Nurses, administrators, advocates have varied opinions on new federal nursing home rule

Pennsylvania Health Care Association CEO Zachary Shamberg said the long-awaited “silver tsunami” has hit the state.

mandate.” When certified nursing assistant Helen Noel arrives for work each day at The Grove at Irwin nursing home, her attention is pulled in multiple directions.

“When I go in, there might be four or five (patient) lights going off,” she said. “Who do I answer — your mother, your sister? You try to answer as many lights as you can before you go on with your duties you have to do. I think it’s sad that nursing has come to this point.”

Noel, a member of SEIU Healthcare Pennsylvania, has worked at the Grove for 34 years and says she loves her job. But staffing shortages that began at the onset of the pandemic coupled with an increased demand for long-term care have made the job more difficult than it used to be.

A new federal law might help improve her working conditions.

Administrators, elder advocates and nurses have mixed opinions about the new Biden administration policy, which sets mandatory ratios for nurses in long-term care facilities and nursing homes.

The law, which takes effect June 21, requires facilities to provide at a minimum 3.48 total nurse staffing hours per resident day of nursing care. This means each resident of the nursing home must receive just under 3½ hours of staff time or care from a nurse every day. The ratio is calculated using the total number of staff, number of hours they work and number of residents in the nursing home.

Similar regulations took effect July 1, 2023, in Pennsylvania that require nursing homes to provide at least 2.87 hours of care for each resident, which will increase to a minimum of 3.2 hours on July 1. The new federal requirements go beyond the state standards, requiring slightly more hours per patient.

“I think it will have a good impact,” said Noel of the new federal law. “It’s about time.”

Many nursing home leaders, however, argue the standard does not provide the right tools to solve what they acknowledge as an ongoing staffing crisis.

“We believe this federal proposal is a misguided attempt to solve the workforce crisis in long-term care,” said Zachary Shamberg, president and CEO of the Pennsylvania Health Care Association, which represents nursing homes.

Struggling nursing homes

To meet the state and federal requirements, Shamberg said, longterm care providers in Pennsylvania alone will need to recruit and retain nearly 8,000 new caregivers over the next two to three years.

Shamberg and other nursing home administration members want the government to provide more money for homes to accomplish this goal to avoid what many nursing home administrators refer to as an “unfunded Nursing homes struggle with low reimbursements for Medicaid patients and an increased demand for care, making money a challenge, Shamberg said.

“If mandates are going to be forced on this provider community, there has to be funding to pay for it,” he said. “There needs to be a recognition by members of Congress, (the Centers for Medicare and Medicaid Services) and the Biden administration that more collaboration, more partnership must happen, or else we will have a challenge in caring for our older demographics.”

The Pennsylvania Health Care Association also supports looking outside the box to find staff amid shortages. Shamberg said the organization wants to see federal immigration reform make it easier for people from other countries to come to the U.S. and work in health care occupations.

The association also is looking ahead at the state level to potential programs that could reduce regulatory barriers for staffers. Some could include staffers who want to work in senior living but cannot because they did not finish high school or hold an equivalent degree. Other programs could give high school students credit toward graduation for working in senior living.

Vicki Loucks, COO of Redstone Highlands, a group of senior living and skilled nursing homes in Westmoreland County, also is concerned about the idea of an unfunded mandate.

Her homes have budgeted above the Pennsylvania state nursing ratios but will need to hire more people to meet the federal requirement. “I do think that the policy as proposed misses the boat a little bit. I don’t think there’s a one-size-fits-all for nursing homes,” she said. “The state or the federal government aren’t offering more money to care for people.”

Turning people away?

Because Pennsylvania has an increasingly aging population, issues of elder care carry a heavy weight, Shamberg said. In an environment in which staff can be hard to find, that strain can mean reduced availability for prospective residents.

“We’ve talked for years (about) the ‘silver tsunami.’ That silver tsunami has crashed down on this state,” he said, referring to looming concerns about older Pennsylvanians who will continue to need more health care as the population ages.

“We are seeing waitlists for nursing homes. We are seeing family members forced to travel hundreds of miles just to find care.”

Susie Tack Beardsley is chief administrative officer at Quality Life Services, which operates a number of nursing homes in Western Pennsylvania, including in Apollo and Sarver. She fears that if nursing homes can’t recruit enough staff to fulfill the required ratios, they will have to reduce spaces for residents.

“We’re all working very hard to recruit, to retain — we’re doing all of the things that are possible. Then to have an unfunded mandate put on all of us, at a time when nursing homes are closing their doors in Pennsylvania, is not sustainable,” she said. “Something has to give, and the numbers don’t work — they just don’t.”

Garry Pezzano, CEO of the Pennsylvania branch of LeadingAge, which represents nonprofit aging service providers, including nursing homes, hopes that additional funding for care homes will come with this year’s state budget.

He, too, has seen nursing homes consider or decide to shrink their bed availability because of a lack of staff.

“Forty-eight percent of the members that we surveyed are telling us that they’ve had to decline hospital admissions,” he said. “This means there are older Pennsylvanians in the hospital that are in emergency rooms; they need to go to the next level of care, they need skilled nursing care, and they’re being held up there.”

The work ahead

For nurses such as Noel at the Grove at Irwin who are caring for residents, staffing shortages present their own challenges. Staff are sometimes asked to take on additional responsibilities.

“I’ve also been pulled to the kitchen after my shift because they didn’t have enough staff,” she said.

Noel is hopeful the federal regulation will bring in more help in the evening and afternoon hours, when staffing is thinnest.

“I think it’s a step forward,” she said. “I know it’s kind of hard this shift, because you’re like a bat — you sleep during the day when everybody’s up, and you’re up when everybody’s sleeping. Your body can’t get used to it. If you had more help on the other shifts, they’d be able to do more.”

Matthew Yarnell, president of SEIU Healthcare Pennsylvania, noted in a statement that nursing home workers have long asked for staffing minimums.

“We’re proud that this administration listened and took action to begin transforming our nursing homes the way residents deserve,” he said. “This rule will make sure every American, no matter their ZIP code, receives safe, quality care. After many caregivers left the bedside from the stress of short staffing, low pay and benefits, and the COVID-19 pandemic, this rule helps make these jobs ones that people will want again.”

Adding more staff to nursing homes could improve care for residents, said Robert Blancato, national coordinator of the bipartisan 3,000-member Elder Justice Coalition advocacy group.

“This is an important first step in addressing the issue of quality care in nursing homes. The commitment of the administration to do this, I think, is commendable,” he said.

“In my judgment, if you have these staffing requirements implemented, it will improve quality of care. Shortages of staffing have always been at the heart of the problem,” he added. “It’s been a slow rebound to get homes back to where they were, and there were still a lot of issues accentuating the shortages. They were around before the pandemic started, and the pandemic made it worse.”

He expressed doubt about the nursing home industry’s concerns about the policy.

“We expected those comments from them. It’s predictable,” he said. “To say across the board that it’s an unfunded mandate that nobody can comply with, I think, is an exaggeration.”

The impact of the regulation, he said, depends on how the long-term care industry handles it in practice.

“There has to be better incentives for people to go into the field — better pay, better conditions and so on,” he said. “That’s where the challenge is going to be — how are you going to implement getting improved conditions and improved wages to get people to come and work in nursing homes? That’s been a struggle for a long time.”

“We are seeing waitlists for nursing homes. We are seeing family members forced to travel hundreds of miles just to find care.”

ZACHARY SHAMBERG

PENNSYLVANIA HEALTH CARE ASSOCIATION