Nursing homes in Pa. move toward higher staffing standards and transparency on ‘who exactly is responsible for the care of residents’

Pennsylvania’s Independent Regulatory Review Commission on Friday approved the first major revamp of the state’s nursing-home regulations since 1997. The new rules include higher staffing levels and more disclosure when nursing homes are sold.

The new Department of Health regulations set new minimum staffing levels for the state’s nearly 700 nursing homes. The facilities will be required to provide 2.87 hours per day of direct care per patient starting in July and then 3.2 hours per day starting in July 2024. The current requirement is 2.7 hours.

The health department had proposed 4.1 hours per day, but the industry said that standard was impossible to meet, given labor shortages.

Certified nursing assistants are the backbone of nursing home care, but the number of new certifications statewide plummeted to 2,000 during the pandemic from 7,000 in 2019, according to SEIU Healthcare of Pennsylvania, a labor union that represents thousands of such workers.

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A representative of Community Legal Services of Philadelphia, which was among the advocacy groups pushing for 4.1 hours of staffing, said in written comments submitted before Friday’s meeting that it was disappointed by the lower staffing standard, but said even the more modest increase will help.

“Adequate staffing means the difference between a resident receiving assistance walking to and using the bathroom rather than falling trying to ambulate by themselves or being left lying in their own waste for long periods,” Pamela Walz, a supervising attorney at CSL, wrote.

The new regulations also limit the number of patients nursing assistants can be expected to care for. Starting in July, facilities will not be allowed to ask a nurse aide to care for more than 12 residents during the day and evening. The number could increase to 20 overnight. In July 2024 those figures fall to 10 during the day, 11 in the evening, and 15 overnight.

To help nursing homes pay for added staff, Harrisburg increased Medicaid rates by 17.5% starting Jan. 1, delivering an additional $306 million to nursing homes in the first six months of 2023. Nursing homes will also receive $159 million in American Rescue Plan Act funds during the fiscal year that ends June 30.

In conjunction with the added funding, nursing homes will have to devote at least 70% of their expenditures to patient care, as opposed to things like rent and management fees.

Other big changes include more disclosures about changes in ownership. Now there are virtually none at the state level — which is troubling to advocates because of rapid turnover in nursing ownership sometimes involving start-ups that don’t have enough money to operate them properly.

Under new rules, which take effect next October, the health department will post notices of ownership changes on its website and provide the public 10 days to comment. The department will also post notices of approvals or denials.

Regulators will have to analyze the financial strength and past performance of owners — including individuals, not just legal entities — and related companies that seek to take over nursing homes in the state. Historically, officials have effectively rubber-stamped license applications because the entity being licensed is almost always a new legal entity with no track record to examine, critics said.

The goal of the new rules on ownership and licensing is to get a better handle on who should be held accountable for care. Nursing home ownership has become increasingly complex, as for-profit operators have taken over the majority of the sector. For-profits typically split real estate from the core business and often house management in a separate related consulting firm.

That complicated structure makes it hard to know “who exactly is responsible for the care of residents in the facility” and “difficult for residents, their families, and even regulators to hold owners accountable for the health and safety of residents,” the department said in the introduction to its proposed regulations.