During
the coronavirus pandemic and as of January 2022, nursing facilities lost
238,000 staff members, 15% of their total workforce.[1] According to a survey by the trade
association American Health Care Association (AHCA), more than 87% of
facilities report insufficient numbers of staff, which they say threatens their
ability to remain open.[2]
Kaiser Family Foundation reports, in its analysis of CMS COVID-19 Nursing Home
Data, that, as of the week ending March 20, 2022, 28% of facilities reported
that they had any staffing shortage.[3]
Regardless of the actual percentage of facilities that are short-staffed, it is
undisputed that staffing levels at nursing facilities have not rebounded from
the pandemic (when they were already too low) and that staffing levels remain
unconscionably low. What are the solutions?
The
nursing home industry supports legislative proposals to weaken training
requirements for staff and to allow poor quality facilities to train nurse
aides. Both proposals undermine key provisions of the 1987 Nursing Home
Reform Law. Advocates for residents see these Congressional bills as
significantly weakening staffing requirements at a time when residents have
more intense care needs than ever and require a more professional and
well-trained workforce. The bills contradict and undermine nursing
facilities’ increased use of nurse practitioners[4] and a growing field of physicians focused
on nursing home care, called SNFists.[5]
Advocates propose more comprehensive solutions to the staffing crisis,
including mandated minimum staffing ratios, more and better training, more and
better wages and benefits, and better working conditions for all workers.
The Biden Administration’s nursing home reform agenda includes these, and many
additional oversight and accountability proposals, that residents’ advocates
have supported for many years.[6]
Weakening Training Requirements
At
the beginning of the pandemic, the Centers for Medicare & Medicaid Services
(CMS) gave blanket waivers (that is, automatic and universal waivers) to
nursing homes for many longstanding statutory and regulatory standards,
including the requirement that nurse aides be trained in a state-approved
program of at least 75 hours.[7]
Many states authorized a temporary nurse aide (TNA) program, which allowed
workers to provide care to residents after receiving considerably less
training, often just an eight-hour on-line training developed and offered by
AHCA.[8] Mark
Parkinson, AHCA’s president and CEO, told participants at a Skilled Nursing News webinar
on March 31, 2022, that more than 300,000 people were trained as TNAs and that
200,000 were working in facilities as TNAs. CMS has now lifted the
blanket waiver of nurse aide training requirements, effective June 6, 2022.[9] However, many
facilities are attempting to convert their TNAs into permanent certified nurse
aides, even though these workers have not participated in their states’ full
training program.[10]
Legislation
to extend the nurse aide training waiver for 24 months was introduced in
Congress. The “Building America’s Health Care Workforce Act,” H.R. 7744,[11] introduced by
Congressman Brett Guthrie (R, KY), Madeline Dean (D, PA), and David B. McKinley
(R, WV), also weakens nurse aide training requirements by allowing time worked
in a facility as a TNA to count towards the federal minimum of 75 hours of
training. AHCA supports the legislation.[12]
Allowing Facilities That Provide Poor Care to Train New Aides
Under
current law, a nursing facility is barred from conducting a nurse aide training
program for two years if it has operated under a waiver of the requirement for
one registered nurse (RN) 40 hours per week, has had an extended or partial
extended survey, or has been assessed a civil money penalty of $5000 or more
(now, more than doubled to reflect cost-of-living increases in civil money
penalties).[13]
The purpose of the ban is to ensure that facilities are prohibited from
conducting a nurse aide training program directly if they fail to meet a
minimal nurse staffing standard and some minimal level of compliance with
federal standards of care.
However,
extensive waivers permit even these poorly performing facilities to conduct
nurse aide training programs under certain circumstances. Federal law
authorizes a waiver
of the two-year nurse aide training ban if the state “determines that there is
no other such program offered within a reasonable distance of the facility,”[14] “assures, through an
oversight effort, that an adequate environment exists for operating the program
in the facility,”[15]
and “provides notice of such determination and assurances to the State
long-term care ombudsman.”[16]
The Secretary may also waive the nurse aide training ban if the civil money
penalty was not related to quality of care.[17]
“Ensuring
Seniors’ Access to Quality Care Act,” introduced in 2019 as S.2993 and recently
reintroduced by Senators Mark Warner (D, VA) and Tim Scott (R, SC), repeals the
automatic statutory two-year ban that prohibits certain understaffed and
poorly-performing facilities from directly conducting their own nurse aide
training programs.
LeadingAge,
the trade association of not-for-profit providers, endorses the “Ensuring
Seniors’ Access to Quality Care Act.”[18]
AHCA supports the legislation as well.[19] The Center for Medicare Advocacy supports the
law’s current requirement that facilities without an RN or with serious care
problems, or both, not train new workers in how to perform aide duties.
Reducing Training for Staff Endangers Staff and Residents
Working
as an aide in a nursing home is dangerous.[20] Analyzing data from the federal
Bureau of Labor Statistics, PHI reports that “nursing assistants are injured
more than three times more frequently than the typical American worker.”[21] A study using
2004 data from the National Nursing Assistant Survey and the National Nursing
Home Survey found that 60.2% of all certified nursing assistants nationally
reported a work-related injury in the year before the survey and 65.8% reported
being injured more than once.[22]
Untrained
or minimally trained workers are more likely to be injured than workers who
have been trained. The researchers found:
As for all types of injuries, CNAs who were new to the profession
and to the facility, as well as those working mandatory overtime and those who
rated their initial training as poor preparation for their work in the
facility, were at higher odds of developing musculoskeletal injuries.[23]
CNAs
who report being generally better prepared for the job are able to handle many
other challenging aspects of direct care better, resulting in fewer injuries.[24]
Allowing
minimally or poorly trained aides to provide care to residents will mean more
worker injuries and, inevitably, poorer care for residents and increased
resident injuries.
Residents’ Advocates’ Staffing Solutions
Advocates
for residents understand that improving staffing in nursing facilities requires
multiple actions, simultaneously implemented. Paying workers a living
wage and benefits, ensuring that staff receive sufficient and appropriate
training, employing sufficient numbers of workers, establishing career ladders,
and treating staff respectfully and as important members of the resident care
team are key actions that enable facilities to recruit and retain permanent
staff.
Studies
repeatedly show, as did a study of staffing in rural communities, that staff
need “better wages, better health insurance, and better pensions, as well as
improved training, supervision, and mentoring.”[25]
In
an April 2022 report, PHI identifies eight solutions, including 24 specific
state policy strategies, for stabilizing the direct care workforce.[26] These
solutions include increasing compensation for direct care workers, whose median
income is now about $20,200. Specific strategies for this solution
include implementing wage reforms, offering supplemental or hazard pay, and
improving benefits.[27]
Milbank Memorial Fund similarly identifies comprehensive recommendations
for strengthening the direct care workforce in Direct Care Workforce Policy and Action Guide.[28]
Conclusion
When
the Nursing Home Reform Law was enacted in 1987, half of the states did not
require that aides receive any training before they provided care to
residents. One of the major changes made by the Reform Law was the
requirement that aides be trained and pass a state competency evaluation in
order to become certified caregivers. The federal bills supported by the
nursing home industry would be an enormous step backwards in public policy.
The Center for Medicare Advocacy supports the President’s comprehensive
nursing home reform agenda as a better way of improving staffing and quality of
care for residents.
___________________
[1] Bureau of Labor
Statistics, “Nursing Homes Have Lost 238,000 Caregivers Since Start of
Pandemic,” BLS January [2022] Job Report
[2] The American Health
Care Association (AHCA), the larger nursing home trade association, released a
survey finding that 87% of nursing facilities face “moderate or high staffing
shortages” and only 2% of facilities are fully staffed. 73% express
concern that staffing issues may force them to close. AHCA, “State of the
Nursing Home Industry: Survey of 759 nursing home providers show industry still
facing major staffing and economic crisis” (Jun. 2022), https://www.ahcancal.org/News-and-Communications/Fact-Sheets/FactSheets/SNF-Survey-June2022.pdf
[3] Nancy Ochieng,
Priya Chidambaram, and MaryBeth Musumeci, “Nursing Facility Staffing Shortages
During the COVID-19 Pandemic,” Kaiser
Family Foundation (Apr. 4, 2022), https://www.kff.org/coronavirus-covid-19/issue-brief/nursing-facility-staffing-shortages-during-the-covid-19-pandemic/#:~:text=Staff%20shortages%20were%20nearly%20as,this%20data%20in%20May%202020
[4] Amy Stulick, “How
the Nurse Practitioner Has Become ‘Front and Center’ as I-SNPs Demand More
Complex Care,” Skilled Nursing
News (Jun. 15, 2022), https://skillednursingnews.com/2022/06/how-the-nurse-practitioner-has-become-front-and-center-as-i-snps-demand-more-complex-care/
[5] Hye -Young Jung,
Hyunkyung Yn, Eloise O’Connell, Lawrence P. Casalino, Mark Aaron Unruh, Paul R.
Katz, “Defining the Role and Value of Physicians Who Primarily Practice in
Nursing Homes: Perspectives of Nursing Physicians,” JAMDA (2022), abstract
available at https://www.jamda.com/article/S1525-8610(22)00239-0/pdf
[6] White House, “FACT
SHEET: Protecting Seniors by Improving Safety and Quality of Care in the
Nation’s Nursing Homes” (Feb. 28, 2022), https://www.whitehouse.gov/briefing-room/statements-releases/2022/02/28/fact-sheet-protecting-seniors-and-people-with-disabilities-by-improving-safety-and-quality-of-care-in-the-nations-nursing-homes/
[7] CMS, “Long Term
Care Facilities (Skilled Nursing Facilities and/or Nursing Facilities): CMS
Flexibilities to Fight COVID-19” (Mar. 28, 2020) Federal
requirements for nurse aide training programs are extensive and comprehensive,
addressing federal standards that state nurse aide training programs must meet;
minimum number of training hours; qualifications of instructors; and designated
subject areas of training. 42 C.F.R. §483.152
[8] Who’s Providing Care for Nursing Home
Residents? Nurse Aide Training Requirements during the Coronavirus Pandemic (CMA
Special Report, Jul. 23, 2020), https://medicareadvocacy.org/wp-content/uploads/2020/07/Report-Nurse-Aide-Training.pdf
[9] CMS, “Update to
COVID-19 Emergency Declaration Blanket Waivers for Specific Providers,”
QSO-22-15-NH & NLTC & LSC (Apr. 7, 2022), https://www.cms.gov/files/document/qso-22-15-nh-nltc-lsc.pdf
[10] Who Provides Care for Nursing Home
Residents? An Update on Temporary Nurse Aides (Special
Report, Sep. 15, 2021), https://medicareadvocacy.org/wp-content/uploads/2021/09/SNF-TNA-Report-09-2021.pdf
[11] https://www.congress.gov/bill/117th-congress/house-bill/7744/text?r=1&s=1
[12] AHCA, “AHCA/NCAL
Issues Statement in Support of Building America’s Health Care Workforce Act”
(Press Release, May 13, 2022), https://www.ahcancal.org/News-and-Communications/Press-Releases/Pages/AHCANCAL-Issues-Statement-in-Support-of-Building-America%E2%80%99s-Health-Care-Workforce-Act.aspx
[13] 42 U.S.C. §§1395i
-3(f)(2)(B)(iii)(I)(a)-(c), 1396r(f), Medicare and Medicaid,
respectively.
[14] 42 U.S.C.
§§1395i-3(f)(2)(C)(i), 1396r(f)
[15] 42 U.S.C.
§§1395i-3(f)(2)(C)(ii), 1396r(f)
[16] 42 U.S.C.
§§1395i-3(f)(2)(C)(iii), 1396r(f)
[17] 42 U.S.C.
§§1395i-3(f)(2)(D), 1396r(f)(2)
[18] LeadingAge,
“LeadingAge Statement on the Ensuring Seniors’ Access to Quality Care Act”
(Jun. 13, 2022), https://insidehealthpolicy.com/sites/insidehealthpolicy.com/files/documents/2022/jun/he2022_1546.pdf
[19] AHCA, “AHCA/NCAL
Issues Statement following Senate Health, Education, Labor & Pension
Committee Hearing On Workforce Shortages in Health Care” (Press release, May
20, 2021), https://www.ahcancal.org/News-and-Communications/Press-Releases/Pages/AHCANCAL-Issues-Statement-Following-Senate-Health,-Education,-Labor-&-Pension-Committee-Hearing-On-Workforce-Shortages-in-H.aspx
(supporting reintroduction of the 2019 Ensuring Seniors Access to Quality Care
Act)
[20] AnnMarie Lee
Walton and Bonnie Rogers, “Workplace Hazards Faced by Nursing Assistants in the
United States: A Focused Literature Review,” Int
J Environ Res Public Health. 2017 May; 14(5): 544, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5451994/;
Stephen Campbell, “Workplace Injuries and the Direct Care Workforce” (PHI Issue
Brief, Apr. 2018), http://phinational.org/wp-content/uploads/2018/04/Workplace-Injuries-and-DCW-PHI-2018.pdf
[21] Id., citing U.S. Bureau of
Labor Statistics (BLS), Injuries, Illnesses, and Fatalities. 2018. Occupational
Injuries and Illnesses and Fatal Injuries Profiles, https://www.
bls.gov/iif/
analysis by PHI (Jul. 23, 2019)
[22] Galinka
Khatutsky, Joshua M. Wiener, Wayne L. Anderson, and Frank W. Porell,
“Work-Related Injuries Among Certified Nursing Assistants Working in US Nursing
Homes,” RTI Press, p. 4 (Apr. 2012), https://www.rti.org/rti-press-publication/work-related-injuries-CNAs/fulltext.pdf
[23] Id. 10
[24] Id. 11
[25] Gail L. Towsley,
Susan L. Beck, William N. Dudley, and Ginette A. Pepper, “Staffing Levels in
Rural Nursing Homes,” Research in gerontological nursing, 4(3), Jul. 2011: p.
1-14, https://libres.uncg.edu/ir/uncg/f/W_Dudley_Staffing_2011.pdf
[26] PHI, State Policy
Strategies for Strengthening the Direct Care Workforce” (Apr. 11, 2022),
reached through a link at http://www.phinational.org/resource/state-policy-strategies-for-strengthening-the-direct-care-workforce/
[27] Id. 9-11
[28] Courtney Roman,
Clare Luz, Carrie Graham, Nida Joseph, and Kate McEvoy, Direct Care Workforce Policy and Action
Guide (May 18, 2022), https://www.milbank.org/wp-content/uploads/2022/05/DirectCareWorker_Toolkit_final.pdf
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