SURVEY PROCESS
FINDINGS
Few nursing facilities are issued deficiencies by Connecticut's Department of Public Health for nursing staff inadequacies.
A review of the adequacy of nursing staff is not a primary focus of the standard survey (i.e., inspection).
Even when serious quality of care problems are identified, it is difficult for DPH inspectors to link those to insufficient staffing because of subjective and immeasurable protocol requirements.
Neither the federal Health Care Financing Administration (HCFA) protocol nor state law provides a benchmark for surveyors to evaluate a facility's nursing staff levels based on a facility's resident case mix.
Connecticut must follow HCFA's protocol, thus, any additional state requirements to evaluate staffing, if too complex, would require additional staff resources for DPH.
RECOMMENDATION
1. The Department of Public Health should obtain a nursing facility's annual number of registered nurse, licensed practical nurse, and nurse aide hours and total resident days from the Department of Social Services as reported in the Medicaid cost report prior to conducting a federal standard survey or state licensure inspection. The Department of Public Health's inspectors should calculate, based on the annual hours, an average daily staff-to-resident ratio for each facility and compare it to actual nursing staff levels during the conduct of the survey and/or inspection.
The Department of Public Health, at the time it conducts the federal standard survey and/or state licensure inspection, shall, in addition to current protocols, assess residents' acuity to ensure sufficient numbers and levels of licensed nurses and nurse aides are provided by the facility to meet required resident care needs.
The basis for the acuity system shall be HCFA's published 1995 and 1997 Staff Time Measurement Studies which determine the nursing minutes needed to care for each resident, ranked into any of 44 established resource utilization groups (RUGs). As needed, the Department of Public Health shall update this requirement taking into consideration any future versions of Staff Time Measurement Studies or RUG reclassifications.
Each resident's acuity shall be based on the data results of the last full resident assessment, as required by the Minimum Data Set, the assessment instrument designed by HCFA to assign each resident into a RUG level.
The total number of care hours required by the RUG category scores shall be compared to the amount of care hours actually provided by licensed nurses and nurse aides. If the number of care hours is less than that provided for in RUG, DPH shall review the facility's documentation, as required by Connecticut State Agencies Regulations Sec. 19-13-d8t(m)(3), as to the methodology used to determine the number, experience, and qualifications of staff necessary to comply with federal and state staffing requirements. Results of the comparison may be used to document insufficient staffing.
FINDINGS
There is some predictability in the number of days between survey cycles with 8 percent of all surveys conducted occurring within seven days (plus or minus) of the facility's most recent survey cycle; 20 percent within 15 days; and more than one-third within 30 days.
It appears more difficult for facilities to predict when a survey might occur based on its geographic location.
An adequate number of night/weekend surveys are being conducted by DPH.
RECOMMENDATION
2. The Department of Public Health should track the date and location of each facility's federal survey and state licensure inspections to ensure more randomness in the number of days between cycles, with no survey or state licensure inspection occurring within 15 days before or after the previous survey or inspection date.
NURSING-STAFF-TO-RESIDENT RATIOS
FINDINGS
Connecticut's current nursing staff ratio requirements are confusing, administratively complicated, and limit a facility's flexibility - currently, there are eight separate nursing staff-to-resident ratios depending on:
· a facility's licensure category, and
· the time of day.
The current ratios were established in 1981, almost 20 years ago while from all accounts in the literature, the health care needs of residents have increased.
With the percent of total nursing home residents aged 85 and older increasing in Connecticut's facilities, other assisted living housing options available for individuals who do not need the level of care provided for in a nursing home, and a trend of shorter hospital stays so that sub-acute care is being provided in nursing homes, homes increasingly care for the most frail and needy population.
DPH began revising the current regulations in 1995 and almost six years later they still have not been submitted to the Regulation Review Committee.
The only nursing staff ratios based on analysis of resident outcomes are those put forth by HCFA.
RECOMMENDATION
3. The state Department of Public Health shall not issue or renew the license of a nursing facility unless that facility employs the nursing personnel needed to provide continuous 24-hour nursing care and services to meet the needs of each resident in the nursing facility.
By October 1, 2001, aggregate licensed nursing and nurse aides staffing levels shall be maintained at or above the following standards for nursing facilities licensed by the Department of Public Health as chronic and convalescent nursing homes and rest homes with nursing supervision:
By October 1, 2002, aggregate licensed nursing and nurse aides staffing levels shall be maintained at or above the following standards for nursing facilities licensed by the Department of Public Health as chronic and convalescent nursing homes and rest homes with nursing supervision:
The director of nurses shall not be included in satisfying the licensed nursing staff requirement for facilities with a licensed bed capacity of 61 or greater.
Facilities with a capacity of 121 licensed beds or greater shall employ a full-time assistant director of nurses who shall not be included in satisfying the licensed nursing staffing requirement.
"Direct care" means hands-on care provided to residents, including, but not limited to, feeding, bathing, toileting, dressing, lifting, and moving residents. Direct care does not include food preparation, housekeeping, or laundry services, except when such services are required to meet the needs of an individual resident on any given occasion.
Each nursing facility licensed by the Department of Public Health as a chronic and convalescent nursing home or a rest home with nursing supervision that fails to meet the minimum nursing staff-per-resident ratios on any day shall submit a quarterly report to the Department of Public Health. The report shall identify the day(s) and shift(s) the minimum nursing staff ratios were not met, how they were not met, and the reason(s) they were not met.
Upon determination by DPH that evidence exists of a pattern of failure to comply with mandated staff ratios, the Department of Public Health shall have grounds to take enforcement action in accordance with C.G.S. Sec. 19a-524.
WAGE, BENEFIT AND STAFFING ENHANCEMENT PROGRAM
FINDINGS
Since information in annual cost reports submitted to the Department of Social Services is increasingly being used for staff and wage analysis among nursing facilities, there is a need to refine the categories to more accurately distinguish nursing staff that provide direct resident care from those performing administrative tasks.
RECOMMENDATION
4. The Department of Social Services should amend pages 10 and 13 of the Medicaid cost report, beginning with the 2001 submission, so that salaries and wages, and hours for RN and LPNs involved in providing direct care to residents shall be reported separately from RNs and LPNs involved in administrative functions.
"Direct care" shall mean the provision of direct care and services to the resident, commonly referred to as hands on care services, including, but not limited to, the administration of medication and treatment, feeding, bathing, toileting, dressing, lifting, and moving residents. Administrative nurse functions shall include, but not be limited to, infection control, in-service training, and maintaining the federally required minimum data set.