Chapter Three

Nursing Staff Ratios

Over the last several years much interest has been focused on the quality of care provided to residents of nursing homes. One area receiving particular attention among policymakers in many states is legislation that establishes or increases a state's minimum number of nursing-staff-to-residents standards in nursing homes. Advocacy efforts by the National Citizen's Coalition for Nursing Home Reform (NCCNHR), a national consumer advocacy group with state chapters, have been successful in bringing the issue of staffing in nursing homes to the forefront. In addition, a recent study by the Health Care Financing Administration also spotlighted the issue, finding a relationship exists between the number and type of nursing staff in a facility and the quality of resident care.

One area in which most states have imposed a stricter standard than required under federal law is in establishing minimum nurse-staff-to-resident ratios. By establishing higher thresholds, states have recognized there is a relationship between the quality of resident care and nursing staff levels. In addition, the ratios have provided regulators with a specific standard to measure whether facilities meet at least the minimums established by the state.

This chapter describes Connecticut's mandatory nursing-staff-to-resident minimum ratios, summarizes other proposals to increase the ratios, and estimates the costs associated with implementing each proposal. The committee's findings and recommendations are presented at the end of this chapter.

Nurse Staffing Regulatory Requirements in Connecticut

Public Health Code nursing staff requirements. Similar to the federal law, Connecticut's Public Health Code requires each nursing home to "employ sufficient nurses and nurse aides to provide appropriate care of patients housed in the facility 24-hours per day, seven days a week." However, Connecticut's PHC also establishes specific nurse and total direct-care-staff-to-resident ratios. In addition, the code requires the actual number, qualifications, and experience of such personnel be "sufficient to assure" that each patient:

• receives treatment, therapies, medications, and nourishments as prescribed in his/her patient care plan:
• is kept clean, comfortable, and well-groomed; and
• is protected from accident, incident, infection, or other unusual occurrence.

The actual number of nurse and nurse aide staff required under the Public Health Code depends on whether the home is licensed as a chronic and convalescent nursing home or a rest home with nursing supervision. As noted in Chapter One, CCNH beds represent 93 percent of the total (32,080) nursing home beds in the state. The nurse-to-resident-hours per day are much less for residents of RHNSs because a much lower level of care is needed by those residents.

The Public Health Code has a stricter standard than HCFA by requiring each type of nursing home have at least one registered nurse on duty 24 hours per day, seven days a week. In a CCNH, there must be at least one licensed nurse on duty at all times on each resident-occupied floor. In a RHNS, the health code requires at least one nurse aide be on duty at all times on each resident-occupied floor, and intercom communication must be available with a licensed nurse. The facility's administrator and director of nursing are required to meet at least once every 30 days to determine the number, experience, and qualifications of staff necessary to comply with the regulations.

Table III-I describes the minimum nurse and nurse aide staffing requirements for CCNH and RHNS beds in Connecticut. The regulations establish minimum standards for nursing-staff-to-resident ratios during two segments of a 24-hour day and are expressed in terms of staff hours per patient (hpp). For example, on average the regulations require each resident receives 84 minutes of total nurse and nurse aide care during the 7 a.m. to 9 p.m. shift - which equals six minutes for each hour. It is important to note, nurse aide hours per patient are not specifically mandated -- a facility can have any combination of licensed nurses and nurse aides to meet the total nursing personnel category -- as long as the total hours of nursing meets the minimum standards.

The current minimum total nursing staff hours per resident in a CCNH bed is 694 hours annually. This means each resident can expect to receive 13.31 hours of direct care each week. Figure III-1 shows the minimum number of nurse and nurse aide hours required per- resident-day is 1.9 hours (one hour and 54 minutes) - an average of less than five minutes of care per resident, per hour. In terms of licensed nursing personnel for a CCNH, the minimum requirement is .64 hours (38 minutes) per day. Licensed nurses or nurse aides may make up the remaining staff per hour. If nurse aides provide all of the non-licensed care that is allowed, they will provide a total of one hour and 16 minutes of care per resident each day.

The requirements for RHNS are also presented in the figure. The nurse-to-resident hours per day are much less for rest homes with nursing supervision because those residents do not require the level of care provided to residents of CCNHs. Since these types of beds account for only 7 percent of all licensed beds in nursing homes, the analysis below focuses only on CCNH beds.

Supervisory nurses. Also, it is important to note, depending on the number of licensed beds in a facility, the regulations allow certain supervisory licensed nurses to be counted toward meeting the minimum direct-care nursing staff requirements. In facilities with 60 beds or less, the director of nursing may or may not be included in meeting the direct-care-staff-to-resident ratios. In facilities with 61 beds or more, the director of nurses must not be included in meeting the above requirements. Also, in facilities of 121 beds or more, the assistant director of nurses must not be included in meeting the above requirements.

Breakdown of staff by shifts. The nursing staff coverage mandated under the regulations divides a 24-hour day into two segments. These segments do not match the three-shift coverage (7 a.m. to 3 p.m.; 3 p.m. to 11 p.m.; and 11 p.m. to 7 a.m.) that is typical in nursing homes. For the purpose of analysis, Figure III-2 configures the nursing staff minimums based on a typical home's nurse staffing pattern - three eight-hour shifts. In addition, nurse aides are listed separately, although beyond the minimum licensed nursing staff requirement, any combination of nurses and aides may be used as long as total nursing staff meets the minimum standards.

For the day shift, 48 minutes of total nursing care per resident is required - an average of six minutes of care per hour per resident. The regulations only require half that number of nursing staff at night, with 24 minutes of nursing care per patient per shift - an average of three minutes per resident per hour. The reason for lower nursing staff at night is because residents are asleep and require less direct care than during the day and evening shift.

Monitoring nursing staff ratios. A facility's compliance with nursing-staff-to-resident ratios is measured through the federal survey and state licensure process. As described in detail in Chapter Two, nursing staff schedules are examined by DPH inspectors to ensure minimum ratios are met. If, during the course of an inspection, serious quality-of-care problems are identified, an in-depth review of staffing will occur. Since 1998, DPH has issued twelve deficiencies to ten nursing facilities for insufficient nursing staff. Plans of correction are monitored by DPH to ensure staffing problems are corrected.

DPH Draft Proposed Regulations

The Department of Public Health is in the process of revising the current minimum ratios of nurses and nurse aides to residents that were adopted in 1980. Although draft regulations have been written, they have not yet been submitted to the attorney general's office for approval.

The draft regulations increase the annual number of nursing-staff-to-resident ratios from 694 to 905 hours - an increase of 211 hours or 30 percent. The proposal also provides more flexibility for nursing facility providers to determine overall nurse staffing patterns by establishing a 24-hour total nursing-staff-to-resident ratio, and only requires set minimums between the hours of 11 p.m. and 7 a.m. Like the current regulations, the draft regulations also require that staffing levels be sufficient to provide necessary care and services to meet the needs of the residents on a continuous basis.

Figure III-3 compares total nurse and nurse aide hours per resident day required under the current and draft regulations. Under the proposed regulations, there must be a total of 2.48 hours of care provided per day, rather than the current 1.9 hours -- an increase of 35 minutes each day.

National Efforts

National Citizens' Coalition for Nursing Home Reform. Beyond the proposals for changes here in Connecticut, efforts have been underway nationwide to examine nursing staff levels and determine whether new federally mandated nursing staff ratios should be adopted. The National Citizens' Coalition for Nursing Home Reform has lobbied for an increase in nursing staff ratios for several years. The nursing staff recommendations proposed by NCCNHR are based on recommendations issued by a panel of experts convened at the John A. Hartford Institute for Geriatric Nursing, New York University, for a conference on "Staffing, Case Mix and Quality" in April 1998. The panel attendees included national experts, consisting of leading nurse researchers, educators and administrators in long-term care, consumer advocates, health economists, and health services researchers.

The panel reviewed current staffing ratios of registered nurses, licensed practical nurses, and nursing assistants, and concluded the current levels are inadequate. Seventeen out of the 30 conference participants endorsed a final staffing recommendation that established 4.55 total nursing hours per resident day as a minimum threshold. Noting that nursing management and leadership are central to providing a high quality of care in nursing facilities, the panel also recommended the director of nursing in nursing facilities have a minimum of a bachelor's degree.

The panel identified cost as a key barrier to adding more nursing personnel. They noted an increase in Medicare and Medicaid spending is needed to increase the number of nursing staff and education and training of staff.

According to NCCNHR, the greatest weakness in the 1987 Nursing Home Reform Act was the failure to establish minimum nursing-staff-to-residents standards. NCCNHR's "Consumer Minimum Staffing Standard" requires a minimum total number of direct nursing care staff of 4.13 hours per resident day, slightly lower than that recommended by the Hartford Institute panel. These standards take into account the time required to assist residents with their activities of daily living, provide treatments and medications, and plan coordination and supervision at the unit level. In addition to the minimum direct-care-staff standard described below, the threshold protocol also requires every nursing facility to have a:

• full-time director of nurses (DoN) who is an RN with a bachelor's degree;
• part-time Assistant RN DoN (full time in facilities with 100 or more beds):
• part-time RN director of in-service education (full time in facilities with 100 or more beds); and
• full-time RN nursing supervisor on duty at all times (24 hours, 7 days per week).

Disclosure. The coalition also recommends that each facility post its current number of licensed and unlicensed nursing staff directly responsible for resident care. As part of the disclosure requirement, current ratios of licensed nurses and nurse aides per resident for each wing or floor of the facility should also be posted.

Department of Health and Human Services study. As noted earlier, in July 2000, HCFA issued phase one of a report to Congress, after studying the relationship between nursing staff levels and resident quality of care for almost 10 years. The study found a strong association between nursing staff levels and quality of resident care, with residents of facilities staffing below certain levels at increased risk of bedsores, malnutrition, abnormal weight loss, and preventable hospitalizations. The study methodology included a review of prior literature, a multivariate analysis of the relationship between staffing and quality in three states (New York, Ohio, and Texas), and a time-motion approach to setting nursing staff standards. Preliminary study findings contained in phase one of the report show a strong association between nursing staff levels and the quality of resident cares.

The HCFA study also examines the nursing staff standards put forth by the Hartford Institute panel and adopted by NCCNHR. It notes that "although expert panels are normally established to follow highly structured protocols in reviewing published research for the purpose of making recommendations, [HCFA] cannot determine how the panel arrived at their recommendations, and found it difficult to reconcile our review of selected research on the relationship between nurse staffing and resident outcomes with the Hartford panel."⁸ As part of the review, however, the study compared nursing staff levels among states and estimated the number of facilities that would need to increase staffing to meet the levels proposed by the Hartford panel. In Connecticut, 97 percent of nursing facilities would need to increase staffing, if the Hartford panel recommendations were adopted.⁹

In its comparison of nursing staff hours per resident day among states, data were obtained from HCFA's computerized reports system (OSCAR). At the beginning of a facility's survey to receive certification under the Medicare and Medicaid programs, facilities are required to complete a standardized HCFA form on nursing staff hours (by type of staff and function) and certify the information is accurate. This information is entered into the OSCAR system by state surveyors. It is important to note however, that staffing data contained in the OSCAR database are self-reported, and not audited by an independent party.

Figure III-4 compares Connecticut's nursing home staff to other homes in the Northeast Region for 1998. According to the OSCAR database, Connecticut's average nursing-staff-hours-to-resident-day is the second lowest in New England - 3.2 hours per resident day. Maine had the highest average staffing ratio at 3.86, followed by New Hampshire at 3.73. Appendix H shows the average nursing hours per resident for each state in the U.S. The report notes that reasons for variation in staffing levels among states could be due to a variety of factors. These include: the reliability of OSCAR data, acuity level of residents, Medicaid reimbursement rates, labor market conditions, differences in practice patterns, or differences in the quality of care.

Preliminary study findings. HCFA's preliminary study findings identify two possible nursing-staff-to-resident-day standards, both lower than those put forth by the Hartford Institute panel or NCCNR. The ratios include a:

• minimum ratio that may reduce the likelihood of quality-of-care problems; and
• higher "preferred minimum" ratio, which the study indicated would contribute to improvements in quality of care.

It is important to note, neither of these standards has been adopted by HCFA. The second phase of HCFA's study is expected to be completed in the Fall of 2001. This phase will: refine ways to adjust minimum staffing requirements for the case mix, or severity of illness, and the amount of care required by residents in a given facility; expand the study beyond the three states included in the research thus far; and determine the costs and feasibility of adopting a federal minimum nursing staff standard.

The two staffing ratios contained in phase one of HCFA's study are shown in Table III-2. The preliminary study findings indicate the minimum staffing level associated with reducing the likelihood of quality problems is approximately 2.75 hours per resident day, regardless of a facility's case mix. The preferred minimum total staffing levels at which quality was improved across the board was 3.00 hours per resident day.¹⁰

In addition, the study emphasized that ideally nursing staff minimum ratios should be based on the acuity (health and care needs) of residents within a facility. The report notes, however, that no models currently exist to group facilities by resident acuity and thereby establish different nursing staff ratios. Finally, the study also noted that even if cost increases could be absorbed that alone may not be enough to obtain nursing staff at realistic wage levels.

Specifically, HCFA's study findings indicate:

• levels or thresholds for nursing staff exist, below which facilities are at substantially greater risk for quality problems;
• thresholds can be identified for all types of nursing staff;
• these thresholds are dependent on a facility's case mix (characteristics of residents in a facility);
• nursing staff levels will need to be increased in a substantial portion of facilities across the U.S. to improve quality of care; and
• facilities have more quality problems if they have less than 12 minutes of registered nursing care, 45 minutes of total licensed staff care, and 2 hours of nursing aide care per resident per day.

Comparisons among Connecticut Regulations and Other Staffing Minimums

Table III-2 compares Connecticut's current and proposed nursing-staff-to-resident ratios with those recommended by NCCNHR, and contained in HCFA's nursing staff study. For the purposes of analysis, Connecticut's and NCCNR's ratios are separated into two categories -- nurse aides and licensed nurses; even though any combination of nurse aides and licensed nurses can be used beyond the minimum licensed nurse requirements. Although NCCNR has the highest total hours, HCFA's preferred minimums exceed all of the other proposals for licensed nurse hours per day.

The program review committee converted the various minimum-staffing ratios from hours-per-resident-day to the number of nursing staff that would be required based on a hypothetical 8-hour a day shift. The results are shown in Table III-4.

Selected Other States

Although the majority of states (35) have established some type of nursing staff requirements that go beyond the federal law (i.e., licensed nursing services 24 hours per day, seven days a week, with a registered nurse on duty for at least eight of those hours), the requirements vary considerably from state to state. In addition, there has been a flurry of proposed state legislation to establish (for states without requirements) or increase nursing-staff-to-resident ratios as the way to improve quality of nursing home care. Indeed, at least 14 states, including Connecticut, raised legislation during the 2000 session concerning nursing staff ratios. States that recently increased their nursing staff standards include California, Delaware, Kentucky, Maine, Maryland, and Minnesota, and all vary in terms of the minimum number of nursing hours per resident-day required. (See Appendix I for Office of Legislative Research Report describing legislation.)

Most of the proposed legislation has been based on the standards put forth by NCCNHR. The reason for this, in the opinion of the committee, is the NCCNHR standards received national exposure and been extensively lobbied. In addition, until HCFA released its study in July 2000, there were no other national proposals existing; thus, NCCNHR's were the only standards. However, it appears the NCCNHR standards were arrived at by a consensus based on expert opinion, rather than any empirical study findings.

Other New England states. The committee also conducted a telephone survey of the other five New England states to determine if they have nursing staff standards and how they monitor staffing in homes. Four of the states do not have standards, but follow federal requirements. Maine and Connecticut are the only two states that have minimum nursing staff ratios in statute or regulation. Rhode Island proposed legislation during its last legislation session, but it was not adopted.

In its last legislative session, the state of Maine adopted legislation increasing nursing staff levels. It defines direct care providers and requires, by October 1, 2000, minimum ratios of one direct care provider for every five residents for the day shift, one to 10 residents for the evening shift, and one to 18 for the night shift. These standards equate to a ratio of 2.84 hours of direct care per resident-day.

According to Maine's Nursing Home Ombudsman's Office, the majority of Maine's 113 nursing facilities already meet the newly adopted standard with only 11 facilities needing to increase their nursing staff levels. In addition, the legislation requires Maine's Department of Human Services to begin developing staffing ratios based on resident acuity levels and report its progress to the legislature by May 2001. However, the program review committee contacted a spokesperson within the Bureau of Elder and Adult Services in December 2000, and was told that work on developing acuity based staffing ratios has been postponed indefinitely, primarily because no accepted model exists, and the state first needs to implement the nursing staff ratios adopted in the legislation.

Committee Analysis of Nursing-Staff-to-Resident Ratios in Connecticut Nursing Facilities

There are no standardized data collected on a routine basis to monitor nursing staff levels in nursing homes so information on nursing-staff-to-resident levels per shift is not readily available. The OSCAR database and the Annual Report of Long-Term Care Facility (known as the Medicaid cost reports) are the only two aggregated sources of staffing data available in Connecticut. Staffing data contained in both the OSCAR database and the 1999 Medicaid cost reports are self-reported, not audited by an independent party, and are not validated against another source.

Nursing facilities report their costs annually to DSS. The Medicaid cost reports provide a comprehensive listing of facility staffing by total costs and hours, including nursing pool (i.e., temporary nursing) staff. The cost reports are used by the state to set a facility's Medicaid reimbursement rate.

Staffing and quality of care. A relationship between staffing and quality of care in nursing homes is inherently logical. However, the correlation is difficult to demonstrate because of the complexities in defining and measuring quality, the lack of valid nursing staff data, and the differences in residents' acuity levels among facilities. The committee obtained inspection data for each facility from the Department of Public Health to determine if the number of deficiencies issued to a facility correlated with the annual number of nursing staff hours each facility reported on its 1999 Medicaid cost report. The purpose of the analysis was to determine if facilities that received a high number of deficiencies reported less staff per resident day than those with zero or only one deficiency.

Analysis of deficiencies issued and staffing levels. The committee found no correlation between the number of deficiencies issued to a facility during its last inspection and the ratio of nursing and aide staff hours per resident day. A primary limitation of the analysis was resident case mix for each facility was unknown. As noted in the HCFA study, "controlling for case mix is essential in explaining the association between staffing and quality. Without adequate control for resident case mix, facilities that staff more heavily could score worse on quality measures merely because their residents have the greatest care needs and are at greatest risk for poor outcomes."¹³

Nursing homes meeting or exceeding nursing staff minimum ratios. The program review committee compared the minimum regulatory nursing staff requirements to actual hours of nursing staff reported by facilities in its Medicaid cost reports. There are several caveats attached to the data used for an analysis of the distribution of nursing staff among Connecticut's nursing facilities. First, the number of hours reported for RNs, LPNs, and nurse aides by facilities is self-reported and not audited by DSS. In addition, there are no uniform definitions for reporting on nursing staff hours. Thus, while some facilities may report paid hours, which include any vacation, sick, and personal time accrued, others might report actual hours worked. Third, nursing staff hours are reported on an annualized basis, but daily, weekly, and monthly nursing staff fluctuations may vary considerably. Finally, data were available for only 226 facilities out of the 253 licensed CCNHs, and estimates are based on an average 95 percent occupancy rate, rather than a facility's actual occupancy.

Based on an analysis of 1999 cost report filings, all of Connecticut's nursing facilities licensed as CCNHs exceed the minimum nursing-staff-to-resident-day ratios established under the regulations. Although the regulations require 694 annual minimum nursing staff hours for CCNHs, all nursing homes licensed under the CCNH category had 754 annual hours or more per bed in direct care staffing. Based upon the data contained in the cost reports, there was an average of 1,435 direct care hours per resident per year; more than double that required under the regulations.

Table III-5 shows the distribution of nursing staff hours in relation to the minimum standard of 694 nursing staff hours per resident day. One hundred and ten homes (49 percent) of those in the database reported nursing staff hours at one-and-one-half to two times the hours required under the regulations. The majority of homes provide nursing staff between one-and-one-half to two-and-one-half times the threshold -- well above the minimum.

The table shows that nursing homes have clearly staffed at levels above the minimum standards set by the state. The reasons for doing so relate to meeting residents' needs and providing a quality of care consistent with the level of funding provided by the state.

Although Connecticut established minimum nursing staff standards in 1980, almost all nursing facilities have staffing patterns that exceed those minimums according to Medicaid cost report data. In addition, since 97 percent of the facilities go beyond the minimum-staffing ratio, the threshold may be meaningless as a measure for regulators to use in determining the adequacy of nursing staff. Finally, although most facilities have higher levels than required, there is still wide variation among nursing facilities. Although the severity of residents' illnesses should account for much of this variation, there has been no analysis done at the state level that links higher nursing staff to facilities that serve sicker residents.

Medicaid Cost Estimates for Increasing Nursing Staff

A key barrier to adding more nursing staff is the cost, especially to the government, which pays a majority of all nursing home expenditures. The amount of increased funding would be dependent upon the number of additional staff needed to meet new minimums, and the cost of that added nursing staff on nursing home operations.

Current per diem rates set by the social services department account for each facility's present staffing levels. If minimum nursing staff standards are raised, per-diem rates would also have to be increased by the state. 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 (PHC). Therefore, any increases in nursing-staff-to-resident ratios would require additional funding, most likely through the Medicaid program.

Table III-6 provides cost estimates for increasing the nursing-staff-to-resident ratios, based on the four nursing staff proposals presented earlier in this chapter. The estimates are derived from 1999 Medicaid cost report information submitted annually to DSS by all nursing facilities. The database contained complete information for 243 facilities. This included 234 CCNH facilities, of which 55 also were licensed as RHNS, and nine freestanding RNHS facilities.

The estimates show the total cost to increase nursing staff levels would range from $12.7 million to $111.1 million, depending on the standard adopted. The state is only responsible to reimburse facilities for residents who receive Medicaid -- about 70 percent of all nursing home residents. The third column of the table shows the increased Medicaid cost. Any Medicaid costs incurred as a result of increasing staffing would be eligible for 50 percent reimbursement from the federal government. The state share (half of the Medicaid cost) is shown in the last column of the table. The extent to which homes staff at higher levels than those mandated - either in order to provide for nursing staff absenteeism or because of greater resident needs - determines if additional costs will be incurred.

It should be noted, under the DPH proposed and the HCFA minimum ratios, no new licensed nurses would be needed by CCNHs. Thirty-one facilities licensed as RHNS would need additional licensed nurse hours, if either of these standards were adopted. Adoption of the NCCNHR standard would impact the most facilities, with 215 CCNHs needing to increase aide hours, and 94 CCNHs needing to increase nurse hours. Almost all of the RHNS would need to hire additional nurses and aides to meet the NCCNHR proposal.

Methodology for estimates. The methodology used to calculate estimated costs is predicated on a number of assumptions. First, all hours reported for licensed nurses are included in the calculation.¹⁴ Next, it was assumed all of the nursing facility staff hours reported included paid vacation, sick, holiday, and personnel time, not only hours worked. Therefore, the annual number of nurse and nurse aide hours reported were reduced by 12 percent (six weeks of paid time off) to estimate actual hours worked.

To account for the use of nurses and aides supplied by temporary agencies, half of the total licensed nurses hours needed were calculated at an average pool nurse wage rate of $36.23, and half at an average facility-based hourly wage rate of $27.54 (includes 23 percent fringe). For nurse aides, one-quarter of the total number of hours needed were calculated at an average pool aide wage rate of $19.50, and three-quarters at an average facility-based rate of $14.82 (includes 23 percent fringe). Finally, an inflation factor of 6 percent was added to the total estimated cost to account for the time lag between the cost information contained in the 1999 Medicaid reports (based on reported expenditures and hours from October 1, 1998, through September 30, 1999) and likely costs at the end of the 2002 state biennium budget year.

Summary of Committee 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; and
•  
• the only nursing staff ratios based on analysis of resident outcomes are those put forth by HCFA.
• on the committee findings that current ratios are outdated, inflexible, and that attempts to approve regulations since 1995 have yet to produce results, the program review committee makes the following recommendations:

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:

• Over a 24-hour period, each facility shall provide:
  • At least 1.66 hours of direct care and services given by nurse aides per resident; and
  • at least 0.7 hours of care and services given by licensed nurses per resident, of which 0.1 hours shall be provided by a registered nurse.

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:

• Over a 24-hour period, each facility shall provide:
  • at least 2.0 hours of direct care and services given by nurse aides per resident; and
  • at least 0.75 hours of care and services given by licensed nurses, of which 0.2 hours shall be provided by a registered nurse.

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.

The program review committee believes the minimum nursing staff ratio suggested in HCFA's study is based on the most comprehensive and defensible research to date. Furthermore, the establishment of minimum nursing staff standards does not negate the federal and state requirements that nursing facilities provide adequate nursing staff to meet residents' needs. Minimum staffing thresholds merely establish a floor below which a facility cannot drop. In addition, the requirements under the Department of Public Health's current regulations (i.e., full-time director of nurses, 24 hour RN coverage seven days a week, and designated RN supervision per shift, etc.) would still be in effect beyond the statutorily increased minimum nursing-staff-to-resident ratios.

When minimum standards are set, the goal is to ensure those standards are adequate for residents with the lowest acuity or fewest needs. Facilities, however, should base nursing staff decisions on the acuity level of residents in their care. The committee believes many facilities already do this. In fact, the average number of nurse and aide hours per resident per year (1,435) for 1999 was more than double the required number under Connecticut's current minimum thresholds.

Minimum staffing ratios are only one tool in ensuring quality of care in nursing homes, but an extremely important one. Therefore, it is imperative the staffing ratios accurately reflect the requirements necessary to meet the needs of residents currently in nursing facilities. The program review committee believes the HCFA minimum standards are the most accurate and appropriate to meet these needs.

To be effective, staffing ratios need to be checked and verified. The program review committee believes the new ratios, along with the improved method to assess staffing during inspections as recommended in Chapter Two, should improve oversight of quality of care. In addition, the recommendation includes another oversight mechanism of staffing ratios - a requirement that facilities report when they cannot meet the minimum standards. While this is a self-reporting requirement, it should provide regulators with additional information in preparing for individual facility inspections, as well as serve as an indicator if staffing problems are occurring in certain geographic locations or within the nursing home industry overall.

The recommendation also provides flexibility in a number of ways. It moves to a single 24-hour ratio for both nursing facility licensure levels (CCNH and RHNS) and eliminates the separate requirements for different ratios for two segments of a 24-hour day. Most of the RHNS are a separate wing of a CCNH facility; thus, facility administrators need greater flexibility in allocating staff resources. Elimination of the segmented shift requirements allows administrators to place staff resources where residents most need them.

Finally, the recommendation has a two-year phase-in for the mandated higher nursing staff levels. The reason for this is three-fold. First, facilities are having difficulty recruiting and retaining licensed nurses and, to a lesser extent, nurse aides. A study currently being conducted by DPH will contain recommendations to address the shortage. Phasing in the nursing staff ratios will allow some time for those DPH recommendations to be adopted and implemented, before the full impact of the increased mandates will take effect. Second, adoption of the HCFA minimum standard will cost the state an additional $6.8 million per year. A phase-in allows those costs to be spread over a two-year period. Lastly, recommendations will most likely be proposed once HCFA completes its study. If funding incentives to increase staff ratios are part of the HCFA proposal, Connecticut should still have an opportunity to access them.

⁸ HCFA, Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes, Report to Congress, July 2000, pp. 6-17 and 6-33.

⁹ Ibid., p. 3-40.

¹⁰ Ibid., E.S.-6.

¹¹ Of the 0.75 hours per resident day, 0.2 must be provided by an RN.

¹² Of the 1.00 hours per resident day, 0.45 must be provided by an RN.

¹³ HCFA, Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes, Report to Congress, July 2000, p. 10-2.

¹⁴ All nursing hours except those of the director of nursing had to be included in the calculation because they are reported together for the Medicaid cost reports. Thus, there is no way currently to separate direct care nursing hours from those spent performing administrative or other indirect care.

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