Time to Ensure Sufficient Nursing Home Staffing and Eliminate Inequities in Care

The overwhelming nursing home resident infection and death rates from the COVID-19 pandemic has led to the question: What policies can best protect nursing home residents now and in the future? In this article we present data that inadequate nurse staffing levels and high staff turnover rates are the fundamental underlying causes of poor quality care in many nursing homes. Understaffing and turnover, especially at for-profit companies and homes with Private Equity (PE) investors, have resulted in unnecessary infections and deaths before and during the pandemic. The poor care has resulted in wide inequities for racial and ethnic minorities and residents on Medicaid as well as disparities for racial and ethnic minority staff. Solutions to these chronic challenges and poor performance are offered in this commentary.

In the 2017-18 period, 75 percent of U.S. nursing homes almost never met the CMS expected RN staffing levels based on resident acuity and inconsistent staffing levels were observed, especially on weekends and holidays [1]. In 2018, the Office of the Inspector General found that, for least 30 days per year, seven percent of nursing homes did not meet the requirements of having one RN on duty at least eight hours a day and one licensed nurse on duty 24 hours a day. Another 47 percent of nursing homes did not meet these requirements for 1-29 days per year [2]. 

Very high staff turnover rates were ubiquitous prior to the pandemic as turnover rates averaged 128 percent for nurses and 141 percent for RNs in 2016 [3]. Turnover rates were higher in CMS homes with low-quality ratings [3], for-profit, chain-owned facilities, those where most residents were receiving Medicaid and those located in urban and high poverty areas. Although high turnover rates are associated with inconsistent and poor quality care, high turnover rates have persisted for years because they result in a net savings to nursing homes [4]. New nursing assistants are hired at minimum wages and those who leave fail to gain wage increases commensurate with experience.

Facilities with a higher concentration of racial and ethnic minority residents are more likely to have lower RN levels and to be staffed by less-skilled workers [5]. This means there is a higher concentration of racial and ethnic minority residents living in poor quality nursing homes with high deficiency levels, due to low staffing [6]. Racial and ethnic minorities, who are more likely to be dually eligible for Medicaid and Medicare than whites, are almost 10 percentage points more likely than non-duals to be admitted to a low-quality nursing homes [7]. Dual-eligibles, more likely to be discharged to nursing homes with low staffing ratios, are subsequently more likely to become long-stay nursing home residents than Medicare-only beneficiaries [8].

Staffing levels in for-profit nursing homes, including nursing home chains, had 16 percent fewer staff than nonprofits after accounting for differences in residents’ needs in 2017. Nonprofit and government facilities provide higher staffing and quality care [9]. Nurse staffing wages, benefits, and pensions (especially for RNs) are major costs for nursing homes and are often cut by for-profit owners who are motivated to maximize profits. Private Equity (PE) companies, representing about 9 percent of nursing home owners in 2015, have excelled at extracting profits from nursing homes by reducing staffing and services. PE buyouts of nursing homes from 2000 to 2017, when compared to acquisitions by non-PE companies, resulted in declines in resident health and regulatory compliance related to cuts to front-line nursing staff [10]. PE ownership increased short-term mortality of Medicare patients by 10 percent (or 20,000 lives) and resulted in declines in resident well-being, staffing and quality standards [10].

Early in the pandemic, California nursing homes with RN staffing levels below the recommended minimum of .75 hours per resident day had a twice the probability of having COVID-19 infections [11]. Nursing homes with higher Medicare five-star ratings and higher RN staffing levels, adjusted for acuity, were less likely to have residents infected with COVID-19. In Connecticut, a twenty-minute increase in RN staffing per resident per day was associated with 22 percent fewer COVID-19 cases and 26 percent fewer COVID-19 deaths [12]. Nursing homes with lower star ratings that reflect staffing, had an increased probability of having COVID-19 resident cases or deaths [13]. A study of US nursing homes with one or more COVID-19 cases found that high nurse aide and total nursing hours were associated with a lower probability of a COVID-19 outbreak and with fewer deaths [14]. In addition, a study of 8 states found that nursing homes with higher star ratings for staffing had lower odds ratios of having high COVID-19 resident case rates [15]. 

During the COVID-19 pandemic, one of every 6 nursing homes self-reported shortages of licensed nurses and nurse aides, but shortages varied widely across states, especially in homes with COVID-19 resident and staff infections [16]. Not surprisingly, nursing homes with higher previous RN staffing levels before the pandemic and those with higher overall quality ratings were less likely to report shortages. Black and Latinx nursing home residents have been disproportionately affected by COVID-19 infections [17]. Nationally, nursing homes with more racial/ethnic minority residents have had more confirmed resident cases and/or deaths and more staff cases [18]. 

Research shows that for-profit nursing homes in general had higher COVID-19 infection and death rates. A California study showed that COVID-19 deaths rates are higher in for-profit homes [13]. Nursing home chains had a higher probability of having a COVID-19 case and for-profit nursing homes were more likely to have higher size outbreaks [19]. For-profit nursing homes in three states had higher COVID-19 death rates [20]. Nursing homes with private equity investors had higher confirmed COVID cases than nonprofit and government nursing homes in the unadjusted outcomes and higher case rates than government nursing homes in the adjusted outcomes [21].

Federal nursing home minimum staffing standards have not been updated for over 30 years. The Nursing Home Reform Act of 1987, requires certified nursing homes to have a licensed nurse on duty 24 hours a day, an RN on duty at least 8 hours every day, an RN director of nursing, and ‘‘sufficient’’ staff and services to help their residents attain or maintain the highest possible level of physical, mental and psychosocial well-being [22]. In 2016, the Obama administration added new requirements for staffing to meet resident care (or acuity) needs and to conduct annual facility assessments of the resources needed to provide competent care [23]. However, a specific minimum standard was not established. Research has demonstrated the importance of having a minimum of 0.75 RN Hours Per Resident Day (hprd) and a total of 4.1 nursing hprd to prevent harm and jeopardy for long stay residents [24]. These standards have since been verified in other studies [25] and have been endorsed by professional associations and experts [26,27].

Nursing homes rarely face consequences for understaffing, because CMS mischaracterizes almost all staffing deficiencies (over 96 percent) as “not causing harm” [28]. Even when CMS finds that there are staffing deficiencies that pose an “immediate jeopardy” to residents, nursing homes are often not sanctioned. Few staffing deficiencies were identified in 2019 and dropped sharply in 2020 [29].

Before the pandemic, nursing positions in nursing homes were among the most dangerous jobs in the country with high injury rates associated with lifting and transferring residents [30]. High occupational exposure to COVID-19 made the job of the almost 1.5 million nursing home staff even more dangerous [31]. Low wages, low benefits and heavy workloads are primarily related to the high nursing turnover rates. RNs in nursing homes receive much lower wages than those for hospital RNs [32]. Most resident care is provided by nursing assistants who make minimum wages (averaging $13.38 per hour and an annual income of $22,200 in 2018) [33]. Nursing assistant wages in nursing homes are lower than for comparable entry level jobs for janitors, retail sales persons and customer service representatives [34]. Altogether, 15 percent of nursing home workers live below 100 percent of the federal poverty level, while 44 percent live below 200 percent of the poverty line [33]. As a result, many nursing home staff work in more than one facility, which was found to be a factor that increased the spread of COVID-19 between facilities during the pandemic [35]. 

In nursing homes, 38 percent of nursing assistants do not have health insurance and 36 percent of workers require some form of public assistance, including Medicaid, food and cash assistance. Many employees do not have sick leave and therefore cannot afford to stay home from work which contributed to the spread of COVID-19 [33].

Most nursing home nursing assistants (92 percent) are female, 57 percent are from racial and ethnic minority groups, and 22 percent were born outside of the US in 2017 [36]. Women of color working in nursing homes are more likely to live in poverty or low-income households and to require public assistance than white women or men. Systemic low pay and benefits therefore result in and perpetuate racial and ethnic disparities and income inequities. Shortages of staff lead to heavy workloads, lack of continuity of care, and poor-quality services.

Establishing minimum staffing standards 

Before and during the pandemic, staffing levels in the majority of nursing homes, particularly in for-profit companies and chains, have been deeply inadequate to meet regulatory standards to provide safe, high quality care to residents. Now is the time to adopt specific minimum staffing standards to meet the requirement of “sufficient” staffing. The minimum standard should be 0.75 RN Hours Per Resident Day (hprd) with 2.8 nursing assistant hprd and a total of 4.1 nursing hprd, and a requirement to provide RN staffing 24-hours a day with higher staffing to reflect resident acuity as needed. Staffing levels need to be adjusted upward for higher acuity as the current regulations require [37]. 

Congress member Schakowsky has recently reintroduced a staffing and nursing home bill H.R. 598, the Quality Care for Nursing Home Residents and Workers during COVID-19 and Beyond Act which would require minimum nursing home staffing, worker safety and financial transparency along with enforcement provisions. The Senate companion legislation, led by Senator Blumenthal, is S. 315, the Quality Care for Nursing Home Residents Act. Alternatively, President Biden could issue an executive order and regulatory changes to ensure adequate staffing levels in all nursing homes and clear enforcement procedures.

Enforcing staffing standards 

As the enforcer of staffing standards, CMS should monitor and audit the payroll-based journal staffing data submitted to CMS quarterly and use this information to ensure adequate staffing levels are met. CMS should revise its vague guidelines on staffing and establish that inadequate staffing violations are automatically classified as either “potential harm,” “actual harm,” or “immediate jeopardy,” depending on the scope of the problem. Pre-established penalties for violations should be issued together with a denial of payment action for new admissions received until staffing levels are deemed to meet federal requirements. Temporary managers should be used when necessary to achieve compliance.

Increasing wages and benefits 

Sick leave and health insurance requirements are needed to stabilize the workforce, prevent workers from coming to work sick, reduce the need for workers to work multiple jobs, and address racial/ethnic disparities and income inequities. COVID-19 emergency sick leave provisions in the bipartisan Families First Coronavirus Response Act (FFCRA) found that states that implemented two weeks of paid sick leave had statistically significant fewer confirmed COVID-19 cases per day [38]. At the same time, nursing homes need to provide adequate wages and benefits to recruit and retain competent and experienced nursing staff. A recent study by Leading Age estimated that raising minimum wages of nursing assistants by 15 percent would provide a living wage. This increase would translate into reduced turnover and a stabilized workforce, decreased staff shortages, increased hours that individuals are willing to work, and increased work productivity. In addition, implementing such a policy would have a substantial positive effect on the economy as a whole [39]. Wage and benefit increases should be built into the Medicare and Medicaid payment systems along with hazard pay to compensate for the risk to staff and ensure adequate staffing during infection outbreaks.

While the worst of the pandemic may be over as vaccines are available, the inadequate staffing levels and wages and benefits result in unacceptably poor quality. It is time to ensure that nursing homes protect not only their residents but also their caregivers.