Nursing homes, struggling with record staff shortages and rising Covid-19 infections, will soon have to publicly report their employee turnover rates and weekend staffing levels for nurses, a move designed to help consumers select quality facilities.
Much of the new information slated to post this month on Medicare.gov’s Care Compare website will not be flattering. That’s because “every nursing home in the country, for the most part, is struggling” with high employee turnover and low staffing, said David Grabowski, a professor of health-care policy at Harvard Medical School.
The new data is expected to show what recent research has already found—that staffing levels for registered nurses, licensed practical nurses, and nurse aides typically drops off on weekends. And many nursing home employees leave their jobs within a year. Both problems are closely linked to poor-quality care.
As nursing homes try to restore public confidence after Covid-19 killed at least 186,000 residents in long-term care, the reporting mandate could provide an untimely black eye for an industry already on the ropes.
“This really feels like a gut punch to nursing homes that are really struggling right now,” Grabowski told participants during a recent web briefing hosted by LeadingAge, which represents nonprofit aging services providers.
The new reporting mandate is reasonable and useful for consumers, Grabowski acknowledged. “This is really bad timing.”
The industry agrees. Nursing homes have lost 234,000 employees, or 15% of their workforce, since the pandemic began, according to the American Health Care Association and the National Center for Assisted Living. “The addition of this reporting requirement when we are in the middle of the worst labor shortage the nursing home sector has ever faced is tone deaf,” the groups said in a statement to Bloomberg Law.
Beginning in July, the new data from roughly 14,000 U.S. nursing homes will help determine a facility’s overall quality rating from the Centers for Medicare & Medicaid Services. Under the new requirement, facilities must report the number of administrators who’ve left in the past year, the percentage of registered nurses who’ve left, and the total number of all nurses who’ve left. Weekend staffing levels for registered nurses, licensed practical nurses, and certified nurse aides must also be reported.
Last year, Grabowski co-authored research that found nearly all direct-care staff at the typical nursing home left their jobs in 2017 and 2018. The projected 94% turnover rate was much larger than previous research had shown and has likely worsened during the pandemic.
A 2019 study by Grabowski and other researchers at Harvard University found 91% of nursing homes met federal staffing levels for registered nurses less than 60% of the time. Staffing levels for registered nurses, licensed practical nurses, and nurse aides were found to fall at night and on weekends. Overall, 54% of facilities met the expected staffing levels less than 20% of the time, the study found.
“We’ve known for a long time that staffing levels are worse on weekends, and this data will validate that,” said Lori Smetanka, executive director of the Consumer Voice for Quality Long-Term Care, said in a statement. “Further, high turnover rates, which average around 100% of staff, are indicative of poorer quality in facilities. This information will help consumers make more informed decisions about choosing long-term care.”
Staffing, Reporting Requirements
Federal law requires nursing homes to provide “licensed nursing services” that are “sufficient” to meet resident needs. But Medicare only requires nursing homes to have at least one registered nurse on duty for eight straight hours per day.
The CMS said the new reporting requirements make good on a policy it would have implemented last year if not for the pandemic. In March 2021, a report by the Department of Health and Human Services’ Office of Inspector General found the Care Compare website could better serve the public and state inspection agencies if it included self-reported nursing home staff turnover data.
“CMS had taken steps to introduce a turnover measure on Care Compare in late 2020, including consulting with outside experts to define and refine a potential measure, however, due to the Covid-19 pandemic, this timeline has been delayed,” the agency wrote in a response letter to the OIG. “CMS will continue to make progress towards reporting both nursing staff turnover and tenure publicly.”
The Care Compare site has posted nursing home staffing data for more than a decade, but in August 2020, the HHS OIG recommended the CMS provide information about how a facility’s weekend staffing levels compare with other facilities with similar quality ratings. In its March 2021 report, the OIG “recommended CMS report measures of nurse turnover as soon as practicable” due to the impact that Covid was having on nursing home oversight.
A Call for Higher Reimbursement
While staffing and job retention were longstanding industry problems that only worsened during the pandemic, the AHCA/NCAL said the new reporting requirement is the wrong approach. It has called for higher reimbursements from Medicaid and more targeted funding to help providers with rising labor, equipment and Covid testing costs.
“While we support transparency and agree that staffing hours and turnover metrics are important, more reporting will not solve this issue,” the group’s statement said.
Grabowski agreed, telling webinar participants that the “ultimate way out” of the industry’s workforce crisis is higher Medicaid reimbursements and additional federal funding.
“We need to put more dollars into paying our staff a living wage, and that’s a policy issue. That’s not a nursing home problem,” Grabowski said. “That’s really something we have to do at a policy level.”