Nursing Homes Staffing and Care Levels
(4/20/13)- Being a nurse's aide in a nursing home is one of the toughest, lowest paying jobs in this country. The median hourly wage for nursing aides is $11.74, according to U.S. Labor Department statistics, compared with $16.71 per hour for all occupations.
It is estimated that one-fifth of the workers are 55 years old or older, so that the industry is faced with a looming crisis, since young people are not going into the profession. The federal minimum-training requirement is 75 hours, though each state can set its own qualifications for certification of a nurse's aide.
Nonfatal injuries are measured in terms of those serious enough to cause days away from work, transfers to a different job or restrictions on work, a gauge known as DART rate. Privately owned nursing-care facilities had a combined DART rate of 5.3 cases per 100 full-time workers in 2011. The average rate is 1.9 for all occupations; 2.1 rate for construction workers, and 2.4 rate for the manufacturing industry.
(12/19/12)- In the latest development in connection with the strike that has been taking place at the 5 Connecticut nursing homes owned by HealthBridge Management, a federal judge in Hartford has ordered the company to reinstate the workers it fired and rescind the pension and health care cuts it had imposed. For additional details on this matter please see our item dated 8/25/12 below.
Judge Robert N. Chatigny of the U.S. District Court in Connecticut ruled that HealthBridge Management had broken the law by refusing to bargain in good faith and by imposing cuts before a true negotiating impasse had been reached.
The judge issued an injunction that requires the company to rehire the workers it had fired, even if it meant firing the replacement workers. The company has filed an appeal of his decision with the Court of Appeals for the Second Circuit, asking it to overturn the injunction
(8/27/12)- As is true for most of corporate America, consolidation and merger seems to be the watchword, as the big corporations get bigger through acquisitions. This was true in the prescription benefits managers area as the merger of Express Script and Medco Health was allowed to proceed to consummation even though the merged company is now the largest one in the field.
In the nursing home industry, the latest development along these lines is the announced buyout of Sunrise Senior Living by Health Care REIT for $644.6 million in cash. The deal will create one of the largest nursing home owners in this country, but as its name implies, it would not come as any great surprise if the deal turns out to be mainly for the real estate value of Sunrise.
(8/25/12)- One of the key elements in assessing how good or bad a nursing home is, is the quality and quantity of its staffing. These are hard economic times so that the cost factor involved in running a facility must enter into the equation also.
Residents of a nursing home will all tell you that it is the nurse's aide who has the most direct dealing with their well-being and comfort level. The job of an aide is indeed a difficult one. From bathing to feeding, from cleaning up after the resident has "messed up" to just socializing with the resident, it can indeed be a very tough job one for anyone.
Many of the aides are long term employees of the facility, who are loyal to both their employee and the resident.
A recent article by Steven Greenhouse in the August 20, 2012 edition of the NY Times entitled: "7 Weeks Into Connecticut Nursing Home Strike, the Accusations Fly" highlights the conflicts that may arise between the employer and the employees in a nursing home.
On July 3, about 600 workers at the 5 Connecticut nursing homes owned by HealthBridge Management went on strike, and the labor dispute still continues today. The company eliminated 6 paid sick days and a week of vacation for many of the workers, froze pensions and required many workers to pay at least $6,000 more a year for family health coverage.
The workers are members of the Service Employees International Union. Negotiations had been going on for about 17 months before the strike began. The homes affected are located in Danbury, Milford, Newington, Stamford and Westport Connecticut. The company has hired 730 replacement workers to tend to the needs of the residents of the homes.
To offset the givebacks, the company has offered the workers a 2.2% pay increase.
Earlier this year, the National Labor Relations Board accused HealthBridge of breaking the law by locking out 100 employees at its nursing home in Milford to discourage them from belonging to the union.
The Board issued its sixth complaint against HealthBridge, charging that it had bargained in bad faith and illegally imposed the benefit cuts. It concluded the HealthBridge should reimburse all 600 strikers for lost wages since the strike began, amounting to an estimated $2.6 million.
(6/4/12)- Geriatricians, federal regulators, consumer advocates, and others have joined forces to set out a national action plan with the aim of reducing the use of antipsychotics in nursing homes across the country by 15% before the end of this year.
"In data collected from nursing homes between July and September of 2010, nearly 2 in 5, or 39%, of nursing home residents national-wide who had cognitive impairment and behavioral problems, but no diagnosis of psychosis or related conditions, received antipsychotic medication," said Shari Ling, MD, deputy chief medical officer, Centers for Medicare & Medicaid Services (CMS) during a telephone press conference.
In another study, more than 17% of residents had daily doses of such medications that exceeded recommended levels, said Dr. Ling.
(8/6/11)- Last October the government officials changed the way it calculates reimbursement rates for Medicare residents of nursing homes, placing them in groups based on the degree of services needed.
The new rates were expected to be budget neutral; instead Medicare payment rose by 16%, or $2.1 billion, from the last half of fiscal 2010 to the fist half of fiscal 2011. Nursing homes shifted a disproportionate number of residents into higher risk levels, despite no noticeable change in the severity of their condition.
The Centers for Medicare and Medicaid Services (CMS) recently announced that it would reduce payments to skilled-nursing facilities by 11.1%, or $3.87 billion, in response to the unexpected increases in nursing home payments this fiscal year.
In addition, under the debt-ceiling and budget reduction deal hammered out in Washington, Medicare payments to health-care providers cuts would automatically take effect if Congress fails to adopt deficit reduction measures hammered out by the 12-member super committee later this year, or if that committee can't find enough savings.
(5/13/11)- For those of you who are familiar with nursing homes and the medical staffing therein, one of the greatest concerns is the capability of the medical staff at the facility. Geriatric medicine is a difficult field that is not as lucrative as are some of the other areas of medical care, so the question often arises in regards to the competency of the doctors in nursing homes.
The results of a federal governmental audit of nursing homes conducted by Daniel R. Levinson, inspector general of the Department of Health and Human Services determined that nearly one in seven elderly nursing home residents with dementia were given antipsychotic drugs even though these medications sharply increased the risk of death and have not been approved for this type of treatment.
The auditors found that of the 2.1 million elderly patients in nursing homes during the first six months of 2007, 304,983 had at least one Medicare claim for an antipsychotic medication. Nursing home residents received 20% of the 8.5 million claims for this type of medicine for all Medicare beneficiaries at a cost of $309 million during that 6 months period of time.
The audit found that more than half of the antipsychotics paid for by the Medicare program in the first half of 2007 were "erroneous", costing the program $116 million for those 6 months.
The drugs included in the audit were Risperdal, Zyprexa, Seroquel, Abilify and Geodon which were "potentially lethal" to many of the patients and are illegally being marketed by the drug companies for this "off label" usage.
(3/7/11)- The Patient Protection and Affordable Care Act of 2010 (PPACA) offers $160 million to the states to improve criminal background checks on prospective employees at nursing homes and other providers of long term care.
A recent report that was issued by Daniel R. Levinson, inspector general of the Department of Health and Human Services concluded that more than 92% of nursing homes employ one or more people who have been convicted of at least one crime.
The department obtained the names of more than 35,000 nursing home employees and then checked with the FBI to see if they had criminal records.
Mr. Levinson said that "Nearly half of nursing facilities employed five or more individuals with at least one conviction. For example, a nursing facility with a total of 164 employees had 34 employees with at least one conviction each."
There are no federal laws or regulations specifically requiring nursing homes to check federal or state criminal records for prospective employees. Ten states require a check of FBI and state records, while Mr. Levinson went on to say that 33 states require a check of state records, the remaining states have no such requirement.
(10/12/10)- The Drug Enforcement Administration (DEA) issued a new guideline that will allow physicians in long-term care facilities to authorize nurses at the facility to phone in their oral prescriptions for certain pain-killing and anti-anxiety medications to pharmacies.
Nurses who work in hospitals or for doctors in private practice are already allowed to transcribe and transmit such prescriptions.
Only doctors and certain other medical professionals can prescribe medications.
The D.E.A. had not previously recognized nurses employed by nursing homes as the legal agents of doctors in conveying controlled substances prescriptions to pharmacies.
The D.E.A. is currently investigating pharmacists in about 5 states for dispensing such medications to nursing homes without direct written orders from a doctor..
(5/20/08)- According to the results of a report from investigators for the Government Accountability Office, done at the request of Senators Charles E. Grassley (Rep-Io.) and Herb Kohl (Demo-Wis) who is chairman of the Senate Special Committee on Aging, governmental nursing inspectors overlook or minimize many serious problems in the institutions that they inspect.
The report stated that the investigators found widespread "understatement of deficiencies," including malnutrition, severe bedsores, overuse of prescription medications, and abuse of nursing home residents.
Nursing homes are typically inspected once a year by state inspectors working under contract from the federal government. The report found that state employees had missed at least one serious deficiency in 15% of the inspections checked by the federal officials. In nine states, inspectors missed serious problems in more than 25% of the surveys analyzed from 2002 t0 2007.
More than 1.5 million people live in nursing homes, and about one-fifth of the homes were cited for serious deficiencies.
"Poor quality of care-worsening pressure sores or untreated weight loss-in a small but unacceptably high number of nursing homes continues to harm residents or place them in immediate jeopardy, that is, at risk of death or serious injury," the report said.
Senators Grassley and Kohl have introduced a bill to upgrade nursing home care and increase the penalties for violations of federal standards. The maximum fine, now generally $10,000, would be increased to $25,000 for serious deficiencies, and $100,000 for one that resulted in a patient's death.
Under their bill, nursing homes would have to provide consumers and the government with more information about their owners and "affiliated or related parties" including any individual or company that had a role in managing their operations.
"We fully endorse and will implement all the GAO recommendations, Vincent J. Ventimiglia Jr., and assistant secretary of health and human services, said in written comments on the report.
(3/3/08)- Health expert estimate that about two million Americans suffer from pressure ulcers each year, usually because of immobility, poor nutrition, dehydration or incontinence. New research is showing that the battle against this affliction can be handled best through a team approach. Whether it be the doctor, nurse, nurse's aide, relative, friend or anyone who comes in contact with a person who is immobile for whatever reason, they must all be conscious of what they can do to prevent this illness from happening.
The CDC spearheaded a collaborative effort at 52 nursing homes throughout the country wherein every person who has contact with a resident would do whatever they could to prevent pressure ulcers from occurring. The Journal of American Geriatrics Society reported last August that team efforts had reduced the number of severe pressure ulcers acquired in-house by 69%.
"Preventing pressure ulcers is a 24/7/365 kind of job," said Jeff West, a clinical reviewer at Qualis Health in Seattle who helped set up the collaborative in 2003. "It's not as if one person can get it all done. And if it fails just a little bit, just during the weekend, for instance, you're not going to get the results. It takes tremendous consistency."
Dr. Joanne Lynn, who helped begin the project when she was a senior natural scientist with the RAND Corporation, but is now with the CDC, said the goal was to educate nursing home workers in bedsore prevention and to encourage them to come up with creative, low-tech solutions of their own.
There are four stages of pressure ulcers. In Stage 1 and Stage 2 the sores are merely superficial wounds on the skin's surface. In Stage 3 and Stage 4 the wound deepens and can even penetrate down to the bone as a result of the death of the skin and the underlying tissues.
(9/24/06)- The owners of a nursing home in St. Bernard Parish, New Orleans, where 36 residents died in the aftermath of Hurricane Katrina were indicted on a charge of negligent homicide and cruelty to the infirm. The owners were initially arrested about two weeks after the storm on August 29, 2005, but a grand jury was unable to convene for months because of the flood.
The owners, Salvador and Mabel Mangano have spoken about the extenuating circumstances that occurred during the hurricane and subsequent flood that prevented them from fulfilling their obligations to the residents of the home, St. Rita's nursing home.
(3/12/05)-The Medicare Payment Advisory Committee (MEDPAC), an advisory panel to Congress, voted to recommend freezing Medicare skilled nursing facility and home nursing payments for 2006. Congress ignored the recommendations of this panel last year, but with Congress looking for ways to cut down on the deficit, this may not be true for this coming year.
A skilled nursing facility pay freeze could mean about a $200 million to $600 million savings in 2006, which would also result in a savings of just about the same amount towards home nursing payments.
Medicare spends about $13 billion a year on home nursing, while nursing homes get about 12% of their revenues from Medicare by providing post-acute rehabilitation and recovery services after a beneficiary is discharged from a three-day stay at the hospital.
(9/29/03)-If you have ever been in the dining room of a nursing home during any of the meal periods you are aware of the problem of having more residents of the home who need assistance with feeding themselves than you have of qualified staff to help them with this function. The nurse's aides often have to feed the bedridden residents who are in their rooms, as well as assist the residents who are in the dining room.
The Department of Health and Human Services has published a new rule in the Federal Register that is aimed at trying to alleviate this problem. The rule takes effect 30 days after it has been published in the register. Under the new rule, nursing homes will be allowed to hire part-time workers to help feed the residents. Under present rules only nurses, nurses-aides or other health care professionals who help feed the residents must have undergone 75 hours of training. The new part time feeding assistants will only have to undergo an 8-hour training course.
Under a 1987 law, nurse's aides must take a standardized test to prove their knowledge and clinical skills, while the feeding assistants will not have to undergo any such competency test. Statistics indicate that 47% of nursing home residents need some form of feeding assistance. Twenty one % of the nursing home residents are completely dependent on feeding assistance. Under the new rules the nursing homes could use clerical workers, laundry employers and members of the housekeeping staff to help feed the residents.
Senator Charles E. Grassley, (Rep.-Io.) said that he was quite concerned with the new rule. He stated "Malnutrition and dehydration are chronic nursing home problems," and feeding residents is a job for skilled employees. It seems quite clear to us that 8 hours of training is not sufficient a time period before you can allow these part time feeders to help feed the residents. If you have seen the dining room during the meal period you would understand exactly how difficult this job can be , and only qualified people should be allowed to perform this function.
According to a report that was recently issued by the General Accounting Office serious deficiencies or harm to residents of nursing homes occurred on average in one in five of the homes over an 18-month period of time that was studied ending January 2002. Senate Finance Committee Chairman Charles Grassley (Rep.-Io.) had requested the report from the GAO's investigative branch.
This 20% ratio was an improvement over the previous study, which had turned up an unacceptable rating on 29% of nursing homes with serious deficiencies. The problem "remains unacceptably high" according to the GAO report. The report is based on state surveys. The report also found that there were a large number of inexperienced surveyors in some states that lead them to understate the quality of the problem. Another area of major concern was the fact that there were inadequate procedures in place to investigate complaints by the residents or their families. Federal surveyors found examples of actual harm being done to residents in about one-fifth of the homes that state surveyors found free of deficiencies.
The nation's 17,000 nursing homes which house about 1.6 million residents, receive about $60 billion annually from Medicare. Senator Grassley stated that a nursing-home payment increase of $6.9 billion over 10 years proposed by the CMS should be used for quality improvements. Senator Grassley also raised questions as to the accuracy and effectiveness of the CMS's new Nursing Home Compare Web site. The GAO report found that although the site is worthwhile, it contains many flaws.
One of our viewers was kind enough to e-mail us a while back with some pertinent information as to the function of the social worker in a nursing home. Unfortunately we misplaced it and did not find it till recently. We want to thank her for taking the time to write us and we do appreciate her corrections to our article. The following is Sharon G. Adler's e-mail to us:
Thank you for your very informative article, I hope that people who are planning on admitting a loved one to a Nursing Home are able to access it. I would like to make one comment. As a Long-term Social Worker for over twenty years I believe that it is inaccurate to say that "The Social Worker coordinates all services and medical treatment". In addition to being a Social Work Director in several homes and as a Consultant in three homes at the current time, it is my experience that Social Workers almost never coordinate any kind of Medical services in any home that I am familiar with. Perhaps you are referring to the Discharge Planning end of this role, but it is always usually the Nursing Supervisors or a Clinical Coordinator who are responsible for making any medical arrangements. Social Workers in Nursing Homes should
not be medical coordinators unless they have dual degrees, like Nurse/Social Worker, and I have never met anyone who holds both degrees. I am sure there might be some people out there, but I have never run across any! People are often confused about the S.W. role in Nursing Homes and it is important to describe that it is the function of the S.W. to attend to the psychosocial, emotional, and concrete needs of residents rather than their medical needs. Of course we also have to be familiar with community resources such as the Light House for the Blind and have some medical knowledge to make assessments regarding residents' levels of functioning and their long range prognoses. In this respect, you are correct, but if you go back to what most homes started out as they are all usually referred to as "Nursing" homes. Nursing is the component responsible for medical assessment and treatment along with the M.D. Your resource list is also a very good one! Thanks again. (Hope) that your article encourages other families to be as involved as you have been that, as you say, is one of the most important components in a successful N.H. placement.
Sharon G. Adler, C.S.W. Consultant
Senator John Breaux, (D. -La.) and Orrin Hatch, (R. -Utah) introduced a bill in the Senate which is aimed at detecting abuse of senior citizens, and requiring FBI criminal background checks of nursing home-aides. The bill would establish offices within the Department of Justice and the Department of Health and Human Services to deal with elder-abuse. The bill would also create new programs to assist victims and establish grants to better educate and train law enforcement officers and prosecutors about elder abuse. More than 50 advocacy groups have formed an Elder Justice Coalition to help insure passage of the measure.
A group of Democrats will introduce a bill in the House that would legislate certain minimum nurse-to-patient staffing ratios in nursing homes that receive payments from Medicare or Medicaid. The ratio is based on a report issued by the HHS that concluded that 90% of the nursing homes are staffed insufficiently to provide adequate care to their residents.
The sponsors of the bill in the house are Democratic Reps. Jan Schakowsky of Ill., Brad Carson of Okl., Henry Waxman of Cal. and Delegate Eleanor Holmes Norton of the District of Columbia. The bill would require facilities to have sufficient staff to provide 4.1 to 4.85 hours of nursing care daily for each resident, including at least 1.7 hours of individual care by registered or licensed nurses.
Anyone searching for a nursing home for a loved one will notice a range of quality of care and staffing levels in different facilities. Standards vary from state to state, and also within the individual states. The federal government attempted to set minimal acceptable standards in 1987 in nursing homes where Medicare and Medicaid funds are involved. Medicaid pays for 68% of the 1.6 million residents in about 17,000 nursing homes located in the U.S. These standards apply to 95 % of the nursing homes in the US. The variations in homes may come from how one interprets the standards. The law used vague terminology, referring to "the highest practical physical, mental and psychosocial well-being" of residents of nursing homes, but never spelled out the appropriate number of employees to achieve these goals.
In 1990, the Department of Health and Human Services was required to report on the care of residents in nursing homes. This report was supposed to be completed in 1992. According to the NY Times of July 23, 2000, "…health officials experienced many delays, and the scope of the project grew as they conducted more research and analyzed huge amounts of data from nursing homes around the country." The 200,000-page report is finally ready to be sent to Congress. The Clinton administration has given inspectors new guidelines to determine if homes meet resident minimum standard needs. There appears to be a difficulty in determining whether homes are in compliance with federal standards under this rule.
This report indicates that 54% of residents of these homes do not get at least two hours of care each day from nurse’ aides, nor do 31% of the residents receive at least 12 minutes of attention from a registered nurse. The implications from this study are that residents are endangered by understaffing, with this contributing to an increase in the incidence of bedsores, malnutrition and abnormal weight loss. The report indicates that more staffing may reduce these incidences and result in lowered referral of residents to hospital for dehydration, life-threatening infections and related disorders. The statistics gathered from the sampling of nursing homes indicated that those nursing homes with low ratio of employees to residents are "significantly more likely to have quality-of-care problems".
Staffing of nursing homes is a difficult issue, but is not one that cannot be solved. The Federal government by setting strict rules for nursing home staffing is acting in its role as watchdog for a population that has reached the winter of their lives with few social support systems to protect them from mishandling. Figures indicate that as many as 70% of these residents never have visitors when in the nursing home setting.
In these settings, they are asked to conform to certain eating hours, speed of eating, sleeping hours, activity hours etc. which may prove stressful both because of not being used to such regimentation, and slowness in adapting to new situations. At the same time, most residents have to deal with multiple illnesses. Greater staffing could enhance the quality of their lives if used in a way that insures the dignity of the individual, but is not necessarily the total answer.
There is need to find improved ways to deal with the process of aging and all its ravishes. At the same time, ways need to be found for the quality of work life for staff to be improved. This goes for all levels of staff from physicians to registered nurses to licensed practical nurses to nurse's aides to companions.
If anything is done with the recommendations of this report, we hope that the enforcement of the regulations will not be so onerous that many seniors will not have a place to go in the twilight of their lives because of the closing of these homes. At the same time however nursing homes must be made to adhere to these regulations. We leave it to citizens like those who read this article to contact their federal representatives to urge them to deal with this issue with due diligence. It has the potential to effect all of us.
If you feel that you have a complaint that is not being properly addressed in regards to a nursing home, there are governmental agencies available for you to address your complaint to. If you have a nursing home complaint in NYC call 1-800-425-0316; Nassau-Suffolk call 1-800-425-0323. Keep in mind that the Centers for Medicare and Medicaid Services is the Federal government's overseer of Nursing Homes in the United States. Their telephone number is 1-800-638-6833. Their web site is http://www.cms.hhs.gov
FOR AN INFORMATIVE AND PERSONAL ARTICLE ON PRACTICAL SUGGESTIONS WHEN SELECTING A NURSING HOME SEE OUR ARTICLE "How to Select a Nursing Home"
Harold Rubin, MS, ABD, CRC, Guest Lecturer
updated April 20, 2013
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