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Biden wants a federal minimum staffing requirement for nursing homes


The Biden administration wants to change the rules for nursing homes. Many don't have enough staff. So the White House wants a federal minimum staffing requirement, which may be easy to say and hard to do. Here's NPR's Andrea Hsu.

ANDREA HSU, BYLINE: Holly Ward has worked as a geriatric nursing assistant in Baltimore for four years. On some days, she has 13 residents in her care to dress, feed, clean, change, move - one after another.

HOLLY WARD: So it becomes like an assembly line.

HSU: And not one that runs smoothly. She'll find that while she's attending to one resident - say, Mr. Smith - Mr. Jones is incontinent.

WARD: Well, I can't do Mr. Smith and do Mr. Jones at the same time.

HSU: So Mr. Jones has to wait in soiled bedclothes, sometimes for a while. It's not the kind of care Holly Ward wants to deliver to her residents.

WARD: Because to care for them, you have to give them dignity, yet you don't give us the staff to provide that.

HSU: Often, important things just don't get done - talking with the residents, providing emotional support.

WARD: They look to you for comfort. But then when you don't have time to adequately give them the comfort that they deserve, it's not fair. And then it's on your conscience.

HSU: Where Ward works is actually better staffed than most nursing homes. At the last place she worked, sometimes she'd have 16 or 18 residents to care for.

Now, the federal government does have some staffing requirements for nursing homes, but the core language is vague. Essentially, nursing homes must have sufficient staff so that residents can live their best lives. Over the years, advocates have said that is not enough, and the Biden administration agrees. Chiquita Brooks-LaSure heads the Centers for Medicare & Medicaid Services.

CHIQUITA BROOKS-LASURE: We think it's really important to set a very specific standard that can be measured again - to really make sure that staff is adequate to ensure quality.

HSU: So Brooks-LaSure says her agency wants to figure out, how much staff should nursing homes be required to have? - and then enforce that with a rule.

BROOKS-LASURE: We've talked about having standards in place within the year.

HSU: Numerous studies have shown that understaffing nursing homes can harm the health of residents. You see more bedsores, more weight loss, overprescribing of antipsychotic medications and, in the pandemic, more COVID.

But nursing home staffing is not just a pandemic issue. Maurice Miller will tell you that. He's 59 years old, and he's lived in a nursing home in Takoma Park, Md., for almost a decade.

MAURICE MILLER: I am a functional quadriplegic as a result of my stroke.

HSU: He relies on the staff to feed him and clean him and change his hospital gown and to make sure his computer is charged and within reach. There are good days when there's enough staff to meet all his basic needs. But then there are bad days.

MILLER: It's a bad day when I am in pain and I'm not going to get relief in a timely fashion.

HSU: Miller says it could be 45 minutes before someone's able to respond to his call button. It's a bad day when he cannot talk to his 94-year-old mother because his laptop, which he operates through dictation, has been pushed out of reach and no one's available to get it for him.

MILLER: And it's a bad day if my roommate is in crisis of some sort. Those are really, really bad days because you're watching someone actually suffer.

HSU: Some days, Miller is told there are not enough staff to move him to his wheelchair, even though his doctor says time out of bed helps his blood pressure, his circulation and his mental health.

MILLER: Because I'm not trapped within these four walls.

HSU: Losing wheelchair time, he says, could result in a downturn in his health. In fact, Maryland, where Maurice Miller lives, does have a minimum staffing requirement for nursing homes, as do most states. But they are all lower than what the federal government recommended two decades ago, the last time they studied this issue. Back then, they said each resident should receive at least 4.1 hours of direct care per day. The only place that has adopted that guidance is Washington, D.C., which is where I find Mary Ajiboye.

MARY AJIBOYE: Good morning, Charity. How are you?

HSU: Ajiboye is the staffing coordinator at Forest Hills of D.C. It's a nursing home with about a hundred residents. She sits in a small office with a computer and a phone.

AJIBOYE: As usual, this is Mary calling from Forest Hill of D.C. I'm trying to find out if you're available to help me tomorrow morning.

HSU: Her job, all day, every day, is to go down a list of nurses and nursing assistants to fill gaps in the schedule. It's not an easy task.

AJIBOYE: Oh, this your weekend to work at other job?

HSU: Charity is not available, so Ajiboye's search continues. Her boss, Tina Sandri, the CEO of Forest Hills of D.C., says staffing takes highest priority.

TINA SANDRI: We think about meeting the numbers every single day. It was a daily struggle before COVID. It is even more so now.

HSU: Turnover at Forest Hills is nearly triple what it was before the pandemic. There is competition for workers like never before.

SANDRI: In D.C., you can work for Amazon at $19 an hour. You can be a dog walker for 18 an hour.

HSU: Sandri says they can't even get nursing assistants in the door for interviews. Nationwide, nursing homes are down more than 230,000 workers since the start of the pandemic. Sandri says she can't raise wages for nursing assistants, who typically start at minimum wage - 15, 20 an hour. As a nonprofit, she says, Forest Hills of D.C. just doesn't have the bandwidth to do so.

SANDRI: We don't have the bottom line.

HSU: So she's meeting D.C.'s staffing requirements by working her staff to the bone - her words.

SANDRI: They're tired. They're burnt out. They're physically exhausted. And even committed people in this industry will turn around and say, I don't know how much longer I can do this.

HSU: As for a federal minimum staffing requirement, she's opposed. Why hold facilities to a number when there aren't people to fill the jobs?

Chiquita Brooks-LaSure at the Centers for Medicare & Medicaid Services says she's listening to industry concerns, including their call for more money to keep up with rising costs, especially labor. But she's also looking into...

BROOKS-LASURE: Are we using our dollars well? Are they going to direct care?

HSU: To the well-being of nursing home residents. Maurice Miller doesn't blame the staff who have left his facility in recent weeks for other jobs. Post-COVID, he says, it's time for them to take care of themselves. But he is appealing to younger people to consider a job in a nursing home.

MILLER: You have an opportunity to save my life, and you have an opportunity to turn this industry on its head.

HSU: Something he hopes to see in his lifetime.

Andrea Hsu, NPR News.


NPR transcripts are created on a rush deadline by an NPR contractor. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.

Andrea Hsu is NPR's labor and workplace correspondent.