Three-fourths of the nation’s nursing homes never meet federal staffing expectations for registered nurse staffing, and RNs are often missing from such facilities on the weekends, according to a new review of a year’s worth of payroll data.
The research also found that 70% of facilities self-reported higher total direct staffing under the CASPER system than in the now-standard Payroll-Based Journal. The discrepancy was most pronounced at for-profit facilities, followed by non-profits and then government-run buildings.
Researchers from Harvard and Vanderbilt medical schools examined records from 15,399 nursing homes covering April 2017 through March 2018. Their results were published online by Health Affairs Monday afternoon.
Study co-author David Grabowski, a professor in the Department of Health Care Policy at Harvard, said he found the RN data “‘staggering,” and that the study results could have broader implications than just immediate revelations about staffing.
“Most of the quality measures reported on Nursing Home Compare are self-reported,” Grabowski noted to McKnight’s. “Unfortunately, CMS rarely audits measures such as the rates of pressure ulcers or pain. As a result, these measures are subject to the same reporting bias we saw with staffing under the CASPER system. We would encourage CMS to increase the auditing of these measures in order to improve the quality of the used in reporting, monitoring and enforcement.”
Grabowski said 75% of SNFs were almost never in compliance with the Centers for Medicare & Medicaid Services’ expectations for staffing given their residents’ particular acuity levels, based on the Staff Time and Resource Intensity Verification Project.
While PBJ data proved 96% of nursing homes had an RN onsite for at least eight hours a day 80% of the year, the weekends told a different story. For RN staffing, 91% of facilities met the expected level less than 60% of the time. Overall staffing also was lower on the weekends, with reductions in LPN and nurse aide hours too.
Larger facilities, on average, had bigger weekend decreases, while facilities with higher five-star overall ratings or lower shares of Medicaid residents had smaller fluctuations.
“Adverse events such as falls and medication errors might be more likely to occur during those understaffed days,” the researchers wrote. “For this reason, CMS should leverage the daily payroll data to incorporate staffing variation over time, in addition to average staffing levels, in its calculation of star ratings.”
Provider organizations have long argued that recruiting and pay are industry-wide challenges. In June, both the American Health Care Association and LeadingAge expressed concern that a CMS proposal to allow low-wage hospitals to increase pay would only increase the burden on SNFs.
“LeadingAge supports all efforts to promote nursing home quality and transparency,” said President and CEO Katie smith Sloan, noting that organization backed the shift from manual reporting to PBJ. “We believe that PBJ is an improvement because it standardizes data collection and holds the promise of more accurate data problems.”
Smith Sloan added that some members have reported the inability to correct errors with the same quarter, which could affect staffing averages. Other organizations have questioned comparing PBJ and CASPER numbers, arguing that PBJ may be underreporting numbers by requiring 30-minute meal breaks or leaving out hours over 40 worked by salaried staff.
The study acknowledged the PBJ method might not accurately reflect salaried staff hours or distinguish between hours worked and paid time off. The authors pointed out, though, that four out of five nursing home employees are paid hourly.
Both LeadingAge and the American Health Care Association cautioned against viewing the staffing numbers in a vacuum.
“While staffing levels are one of many important metrics in quality care, judging the quality of a nursing home based solely on staffing is misguided,” said Courtney Bishnoi, Vice President of Quality and Programs at AHCA. “There is no question that the long-term care profession, along with health care providers across the spectrum, are facing a crisis…. AHCA is working with lawmakers to share policy that will help increase the number of workers.”
In his comments to McKnight’s, Grabowski acknowledged providers’ staffing struggles.
“On a large number of days, we do not have sufficient RN staffing in most nursing homes,” he said, again noting the weekend reductions. “A clear solution is to pay higher rates to entice caregivers to work on these days. For a nursing home caring for a greater share of Medicaid residents, however, they may not be able to pay these higher weekend-staff rates due to lower Medicaid payments.”
The team also found that staffing levels spiked significantly in the two weeks around a survey team’s visit.
Grabowski said his team isn’t advocating for penalties related to “staffing up” but suggested surveyors should know whether the staffing level at the time of the inspection is typical.
“We need to use expected staffing in quality reporting, monitoring, and enforcement,” he said. “CMS needs to address the gap between their expectations and the regulations regarding RN staffing.”