Nursing home workforce crisis deepens with minimum staffing standards – Herb Weiss

By Herb Weiss, contributing writer on senior issues

“The long-term care industry is enduring the worst workforce crisis in its history, in Rhode Island, and across the country. Although providers are committed to recruiting and retaining staff to provide quality care for residents, despite our best efforts, many nursing homes have fallen short of the staffing ratio set by the RI Department of Health,” notes James Nyberg, Executive Director of the East Providence-based Leading Age Rhode Island (LARI), representing nonprofit providers of aging services.

“We are extremely  concerned about the impending fines that will be imposed on nursing homes here in Rhode Island as a result of our state’s existing nursing home minimum staffing ratio statute,” said Nyberg. Because of staffing ratio mandates, “the industry would have faced fines of over $11 million, in just one sample quarter (April – June 2022), since over 70% of nursing homes are not in compliance,” he said.  

“While April-June was a sample, the fines go into effect for July-September and we will receive a similar notice in just a few weeks, with only 10 days to pay the fine,” says Nyberg, stressing that these fines will only increase going forward if nursing homes are unable to meet the minimum staffing ratio.

Nyberg calls on the Rhode Island General Assembly to rescue Rhode Island’s nursing homes and provide relief from these penalties by delaying them and exploring an alternative approach to support the efforts of nursing homes to meet the ratio.  He warns that the current fine-based approach is excessive and counterproductive and will lead to reduced access to care and threaten the survival of the state’s nursing homes.

Nyberg points out that the current workforce shortages are already preventing nursing homes from filling open positions, limiting new admissions, and forcing organization closures (five nursing homes have already closed since the COVID pandemic began).  These challenges are also resulting in backlogs at hospitals, which are unable to discharge patients due to reduced capacity in nursing homes.  

“We are working with numerous stakeholders on various initiatives to develop a pipeline of workers, but the simple fact is that it will take time.  In addition, as you know, the industry has faced years of underfunding from Medicaid, which pays for the majority of nursing home care.  This has made recruiting and retaining workers more difficult than ever,” says Nyberg. 

John Gage, President of the Rhode Island Health Care Association (RIHCA) agrees with Nyberg’s assessment of the nursing home workforce.  “Nursing homes across the nation are facing an historic labor shortage as the direct result of chronic Medicaid underfunding and the devastating impact of the Covid-19 pandemic on the workforce, he says, noting that the state’s nursing home workforce is down 20% since the start of the pandemic, with 2,000 workers lost from Jan. 2020 to June 2022.  Nationwide, the nursing home workforce is down 210,000 workers.

According to Gage, Rhode Island’s staffing mandate, while well-intentioned, will siphon tens of millions of dollars from resident care. In the first year of full implementation of the state’s minimum staffing mandate, RIHCA estimates that facilities will be fined upwards of $60 million. “These fines will imperil care, not bolster it,” he warns.  

Without legislative action, Rhode Island nursing homes will be fined an estimated $11 million on or about February 28, 2023, because of their inability to attract workers to meet the mandate from July 1, 2022, through September 30, 2022, Gage charges. “There are simply not enough available workers to fill the open staff positions, and resources are scarce.  Nursing homes will be devastated by these fines.  Facilities will reduce admissions, backing up hospital referrals and clogging hospital beds.  More nursing facilities will close – five have already closed since the beginning of the pandemic,” he predicts.  

Gage asks, “Who will care for Rhode Island’s frailest elders?” To recreate a minimum staffing mandate in nursing homes on the federal level would be a huge mistake, especially given the historic workforce crisis here in Rhode Island and nationwide,” he says.  

Gage’s comments echo concerns expressed by another group of US Senators in Jan. 20 correspondence (https://www.tester.senate.gov/wp-content/uploads/1-20-23-Nursing-Home-Staffing-Mandate-Letter-FINAL.pdf) sent to CMS by Senators John Bourasso, Jon Tester, and eleven other US Senators.  They caution the agency that a one-size fits all mandate would undermine access to care for patients, and they encouraged CMS to work with Congress on tailored solutions that address the workforce challenges facing nursing facilities.

At the federal level

Just days ago, U.S. Senators Bob Casey (D-PA), Chairman of the Senate Committee on Aging, and Ron Wyden (D-OR), Chairman of the Senate Finance Committee, called on the Centers for Medicare & Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure to encourage the federal agency to establish minimum staffing standards in nursing homes to ensure high-quality care for nursing home residents. In Feb. 10 correspondence, Casey and Wyden, along with Senators Sherrod Brown (D-OH), Kirsten Gillibrand (D-NY), Richard Blumenthal (D-CT), Cory Booker (D-NJ), and Elizabeth Warren (D-MA) urged CMS to advance the agency’s ongoing study to determine adequate staffing requirements in nursing homes.

“We appreciate the work that CMS has undertaken to promote safety and quality in nursing homes and applaud the Biden-Harris Administration’s commitment to protecting our nation’s seniors,” said the senators in Feb. 10 correspondence, urging CMS to “bring this work to completion.” 

“In our view, that means continuing the agency’s ongoing study to determine the level of staffing that is necessary to ensure safe and high-quality care for nursing home residents, developing an evidence-based and actionable proposal for mandatory minimum staffing levels, and a robust and transparent process—including direct stakeholder engagement— that will allow for further discussion and fine-tuning of requirements before the proposal is finalized,” wrote the senators.

The senators noted that studies have shown a correlation between inadequate staffing levels and lower quality of care. More recent studies have demonstrated that higher nurse staffing ratios mitigated the effect of COVID-19 outbreaks in nursing homes and resulted in fewer deaths. A recent Department of Health and Human Services Office of Inspector General report examining the high level of COVID-19 infections in nursing homes also pointed to the need for the establishment of minimum staffing requirements.  

In the correspondence, the senators cite the Social Security Act, which requires skilled nursing facilities to “provide 24-hour licensed nursing service which is sufficient to meet nursing needs of its residents,” including the services of a registered nurse at least 8 consecutive hours per day, 7 days a week. The letter commends CMS for working to update this vague standard that has led to substantial variation in staffing levels and quality of patient care across facilities.

“Achieving the shared goal of ensuring quality care in nursing homes nationwide is a complex undertaking, says LeadingAge’s Ruth Katz, senior vice president, policy. LeadingAge is an association of nonprofit providers of aging services, including nursing homes.

“As our Get Real on Ratios proposal highlights, a number of conditions must be met in advance of any mandate implementation,” suggests Katz. “The senators correspondence to CMS is a promising development; it covers many of the same points as our Get Real on Ratios proposal – a recognition of the critical need for adequate reimbursement; that one size does not fit all, and that workforce shortages will need to be addressed with additional support. Without addressing these, staffing mandates are impossible. We look forward to continuing our discussions with Congressional leaders on this critical issue so that older adults and families can access much-needed care and services,” she says.

“The Senior Agenda Coalition of RI fully supports the need to develop national staffing standards to ensure quality care is provided to nursing home residents across our nation. It is important to note that Rhode Island has been a leader in this area. For many years our state has required 24/7 RN coverage in nursing homes and in 2021 the legislature passed the Nursing Home Staffing and Quality Care Act that includes staffing standards,” says Maureen Maigret, Policy Advisor to Senior Agenda Coalition of RI. “Now we must work to address workforce shortage issues and ensure that adequate government resources are provided especially through Medicaid payments so the standards can be met, and our critical direct care workers receive competitive living wages in order to keep them working in long term care,” she adds.

As the House Leadership hammers out the FY 2024 budget, it is crucial that adequate Medicaid funding is allocated to allow nursing homes to attract the necessary staff to meet the state’s minimum nursing standards that it codified into law. We must address this policy problem now rather than just kick the can down the road.

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Herb Weiss, LRI’12, is a Pawtucket-based writer who has covered aging, health care and medical issues for over 42 years. To purchase his books, Taking Charge: Collected Stories on Aging Boldly, and a sequel, compiling weekly articles published in this commentary, go to herbweiss.com.