safety and Quality of Care in the Nation’s Nursing Homes

FEBRUARY28,2022 

All people deserve to be treated with dignity and respect and to have access to quality medical care. And in no case should a health care facility be causing a patient harm. The President believes we must improve the quality of our nursing homes so that seniors, people with disabilities, and others living in nursing homes get the reliable, high-quality care they deserve. That’s why he is announcing a set of reforms—developed by and implemented through the Department of Health and Human Services (HHS)—that will improve the safety and quality of nursing home care, hold nursing homes accountable for the care they provide, and make the quality of care and facility ownership more transparent so that potential residents and their loved ones can make informed decisions about care.

To do this, the reforms the President is announcing will ensure that:

• every nursing home provides a sufficient number of staff who are adequately trained to provide high-quality care;
• poorly performing nursing homes are held accountable for improper and unsafe care and immediately improve their services or are cut off from taxpayer dollars; and
• the public has better information about nursing home conditions so that they can find the best available options.

The pandemic has highlighted the tragic impact of substandard conditions at nursing homes, which are home to many of our most at-risk community members. More than 1.4 million people live in over 15,500 Medicare- and Medicaid-certified nursing homes across the nation. In the past two years, more than 200,000 residents and staff in nursing homes have died from COVID-19—nearly a quarter of all COVID-19 deaths in the United States.

Despite the tens of billions of federal taxpayer dollars flowing to nursing homes each year, too

many continue to provide poor, sub-standard care that leads to avoidable resident harm. In fact, failure to comply with Federal guidelines at nursing homes is widespread. The Government Accountability Office found that, from 2013 to 2017, 82% of all inspected nursing homes had an infection prevention and control deficiency, including a lack of regular handwashing, that was identified through Medicare and Medicaid surveys.

Without decisive action now, these unacceptable conditions may get worse. Private equity firms have been buying up struggling nursing homes, and research shows that private equity- owned nursing homes tend to have significantly worse outcomes for residents. Private equity firms’ investment in nursing homes has ballooned from $5 billion in 2000 to more than $100 billion in 2018, with about 5% of all nursing homes now owned by private equity firms. Too often, the private equity model has put profits before people—a particularly dangerous model when it comes to the health and safety of vulnerable seniors and people with disabilities. Recent research has found that resident outcomes are significantly worse at private equity-owned nursing homes:

• A recent study found that residents in nursing homes acquired by private equity were 11.1% more likely to have a preventable emergency department visit and 8.7% more likely to experience a preventable hospitalization, when compared to residents of for-profit nursing homes not associated with private equity.  
• One working paper examining 18,000 nursing home facilities over a seventeen-year period found that private equity ownership increased excess mortality for residents by 10%, increased prescription of antipsychotic drugs for residents by 50%, decreased hours of frontline nursing staffing by 3%, and increased taxpayer spending per resident by 11%. That suggests an additional 20,150 lives lost as a result of private equity ownership.
• Another study found that private equity-backed nursing homes’ COVID-19 infection rate and death rate were 30% and 40% above statewide averages, respectively.

Research also suggests that, despite depriving residents of quality care, private equity- owned nursing homes actually led to an uptick in Medicare costs, too.

Today, the Biden-Harris Administration is announcing new steps by Department of Health & Human Services (HHS) through its Centers for Medicare & Medicaid Services (CMS), to improve the quality and safety of nursing homes, to protect vulnerable residents and the health care heroes who care for them, and to crack down on bad actors. The Administration is committed to these urgent actions as first steps toward fulfilling a broader commitment to ensure taxpayer dollars go toward the safe, adequate, and respectful care seniors and people with disabilities deserve—not to the pockets of predatory owners and operators who seek to maximize their profits at the expense of vulnerable residents’ health and safety.

Ensuring Taxpayer Dollars Support Nursing Homes That Provide Safe, Adequate, and Dignified Care

CMS is launching four new initiatives to ensure that residents get the quality care they need— and that taxpayers pay for. These initiatives will help ensure adequate staffing, dignity and safety in their accommodations, and quality care.

• Establish a Minimum Nursing Home Staffing Requirement. The adequacy of a nursing home’s staffing is the measure most closely linked to the quality of care residents receive. For example, a recent study of one state’s nursing facilities found that increasing registered nurse staffing by just 20 minutes per resident day was associated with 22% fewer confirmed cases of COVID-19 and 26% fewer COVID-19 deaths. CMS intends to propose minimum standards for staffing adequacy that nursing homes must meet. CMS will conduct a new research study to determine the level and type of staffing needed to ensure safe and quality care and will issue proposed rules within one year. Establishing a minimum staffing level ensures that all nursing home residents are provided safe, quality care, and that workers have the support they need to provide high-quality care. Nursing homes will be held accountable if they fail to meet this standard.
• Reduce Resident Room Crowding. Most nursing home residents prefer to have private rooms to protect their privacy and dignity, but shared rooms with one or more other residents remain the default option. These multi-occupancy rooms increase residents’ risk of contracting infectious diseases, including COVID-19. CMS will explore ways to accelerate phasing out rooms with three or more residents and to promote single- occupancy rooms.
• Strengthen the Skilled Nursing Facility (“SNF”) Value-Based Purchasing (“VBP”) Program. The SNF-VBPprogram awards incentive funding to facilities based on quality performance. CMS has begun to measure and publish staff turnover and weekend staffing levels, metrics which closely align with the quality of care provided in a nursing home. CMS intends to propose new payment changes based on staffing adequacy, the resident experience, as well as how well facilities retain staff.
• Reinforce Safeguards against Unnecessary Medications and Treatments. Thanks to CMS’ National Partnership to Improve Dementia Care in Nursing Homes, the nation has seen a dramatic decrease in the use of antipsychotic drugs in nursing homes in recent years. However, inappropriate diagnoses and prescribing still occur at too many nursing homes. CMS will launch a new effort to identify problematic diagnoses and refocus efforts to continue to bring down the inappropriate use of antipsychotic medications.

Enhancing Accountability and Oversight

Holding nursing homes accountable for their performance requires a robust compliance program—a program that has adequate funding to perform inspections and that imposes meaningful penalties when deficiencies are found. Federal taxpayer dollars should not flow to nursing homes that are unsafe.

• Adequately Fund Inspection Activities. For over seven years, funding to conduct health and safety inspections has remained flat while the number of complaints about nursing homes has surged. To protect residents and crack down on unsafe nursing homes, President Biden will call on Congress to provide almost $500 million to CMS, a nearly 25% increase, to support health and safety inspections at nursing homes.
• Beef up Scrutiny on More of the Poorest Performers. CMS’s Special Focus Facility (SFF) program identifies the poorest-performing nursing homes in the country for increased scrutiny in an effort to immediately improve the care they deliver. The SFF program currently requires more frequent compliance surveys for program participants, which must pass two consecutive inspections to “graduate” from the program. The SFF program will be overhauled to more quickly improve care for the affected residents, including changes that will make its requirements tougher and more impactful. CMS will also make changes that allow the program to scrutinize more facilities, by moving facilities through the program more quickly. Facilities that fail to improve will face increasingly larger enforcement actions, including termination from participation in Medicare and Medicaid, when appropriate.
• Expand Financial Penalties and Other Enforcement Sanctions. CMS will expand the instances in which it takes enforcement actions against poor-performing facilities based on desk reviews of data submissions, which will be performed in addition to on-site inspections. In July 2021, CMS rescinded a Trump Administration change that lowered penalty amounts on bad actor nursing homes for harmful deficiencies by imposing only a one-time fine, instead of more aggressive per-day fines that charge for each day a facility is out of compliance. CMS will now explore making such per-day penalties the default penalty for non-compliance. CMS will also use data, predictive analytics, and other information processing tools to improve enforcement. President Biden is also calling on Congress to raise the dollar limit on per-instance financial penalties levied on poor- performing facilities, from $21,000 to $1,000,000.
• Increase Accountability for Chain Owners of Substandard Facilities. President Biden is calling on Congress to give CMS new authority to require minimum corporate competency to participate in Medicare and Medicaid programs, enabling CMS to prohibit an individual or entity from obtaining a Medicare or Medicaid provider agreement for a nursing home (new or existing) based on the Medicare compliance history of their other owned or operated facilities (previous or existing). He is further calling on Congress to expand CMS enforcement authority at the ownership level, enabling CMS to impose enforcement actions on the owners and operators of facilities even after they close a facility, as well as on owners or operators that provide persistent substandard and noncompliant care in some facilities, while still owning others.
• Provide Technical Assistance to Nursing Homes to Help them Improve. CMS currently contracts with Quality Improvement Organizations that help providers across the health care spectrum make meaningful quality of care improvements. CMS will ensure that improving nursing home care is a core mission for these organizations and will explore pathways to expand on-demand trainings and information sharing around best practices, while expanding individualized, evidence-based assistance related to issues exacerbated by the pandemic.

Increasing Transparency

For too long, corporate owners and operators have not been held to account for poor nursing home performance. CMS will improve the public transparency of facility ownership and safeguard nursing home residents.

• CMS will create a new database that will track and identify owners and operators across states to highlight previous problems with promoting resident health and safety. This registry will use information collected through provider enrollment and health and safety inspections to provide more information about prospective owners and operators to states. Giving the public a resource to better understand owners’ and operators’ previous violations will empower states to better protect the health and safety of residents.
• Improve Transparency of Facility Ownership and Finances. CMS will implement Affordable Care Act requirements regarding transparency in corporate ownership of nursing homes, including by collecting and publicly reporting more robust corporate ownership and operating data. It will also make this information easier to find on the Nursing Home Care Compare website.
• Enhance Nursing Home Care Compare: CMS will implement a range of initiatives to improve Nursing Home Care Compare, the rating website designed to help families pick a facility for their loved ones. Under the Biden-Harris Administration’s leadership, CMS has already published new measures on Care Compare, which allow users to consider nursing home staff turnover, weekend staffing levels, and other important factors in their decision- making process. When the new minimum staffing requirement comes online, Care Compare will also prominently display whether a facility is meeting these minimum staffing requirements. CMS will further improve Care Compare by improving the readability and usability of the information displayed—giving you and your family insight into how to interpret key metrics. Finally, CMS will ensure that ratings more closely reflect data that is verifiable, rather than self-reported, and will hold nursing homes accountable for providing inaccurate information. The President is calling on Congress to give CMS additional authority to validate data and take enforcement action against facilities that submit incorrect information.
• Examine the Role of Private Equity. As described above, private equity investors are playing a growing role in the nursing home sector, and published research increasingly indicates that facility ownership by investment groups leads to worse outcomes while costing taxpayers more—particularly as these owners have sought to cut expenses at the cost of patient health and safety, including during the COVID-19 pandemic. HHS and other federal agencies will examine the role of private equity, real estate investment trusts (REITs), and other investment ownership in the nursing home sector and inform the public when corporate entities are not serving their residents’ best interests.

Creating Pathways to Good-paying Jobs with the Free and Fair Choice to Join a Union

• Ensure Nurse Aide Training is Affordable. Lowering financial barriers to nurse aide training and certification will strengthen and diversify the nursing home workforce. CMSwill establish new requirements to ensure nurse aide trainees are notified about their potential entitlement to training reimbursement upon employment. CMS will further work with states to ensure reimbursement is being distributed and that free training opportunities are widely publicized.
• Support State Efforts to Improve Staffing and Workforce Sustainability. Strengthening the nursing home workforce requires adequate compensation as well as a realistic career ladder. CMS will develop a template to assist and encourage States requesting to tie Medicaid payments to clinical staff wages and benefits, including additional pay for experience and specialization.
• Launch National Nursing Career Pathways Campaign. CMS, in collaboration with the Department of Labor, will work with external entities—including training intermediaries, registered apprenticeship programs, labor-management training programs, and labor unions—to conduct a robust nationwide campaign to recruit, train, retain, and transition workers into long-term care careers, with pathways into health-care careers like registered and licensed nurses.

Ensuring Pandemic and Emergency Preparedness in Nursing Homes

• Continued COVID-19 testing in long-term care facilities. Throughout the pandemic, the Biden-Harris Administration has provided approximately 3 million tests per week to all Medicare- and Medicaid-certified nursing homes and thousands more assisted living facilities, supporting outbreak testing and regular testing of staff. HHS will continue to support this key mitigation strategy for vulnerable residents and the staff that care for them.
• Continued COVID-19 vaccinations and boosters in long-term care facilities. The Biden- Harris Administration has provided the full support of the federal government to states in ensuring that staff and residents across long-term care facilities have access to vaccinations and booster shots. Today, facilities are required to ensure staff are vaccinated and more than 87.1% of residents have received their primary series. CDC continues to offer all facilities the ability to be matched with a federal pharmacy partner to host an on- site vaccination clinic. CMS has reached out to thousands of these facilities directly to offer support, and the Agency for Healthcare Research and Quality has made a wide set of tools available. HHS will continue to promote access to these clinics and efforts to integrate vaccinations into routine services, incentivize vaccinations through provider quality payment programs, and continue to provide a full range of resources to continue to build confidence in the vaccine.
• Strengthen Requirements for On-site Infection Preventionists. CMS will clarify and increase the standards for nursing homes on the level of staffing facilities need for on-site infection prevention employees, undoing the Trump Administration’s changes to these requirements to help improve resident health and safety.
• Enhance Requirements for Pandemic and Emergency Preparedness. Both the pandemic and the increase in natural disasters have demonstrated how critical proactive emergency preparedness is to keeping residents of nursing homes safe. CMS is examining and considering changes to emergency preparedness requirements and is working to bolster the resiliency of the health care sector as part of an Administration-wide effort to be ready for the next pandemic and the next weather-related emergencies.
• Integrate Pandemic Lessons into Nursing Home Requirements. The pandemic has underscored the need for resident-centered updates to nursing homes’ requirements of participation in Medicare and Medicaid. CMS will integrate new lessons on standards of care into nursing home requirements around fire safety, infection control, and other areas, using an equity lens.

Tennessee Primary

 Tennessee Primary August 4, 2022

The Tennessee Primary Election is coming up on August 4, 2022. Voters will nominate candidates for governor and U.S. House, as well as candidates for a number of state and local offices. Here’s what you need to know to cast your ballot and make sure it’s counted.

Register to Vote: The deadline to register to vote in this election has passed.

Vote by Mail: Some Tennessee voters can apply for a vote-by-mail ballot. The last day to request a vote-by-mail ballot for this election is July 28, 2022. You can apply for a ballot to vote by mail here. When returning your ballot, it must be received by the close of polls on August 4, 2022.

Vote Early: Early voting will begin on July 15, 2022, and will be available until July 30, 2022. You can find your nearest early voting location here.

Vote on August 4: If you will be voting in person, please follow all guidelines and contact your County Election Official for all the options on how to vote or return your ballot in person.  Find your polling location here.

Find Out What’s on Your Ballot: You can preview what’s on your ballot here.

Voter ID Requirements: If you are voting in person in Tennessee, you must present an acceptable form of ID. You can see what types of IDs are acceptable here.

Voting & COVID-19: Due to the COVID-19 pandemic, there may be changes to voting information. Please check vote.org/covid-19 for the latest update.

You Have the Right to Vote. If You Have Any Problems Voting: Call or text the nonpartisan Election Protection Hotline at 866-OUR-VOTE (1-866-687-8683).

If You Have Other Questions About Voting: The best source of information is always your local election office. You can find your county election officials’ contact information here.