AN ACT IMPROVING NURSING STAFFING LEVELS AND ENFORCEMENT.

1. phases in higher minimum direct care staffing standards in chronic and convalescent nursing homes (CCNH) over three years starting October 1, 2008;

2. requires the Department of Public Health (DPH), when inspecting homes, to consider compliance with direct care staffing standards;

3. requires noncompliant homes to meet new reporting requirements;

4. allows the Department of Social Services (DSS) to recover from noncompliant homes all or part of the Medicaid funding it gave them to increase direct care staffing;

5. requires homes to publicly disclose certain information about direct care staffing schedules and ratios starting May 1, 2009; and

6. directs DPH to adopt implementing regulations.

The bill defines “direct care” as hands-on care provided to residents of nursing homes, including feeding, bathing, toileting, dressing, lifting, and moving residents. It does not include food preparation, housekeeping, or laundry, except when these services are required to meet a resident's needs on a case-by-case basis. It likewise excludes care provided by paid feeding assistants as allowed under federal law. (Feeding assistants are people trained specifically to feed residents or help them eat at mealtimes. )

It defines “licensed nurse” as a state-licensed registered nurse or licensed practical nurse.

It also defines “nurse's aide” as an individual who provides nursing or nursing-related services to chronic and convalescent nursing home residents. It does not include a health professional otherwise licensed or certified by DPH or a volunteer.

Under the bill, a CCNH must maintain aggregate licensed nurse and nurse's aide staffing levels over a 24-hour period at or above the following:

1. beginning October 1, 2008, at least 3. 5 hours of direct care per resident;

2. beginning January 1, 2009, at least 3. 9 hours of direct care per resident; and

3. beginning May 1, 2009, at least 4. 2 hours of direct care per resident.

Current law requires a CCNH to maintain aggregate licensed nurse and nurse's aide staffing levels of at least 1. 9 hours of direct care per resident per day (see BACKGROUND).

The bill also requires homes to meet the following nurse's aide-to-patient ratios beginning May 1, 2009:

The bill requires DPH, when conducting an annual or follow-up inspection, to determine a home's compliance with minimum direct care staffing standards. To make its determination, the department must request copies of and compare the home's census records, schedules, and payroll records for the month immediately before the inspection. It must include in its determination any hours worked by temporary or agency staff but must exclude any paid time off, including sick, vacation, or personal time.

Starting October 1, 2009, the bill requires DSS to use annual cost reports submitted by each home to determine the home's average hours of direct care per resident per day. To make its calculation, DSS must divide the total number of resident days reported by the total number of licensed and unlicensed direct care hours, excluding any administrative hours. It must provide these calculations to DPH to help DPH determinate the home's compliance with minimum direct care staffing standards.

Currently, nursing homes annually submit financial information to DSS for the purpose of per-diem rate setting. The information, which DSS audits, includes expenditures, revenue, paid hours worked, and balance sheet data.

The bill requires DPH to notify a facility if it is noncompliant with the direct care staffing standards. The facility must file a report with DPH within 14 days of the notification explaining the reason for its noncompliance and its corrective action plan. If DPH finds that the facility has not implemented its corrective action plan, the facility must file monthly staffing reports with DPH for at least one year or until three months after the facility is found in compliance, whichever is longer.

If DPH receives a complaint against a facility alleging inadequate staffing levels, the bill requires it to inspect the home's records for the period cited in the complaint.

The bill allows the state long-term care ombudsman, or her designee, to inspect the resident care schedules and payroll records of any CCNH when visiting the facility to advocate for one or more resident, respond to a complaint or inquiry, or meet with a resident or family council.

The ombudsman must report any noncompliance with the new staffing standards to DSS and DPH for follow-up.

The bill allows the DSS commissioner to recover all or part of the facility's Medicaid funding allocated for increasing the facility's direct care staffing if a home fails to comply with minimum direct care standards. The commissioner may allow a facility to keep a portion of the funds allocated to improve its staffing ratio. The bill does not specify at which point DSS may consider a nursing home to be in non-compliance (e. g. , when the home fails to implement its DPH corrective action plan or at any time a home does not meet minimum staffing standards)

Starting May 1, 2009, the bill requires CCNHs to publicly disclose information about staffing schedules and ratios. They must post, for each unit and shift, the current number of licensed and unlicensed direct care nursing staff, displaying current staff-to-patient ratios for licensed nurses and certified nurse's aides separately and in the form of average daily staffing ratios based on the most recently concluded cost reporting period. They must post the information (1) in a way that is visible and accessible to all residents and their families, caregivers, and potential consumers and (2) on a uniform form that DPH provides.

The homes must also display in the vicinity of the other posted information, a poster, provided by DPH, describing the minimum staffing standards and ratios.

The bill also requires that at the beginning of each shift, homes must prominently post on each unit, a list in at least 48 point font of the first and last names of nursing staff on duty.

Starting January 1, 2009, the bill requires DPH to report to the Human Services and Public Health committees on the average direct care staffing hours per resident per day and the minimum direct care staffing ratios for each CCNH in the state. The report must highlight those facilities that did not comply with bill's standards.

DPH licenses nursing homes at two levels of care: (1) CCNHs, which provide skilled nursing care, and (2) rest homes with nursing supervision (RHNS), which provide intermediate care. A nursing home can be licensed at one or both levels of care.

Minimum staffing requirements for CCNHs and RHNSs are set by regulation (Conn. Agencies Reg. § 19-13 D8t). The actual standards vary somewhat depending on whether the nursing home is providing CCNH or RHNS levels of care. Most of the nursing home beds in the state are CCNHs. The nurse-to-resident hours per day are set separately for the periods from 7 a. m. to 9 p. m. and 9 p. m. to 7 a. m. and are less for RHNSs than for CCNHs, as shown below.

SB 385, reported by the Aging, Public Health, and Appropriations committees requires nursing homes to maintain minimum staffing levels of 2. 32 nurse's aide direct care hours per patient per day and 1. 18 licensed nurse direct care hours per patient per day. It also contains inspection, reporting, and enforcement provisions.

HB 5864, reported by the Public Health and Appropriations committees, phases in the same minimum nursing home staffing levels over a three-year period for both CCNHs and RHNSs, but does not include nurse's aide-to-resident ratios.

SB 32, reported by the Human Services and Appropriations committees, has provisions on enforcement and financial reporting requirements for nursing homes.

Yea

Nay

(03/18/2008)

Yea

Nay

(03/28/2008)

*Shift*	*Minimum Full-time Nurse's Aides to Resident Ratio*
7: 00 a. m to 3: 00 p. m (day shift)	1: 5
3: 00 p. m. to 11: 00 p. m (evening shift)	1: 10
11: 00 p. m to 7: 00 a. m. (night shift)	1: 15