The Concern of Quality Care in Regards to Nursing Home Staff

The United States has around 55.8 million (16.8%) of the population aged 65 or older, according to the 2020 Consensus, with 1.3 million of those elderly adults living in nursing homes. Nursing homes are senior living communities that provide a range of health and personal care services, typically providing 24/7 supervision and help with various activities of daily living or post-acute care. Most of their employees are care aides, which are licensed practical nurses (LPNs) and registered nurses (RNs) employed to provide professional care. Those in nursing homes represent 2.3% of the elderly population, and this elderly population is expected to grow to 95 million by 2060. Ensuring and maintaining quality care in regards to respect and compassion is the framework for promoting health and overall well-being for the population of citizens we will someday grow up into. The provision of quality care within nursing homes is a large concern, amplified by the reports of the growing elderly population. The challenges in nursing homes can be categorized into systematic issues of staffing, which include cases of chronic understaffing, high turnover rates, neglect, and abuse allegations. Inadequate regulatory oversight, a lack of transparency, and financial pressures further elevate those challenges. The COVID-19 pandemic heightened the nursing shortages happening in healthcare fields. At the height of the pandemic, nurse-to-patient ratios skyrocketed to as high as 1-4 due to staff shortages. This caused high levels of stress and burnout, increasing turnover and opening positions in hospitals nationwide. Even as the pandemic wanes, the impact of the nursing shortage remains. Higher staffing levels are associated with better patient outcomes, shorter hospital stays, and reduced mortality rates. Strong staff figures also reduce nurse stress and burnout. The Centers for Medicare and Medicaid Services published a study suggesting that nurses should provide each nursing home resident with at least 4.1-4.85 hours of direct nursing care per day, depending on how long the resident stays in the home. However, reports also show that 87% of nursing homes experience modern or high staffing shortages. There is little consequence if a nursing home falls short of these safe-staffing standards. They can remain open while offending staff can keep their licenses, unless short staffing causes direct harmful outcomes for patients. Because Congress has not set mandatory minimum staffing requirements yet, 30 states have established their own mandatory minimum number of hours of direct nursing care per resident per day. These states mandate fewer hours of direct care than the national recommendation, which is well below the individual healthcare needs of each resident. Nursing homes can also apply for waivers, provided by Congress, rather than meet the requirements in some cases. There should be more reforms set in place to provide sufficient care from staff to each resident residing in nursing homes.

 In February 2022, current president Joseph Biden announced reforms to improve the quality and safety of care in nursing homes, developed and implemented by the Department of Health and Human Services (HHS). The Biden-Harris Administration’s Nursing Home Reform initiative states that every nursing home will provide a sufficient number of staff who are adequately trained to provide high-quality care; poorly performing nursing homes shall be held accountable for improper and unsafe care and immediately improve their services or be cut off from taxpayer dollars; and the public will have better information about nursing home conditions so that they can find the best available options. One key initiative within his strategy is to establish new minimum staffing requirements, and so the Centers for Medicare and Medicaid Services (CMS) have issued a Request for Information and conducted a new study. The information obtained through these efforts will inform future proposed rulemaking on minimum staffing requirements, which CMS plans to issue in spring 2023. But there has now been an update on state and federal long-term care staffing requirements in September 2023. The rule would require 24/7 RN staffing and set HPRD requirements for RNs and CNAs, but it does not include requirements for LPNs or LVNs. All facilities have to complete a needs assessment within 60 days of the rule implementation. Urban and suburban facilities would have three years to implement staffing requirements, with rural ones having five years. There would be an exemption from the rule if a facility could document the unavailability of a local nursing workforce and showcase good effort in fixing the issue.

The recent federal proposal on staffing is a pivotal step towards enhancing senior care. However, there is a sentiment that the proposed standards, including the extended timeline for rural facilities, will fall short of addressing the immediate concerns and needs of the residents. One such proposal to these reforms involves tightening the gap between where we are currently and national standards as well as introducing several incentives to improve the caregiver workforce. Some suggest there should be a prompt elimination of extended timelines for rural nursing homes to meet staffing rules. Every resident, regardless of location, deserves prompt access to high-quality care. To eliminate the disparities between rural and urban facilities, there should be collaboration with federal and state regulatory bodies to establish a standard set of regulations for senior homes within the framework of each facility's individual needs and challenges. There should also be targeted funding and support, including grants and tax incentives, to bridge the gap between the two types of facilities. Public audit reports provide both transparency and accountability about the facilities families entrust with their care. Including audits of staffing data that residents and their families complete about facilities, showcasing information about staffing levels, qualifications, and deployment within long-term care facilities would create a comprehensive reporting mechanism that can be reported on publicly. Furthermore, there could be additional tuition costs covered due to the increased number of openings for RNs. Departments such as The Health Resources and Services Administration could fund nursing students who agree to work in facilities with chronic shortages with additional investments. Likewise, the Department of Labor could also increase its $80 million in grants in accordance with the number of qualified nurses needed by the states in the coming years.

When nursing homes fail to provide high-quality care, it can lead to negative health outcomes and a decreased quality of life, and lack of respect for their dignity. Addressing this problem requires mandatory reforms in how such facilities are operated, as well as support for the proper management of such establishments. The elderly have spent their entire lives contributing to the world and now rely on us to provide them with the care and respect they deserve. I want those in power, both advocates and the local government, to understand that the need for quality care is not just coming from a professional standpoint but also from a moral duty to protect and serve elders in their last years of life with dignity and compassion.