Thirty minutes, every other month was all it took for Tina McDonald to make a difference in the lives of Claudia Dunagan and her nonagenarian mother, Hazel.
Armed with a smile and a bag of sterilized foot care equipment, McDonald, a wound and ostomy nurse, skillfully and gently trimmed the thick toenails that Hazel, a homebound diabetic, could no longer care for herself.
For 16 months, it was the perfect solution. Until it wasn’t.
Two months after Hazel’s 100th birthday, in January 2024, McDonald texted Dunagan to cancel their upcoming appointment. The Rhode Island Department of Health had issued a cease and desist order, forcing her to halt the business she’d begun 12 years earlier, unknowingly violating state laws governing foot care.
Dunagan, 77, searched for an alternative, asking certified nursing assistants and home hospice nurses, even considering a pedicurist willing to come to her Providence condo. Their answers were the same: “We can’t touch feet.”
Basic foot care is especially crucial, but also more complicated, for people with diabetes, arthritis and other underlying blood and vascular conditions, which are also more prevalent in seniors. Lack of regular nail trims and callus shaving can lead to serious medical consequences, including infections and falls.
“There was no one in the entire state,” Dunagan said in a recent interview. “I had zero options.”
Legislation introduced this year by Rep. Jennifer Boylan, a Barrington Democrat, sought to give the mother-daughter duo, and others like them, a solution. The bill would clarify the uncertainty in state law by explicitly allowing certified nurses to perform routine preventive and maintenance foot care at home. It seemed an obvious solution — one allowed in every state in the country except Rhode Island.
“It sounds trivial to someone who is healthy and can reach their feet, but as soon as you can’t, it’s not,” Boylan said. “It’s quite frankly unacceptable that people are going without care. In an elderly population, every day, every month counts.”
Boylan’s bill won unanimous support in the Rhode Island House in a June 12 vote. But it failed to advance in the Rhode Island Senate, and ultimately, died without even a hearing before the Senate Committee on Health and Human Services.
Greg Paré, a spokesperson for the Senate, said it was a timing and logistics problem — without a Senate companion, the chamber had to wait till Boylan’s bill passed the House to consider it. There just wasn’t enough time before the 2025 legislative session ended on June 21.
“Should a version of this legislation come before the Senate earlier in next year’s session, it will be reviewed,” Paré said in an email.
Boylan pledged to reintroduce the same, revised bill early in the 2026 session. She already has a Senate sponsor, Sen. Lori Urso, a Pawtucket Democrat.
350 people on waiting list
Dunagan’s mother died in February 2024. But hundreds of homebound seniors and their caregivers are still searching for someone to provide the basic foot care critical for safety, wellness, and dignity.
McDonald amassed a 350-person waiting list during the four months of 2023 when she paused her practice while the state nursing board conducted a review after receiving an anonymous complaint.
State nursing law doesn’t explicitly prohibit nurses from providing home foot care. They don’t name it as a provided service, either. Meanwhile, a separate section of state law governing podiatry stipulates that only licensed podiatrists can treat feet.
The state health department cited the podiatry law as the reason why McDonald could not provide home foot care.
“The nursing regulations are vague,” McDonald said. “To me, this falls within our nursing practice, but I didn’t want to risk losing my license.”
Lynda D’Alessia, state nursing director, did not respond to inquiries for comment.
There was no one in the entire state. I had zero options.
McDonald has now rebuilt her business to exclusively focus on Massachusetts and has a contract with Bristol Aging & Wellness, a nonprofit serving seniors in Bristol County, Massachusetts. Her former patients did not fare as well.
Anne Hagan, a home hospice nurse who lives in Warwick, wrote to lawmakers with a litany of stories, including a homebound veteran whose neglected toenails had grown so long and thick he couldn’t trim them with standard clippers. He eventually took a jackknife to his nails, ending up in a “pool of blood,” Hagan wrote.
Leigh Anne Cappello, a Barrington resident, described an aging family member whose foot cyst became infected after it went undetected.
“It is easy to go unnoticed since their feet are largely covered in socks, slippers or shoes,” Cappello wrote. “What could have been addressed with some basic foot health/hygiene care turns into a more difficult problem that can even affect mobility — something that is so critical to their overall health.”
McDonald sympathized in her testimony to House lawmakers during a March 27 hearing on Boylan’s bill.
“If you’ve never been a family caregiver, it is difficult to imagine the stress, exhaustion, isolation and grief that one experiences,” McDonald told House lawmakers who serve on the Committee on Health and Human Services. “As access to services outside the home becomes less accessible, the pressure on the caregiver increases. Nurses need to be allowed to fill in the gaps, to let people age in place with dignity.”
The Rhode Island Developmental Disabilities Council, the Rhode Island Nurses Association, AARP and a host of local senior services agencies backed Boylan’s bill, too.
Many were surprised to learn that home foot care nurses weren’t already allowed.
“Everybody seemed genuinely unaware of this gap in services,” said Carol Anne Costa, executive director for the Senior Agenda Coalition of Rhode Island.
Everybody seemed genuinely unaware of this gap in services.
Costa expects the gap will widen as Rhode Island’s senior population swells and its residents look to live out their final years at home.
“As a rule, we have been very successful in enabling older adults to age in place,” Costa said. “With that success naturally comes the need for more services to sustain them in their homes.”
Podiatrists push back
Representatives from the American Podiatric Medical Association and the Rhode Island Podiatric Medical Association wrote to lawmakers with concerns over the health and safety implications of letting nurses provide home care to patients whose age or other diagnoses — like diabetes — make even routine trimmings more risky.
“While routine foot care sounds nice, more often than not, it is not routine and it is more than foot care,” Dr. Sarah Cathcart, vice president of the Rhode Island Podiatric Medical Association, told lawmakers during the March 27 committee hearing.
Cathcart works at South County Foot and Ankle in Warwick, and said she, and most other podiatrists make house calls outside of regular office hours.
But, Cathcart acknowledged when questioned by lawmakers, home visits are usually to existing patients — not new ones.
And federal Medicare rules require that any patients receiving care at home from a podiatrist first secure a medical necessity determination from a primary care provider.
“I have to protect my license and my practice,” Dr. Michael Reuter, a podiatrist with Brown University Health in East Providence, told lawmakers during the committee hearing.
The Rhode Island Podiatric Medical Association and its members did not respond to follow-up inquiries.
McDonald doesn’t take insurance and therefore doesn’t need any paperwork to make a house call. She charges $100 per visit, seeing 30 to 40 people weekly. Podiatrists told lawmakers they treat a couple people at home per week, or less.
Seeking to assuage podiatric concerns, Boylan changed her bill between its initial committee hearing and approval on the House floor, adding more specific requirements to the training and scope of services that qualifying nurses could provide. She also moved the proposal from the state law governing podiatrists to the section on nursing, modeling the language after the advisory rules set by the Massachusetts Board of Nursing.
The health department did not take a position on Boylan’s bill.
“We would only take a position if something in a piece of legislation represented a health or safety concern, or if we believed that our support for a bill would clarify its benefits for legislators and the public,” Joseph Wendelken, a spokesperson for the health department, said in an emailed response.
Claudia Dunagan never found someone else to trim Hazel’s toenails after McDonald was ordered to stop coming. Her last view of Hazel after she died was of her feet, the long, curling toenails peeking out from beneath the blanket covering her mother’s body.
“When I saw her feet, that was the one relief I had that she died then, because there was no one to care for them,” Dunagan said.
This story was originally published by the Rhode Island Current.
