'Access-to-care crisis:' Nursing homes brace for stricter staffing rules amid workforce challenges

REPOSTED FROM SCRANTON TIMES BY JEFF HORVATH 

When the state ordered the emergency relocation of 85 residents late last month from a struggling South Scranton nursing home, several nearby facilities voiced a common concern to an advocacy association representing the industry in Pennsylvania.

Accepting residents evacuated from Mountain View Care and Rehabilitation Center could jeopardize their ability to meet minimum staffing standards enforced by the state Department of Health.

"In every conversation that we had with our members, they asked us: 'If I take residents from Mountain View, will the Department of Health waive the staffing ratios?'" Pennsylvania Health Care Association President and CEO Zach Shamberg recalled. "'If they can, I can take 10 people. If they don't, or are unwilling to do that, I can't take any.' That's how bad it was, and that's what the mandate is doing in practicality. ... It's preventing providers from caring for those vulnerable seniors even in a time of emergency."

Regulations that went into effect last July require facilities to provide each resident 2.87 hours of direct care per day. That minimum standard will increase to 3.2 daily hours of direct care effective July 1.

Defenders of minimum staffing standards argue they're necessary to ensure residents receive quality care in safe environments, with some arguing Pennsylvania regulations don't go far enough. But many providers bracing for the increase amid ongoing workforce challenges regard it as an unfunded mandate limiting their ability to accept referrals.

Empty beds

A recent PHCA nursing facility survey found roughly 50% of respondents denied admission in the first quarter of 2024 because they lacked sufficient staff to care for additional residents. About 52% cited the staffing ratio mandates and the inability to hire more workers as the reason for denying admissions.

Every respondent reported having open direct care positions for registered nurses, licensed practical nurses and certified nursing assistants, with nearly 60% saying they're not prepared to meet the new standard when Pennsylvania's staffing mandate increases July 1.

Allied Services Skilled Nursing and Rehabilitation Center in Scranton typically admits between six and 10 residents per day to the 327-bed facility, but can't keep up with hospital discharge demand even at that pace.

"We have anywhere from 20 to 30 referrals a day that are on our waiting list that we just can't admit because we can't achieve the staffing levels to take care of 20 or 30 more people," Allied Vice President of Skilled Nursing James Cooney said. "We have 50 empty beds usually on any given day and the census level that we maintain ... is just what we can do to keep ourselves in compliance with regulations in terms of staffing."

Despite concerted efforts to recruit and retain workers with raises, bonuses and other incentives, staffing and related challenges persist at Allied facilities, including Allied Services Meade Street Skilled Nursing and Allied Services Center City Skilled Nursing in Wilkes-Barre.

Allied completely renovated both Wilkes-Barre facilities since acquiring them in 2019 from the Diocese of Scranton, modernizing amenities while increasing bed capacity. Meade Street Skilled Nursing had 25 empty beds as of Wednesday; Center City Skilled Nursing had 34.

Staffing and inadequate Medicaid funding to recruit and retain workers are factors limiting Allied's ability to fill each facility, Allied spokesman Jim Brogna said.

PHCA and other advocates are calling on the state to fund the staffing mandate by increasing its contribution toward Medicaid reimbursements for facilities serving low-income residents. Current reimbursement rates aren't keeping pace with the cost of caring for that population, depriving facilities of funding that could otherwise be invested in staffing, officials said.

"There has not been enough funding allocated in the state budget to Medicaid reimbursement to ensure that providers can meet this mandate," Shamberg said.

Carbondale Nursing and Rehabilitation Center Administrator Noelle Kovaleski told a panel of Democratic state lawmakers last month that her facility's Medicaid reimbursements fell short in 2023 by nearly $40 a day for each Medicaid resident. That amounted to a roughly $1 million funding shortfall for the year.

Like Allied, Carbondale has been forced to limit its census and deny admissions to comply with state staffing requirements set to increase again in just over a week. It will have to further limit admissions to comply with the increase, contributing to a broader access-to-care issue, Kovaleski said.

While hers was among the facilities unable to accept relocated Mountain View residents due to staffing challenges, all Mountain View residents were successfully moved to other locations.

Defending mandates

Richard Mollot, executive director of the Long Term Care Community Coalition, a New York City-based nonprofit advocating for nursing home residents' rights, defended stricter staffing requirements.
 

Speaking generally and not about any particular provider, he said the regulations safeguard against nursing homes and long-term care facilities limiting staff to maximize profits at the expense of resident safety.

Pennsylvania's minimum standard and a recently finalized federal rule requiring facilities to provide 3.48 hours of care per resident day — a regulation set to take effect in two years for urban providers and three years for rural facilities — both fall short of the 4.1 hours per resident day a 2001 federal study deemed necessary to meet a typical resident's clinical needs, Mollot said.

"The baseline in Pennsylvania, the baseline in virtually all of the states and under the Biden Administration's new rules are very, very low," he said. "It's really a floor, and it's a floor that is well below any appropriate amount for good resident care."

Failure to provide at least 4.1 hours of care per resident  day can increase the risk of pressure ulcers, falls and other unwanted outcomes, Mollet said.

"The most fundamental federal requirement for nursing homes, in my view, is that they only accept and retain individuals for whom they have sufficient staffing and supplies to provide appropriate care with dignity," he said in an email.

Mark O’Neill, press secretary for the state Department of Health, said the department's top priority is resident health and safety. 

"And the minimum staffing ratios outlined in the long-term care nursing facility regulations will help us keep Pennsylvanians safe and healthy by ensuring more hours of care for those in nursing homes," he said in a statement. "Throughout the regulatory process, the Department of Health worked closely with long-term care nursing facility stakeholders to develop minimum staffing ratios that protect residents while balancing workforce recruitment and retention concerns."

No flexibility

In order to comply with the current state mandate, Carbondale Nursing and Rehabilitation is operating with about 15 of the facility's 115 beds unfilled. Officials expect to further limit the census to 96 beds when the new standard goes into effect July 1.

Among other issues, Kovaleski said the minimums don't allow for flexibility in emergency situations, such as the Mountain View closure, or in cases when staff are unexpectedly unavailable to work.

"We're professionals in this business," she said last week. "We know what level of care we need to provide for the residents to be safe. It varies, depending on the residents that you have at the time."

"The problem with the ratios is they leave no wiggle room for you," she continued. "We always staff at what the ratios are or above, but if you have three call-offs what do you do?"

Shamberg and Kovaleski also spoke to hiring difficulties many providers face, with the latter noting she had an open RN position advertised for more than a year without a single candidate expressing interest.

"There are not enough qualified individuals in Pennsylvania today for providers to meet this mandate, so it's putting many providers and our vulnerable seniors in a lose-lose situation," Shamberg said.

Moreover, Brogna said surrounding states with higher Medicaid reimbursement rates that invest more in long-term care allow providers there to more competitively court potential workers. That has contributed to the exodus of nurses and other caregivers and exacerbated workforce shortages locally and across Pennsylvania, he said.

'Not viable'

Nearly 50% of the nursing home owners and operators that responded to the recent PHCA survey reported plans to sell or close one or more facilities within the next year. A larger share, 85%, said the nursing facility operating environment is not viable, with the majority attributing that to inadequate reimbursements.

PHCA wants the state to adopt and invest $100 million in a program that would provide supplemental quarterly payments to high-performing facilities.

It's also called for a $25.4 million investment toward Medicaid reimbursements, but Shamberg said recently that even that wouldn't sufficiently address the pronounced workforce challenges the industry faces.

"So we're going back to legislative leaders now to say if we want to stop the bankruptcies, if we want to stop the closures, if we want to stop the access-to-care crisis, much more needs to be done," he said.

Contact the writer: jhorvath@scrantontimes.com; 570-348-9141; @jhorvathTT on Twitter.