Introduction
Staffing in Nursing Homes
The Legislative Program Review and Investigations Committee voted to study Staffing in Nursing Homes in March 2000.1 The study focuses on the current minimum nursing-staff-to-resident requirements, 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.
Several factors impact the quality of nursing care provided to residents of nursing homes. Some, such as ensuring staff complete a certain number of training hours, are easier to legislate than others, like guaranteeing each resident is treated with compassion and kindness. A recent study released by the Health Care Financing Administration (HCFA) identified the type and number of nursing staff available to provide care to residents as a key measure of quality.2 The study, the first to measure resident outcomes in relation to nursing staff levels, found residents were at increased risk for malnutrition, bedsores, dehydration, and preventable hospitalizations when nursing staff levels dropped beneath 2.75 hours per resident day.
Nursing-staff-to-resident ratios. The program review committee concludes the staffing ratios in Connecticut nursing homes need to be raised. Although regulations of Connecticut's Department of Public Health establish minimum nursing-staff-to-resident ratios (1.9 hours per resident day), these regulations were adopted over 20 years ago. From all accounts in the literature, health care needs of residents have increased. In recognition of this, revision of the regulations began in 1995 -- draft proposed regulations increase the ratio to 2.48 hours per resident day -- but the department has still not submitted them to the legislature's regulation review committee. Thus, although DPH initiated the move to increase the nursing-staff-per-resident-day ratio, the standard remains the same almost six years later.
In addition to the long delays, the proposed DPH regulations may not raise the minimum ratios to adequate levels and therefore the committee did not support that proposal. The committee found the HCFA nursing-staff-to-resident ratio is based on the most comprehensive and defensible research to date, and, therefore, believes it is the most valid. The committee therefore recommends the HCFA study standard, which requires:
This recommended standard would require minimum nursing staff thresholds, merely establishing a floor below which a facility cannot drop. It does not negate the federal and state requirements that nursing facilities provide adequate nursing staff to meet residents' needs.
Medicaid costs to increase ratios. Government, mainly through Medicaid reimbursement to nursing facilities, pays a majority of the total nursing home expenditures. Connecticut General Statutes Section 17b-340 provides that nursing homes are eligible for direct reimbursement of costs added to comply with changes in the Public Health Code. If minimum nursing staff standards are raised, facilities' per diem Medicaid reimbursement rates would also have to be increased by the state.
The committee estimates the additional Medicaid costs to the state to implement the HCFA minimum staff ratio will be about $6.8 million. The committee's estimates are contained in Chapter Three, and based on 1999 annual cost report information submitted to the Department of Social Services (DSS) by each Connecticut nursing facility that receives government reimbursement. Increasing nursing staff ratios to 2.75 hours-per-resident-day will require an addition Medicaid cost of $13.7 million but half of that will be reimbursed to the state by the federal government. Because of these costs, and given Connecticut's budgetary constraints, a two-year phase-in of the standard is recommended. In addition, Congress may provide federal funding, as a result of HCFA's study, as an incentive for states to increase nursing staff ratios. The recommended phase-in would mean Connecticut would still be eligible for any federal funding if it was provided within the next two years.
Nursing staff shortages. Concerns also exist among industry representatives and some policymakers that higher nursing staff thresholds should not be mandated when facilities are having difficulty recruiting nursing staff, particularly licensed nurses. The committee believes its recommendation will not seriously impact that shortage. First, it should be emphasized many of the nursing homes in Connecticut already meet the recommended standard. Much of the staffing increase would be needed by facilities licensed as rest homes with nursing supervision (RHNS). There were 243 facilities with data on file at DSS -- 234 chronic and convalescent nursing homes (CCNH), and 63 RHNS, of which 52 are within a CCNH and nine are freestanding.
The committee found all nursing homes licensed as chronic and convalescent nursing homes (CCNH):
For rest homes with nursing supervision, 29 facilities would need to increase licensed nurse hours and 52 facilities need to increase nurse-aides-to-resident ratios.
Second, facilities not currently meeting the proposed ratio will benefit from the recommended two-year phase-in. This should provide facilities with some additional time to recruit staff, while DPH implements any recommendations put forth resulting from its study of the nursing shortage in Connecticut. In addition, the methodology used by the committee to calculate the cost estimate for increasing nursing staff to the HCFA ratio allows for the potential use of temporary agency nurses and aides by facilities to meet the new standard.
Turnover in staffing. The program review committee recognizes that one of the issues with staffing in nursing homes is the ability of facilities to retain personnel once hired. The Connecticut Department of Labor provided data for the study that measures overall turnover for all staffing in nursing facilities for each calendar quarter during 1998 and 1999. This would include turnover for staff in housekeeping, kitchen, laundry, and other indirect staff as well as for nurses and nurse aides. The committee averaged the leaving rate of all facilities for each year and determined the turnover rate was 43.3 percent in 1998 and 46.3 percent in 1999.
The committee understands these turnover rates are very high -- almost one of every two employees left during each of the two years -- and believes the rates are an indication of the extremely difficult and demanding nature of working in nursing homes. However, the committee believes raising the minimum ratios in nursing facilities may reduce job burnout by making the work environment less stressful and thus reducing turnover.
Assessment of staffing adequacy. The committee also examined how DPH determines, when conducting an inspection, if nursing staff is adequate to care for residents. Although both federal and state laws require nursing facilities to provide sufficient nursing staff to meet the needs of the residents, the committee found the department's ability to assess staffing, beyond determining if the minimum standards have been met, is extremely limited. The committee found 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. A methodology to conduct this evaluation has been recommended by the committee.
Nursing Home Financial Advisory Committee. Finally, this study includes monitoring and reporting on recommendations proposed by the Nursing Home Financial Advisory Committee. This committee was charged with examining financial solvency of nursing homes on an ongoing basis, supporting the Department of Social Services (DSS) and DPH in their mission to provide oversight to the nursing home industry, and conducting a study of the nursing home rate-setting system.
The advisory committee held eight meetings and has been unable to reach any consensus or develop recommendations on how financial solvency of nursing homes should be monitored by DSS. The last meeting of the committee was July 18, 2000, and another was recently scheduled for January 31, 2001. The committee has not undertaken the rate-setting study because legislative funding was never provided.
Report organization. This report contains four chapters. The first presents general background information about nursing homes in Connecticut and the people who reside in them. The next two chapters focus on nursing staff -- what the requirements are, how they are monitored and enforced by Connecticut's Department of Public Health, and what efforts are underway to increase nursing staff. Chapter Two describes the inspection process used by the Department of Public Health to assess the adequacy of nursing staff. The committee's findings and recommendations to improve the inspection process are also provided. Chapter Three summarizes Connecticut's current regulatory nursing-staff-to-resident ratios, describes different nursing staff-to-resident proposals being discussed both nationally and in Connecticut, and presents findings and recommendations related to each proposal. The last chapter analyzes the impact of the Wage, Benefit, and Staffing Enhancement Program, approved by the legislature in 1999, to increase wages and benefits for nursing home employees.
Agency Response
It is the policy of the Legislative Program Review and Investigations Committee to provide state agencies subject to a study with an opportunity to review and comment on the recommendations prior to publication of the final report. The response from the Department of Public Health is contained in Appendix A and the Department of Social Services response is in Appendix B.
1 Nursing staff is defined as registered nurses (RNs), licensed practical nurses (LPNs), and nurse aides.
2 HCFA, Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes, Report to Congress, July 2000.