With nursing homes and other long-term care facilities desperately short of nurses and aides, it is more important than ever for consumers to know about staffing levels, quality, and turnover. But it has been difficult to get some key information. Now, the government has taken a modest step to help.
In January, the Centers for Medicare and Medicaid Services (CMS) began posting new information about weekend nursing home staffing of Registered Nurses (RNs) as well as a total staffing including Licensed Practical Nurses (LPNs), Licensed Vocational Nurses (LVNs), Certified Nurse Aides (CNAs), and nurse aides in training. CMS also has begun reporting data on turnover rates of nurses and administrators.
This information is valuable for consumers, but it is not enough.
What you will see
For now, you can see the data at CMS’s Care Compare website, although my random search found that many facilities have yet to report on turnover. In July, both sets of information are scheduled to be added to CMS’s Five Star rating system. Keep in mind that this disclosure applies only to nursing facilities. Assisted living is exempt from this federal reporting.
What is Care Compare telling consumers? I looked up a facility near my home in Maryland and could see that its RNs provide an average of 42 minutes of care per resident per day, equal to the national average but below the state average of 53 minutes. On weekends, average daily RN time fell to about 38 minutes per resident, above the national average of 29 minutes and comparable to the state average.
Overall, this facility provides an average of about 3 hours and 56 minutes of daily assistance for each resident, about 10 minutes more than the national average and roughly equal to the Maryland state average.
More to the story
But staff counts tell only part of the story. Residents and their families also need to know about staff turnover and training. Researchers have known for well over a decade that all these factors are critical when it comes to the quality of care in facilities.
A facility with a revolving door of inexperienced staff may well deliver poorer care than one with fewer staffers who are better trained and longer-tenured. In addition, raw staffing levels may not reflect the actual needs of residents. For example, a facility with a greater proportion of residents with very high care needs may need more and better-trained staff than one with healthier residents.
Even before the pandemic, staff turnover was a huge problem. CMS estimates it is about 50 percent (meaning about half the staff leaves in any given year). That is shockingly high but other estimates are much more troubling.
In 2017-2018, annual staff turnover at nursing homes averaged a staggering 120 percent, according to a 2021 study by Ashvin Gandhi, Huizi Yu, and David Grabowski published in the journal Health Affairs (paywall). Importantly, there is a lot of variation around that number. For-profit facilities had more job churn than non-profits. Facilities with highest percentage of Medicaid residents had more turnover than those with more who paid privately.
State standards for nursing home staffing also vary widely. For example, the advocacy group Consumer Voice reports that only the District of Columbia requires staffing levels of 4.1 hours per resident day, the minimum level for quality care according to a 2001 CMS report. Arizona, by contrast, requires less than one hour of staff time for each resident.
A separate study by Rachel Werner and Norma Coe, also published by Health Affairs, found the number of staff declined even more after the onset of the pandemic. But because the number of residents also fell, the amount of staff time per resident was roughly the same as before COVID-19.
Staffing and Covid
And when it comes to COVID-19 outbreaks in nursing facilities, staff matters. A study by Rebecca Gorges and Tamara Konetzka published in the Journal of the American Geriatrics Society finds “higher [nursing aide] hours and total nursing hours may help contain the number of cases and deaths” in facilities. Those results were similar to studies in California and Connecticut.
Now that the resident census is slowly rising in facilities, staff is more difficult to find than ever. Thus, it is essential that consumers have up-to-date information on staffing, including training.
CMS waived some of its training requirements for nursing homes aides during the pandemic. That helped facilities adapt to staff shortages but creates new concerns. For example, staff that is poorly trained in infection control, such as hand washing and wearing masks, gowns, and gloves, may have been responsible for some of the deadliest outbreaks of Covid-19. And before covid, of flu and norovirus.
Financially-strapped nursing facilities are pressuring states to further water down staffing standards. But even under current rules, consumers need the best possible information about nursing home quality and safety. And staffing data are a key piece of that puzzle.