Elizabeth Lang, who lives in Pittsburgh’s South Hills, still remembers the difficulties her parents faced when they could no longer live in their own home.
“I watched my parents' needs not be met at a nursing home that promised good care but didn't deliver because the Company was overworking their nurses and staff … Frustrated nurses took a long time responding to their requests for basic needs, like changing my dad's soiled incontinence wear,” Lang wrote.
She is one of thousands who have weighed in on a federal proposal that would impose new minimum staffing standards on nursing homes.
Advocates say the new rule has the potential to improve care for millions of nursing home residents who depend on staff to help them get dressed, bathe, eat, and go about their days.
The proposal, rolled out by federal regulators in September, would require a registered nurse to be on site in nursing homes 24 hours per day and 7 days per week. It would also require facilities to provide 0.55 registered nurse hours per resident day, and 2.45 hours of care from nurse aides per resident day.
“Numerous studies … have shown that staffing levels are closely correlated with the quality of care,” the Centers for Medicare and Medicaid Services wrote when it put forth the regulations.
The Biden administration emphasized the nursing home industry “receives nearly $100 billion annually from American taxpayers, yet too many nursing homes chronically understaff their facilities — resulting in poor, substandard care that endangers residents,” it said in an announcement about the proposal.
South Park resident Shannon Mahoney, who works as certified nursing assistant, or CNA, at a nursing home in Washington County, says residents suffer when there aren’t enough staff.
“If there’s more workers there, then these residents can be given the care that they deserve,” she said in an interview. “I mean, they pay all this money to be in this [facility] and it's their home. So you need the staff in there to make sure they're comfortable, they're fed, you know, they get their meds on time.”
The issue will only grow more pressing. The number of adults over age 75 in Pennsylvania is projected to increase by more than 13 percent in the coming years, as Baby Boomers age.
‘We’re already in a workforce crisis’
Nursing home operators and industry groups have pushed back, saying the new rules come without additional funding, and the field is already suffering from a severe staffing shortage, exacerbated by the pandemic.
“Right now, if those requirements were put into place, it'd be very hard for any facility to meet those requirements,” said Dennis Biondo, who runs Allegheny County’s four Kane Community Living Centers.
“They're making demands when we're already in a workforce crisis,” President and CEO of industry group LeadingAge PA Garry Pezzano, said of the potential regulations.
Pezzano’s group, which represents both for-profit and nonprofit nursing homes, estimates the rule change would cost nursing homes in Pennsylvania an additional $500 million annually, or about $700,000 annually per provider. “Where's the money?” he said.
Perhaps not surprisingly, a major healthcare union representing nursing home workers has welcomed the Biden administration’s move.
“We have a real care crisis. We had one before COVID. It's even worse now,” said Matthew Yarnell, president of SEIU Healthcare Pennsylvania, which represents thousands of workers at more than 100 different skilled nursing facilities around the state. Yarnell said the union is also glad to see additional transparency requirements for the industry included in the proposal.
“I think it's wrong for the industry to be saying we can't do this, or it's too severe, or there's not a workforce, when we know that if we focus resources at the bedside, make these good jobs, people will do this work.”
Low reimbursements, low wages
Wages for nursing assistants in Pittsburgh averaged about $36,430 annually last year, according to the federal Bureau of Labor Statistics. Such jobs often don’t provide affordable health insurance, or retirement security, said Yarnell.
“So, when you think about what it takes to make a good job, this industry, I think, has to do that,” he said.
But low wages for workers are driven by low government reimbursement rates. Nursing homes are generally reliant on Medicaid funding — a program jointly funded by states and the federal government — but that rarely covers the full cost of a person’s care.
It’s still unclear if the proposed changes by themselves will be enough to improve care for residents, said Rachel Werner, executive director of the Leonard Davis Institute of Health Economics at the University of Pennsylvania.
“The proposed changes definitely increase staffing levels. Whether or not the increases are enough is a question that's open for debate. I would say it's a step in the right direction,” she said.
However, Werner cautioned that a staffing mandate alone might not be helpful.
“The downsides of what's been proposed are, one, the levels are probably not high enough given the complexity of care that occurs in nursing homes and two, it's pretty much an unfunded mandate. Medicaid rates are not going up, but staffing levels are going to have to go up. And so how nursing homes are going to pay for that is an open question.”
Some states, Dr. Werner said, have experimented with other measures to improve quality care, like requiring a high percentage of Medicaid dollars to go directly to patient care rather than to other expenses.
More workforce development programs
Industry group Leading Age PA doesn’t dispute that staffing is important, Pezzano said.
“We want the highest quality of care and certainly agree that there are proper staffing levels, to make it safe for residents and to make it safe for the caregivers,” he said.
But Pezzano said when the state put in place staffing requirements, those came with additional funding to help nursing homes meet the new rules and questioned why the federal government wouldn’t do the same.
Biondo, who runs the Kane Centers in Allegheny County, said he hopes any new mandate comes with a workforce development plan.
“Hopefully, over the next three years … those requirements will be matched with an increased push to get more employees into the health care field, whether it's someone going to nursing school, getting a break on tuition or an ability for them to have their loans deferred or canceled after a number of years that they work in the industry,” he said.
His concerns were echoed by the Pennsylvania Coalition of Affiliated Healthcare and Living Communities, a group representing county-run nursing homes in Pennsylvania.
“Imposing increased staffing requirements without ensuring the success of workforce development programs is premature and may lead to heightened citations and facility failures,” the group’s executive director wrote in a letter to federal regulators.
Union president Yarnell and other advocates for the regulations point out that the administration has proposed a lengthy time for nursing homes to reach the new standards — three years for most nursing homes, and up to five years for those in rural areas.
More broadly, Yarnell said, the country needs to shift how it views care jobs and the largely female care workforce.
“The majority of caregivers tend to be women, many women of color, immigrant workers, and I just think it's not by accident that these have been jobs that have been kind of dismissed or ignored,” Yarnell said. “We have a tremendous amount of work to do…to make sure that caregiving is seen as a profession and resourced and paid and treated as such.”
The deadline to comment on the proposed federal regulations is Monday, Nov. 6. You can read them and comment here.
