Staffing In Nursing Homes (2000)

The Legislative Program Review and Investigations Committee voted to study Staffing in Nursing Homes in March 2000.¹ The study focused on whether the current minimum nursing-staff-to-resident regulations were adequate, how actual staffing levels relate to the minimum standards, and how the Department of Public Health (DPH) monitors the adequacy of nursing staff. The impact of the 1999 legislative Wage, Benefit, and Staffing Enhancement Program was also included in the scope of the study.

The committee found Connecticut's current nursing staff ratio requirements, delineated in regulation, confusing, administratively complicated, and outdated. The current regulations were established in 1981 and DPH began revising them in 1995. However, the committee found almost six years later they still had not been submitted to the Regulation Review Committee. Furthermore, based on the department's compliance response submitted in January 2002, the department has not proceeded with the proposed regulations, noting that the current regulations already require homes provide sufficient staffing.

During the committee's study, the Health Care Financing Administration (HCA) completed the first phase of a comprehensive study of nursing home staffing and issued preliminary findings regarding minimum nursing staff ratios. The committee found the HCFA nursing-staff-to-resident ratios based on the most comprehensive and defensible research to date and therefore, recommended increasing the minimum nursing staff ratios from 1.9 hours per resident day to 2.75 hours per resident day with a two-year phase-in period.

In terms of the inspection process, the committee found few nursing facilities are issued deficiencies by Connecticut's Department of Public Health for nursing staff inadequacies during inspections. The reason for this, the committee found, is because there is a lack of federal and state guidance to inspectors on how to evaluate the adequacy of nursing staffing levels based on the needs of residents. The department noted in its compliance response that more facilities have been issued a deficiency for insufficient staffing, with 13 issued between October 2000 and December 2001, compared to nine in FY 00 and three in FY 99.

Based on its findings, the committee proposed two administrative and two legislative recommendations, which were raised in SB 1173. The bill established a methodology for DPH inspectors to use to assess nursing staff adequacy during an inspection in relation to the level of care needed by residents. It increased the current regulatory minimum nursing-staff-per-resident-day ratio from 1.9 hours per resident day to 2.75 hours per resident day and established these ratios in statute. Finally, it required nursing homes to report to DPH if they did not meet the minimum ratios, and provided for enforcement action by DPH if the commissioner found a pattern of noncompliance. No action was taken on the committee's bill by the Public Health Committee, however another bill, HB 5668, which contained all of the committee's recommendations was left tabled for the House Calendar.

Although neither bill ultimately was enacted, P.A. 01-2, June Special Session provides for the DSS commissioner, within available appropriations for FY 03 and 04, to provide rate relief to enhance staffing in nursing homes to the levels recommended by the program review committee. The legislature appropriated funding of $2 million for FY 03 for implementation, but it has yet to be allotted.

Administrative recommendations required DPH track the date of nursing home inspections to ensure randomness. The Department of Social Services was also required to amend the annual cost reports submitted by nursing facilities so that salaries and wages, and hours are reported separately for nurses providing direct resident care from those performing administrative functions.

¹ Nursing staff is defined as registered nurses (RNs), licensed practical nurses (LPNs), and nurse aides.