As shifting state staffing mandates and looming federal requirements run up against the ongoing nursing home workforce shortage, industry leaders are taking a closer look at how exactly staffing requirements have affected quality of care.
AARP Florida on Monday released a report outlining the state’s direct care requirements for the last decade – and how they have affected quality just as residents were experiencing higher acuity and complications from chronic diseases.
The report details staffing changes for nursing homes in the state in order to give policy makers a “clear sense of the staffing history,” Jeff Johnson, Florida director of AARP, told the Orlando Sentinel.
Specifically, Johnson said changes made during the last legislative session in 2022 endangered patient care – reducing daily minimum certified nursing assistant (CNA) hours from 2.5 to 2, with personal care assistants (PCAs) or aides-in-training, counting toward this 2-hour requirement.
Licensed nurses, both registered nurses (RNs) and licensed practical nurses (LPNs), must still provide each resident with at least one hour of care per day.
Overall, Florida’s daily care requirement is 3.6 hours per resident. The big difference – and what sets Florida apart from other states – was in the 0.6 hours not provided by a CNA, LPN or RN. Non-nursing staff, including but not limited to dietary, therapeutic, mental health and paid feeding assistants count toward this remainder.
The shift is likely linked to staffing shortages felt throughout the nation. An estimated 400,000 nursing home workers have left their jobs between January 2020 and January 2022, according to the report.
More recently, the American Health Care Association (AHCA) found workforce challenges were rampant across both private and government-run nursing homes. State veterans’ homes and other government-run facilities, just like private nursing homes, are struggling to find workers and recover after staffing losses during the pandemic.
The staffing shortages are also leading to empty beds and lost revenue for nursing homes.
Florida Department of Veterans’ Affairs reported 34 veterans awaiting placement and 120 applications in progress. Port St. Lucie, for example, in the state has 120 available beds but only a staggering 19 residents.
Coupled with occupancy and staffing challenges in the state, current standards in Florida are a far cry from what they were in 2001, the AARP report found.
In 2001, Florida was a leader among states in minimum staffing standards, increasing nursing staffing standards from a low 2.3 hours per resident per day to 3.9 – including a minimum of 2.9 in CNA hours.
The increases were phased in over time and considered a “nationally groundbreaking move” at the time. It’s around this time that the Centers for Medicare & Medicaid Services (CMS) conducted its initial study into staffing hours, coming up with a total of 4.1 per resident per day, according to the report.
In 2003 and 2010, state legislators changed how providers could calculate CNA hours, allowing daily hours to dip if average hours met a certain threshold. In 2011, amid Medicaid budget cuts, lawmakers reversed its 10-year goal, lowering daily CNA staffing hours to 2.5 and dropping the combined CNA, LPN and RN minimum to 3.6 hours per resident per day.
In terms of Florida’s latest change to add non-nursing staff to the daily hour requirement, there isn’t a whole lot of concrete data yet, according to the report.
“As Florida embarks on a new way of defining direct care staff roles, little is known about the effectiveness of staff members outside the nursing contingent,” AARP Florida researchers said.
So far, two studies found that increasing social services and activities staff could reduce nursing home regulatory deficiencies and consumer complaints.
Another study found physical and occupational therapy staffing could improve quality measure performance, including residents’ need for assistance with daily activities and the number of falls resulting in serious injury.
“However, the positive results applied only to certified therapists. Higher physical therapy assistant staffing was associated with increases in serious falls,” researchers said in the report.
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