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As the need for nursing homes grows, nurses are in short supply

Kimberly Adams Oct 25, 2023
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Nursing home resident Nancy Hoover with Joan Strassner, a licensed practical nurse. Strassner likes to sing with residents but is often swamped with work due to tight staffing. Maya Marchel Hoff/Marketplace

As the need for nursing homes grows, nurses are in short supply

Kimberly Adams Oct 25, 2023
Heard on:
Nursing home resident Nancy Hoover with Joan Strassner, a licensed practical nurse. Strassner likes to sing with residents but is often swamped with work due to tight staffing. Maya Marchel Hoff/Marketplace
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Alicia Gordon, 62, has been a caregiver for decades. At various times, she cared for her husband, her sister, her father until he passed and now her mother in Annandale, Virginia, who is about to turn 86. But Gordon said she’d rather care for loved ones herself rather than let them spend a night alone at a nursing home. 

Three women sit together on a couch in a living room.
Alicia Gordon, left, with her mother, Beverly Sleph, and her sister, Pami. (Courtesy Gordon)

“It’s not the quality of the care that’s available,” Gordon said. “It’s the amount of care that’s on duty. The nurses, for the most part, are amazing, [but] they’re overworked. They’re exhausted. They have too much responsibility. And then the [nurse] technicians aren’t there. There are just not enough bodies.”

Gordon was one of thousands of people who have already weighed in on a proposed rule from the Centers for Medicare & Medicaid Services that would, for the first time, set federal minimum staffing standards for nursing homes. According to CMS, “Nursing homes would need to provide residents with a minimum of 0.55 hours of care from a registered nurse per resident per day, and 2.45 hours of care from a nurse aide per resident per day, exceeding existing standards in nearly all states.”

Additionally, the rule would require facilities “to ensure a registered nurse is on site 24 hours per day, 7 days per week and to complete robust facility assessments on staffing needs.” 

Individuals like Gordon are among a broad group of supporters of the proposed rule, including labor unions that represent nurses. In written testimony submitted for a congressional hearing on the topic, Shelly Hughes, a member of the Service Employees International Union from Washington, said: “On average, nursing assistants support 13 residents during a typical shift, but I’ve spoken with CNAs who have been responsible for upwards of 30 residents — alone. The math doesn’t add up. How can you care for 30 individuals in just 12 hours?”

But those opposed to the proposed regulations argue that the limited staffing has more to do with the industry’s pervasive labor shortages than personnel choices by individual facilities. 

“We share the goal of quality care, absolutely. Hands down,” said Katie Smith Sloan, president and CEO of LeadingAge, an association of nonprofit providers of aging services, including nursing homes. The group estimates the country would need at least another 90,000 nurses to meet the requirements of the proposed mandate. 

“We know that there’s a high correlation between consistent, reliable staffing, well-trained, well-supported, well-paid staffing, and quality care,” Sloan said. “But right now, until we address the workforce shortage — the workforce crisis — that we’re facing, there is no way that we can adhere to a staffing mandate and we will not achieve the goals that the administration has set out.”

That concern was echoed by Martin Allen, senior vice president for reimbursement at the American Health Care Association, an industry group that also represents for-profit care providers. 

“We would like to hire more nurses and nursing assistants in order to meet this mandate, but they’re just not there. And while there is a phase-in for this proposal, you know, we don’t think that it’s realistic,” said Allen, whose group estimates the CMS proposal would cost nursing homes $6.8 billion per year

And for evidence, folks in the industry point to what’s already happening. At the nonprofit Virginia Mennonite Retirement Community in Harrisonburg, Virginia, rooms and wings of the skilled-nursing facility sit empty. According to Rebecca Kline, an RN and director of nursing there, they technically have space for 120 patients, but they only have staffing for 90. And to keep those jobs filled, Kline said she’s constantly recruiting. 

“So we have approximately three full-time nurse positions and multiple part-time and flex positions, as well as a number of CNA positions right now. We would like to hire 10 full-time CNA positions so that we could be completely fully staffed,” she said.

Kline and others worry that if the workforce issues aren’t solved before a federal mandate, some facilities may have to reduce services even further or close altogether. 

Rebecca Kline points down an empty hallway in a nursing home.
Rebecca Kline shows an empty wing at the Virginia Mennonite Retirement Community, where she is director of nursing. (Kimberly Adams/Marketplace)

According to the Kaiser Family Foundation, “fewer than 1 in 5 [nursing homes] could currently meet the required number of hours for registered nurses and nurse aides, which means over 80% of facilities would need to hire nursing staff.” 

The CMS proposal does call for a staggered implementation, as well as an exemptions process and phased implementation of any new rules. But Deb Bakerjian, a professor and associate dean at the Betty Irene Moore School of Nursing at the University of California, Davis, worries about delaying a mandate too long.

“If we don’t pay attention to this, we’re going to have some terrible outcomes as more and more of our older adults get to this time in their life where they may need extra help,” she said. 

Bakerjian also said the nursing home industry could be doing more to improve staffing. Especially the 71% of the nation’s nursing homes that are for-profit.

“We have a lot of nursing homes that are owned by financial institutions. They own the real estate, and therefore whoever is managing the nursing home is separated from the ownership,” Bakerjian said. “And this has created a lot of problems because the money that’s coming into the nursing home is being siphoned off for the real estate part of it, and it leaves less operational dollars. And we’re not going to solve all of these problems until that is also dealt with.”

The comment period for the proposed CMS rules closes Nov. 6.

Additional reporting by Maya Marchel Hoff.

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