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With more and more patients quickly discharged from acute care hospitals to skilled nursing facilities (SNFs), SNF residents are more clinically complex than ever. Despite the fact that residents have greater health care needs, federal standards for professional staffing at SNFs have not changed in more than 30 years. The consequences are dire. The Inspector … Read more

Reducing the re-hospitalization of nursing home residents is a constant and important public policy goal. At present, the goal is largely met by imposing financial sanctions against hospitals[1] and skilled nursing facilities (SNFs)[2] when residents are re-hospitalized. A better way of reducing re-hospitalizations of nursing home residents would be ensuring that residents get the care … Read more

States Whose Nursing Facilities Employ Few Registered Nurses Are More Likely To Be Penalized for Readmissions of Their Residents to Hospitals In 2014, as part of the Protecting Access to Medicare Act, Congress created the Skilled Nursing Facility Value-Based Purchasing Program, whose financial incentives are intended to reduce rehospitaliations of nursing home residents.  In December … Read more

Most nursing facilities do not have sufficient numbers of nurses to provide the care that residents need.  The result is poor care outcomes for residents – avoidable pressure ulcers, medication errors, inappropriate use of psychotropic medications, failure to assist residents with activities of daily living, avoidable weight loss, falls, and more.   The problem of insufficient … Read more

Human Rights Watch (HRW) published a devastating report in February 2018, which found that over 179,000 nursing home residents were being administered off-label antipsychotic drugs every week.[1] Antipsychotic drugs are indicated to treat specific clinical conditions, such as schizophrenia, and not the behavioral symptoms of dementia. Nevertheless, the HRW report noted that most of the … Read more

A joint Statement from the Center for Medicare Advocacy and the Long Term Care Community Coalition Background. Substandard care and insufficient staffing are longstanding problems in too many nursing homes across the United States. The nursing home industry often blames lack of funds for the failure to ensure appropriate staffing. However, the nonpartisan Medicare Payment Advisory … Read more

Charlene Harrington, professor emerita at the University of California San Francisco, and Center for Medicare Advocacy Senior Policy Attorney Toby S. Edelman have written an analysis of the class action lawsuit against twelve Golden Living nursing facilities in Arkansas for insufficient nurse staffing. The case was settled for $72 million in 2017.[1]  In “Failure to … Read more

______________ The front page of The New York Times last Sunday—July 8, 2018—featured an article on nursing home staffing. “’It’s Almost Like a Ghost Town.’ Most Nursing Homes Overstated Staffing for Years,” by Jordan Rau, reveals that a new reporting system based on payroll-based data indicates facilities have less staffing, especially on weekends, than previously … Read more

Nurse Staffing in Nursing Homes: CMS Transition to Payroll-Based Journal Staffing Data on Nursing Home Compare Will Provide Better Information for the Public Beginning in April 2018, the Centers for Medicare & Medicaid Services (CMS) will begin using Payroll-Based Journal (PBJ) staffing data to determine each facility’s staff rating on Nursing Home Compare. All facilities … Read more

A lawsuit by former residents at 12 Arkansas nursing facilities owned by Golden Living alleged that the facilities were chronically understaffed between December 2006 and July 2009, in violation of the facilities’ admission agreement, the Arkansas Long-Term Care Residents’ Rights Act, and the Arkansas Deceptive Trade Practices Act.[1]  The case was settled in 2017 for … Read more

New LTCCC Issue Alert: Nursing Home Staffing Requirements

The Long Term Care Community Coalition (LTCCC), in partnership with the Center for Medicare Advocacy, publishes monthly issue alerts on the rights of nursing home residents. These issue alerts focus on specific standards of care that nursing homes must follow as a requirement of participating in Medicare and Medicaid. The goal of this project is … Read more

Mandating specific levels of direct care nursing staff would seem to be a straightforward method to improve staffing in nursing facilities.  If more nursing staff are needed, why not simply require facilities to employ more nurses?  The strategy is far more complex, however, than it at first appears.  This paper reviews which states have tried … Read more

This project has produced a series of short papers evaluating various state approaches to improving nurse staffing levels at nursing facilities.  The papers have addressed state-mandated nurse staffing levels, wage pass-throughs, increasing reimbursement, and public and private (non-tort) litigation.  This paper, in contrast, considers whether regulatory changes at the federal level, while not specifically directed … Read more

On October 4, 2016, the Centers for Medicare & Medicaid Services (CMS) published revised Requirements of Participation (RoP) for skilled nursing facilities (Medicare) and nursing facilities (Medicaid).[1]  Although the substantive standards for nurse staffing are unchanged, CMS’s reorganization of the RoPs included moving the nurse staffing requirements to a different section[2] and moving standards for … Read more

In 2014, The New York Times reported that nursing facilities were gaming the Five-Star Quality Rating System on Nursing Home Compare and that “even nursing homes with a history of poor care rate highly in the areas that rely on self-reported data."[1]  The Times reported that nearly two-thirds of 50 facilities on CMS's watch list … Read more

Public coverage of the new nursing home Requirements of Participation (RoPs)[1] – the standards of care that nursing facilities must meet in order to be eligible for reimbursement by the Medicare and Medicaid programs – has focused primarily on their prohibition against facilities’ use of mandatory pre-dispute arbitration agreements.[2]  While advocates for residents applaud this … Read more

The single factor most critical to high quality of care and quality of life for nursing home residents is the staff who provide residents with care.  Most direct care in nursing facilities is provided by nurse aides, primarily women of color, who are poorly paid and often poorly treated.  In a sobering new report, Raise … Read more

Introduction One approach to improving nurse staffing levels is increasing reimbursement to nursing facilities, on the assumption and expectation that nursing facilities will use some of the increased reimbursement to increase their staffing.  This approach – at the federal level with Medicare and at the state level with Medicaid, in both Florida and California – … Read more

A December 2015 Health Affairs study of freestanding Skilled Nursing Facilities (SNFs) from 2001 thru 2011 found that registered nurses (RNs) were less likely to work at nursing homes with high concentrations of racial and ethnic minorities.[1] This study reports on significant health disparities for racial and ethnic minority SNF residents. In the Health Affairs … Read more

Medicare and Medicaid payments to nursing facilities, amounting to more than $80 billion in calendar year 2013,[1] are the most visible way that government financially compensates the nursing home industry.  In addition, but generally unacknowledged, federal and state governments heavily subsidize the industry through needs-based public benefits that many of the industry’s low-paid workers receive.  … Read more

On July 16, 2015, the Centers for Medicare & Medicaid Services (CMS) published proposed rules to revise the nursing home Requirements of Participation (RoPs) – the federal rules that govern the standards of care that facilities must meet in order to participate in the Medicare or Medicaid programs, or both.[1]  At the request of many … Read more

Former residents at 12 nursing facilities owned by Golden Living in Arkansas (or their special administrators, guardians, or attorneys-in-fact) filed a lawsuit challenging the facilities’ chronic understaffing between December 2006 and July 1, 2009.  Plaintiffs moved for class certification on three claims – breach of the facilities’ standard admission agreement, violation of the Arkansas Long-Term … Read more

Fast-food workers have been demonstrating for a higher minimum wage and recently, various corporations have increased the wages of their lowest-paid workers.  Has the movement come to the health care industry? On May 22, 2015, the country’s largest Roman Catholic health system, St. Louis-based Ascension Health, announced that it would pay workers at least $11 … Read more

Two-Thirds of Nursing Facilities Nationwide Will See Decline In their Quality Measures; One-Third of Facilities Will See Decline in Their Overall Score As promised in October 2014,[1] the Centers for Medicare & Medicaid Services (CMS) has made significant changes to Nursing Home Compare, effective February 20, 2015.  The changes recalibrate the Quality Measures (QMs), add … Read more

Although inadequate staffing is a claim in many negligence and wrongful death lawsuits against nursing facilities, some litigation addresses insufficient staffing directly as the sole issue.  Two cases are discussed here: the New Mexico Attorney General’s recently-filed lawsuit against the twelfth largest nursing home company in the country, Preferred Care, alleging that the company provided … Read more

Inadequate nurse staffing is the most significant predictor of poor care in nursing facilities.  Despite the fact that understaffing is a pervasive and nationwide problem,[1] understaffing is rarely cited by state survey agencies.[2]  One reason for the lack of deficiencies and enforcement actions is that the federal standard for nurse staffing is vague.  Aside from … Read more

A recent study in the Journal of Health Care Finance finds that Florida nursing facilities owned by private equity firms have fewer registered nurses and more deficiencies than chain-owned for-profit facilities and that the longer the facilities are owned by private equity firms, the fewer registered nurses they employ and the more deficiencies they have.[1]  … Read more

Federal law sets out few specific requirements for nurse staffing.  These requirements have not been revised since they were established by the 1987 Nursing Home Reform Law[1] and became effective on October 1, 1990.  Nursing Home Reform Law and Regulations Numbers of staff: The Reform Law requires that facilities employ a registered nurse (RN) for … Read more

The federal Nursing Home Reform law requires nursing facilities to have "sufficient" staff to meet their residents' needs.[1]  Sufficient nursing staff is universally recognized as a key requirement for making high quality of care possible and available for residents.  To determine whether nursing facilities are in compliance with nurse staffing (and other) federal standards of … Read more