Nursing homes face staffing shortages amid Medicare proposed staffing requirements

Oct. 16—Medicare is proposing minimum staffing requirements for nursing homes, the majority of which are already not meeting at least one of those standards, the American Health Care Association says.

The Centers for Medicare and Medicaid Services (CMS) is currently receiving comments on these proposed staffing minimums through Nov. 6. The proposed rule would require a registered nurse on site all day, every day, as well as require nurses to spend 0.55 hours per resident per day. Nurse aides would also be required to spend 2.45 hours per resident per day.

Minimum staffing standards for nursing homes will improve resident safety and the quality of care, said Xavier Becerra, secretary of the U.S. Department of Health and Human Services.

"When facilities are understaffed, residents suffer. They might be unable to use the bathroom, shower, maintain hygiene, change clothes, get out of bed, or have someone respond to their call for assistance. Comprehensive staffing reforms can improve working conditions, leading to higher wages and better retention for this dedicated workforce," Becerra said.

Impact on nursing homes

More than 90% of nursing homes in the U.S. are already not meeting at least one of those requirements, according to the American Health Care Association, a trade organization representing more than 14,000 nursing homes and other long term care facilities across the country.

Nursing homes would face a financial burden from the additional staffing, opponents of the requirements say. The minimum standards will cost nursing homes approximately $6.8 billion per year, the American Health Care Association says. The CMS estimate was $4 billion per year.

"When nearly every nursing home in the country would be considered out of compliance if this went into effect today, it demonstrates how out of touch Washington bureaucrats are with reality," said Mark Parkinson, president and CEO of the American Health Care Association. "Nursing homes are already grappling with a growing caregiver shortage; to demand they hire 100,000 additional caregivers, without any meaningful resources or support, is a disservice to our nation's seniors."

Local nursing homes

Residents in Dayton and the surrounding regions have had mixed experiences with their loved ones staying in area nursing homes, with even some of the best experiences still seeing difficulties from understaffing.

"It was exceptional," Urbana-resident Terri Marratta said about the experience her mother had in a nursing home. Even with the overall good experience her mother had at the nursing home she was in, Marratta said they still saw a shortage of staff impacting everyday needs, like trips to the bathroom or showers.

"They were understaffed, which is, I think, pretty much the way of the world anymore at places like that," Marratta said. The staff there, though, was compassionate and friendly, she said, asking about her mother's interests and developing connections with her.

Medicare ranks nursing homes on a five-star scale based on health inspections, staffing, and quality measures. Nursing homes also receive an "overall" score based on the scores of those three categories. For 78 nursing homes within a 25-mile radius of Dayton, more than half, or 41, of them received overall ratings of "much below average" or "below average," which are one- and two-star ratings, respectively. Fourteen nursing homes were "average," 10 were "above average," and 13 were "much above average."

For staffing, Medicare looks at the average amount of time staff are available to spend with each resident each day, along with staff turnover. Out of those 78 nursing homes, 45 were "much below average" and 16 were "below average." Twelve nursing homes received "average" rankings, and only five were "above average." None received the highest ranking of "much above average."

Ronald Cobb, who lives in New Carlisle, had a more difficult experience with the nursing homes his father received care from. At one facility, his father fell out of bed and broke his hip, Cobb said. When the family questioned what happened, Cobb said they were told that if they did not like the care there, then they could leave. His father then went to a different facility, which Cobb said was "just as bad."

"They don't check on the patients as much," Cobb said. This caused an issue with his father not getting the help he needed to use the bathroom, he said.

"Like I told my kids, don't ever put me in a nursing home, I'll die in my own home," Cobb said.

The difference for dementia patients

The needs of the resident in the nursing home can be relative to what put them in that situation, such as if it was an injury, a mobility issue, or a cancer diagnosis compared to dementia.

"It's really difficult when it's dementia because the patient can't really actively participate in helping you give them the proper care," said Dayna Ritchey, program director for the Alzheimer's Association Greater Cincinnati and Miami Valley chapters.

Karen Beverley of Kettering experienced difficulties when her father needed care beyond assisted living. Her father, who had dementia, went through two rehab facilities and two memory care facilities with mixed results, she said.

At the three facilities where they had poor experiences, the issues ranged from sanitation and hygiene issues like bedding not being changed to employees not being adequately trained to work with dementia patients, she said. At his first memory care facility, he ended up breaking a hip due to falling out bed.

Beverley experienced the difference going to a facility where employees understood dementia.

"They were well trained. They even had a workshop for the caregivers, the family caregivers," Beverley said. The facility, which was a small, private facility, was designed for people with dementia. It was also cleaner, she said, adding, "The staff just seemed to be happier."

Since people with Alzheimer's and other forms of dementia have short-term memory issues, routine becomes important, including when it comes to the staff members, Ritchey said.

"A lot of times, people with dementia don't know of their limitations," Ritchey said. In those situations, it can feel violating to the dementia patient if an aide or nurse is trying to help them use the bathroom or shower.

"It's frustrating for everybody involved. Families get frustrated by that, too," Ritchey said.

Fewer employees also makes it more difficult to provide person-centered care.

"Depending on what the needs are of these residents, who knows if they're all going to be happy at the end of that shift," Ritchey said, comparing an employee with only four residents to manage to an employee with double the number of residents in the same shift. "One of them may still be sitting in soiled clothes at the end of that shift depending on what's happening with these other people."

Future needs of a growing population

Steve Schnabl, an Oxford resident, decided to retire and become a full-time caregiver to his wife when she needed care in order to keep her from having to stay in a nursing home.

"I don't want her to be in one again," Schnabl said. "She would call in the middle of the night to ask me for help because no one would respond to the bell to help her if she needed to go to the bathroom."

There wasn't enough staff to take care of everybody, he said.

Nursing homes are also expensive, and Schnabl said taxpayers may be worried this is going to fall on them to fund.

Statewide, the average cost of staying in a nursing home is more than $5,000 per month, according to the state's long-term care consumer guide. Medicaid pays for the largest share of long-term care services, according to the U.S. Department of Health and Human Services' National Clearinghouse for Long-term Care.

Adults over 60 are one of the faster growing populations, which is why some are saying now is the time to get prepared.

"I'm really scared that we're headed toward quite an explosion in need for service and lack there of," Schnabl said.

For those who would like to comment on CMS' proposed staffing requirements, comments must be submitted to the Federal Register no later than Nov. 6. For more information on how to submit comments or to review the entire rule, visit the Federal Register website at federalregister.gov/public-inspection/current.