The Kaiser Family Foundation (KFF) recently performed analyses indicating that nursing homes have over-reported their staffing, especially on weekends, for decades.  The importance of this deceptive practice is that staffing levels reported by nursing homes have been an important part of the Center for Medicare & Medicaid Services nursing home performance reporting system, Nursing Home Compare 5-star rating system, for decades. Homes receive from one to five stars for their reported staffing, and their “score” of staffing plays an important role in determining a home’s overall 5-star quality rating.

As a researcher who has studied nursing home care for the last three decades, the results of those analyses are, unfortunately, not a surprise. I was a member of the original technical expert panel that advised the Center for Medicare & Medicaid Services’ (CMS) contractor in their development of the Nursing Home Compare system for nursing homes. At that time, I and others argued vigorously and unsuccessfully that payroll records should be used to measure staffing, rather than facilities’ self-reports of staffing by facility staff.  The system was launched in 1998. Only these many years later, with the passage of the Affordable Care Act in 2010, was that reform finally enacted.

The tale told by the KFF analyses confirms on a nation level what my colleagues and I at the Texas A&M School of Public Health found, over a decade ago, when we compared what nursing homes in Texas reported to CMS prior to their survey with the staffing data in their annual cost reports. Our results indicated that many nursing homes in Texas consistently over-reported staffing. This over-reporting was especially significant among those homes operated as for-profit enterprises and those homes that were part of multi-facility systems (i.e., nursing home chains).

While the study findings are not surprising, the response to these results by the spokesperson for the nursing home industry was, unfortunately very close to exactly what one would expect. In Jordan Rau’s discussion of the KFF’s results in the New York Times, which focused heavily on nursing home staffing on weekend, the responses from the trade association for America’s for-profit nursing homes, The American Health Care Association (AHCA), were so shockingly inadequate as to leave one gob smacked.

Rau’s article includes commentary from Dr. David Gifford, a geriatrician who is a senior vice president at AHCA, and we can assume he is speaking for the association and the industry. He provides what he considers “legitimate reasons” for lower staffing on weekends.  First, he argues that the poor staffing on weekends is reasonable because fewer resident activities occur on weekends; second, he asserts that lower staffing on weekends is not problematic because more assistance from family members is available on weekends.

As Dr. Gifford well knows, resident activities are handled by a facility’s activities staff, not direct care staff such as licensed nurses or certified nursing assistants. Resident activities do occur less frequently on weekends. What that response, an exercise in misdirection, fails to address is that on Saturday or Sunday residents don’t need less assistance with dressing, less help moving about, less assistance getting to and using the toilet, or help eating than they need on Friday or Monday.

The idea that family caregiving on the weekends substitutes for care by licensed professionals ignores some glaring and very basic facts. First, many residents in nursing homes have no family nearby who can provide the help they need on weekends or any other day of the week. Second, people reside in nursing homes specifically because they could not receive the care they needed in their homes. For residents whose care is paid by public payors, the majority of residents, their physicians certified that they needed around the clock care by the healthcare professionals offered by nursing homes. Even if family are present, the things that they can do are no substitute for the 24/7 care of health professional who constitute nursing home staff.

Dr. Gifford also argues that staffing levels are not the issue; instead, outcomes are the issue.  Yet, the reason that the experts on the technical expert panel for the Nursing Home Compare system argued to include direct care staffing in the performance measurement model was simple. The relationship between staffing and quality of care is one of the most fundamental and consistent findings concerning what affects affecting the quality of care and outcomes of nursing home residents. Our best research consistently shows that good outcomes, quite simply, depend heavily on good staffing.

I suspect the only way staffing problems will ever be resolved is when payors, like Medicare and Medicaid, provide meaningful monetary incentives for homes to exceed the current minimal staffing standard and assess large fines when homes don’t maintain those minimum standards.  Because this is a for-profit industry, those fines should be carefully calibrated. Any fines would need to be much larger than the cost to the home of increasing staff to the needed levels. If not, homes might be willing to pay a fine less expensive that the cost required to raise staffing to an acceptable level. The case for better staffing would also be helped if surveyors inspecting nursing homes determined whether violations of care standards, such as not turning and positioning residents at risk of pressure ulcers, resulted from inadequate staffing.

Unfortunately, the discussion of staffing entirely ignores the core problem in nursing home care.  Nursing home residents are typically over 80 years of age, suffer from multiple chronic conditions that affect their daily functioning, and many have significant levels of cognitive impairment.  These are among the most truly vulnerable individuals in our entire society.  We must remember that nursing homes are what sociologist call “total institutions.” Nursing home residents are almost wholly dependent, both for their care and dignity, on the home and the staff providing their care.

Yet, as a nation, we have largely entrusted the care and wellbeing of this vulnerable population to for-profit enterprises. Roughly 70 percent of nursing homes in this country operate as for-profit entities. For many nursing home operators, what they do is simply run a business intended to provide profits for owners or shareholders. Unfortunately, the desire of the owners or shareholders for what they consider a “satisfactory” return on their investment too often supersedes the needs of residents.

Another report in the New York Times gives us considerable insight into how nursing homes owners generate that satisfactory return. A popular business model used by for-profit nursing homes is that the homes are owned by one entity that then pays for goods and services (e.g., rent, management services, laundry, pharmaceuticals, or dietary products) provided by other firms also owned by the people who own the nursing home. These services are often provided to the home at prices that far exceed normal market prices.  These arrangements draw money, which could be used to provide better staffing and quality of care, out of the nursing homes into the profits of these related firms. Nursing home care has become so profitable that in recent years, the industry has drawn private equity firms into the nursing home business. These firms see nursing home chains as attractive profit centers, not sites of care for frail Americans.

One would hope that the governmental agencies charged with regulating nursing homes and protecting residents would curb any operator’s tendency to indulge the urge to sacrifice quality for profits. Those hopes are brutally dashed when on goes on the web and views the chillingly horrific video a family member recently made with a secret camera in a Raleigh, North Carolina nursing home. A man fell from his bed while attempting to reach a bathroom begs from the floor for help from aides. He lies on the floor for over an hour. During that time, the aides assigned to care for him ridiculed him, humiliated him, and treated him badly. (see https://www.wral.com/video-shows-patient-lying-on-floor-being-berated-at-north-raleigh-nursing-home/17571953/)

Those horrible aides in North Carolina were, of course, fired by the home’s owners. In addition, the owners indicated other home staff in those homes were receiving additional training. After watching that video one wonders how one develops an effective training curriculum to teach people to become decent, caring human beings.

Even though, one often hears that the fish rots from the head, the home’s owners firmly restated their unswerving and deep commitment to quality care.  They did so despite the findings of the state regulatory agency that belatedly reviewed the home’s records and found a multitude of serious violations. Some of these violations were noted on inspections from earlier years, but they were not corrected as promised and as required by the state.

Hopes for the public sector to act as a powerful counter-balancing force become even more forlorn when one observes CMS’s recent strategy under the Trump administration of dramatically weakening enforcement of existing regulations protecting residents.  CMS’s latest initiative is their “Patients Over Paperwork” in October of 2017.

This initiative that will undoubtedly result in greater industry input into and control over the regulatory process. For example, just a month later after the program’s launch, CMS announced an 18-month moratorium on the imposition of fines or other penalties for a series of regulatory requirement including requirements related dementia care, care plan development, CMS held a “listening session” with industry representatives in December of 2017. In January of 2018, the Patients Over Paperwork newsletter indicated that CMS was responding to industry concerns by delaying fines and other enforcement mechanisms for regulations that became effective in November of 2017. A full review of all nursing home regulations, with the purpose of reducing the regulatory burden, was promised by CMS for 2018.

Without doubt, there are good for-profit nursing homes that treat their residents very well. However, these homes provide that good treatment despite the inherent conflict endemic to the industry ― to desire to maximize profits or to provide high quality care. Our nation has developed a system of nursing home care that too often transforms some of the weakest and most vulnerable among us become resources used to generate the greatest profit possible, rather than vulnerable people who deserve care that preserves their dignity and meets all their care need.