HD29 - Nursing Facility Staffing Guidelines Report


Executive Summary:
The 1994 General Assembly requested that the Secretary of Health and Human Resources review staffing guidelines for nursing facilities to determine whether staffing requirements currently in effect in the Commonwealth of Virginia adequately protect the health, welfare and safety of nursing facility residents.

The Virginia Department of Health is the designated State Agency responsible for assuring compliance with Federal regulations pertaining to nursing facility Medicare/Medicaid certification. The 1987 Omnibus Budget Reconciliation Act (OBRA) legislation mandated that nurse staffing in nursing facilities be "sufficient" to meet resident care needs, but specified only that each certified nursing facility have a registered nurse (RN) director of nursing, and a licensed nurse on duty at all times (including an RN eight hours a day). These few specific requirements may be waived in Medicaid facilities; however, Virginia does not allow waivers.

Chapter Five of Title 32.1 of the Code of Virginia requires nursing facilities to be licensed and the State Board of Health promulgates regulations for these facilities. State licensure law must conform to the federal law for certification regarding minimum nursing facility staffing requirements. The State may also require additional conditions for licensure of facilities. Virginia has no additional staffing requirements for licensure. The licensure requirements are the same as the Federal certification requirements.

A study conducted by the National Committee to preserve Social Security and Medicare (November, 1993) found that only 5 percent of the 15,043 federally certified nursing facilities meet a recommended minimum standard for staffing.

Staffing is the primary resource allocation issue in managing a nursing facility. It is also the vehicle for ensuring adequate care to a very vulnerable population.

Methodology

• Formation of a task force representing consumers, advocates, providers and interacting state agencies to review data and make recommendations.

• Survey of forty-four (44) identified states requiring additional nurse staffing. The survey requested information on specific resident outcomes as a result of additional staffing.

• Analysis of data provided by Department of Health Professions, Board of Nursing, regarding nursing staff availability by region and ZIP code.

• Analysis of Department of Medical Assistance Services' data on Nursing Facility Staffing Ratios for FY 1993 and Virginia Health Care Association's Annual wage Survey and Nursing Hours Per Patient Day/Resident study.

• Conduct interviews with consumers, advocates, and providers.

• Review of current studies/literature addressing nursing facility staffing standards.

Analysis

• Additional nurse staffing requirements are not necessary to ensure the health, welfare and safety of residents. Current nursing facility staffing equals or exceeds staffing in states with mandated staffing requirements. Sixty-one percent (61%) of respondents interviewed believe current nursing facility staffing requirements ensure the health welfare and safety of residents.

• Complaints/adverse actions have no direct correlation to level of nurse staffing. Lack of a comprehensive employee orientation, which is facility specific, has a direct correlation to facility complaints.

• None of the forty-four (44) states surveyed have collected objective data on the impact of additional staffing on resident care outcomes.

• Seventy-seven percent (77%) of respondents interviewed believe additional nursing staff are available in the state.

• An increase of one Registered Nurse seven (7) days/week/24 hours/day/facility would increase the 258 providers cost a minimum of $32,659,704.

• Training programs in customer service addressing cultural diversity, stress management and communication skills are not offered to employees of all nursing facilities.

• The Congress of the United States, following 1993 hearings on the current state of staffing of nursing personnel in hospitals and nursing facilities, directed the Secretary of the Department of Health and Human Services to request a study from the Institute of Medicine, National Academy of Sciences, to determine whether and to what extent there is a need for an increase in the number of nurses in hospitals and nursing facilities in order to promote the quality of patient care. The results will be available in 1996.

Recommendations

The Task Force recommends the following:

1. The Virginia Department of Health/Office of Health Facilities Regulation, Long Term Care Division Subgroup Two, whose membership includes industry providers and advocates, responsible for review and revision of nursing facility regulations should:

a. Consider requiring for all nursing facility staff a comprehensive facility-specific orientation to include, but not be limited to, life safety policies/procedure, patient rights, and dignity issues.

b. Consider requiring a customer service program for all nursing facility employees regarding the aging process, cultural diversity, and mechanisms to cope with and avoid confrontational situations.

2. The Virginia Department of Health/Office of Health Facilities Regulation, should continue to collect and study, in cooperation with industry providers and advocates, available data on nursing facility staffing, and reconvene the Task Force to review the Institute of Medicine study on nurse staffing when it is published in 1996.