Low Quality Jobs Equal Low Quality Care in Nursing Homes

In February 2022, President Biden announced a series of landmark nursing home reforms designed to address decades of poor care, inadequate enforcement and insufficient transparency in how nursing homes spend tens of billions of taxpayer dollars each year. Central to these reforms is the creation of a minimum staffing standard. President Biden’s proposal would create a federal regulation requiring nursing homes to provide a minimum number of direct care nursing hours to each resident per day.

Residents, families and advocates applauded the announcement. Adequate staffing is the cornerstone of high-quality care in nursing homes. Advocates for nursing home residents have been fighting for decades to get a federal minimum staffing standard. However, many in the nursing home industry raised red flags, citing an inability to recruit new staff, which would make meeting a new standard impossible.

Shockingly, CMS revealed that, on average, nursing homes replace 52% of their nursing staff each year.

In June, Consumer Voice, in response to a Request for Information from the Centers for Medicare & Medicaid Services (CMS), offered a variety of suggestions on how a minimum standard should be ascertained and implemented. Central to our comments was the critical need to address staff turnover in nursing homes. In January 2022, CMS began releasing nursing staff turnover information for each facility in the country, citing the direct link between better care quality and health outcomes in nursing homes with lower annual staff turnover. Shockingly, CMS revealed that, on average, nursing homes replace 52% of their nursing staff each year.

The Job and Care Quality Crisis Report

On September 8, 2022, Consumer Voice released a report, High Staff Turnover: A Job Quality Crisis in Nursing Homes, that took a closer look at the negative impact high staff turnover has on care quality. In addition, the report looked at the causes of high staff turnover, which research shows is related to poor wages and benefits, impossible workloads, lack of training, few opportunities for career advancement and poor management. The available data regarding jobs and job quality in nursing homes reveal that years of poor treatment of nursing home workers has resulted in a job-quality crisis, where the average nursing home must replace every other nursing home staff member each year.

Our report found that roughly 30% of nursing homes have an annual staff turnover rate of 60% or higher. Unsurprisingly, additional data from CMS reflects that nursing homes with higher staff turnover provide poorer care. Some key findings include that nursing homes with higher staff turnover:

  • Perform poorly on all of CMS’ 5-Star ratings, including overall, staffing and health inspection ratings.
  • Are cited more frequently for resident abuse.
  • Have higher numbers of substantiated complaints.

Another Consumer Voice report released in earlier this year, Staffing Matters, found identical trends for nursing homes with low direct care staffing. Data confirms that residents are safer and receive better care in nursing homes with higher daily staffing and lower annual staff turnover.

As noted above, the causes of high staff turnover are well-documented. Despite being heralded as heroes throughout the COVID-19 pandemic, nursing home staffers fled their jobs in droves, in part due to illness, and even death, but also because job quality is so poor.

The median income for a certified nursing assistant (CNA) in the United States is $25,200. A whopping 34% of CNAs are on public assistance. And 15% of CNAs have no health insurance, while 22% rely on Medicaid. Additionally, registered nurses make on average 7% less in a nursing home than they would working in hospitals.

Most CNAs are responsible for 13 residents per shift, instead of the recommended 6.

Poverty level wages are made worse by impossible workloads. A landmark CMS staffing study conducted in 2001 recommended that a CNA only be responsible for six residents per shift. Yet, the current reality is that on average CNAs are responsible for more than twice that number, 13 residents per shift. And 10% of CNAs in the United States are responsible for 19 or more residents.

Additional factors, such as inadequate training, little opportunity for career advancement and poor management contribute to staff turnover. Our report explores each of these issues and offers solutions to address them.

In addition to addressing the issues that contribute to inadequate staffing and high staff turnover, we must take steps to address how nursing homes spend the tens of billions of dollars they receive from Medicare and Medicaid each year. In 2020, nursing homes received $67.6 billion in Medicare and Medicaid payments, with the average Medicare profit margin being roughly 16%. Yet, there is little to no scrutiny of how these dollars are spent. This absence of oversight of how tax dollars are spent is why President Biden has promised increased scrutiny on nursing home finances. Years of accounting hijinks has allowed nursing homes to annually divert billions of dollars away from nursing home staffing and resident care to profits for owners and corporations. National Consumer Voice for Quality Long-Term Care is working on a new report that will go into greater detail on why increased scrutiny is needed.

No population suffered more than nursing home residents during the pandemic—nearly 156,000 residents died from COVID-19, while countless others suffered from isolation and neglect. The pandemic laid bare decades of systemic problems that have plagued nursing homes—particularly inadequate staffing. President Biden’s announced reforms, including the staffing standard, are essential to protecting nursing home residents. We must invest in staff, reduce staff turnover, and ensure that nursing home residents are receiving high quality care.

Sam Brooks, JD, is director, Public Policy, at National Consumer Voice for Quality Long-Term Care in Washington, DC.