SNF Operators in Favor of Staffing Standards But Not Without Funding, Role Expansion

Ahead of a federal minimum staffing ratio to be proposed for the nation’s nursing homes, data continues to show a shortfall of available staff to meet such requirements.

Many operators are in favor of higher staffing levels, but not without state or federal funding to hire and retain the appropriate level of staff. Others hope the types of positions counted in a staffing minimum will be expanded beyond registered nurses (RNs), licensed practical nurses (LPNs) and certified nursing assistants (CNAs).

The current federal requirement does not provide a specific daily minimum standard, rather, it states that nursing homes must provide “…sufficient nursing staff to attain or maintain the highest practicable … well-being” of every resident.

A recent Pulse survey conducted by Skilled Nursing News showed that 40% of respondents who operate in a state where staffing mandates are in place are unable to meet those requirements. About 56% of respondents to SNN’s survey said they operate in a state that requires staffing minimums.

Nearly 67% of survey respondents said they would also like to see other positions considered in creating a minimum staffing standard. Therapy providers were at the top of the list, followed by social workers and psychologists, temporary nursing assistants (TNAs) and activity coordinators, among other roles.

Though unscientific and relatively small in size, the survey data further drives home what is evident in larger data collection via the American Health Care Association (AHCA), LeadingAge, CliftonLarsonAllen (CLA) and the Bureau of Labor Statistics (BLS).

The SNN survey compiled data based on 99 respondents, a majority of which range from small, mid- and large-size operators.

The pros and cons of expanding the caregiver definition

University of Rochester Assistant Professor Brian McGarry’s impulse is to disagree with operators seeking to add other positions to the minimum staffing ratio list, as he is concerned that too many positions could skew data.

“As a physical therapist myself, I can attest [that] obviously their care is hands-on but very focused and goal oriented. [PTs] can sometimes support some of the personal care needs, but that’s not their main duty,” he said.

Likewise, social workers and psychologists provide an invaluable service to residents, but they’re not necessarily helping with meals or toileting, he added.

Activity coordinators too are hugely important to resident quality of life, McGarry told SNN, but staffing standards are really more geared toward basic minimum and personal needs of residents.

“It’s almost like they’re trying to circumvent the system and boost the hours of direct care numbers by pulling in other types of staff who are hugely important for resident quality of life and resident care but are not directly involved in providing those basic human needs,” McGarry said. “Lumping them together is in large part an effort to boost the direct care hours without actually adding staff.”

Florida, for example, has already expanded its minimum staffing requirements ahead of the Centers for Medicare & Medicaid Services (CMS) proposal. Gov. Ron DeSantis in April signed House Bill 1239 into law, which keeps 3.6 hours of direct care per patient per day, but allows other positions, such as physical therapists and occupational therapists, to be factored into the calculation.

CNAs in the state, by contrast, saw a decrease in minimum hours from 2.5 to 2 per patient per day. The Florida Health Care Association (FHCA) supported the governor’s decision, while representatives from AARP and SEIU expressed concerns that the new requirements could reduce CNA direct care.

Adding roles with more of an indirect impact on residents would no longer accurately reflect how much direct personal care a patient is receiving, McGarry noted. Such roles could be applied to a separate measure focused on quality of life.

Valley Hi Nursing & Rehabilitation Administrator Thomas Annarella, on the other hand, said he “couldn’t agree more” with adding other positions to the minimum staffing requirements, noting there have been a lot of positions added that didn’t exist pre-pandemic.

What Annarella calls the “universal worker” supports the three main clinical positions by answering call lights and transporting residents to various activities or different parts of the building.

The term is specific to Illinois-based Valley Hi, Annarella said, and refers mostly to high school students that come in and start training through various allied health programs at nearby school districts.

“We try to get people into our system and get them on a career path; they’re providing some level of assistance, with the supervision of a nurse or a CNA. In some ways they should be counted as well,” said Annarella.

Massachusetts Senior Care Association President Tara Gregorio said during a panel discussion at the annual Zimmet Healthcare Services Group conference earlier this year that it was “critically important to recognize the caregiver team beyond the traditional CNA, LPN and RN, especially given that every facility is so different in terms of makeup and population.

For example, Massachusetts has a number of facilities that treat substance abuse disorder (SUD) which can require a different kind of staff makeup compared to a long-term, custodial type care facility.

It is also one of the states with nursing home staffing standards — 3.58 staffing hours per patient day for the calendar quarter. Resident care assistants (RCA), often also referred to as temporary nursing assistants (TNA), do count toward that minimum.

“We just have to make sure that whatever we see on a state and federal level has that flexibility to really reflect the uniqueness of a nursing facility,” Gregorio said during the August panel.

McGarry and Annarella both agreed that it would be interesting to see if CMS includes such positions, but would perhaps weigh them differently based on the amount of direct care they provide.

“You can’t count them at 100%. But if they’re helping us in the dining rooms and they’re doing some light in-room assistance, answering call lights – that should count for at least a percentage,” he added.

In other words some positions, depending on how much direct care they provide each day, need to be counted differently in a minimum staffing standard.

Tying staffing to funding

A majority of operators agree that a federal requirement is needed. Approximately 54% of SNN survey respondents said federal staffing standards are required to achieve 4.1 hours of total direct care, while nearly 46% say it’s not necessary.

“[Trade organizations] … have at least lobbied for it to be a two-pronged approach of minimums with additional federal resources either through one time cash influxes or increased Medicaid reimbursement rates,” McGarry said.

Some states already have minimum staffing standards in place, including Illinois, which has tied a portion of a $700 million boost to nursing home funding to improve staffing standards.

About 94% of nursing homes would need to increase staffing levels just to be in compliance with a 4.1 minimum staffing ratio, according to CLA data – CMS arrived at this ratio in 2010 during its last study on a potential federal standard.

While the industry has seen a slow recovery this year, the workforce number is nowhere close to what nursing homes were reporting a decade ago; about 21% of the workforce still hasn’t returned.

In January 2012, nursing home staff count was approximately 1,666,800; that number plummeted to 1,346,600 in January 2022, according to BLS data.

“An important part of the discussion, when thinking about federal mandates and trying to bring nursing homes up to the benchmark of 4.1 hours of direct care per day, we know that a lot of nursing homes are not at that level right now,” McGarry said.