AN ACT CONCERNING A NURSING HOME IMPROVEMENT PLAN.

1. requires a nursing home, as a condition of continued licensure by the Department of Public Health (DPH), to develop a nurse staffing plan and establish a staffing committee to help prepare it;

2. phases in new minimum nurse staffing levels for nursing homes based on an hours per day of direct care per resident standard that must be maintained over a 24 hour period;

3. requires the Department of Social Services (DSS), in consultation with DPH, to produce an annual inventory of nursing home beds in the state; and

4. requires DSS, in reviewing nursing home certificate of need (CON) applications, to consider additional factors such as the inventory required above, the nursing facility's age, and models of long-term care.

EFFECTIVE DATE: July 1, 2008 for the inventory and CON sections; October 1, 2008 for the nurse staffing plan and staffing level provisions.

Beginning July 1, 2009 and as a condition of continued licensure, the bill requires each DPH-licensed nursing home to develop a nurse staffing plan that is sufficient to provide adequate and appropriate health care service delivery to its patients in the license period. For purposes of the bill, “nursing home” means any chronic and convalescent facility (CCNH) or any rest home with nursing supervision (RHNS). The plan must promote a collaborative practice in the nursing home that improves patient care and the level of services provided by nurses and other members of the patient care team. The nursing home must make the plan available to DPH upon request.

1. include the minimum professional skill mix for each patient care unit in the nursing home, including any special care units;

2. identify the home's employment practices concerning use of licensed temporary and traveling nurses;

3. establish the level of administrative staffing in each patient care unit that ensures direct care staff are not used for administrative functions;

4. describe the nursing home's internal plan review process;

5. identify collective bargaining agreements that the home is a party to and certify the home's compliance with them; and

6. include the home's mechanism for involving direct care staff, including licensed nurses and other members of the home's patient care team, in developing the staffing plan.

The bill requires each nursing home to establish a staffing committee to help prepare the nurse staffing plan. This committee must include registered nurses (RNs) who provide direct patient care, licensed practical nurses (LPNs), and certified nursing assistants. Each nursing home, in collaboration with its staffing committee, must implement the plan.

The bill requires each nursing home to employ sufficient nurses and nurse's aides to provide appropriate direct care to residents 24-hours per day, seven days per week. The nursing home 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 and services per resident;

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

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

Currently, minimum nurse staffing levels are set by regulation in the Public Health Code (see BACKGROUND).

The bill defines “direct care” as hands-on-care provided to nursing home residents, including feeding, bathing, toileting, dressing, lifting, and moving the residents. It does not include food preparation, housekeeping, or laundry services, except when such services are required to meet the needs of a resident on an individual situational basis. Also under the bill, direct care does not include care provided by paid feeding assistants.

The bill requires the DSS commissioner, in consultation with the DPH commissioner, to complete an annual inventory of all publicly funded and private pay nursing home beds in the state. The first inventory must be done by December 31, 2008. The DSS commissioner must report annually on the inventory results to the Human Services and Public Health committees. The first report is due by February 1, 2009. The report must identify any geographic areas needing additional nursing home beds and the number needed and those areas with a surplus.

1. transfer all or part of its ownership or control prior to initial licensure,

2. introduce any additional service or function into its program of care or expand an existing service or function,

3. terminate a service or decrease substantially its total bed capacity,

4. make a capital expenditure over $ 1 million that increases the facility's size by the greater of over 5,000 square feet or five percent of the existing footage,

5. make a capital expenditure of $ 2 million, or

6. acquire major medical equipment requiring a capital expenditure of over $ 400,000.

Under current law, there is a moratorium on CONs for additional nursing home beds until June 30, 2012. Exceptions are provided for:

1. beds restricted to use by patients with AIDS or traumatic brain injury;

2. beds associated with a continuing care facility that guarantees life care for its residents;

3. Medicaid-certified beds to be relocated from one licensed nursing facility to another licensed nursing facility, provided (a) the availability of beds in an area of need will not be adversely affected, (b) such relocation will not result in an increase in state expenditures, and (c) the relocation results in a reduction in the number of nursing facility beds in the state;

4. a request for no more than 20 beds from a nursing facility that does not participate in Medicaid or Medicare and demonstrates the financial ability to provide lifetime nursing home services to its residents without such participation; and

5. a request for no more than 20 beds associated with a free standing facility providing hospice care services for terminally ill persons authorized by DPH to do so (CGS § 17b-354).

The bill requires DSS, when determining whether to approve a nursing home's CON request, to also consider (1) the inventory of nursing home beds for a particular geographic region, (2) the facility's age, and (3) whether the model of long-term care the facility provides is consistent with the state's long- term care plan developed by the Long–Term Care Planning Committee.

The DSS commissioner must grant, modify, or deny the CON after considering these factors and according to requirements of current law. Under the bill, the commissioner can deny the CON if he determines that the proposed capital project is inconsistent with the state's long-term care plan. He must give priority to approval of capital projects that (1) promote the development of alternative models of long-term care that are consistent with the state plan, including the Green House model and the Small House model and (2) increase long-term care options in geographic areas with a shortage of beds.

DPH licenses nursing homes at two levels of care: CCNH, which provide skilled nursing care, and 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 (CT Agencies Reg. § 19-13D8t). The actual standards vary somewhat depending on whether the care is at a CCNH or an RHNS level. Most of the nursing 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. (Under the bill, there is one standard for both types of nursing home and the requirement must be met over a 24-hour period. )

Generally, “Green Houses” or “Small Houses” are “deinstitutionalized” nursing homes. They are self-contained dwellings for seven to 10 residents requiring nursing home levels of care. They incorporate physical design changes such as private rooms and bathrooms, a residential-style kitchen, a communal dining area, and accessible outdoor space. Institutional elements are avoided. A cluster of green houses, in effect, form a nursing facility.

SB 385 (File 596) and HB 5794 have provisions on nursing home staffing levels. SB 32 addresses nursing home CONs.

Yea

Nay

(03/17/2008)

Yea

Nay

(03/28/2008)


Direct Care Personnel	CCNH		RHNS
	7 a. m. to 9 p. m.	9 p. m. to 7 a. m.	7 a. m. to 9 p. m.	9 p. m. to 7 a. m.
Licensed Nursing Personnel	. 47 hours per patient (hhp) (28 min. )	. 17 hpp (10 min. )	. 23 hpp (14 min. )	. 08 hpp (5 min. )
Total Nurses and Nurse Aide Personnel	1. 40 hpp (1 hr. 24 min. )	. 50 hpp (30 min. )	. 70 hpp (42 min. )	. 17 hpp (10 min. )