How Skilled Nursing Facilities Can Prepare For Inevitable Staffing Ratio Increases

Most of us who have worked or are working in the skilled nursing profession know that federal law requires Medicare- and Medicaid-certified nursing homes to have a registered nurse (RN) on duty at least 8 hours a day, 7 days a week; a licensed nurse (RN or LPN) on duty 24 hours a day; and that there are no minimum staffing levels for nurse aides, who provide most of the day-to-day care. Instead, nursing homes are required "to provide sufficient staff and services to attain or maintain the highest possible level of physical, mental, and psychosocial well-being of each resident."

However, many states impose additional staffing requirements that facilities must maintain, and they are ever-changing with the pandemic having recently been the impetus for some states to implement new laws in this area. In some cases, the changes are viewed by providers as positive but in most, they are viewed as an unfunded mandate of a one-size-fits-all solution that removes flexibility to schedule staff in an optimum manner to best meet resident needs.

There’s no question that there have been numerous studies demonstrating that increased staffing is correlated with improved clinical outcomes over a number of care domains. However, there are also numerous examples of facilities with lower staffing having great clinical outcomes, as well as facilities with higher staffing having poor outcomes.

This blog will look at some of the recent mandates and offer guidance on how providers can best prepare to meet increased staffing requirements.

New York Mandates 3.5 Care Hours Per Resident Per Day, Going Into Effect January 2022

Gov. Andrew Cuomo (D) recently signed legislation to establish minimum staffing standards that include at least 3.5 hours of nursing care per resident per day. At least 2.2 of those hours must be provided by certified nurse aides and 1.1 by licensed practical nurses or registered nurses. The bill had originally called for nursing home residents to receive at least 4.1 hours of direct care each day, which would be in line with a federal study from 2001. Sponsors of the bill said it was lowered to 3.5 as part of negotiations with nursing homes.

The bill also requires nursing homes to publicly disclose their staffing levels in a fashion that is visible and accessible to residents, families and staff.  Facilities have until January 1, 2022 to comply and may face penalties if they fall short.

Over the years, we’ve seen other states enact similar staffing requirements. Just this year, New Jersey mandated a 1:10 caregiver to resident ratio, Arkansas raised their required hours by 30% and other states, such as Massachusetts, Oregon and Rhode Island, are looking into adopting stricter staffing minimums.

Addressing The Staffing Shortage

Providers have historically challenged these mandates due to the industry’s long-standing staffing shortages. They are already struggling to staff their buildings to their current HPD requirements, so how could they possibly meet the increased hours?

Several states are taking this into account. For example, when California raised its ratio from 3.2 to 3.5 back in 2018, the law also included two waivers for which facilities unable to recruit sufficient staff to meet the new standard could apply. The Workforce Shortage Waiver applies to facilities that are unable to hire sufficient staff to provide 3.5 direct care service hours and/or the 2.4 CNA hours due to a workforce shortage in their local market. These facilities are still required to meet California’s previous 3.2 labor hour standard. The Acuity Waiver applies to facilities that run total direct care hours of 3.5 or greater but don’t meet the 2.4 CNA hour requirement because they run higher nursing (RN & LPN) hours. Typically, this would apply to facilities such as transitional care units that, due to their patient population, provide more nursing care and consequently, don’t need to staff CNAs at 2.4 HPPD.

In conjunction with their increase, New Jersey also established a retention and recruitment task force to help nursing home operators find sufficient workers to meet the new requirements after operators in the state had indicated that they could not implement the stricter care ratios without workforce development assistance.

The Critical Need For A Stable Workforce In Senior Care

The pandemic seems to have increased the urgency and sped up the implementation of many of these mandates. And while meeting these new requirements will be an adjustment for providers, there are a few key practices you can implement today to make the transition easier.

Maximize The Staff You Have

Strategic labor management is a key piece in the staffing puzzle. Providers need to see how they’re staffing today and in the future, and be able to set labor budget goals and minimums. Scheduling software gives organizations a clear picture of staff utilization to ensure all team members are working to their full capacity. Maximizing the use of your staff (e.g. ensuring that all of your full-time staff are working full-time hours) is one of the easiest and most cost-effective ways to fill gaps in the schedule.

It’s also important to create a mobile workforce management experience for your employees—one that makes it easy to view their schedule, request open shifts and be notified in the event of a call-off or last-minute need. This can go a long way in not only improving staff satisfaction, but ensuring you’re truly maximizing the staff you have.

Recruitment & Retention: Focus On The Employee Experience

While certain states have created waivers and task forces to help organizations meet the new staffing requirements, many have not. Even those with the extra assistance will be placing a stronger emphasis on recruitment and retention moving forward.

When it comes to recruiting, be sure you are casting the widest net possible. Post your openings to the latest job boards and on your social media channels. Make your employees part of the process by asking them to share these posts with their networks and refer their friends.

Next, be sure you are creating a positive candidate experience. This includes following up with applicants quickly using their preferred communication method, keeping them up to date on next steps and simplifying key tasks in the hiring process like background screening and paperwork. Technology can certainly help your organization provide that positive candidate experience and OnShift Employ, our talent acquisition software, has helped providers achieve up to a 35% reduction in time to hire.

Since recruiting is more challenging for providers these days, many have placed an increased focus on their current employees. Best practices on the retention front include keeping lines of communication open, offering meaningful perks and incentives, and fostering stronger employee-manager relationships. Employee engagement software facilitates all of the above and has helped organizations reduce turnover by up to 54%.

Finally, recognize those employees that show up day in and day out. As a recent caregiver survey showed, many senior care employees are struggling with burnout and are looking to their organization to make improvements when it comes to being short staffed. While staffing struggles are likely to continue for the foreseeable future, it’s critical that you remind your current employees that their contributions matter. Rewards programs, access to earned wages and other benefit programs can help show your staff you recognize their struggles and that you want to create a positive, rewarding experience at work.

OnShift Is Here For You

Skilled nursing facilities will continue to face tighter and tighter regulations related to resident care. However, meeting these new staffing requirements is possible with the right processes in place.

OnShift will continue to keep providers in the loop as regulation changes arise. Please feel free to reach out to us if you have any questions or want to learn more about how OnShift supports staffing mandates with our innovative software for hiring, scheduling and engaging employees.