Early this year, as legislators were beginning their work at the state Capitol amid a prolonged health crisis, a task force was created to study the dire conditions in Connecticut’s nursing homes.
It issued a raft of suggestions, including higher minimum staffing levels, more stringent infection control measures and requirements for maintaining adequate personal protective equipment. The pandemic shined a bright light on many of these stubborn issues in nursing homes, especially staffing shortages that advocates say caused delays in care and made the spread of infection more difficult to contain.
But with two weeks left in the session, lawmakers have yet to tackle some of these key changes. Two separate bills allowing the use of cameras and other technology in nursing homes cleared a single chamber, as did a measure permitting residents of long-term care facilities to designate an “essential support person” who may enter a nursing home in spite of visitor restrictions.
While advocates support those proposals, they are calling on legislators to also take up some of the broader reforms.
“We’ve seen more movement on the pieces related to social connection and visitation and less movement on some of the very badly needed structural changes to how nursing homes operate,” said Anna Doroghazi, associate director of advocacy and outreach for the AARP in Connecticut. “I think staffing levels now are worse than a year ago, because you just can’t find people that want to take these jobs for minimum wage. The nursing homes have said they really need more staff at this point.”
At least nine bills have been introduced this year addressing problems in long-term care facilities, from infection control to technology to visitation. Two of them – which have not come up for a vote in either chamber – would raise the minimum hours of direct care per resident.
The state’s public health code requires 1.9 hours of nursing staff care per resident each day. The bills would raise the mandatory minimum to 4.1 hours, echoing recommendations by the Centers for Medicare and Medicaid Services.
Increasing those hours would help nursing homes deliver better care, advocates say. Mairead Painter, the state’s long-term care ombudswoman, has heard from residents who are waiting long periods of time for breakfast, for help taking a shower or for other basic needs.
“They have to wait much later in the morning, sometimes 10 o’clock or 11 o’clock, to get up. And it’s not because the staff isn’t working incredibly hard. It’s because they need to take care of the people who might be at a higher risk first,” she said. “If [a resident] might fall, they take care of that person first, which means other residents have to wait. They don’t get up for breakfast; they don’t get to go to the first programs in the morning. And it impacts their quality of life, their dignity, their ability to live to their fullest potential.”
“It’s not a matter of the staff not wanting to help them,” Painter said. “There’s just not enough staff to help them.”
The staffing shortages were felt acutely last fall and winter, as Connecticut faced another wave of COVID-19 cases and many workers were retiring, stepping away to home-school their children or leaving for jobs in less risky settings.
Painter said staffing issues were still being discussed recently. Juggling new admissions while caring for existing residents is another challenge.
“They’ve brought up recently that with new admissions, they haven’t had enough staff to help orient the new person,” she said. “If there’s a new admission, the other residents are impacted, because [staff] are trying to help the new person settle in, and the other residents have to wait. It’s very challenging around mealtimes if individuals need assistance; sometimes the food is very cold by the time they get it.”
Employees have also complained about staffing shortages in facilities. Several wrote to lawmakers encouraging them to pass legislation addressing staffing levels.
Tanijah Williams, a certified nursing assistant at Arden House in Hamden, said she and her colleagues have experienced burnout and are concerned for the welfare of residents.
“I provide numerous services for my residents, like bathing, showering and dressing them, transferring them, toileting them and feeding them. … These activities are important because they deserve it,” she said in written testimony. “Unfortunately, we don’t have good staffing, so we can only do so much. With better staffing would come a higher level of quality care, plain and simple.”
Along with staffing levels, advocates are calling on legislators to strengthen infection control measures and ensure nursing homes have enough protective gear.
One proposal that has not yet come up for a vote would require long-term care facilities to employ a full-time infection control and prevention specialist; would mandate that a nursing home’s infection control and prevention committee meet “at least monthly,” and in the event of an infectious disease outbreak, daily; require every nursing home’s administrator and supervisor to complete an infection prevention training course by January 2022; and would mandate regular testing of residents and staff during an outbreak.
That bill also directs the state’s public health department to maintain at least a three-month supply of protective equipment, such as masks and gowns, for long-term care centers and requires the heads of nursing homes and assisted living facilities to “ensure they acquire adequate supply from DPH and maintain it for their staff.”
Throughout the pandemic, nursing home workers have reported a lack of protective gear in many facilities, with some employees having to recycle masks for extensive periods of time or don trash bags because fresh gowns were not available.
Lawmakers say they have heard the concerns from constituents and advocates, and they are trying to take up broader legislative reform before the session ends on June 9.
“This was a very tough year for people who had family that were living in nursing homes, and it remains a little bit difficult,” said Sen. Cathy Osten, a Democrat from Sprague. “There are some changes that have to be made, whether it’s changes in the qualifications of workers, changes to staffing levels, technology – all of these things are important, and a number of them will happen. We’re just trying to figure out what the best route is.”
One of the stumbling blocks has been the high cost of increased staffing levels. To raise the mandatory minimum to 4.1 hours of nursing staff care per resident per day, lawmakers said it would cost hundreds of millions of dollars. Medicaid covers the cost of roughly 70% of all nursing home care provided in Connecticut, and Medicare covers about 15%.
“Staffing ratio requirements will result in a significant cost to [the Department of Social Services] to the extent nursing home staffing costs are reflected in future Medicaid payments,” officials from the state’s Office of Fiscal Analysis wrote in an explanation of the bill. “The bill specifies that a total of 4.1 hours of direct care be provided per resident per day, including 3.75 hours by a registered nurse (RN), 0.54 hours by a licensed practical nurse (LPN), and 2.81 hours by a certified nurse’s assistant (CNA).
“Based on 2019 nursing home staffing data, none of the approximately 200 homes can meet the bill’s requirements for RNs (with an average of 0.70 hours of direct care provided per resident per day). Approximately 10% of homes do not meet the LPN staffing requirements, while approximately 80% do not meet the requirements for CNAs. The cost for nursing homes to staff at the proposed levels will depend on the actual number and level of staff required and their associated wages, but is anticipated to be at least $200 million,” they wrote.
Sen. Mary Daugherty Abrams, D-Meriden, a key supporter of the nursing home legislation, has proposed an amendment to the staffing bills that would instead require at least three hours of direct care per resident per day. More nursing homes are already coming close to that level, she said, so the cost to bring the remaining facilities along would be far less.
“We still felt that it would make a significant difference,” Abrams said. And the lower price tag – she estimated it would be less than $500,000 – would make it an easier sell in the House and Senate.
Despite the limited time left in the session, Abrams said she is hopeful some of the broader reforms will get a vote.
More than two dozen people, including many lawmakers, participated in a task force last winter that explored pervasive and systemic problems in nursing homes and made recommendations for change. Abrams said she takes that seriously.
“House members and Senate members put in a lot of time to find out what we could be doing better for the residents and staff of nursing homes, whether it’s during the pandemic or not,” she said. “It’s vitally important that we followed through on that work.”