Sofia Agranovich has lunch at Beechwood Rehabilitation and Nursing Care. It was the third day that a limited number of residents were allowed to have meals together in the dining room, sitting distanced from one another. Yehyun Kim /

Editor’s Note: This story was originally published on July 22, 2021. Read more of CT Mirror’s “Best of 2021” stories here.

With nursing homes weathering the brunt of Connecticut’s COVID-19 deaths, family members and advocates lobbied hard for legislative change this year.

The centerpiece of their effort was a request to boost the mandatory minimum staffing hours – time that a nurse or certified nursing assistant spends directly with a resident – from 1.9 to 4.1.

After months of debate, lawmakers settled on raising the minimum required hours to three, saying it was too costly to support staffing increases that would bring all nursing homes up to 4.1. The change takes effect in January.

But nearly all of Connecticut’s nursing homes already provide at least three hours of direct care per resident each day. Only two fall considerably short of the three-hour threshold; both were previously subject to a much lower staffing minimum.

Only a little more than a third clear the 4.1-hour threshold, according to a CT Mirror analysis.

“There’s definitely still work to be done,” said Anna Doroghazi, associate director of advocacy and outreach for the AARP in Connecticut, which pressed for the increased hours. “I think we understand that sometimes progress has to be incremental. It would have been ideal and better for nursing home residents, and probably the staff as well, if we had seen the increase all the way up to 4.1 hours.”

Even though the next regular legislative session doesn’t begin until February, advocates are gearing up for another attempt at nudging the minimum required hours of direct care. The two key hurdles: the cost of higher staffing and trouble recruiting and retaining workers to maintain those increased hours.

The higher mandatory hours have serious implications for the elderly and people with disabilities who populate nursing homes. Lower staffing levels equate to fewer hours of direct care with residents. That might mean residents wait longer for meals, showers or trips to the bathroom, or that they don’t make it to morning activities.

Lower staffing levels can lead to malnutrition, dehydration, unplanned weight loss, injuries from falls and avoidable declines in mobility, advocates say. It can also stoke feelings of fear and isolation, prevent close ties with staff and foster a loss of dignity.

More staffing would help residents “have access to use the bathroom when they need and not have to wait 45 minutes to an hour, and have access to warm food, not eating cold food or things that are soggy because they’ve sat,” said Mairead Painter, the state’s long-term care ombudswoman.

Tania Ryea, whose mother, Janice, lives in a nursing home in Connecticut, wrote to lawmakers in March, saying that staffing levels at long-term care facilities were “less than adequate.”

Janice has dementia, she said, and during the COVID-19 lockdown, she became immobile, stopped feeding herself, lost weight and was kept on a medication longer than required.

“Psychiatric care, family/loving interactions, emotional support, and medication management are critical to her care. If she does not have personal, loving interactions, she becomes anxious and restless,” Ryea, a Tolland resident, wrote to members of the Public Health Committee. “If she does not have someone to talk to, she becomes depressed. If her daily hygiene needs are not met, she will become physically ill.”

Employees, too, have called for higher staffing levels, saying they are unable to spend much time with residents when they are stretched thin.

More than two dozen workers, including licensed practical nurses and certified nursing assistants, wrote to legislators and testified before the Public Health Committee this year in support of more staffing.

“I care for 34 residents, so in seven hours that breaks down to about 12 minutes of care per resident,” Chelsea Daniels, an LPN at Fresh River Healthcare in East Windsor, testified. “And that does not equate to a continuous 12 minutes. That is 12 minutes in total throughout the day.

“That means 12 minutes dedicated to preparing medications, administering treatments, administering medication, and documentation on multiple platforms. All while hoping to have time for the basic conversation that most residents are eager to have.”

Connecticut ranks 24th in the country in the average hours of direct care provided to residents each day, according to an analysis of CMS data from the Long-Term Care Community Coalition, an advocacy group based in New York. The national average stood at 3.47 in the final quarter of 2020.

Nationwide, the 4.1-hour minimum is still out of reach in many states.

Only Alaska, North Dakota and Oregon provide an average of 4.1 hours or more of direct care per resident each day, according to the Long-Term Care Community Coalition analysis. Two more come close – Hawaii with an average of 4.09 hours and California with 4.05 hours. No other states cleared the four-hour threshold.

The District of Columbia requires nursing homes to provide a minimum of 4.1 hours of direct care per resident per day, though the facilities can apply for a waiver allowing 3.5 hours in certain situations.

Connecticut averages 3.56 hours of direct care. And while just over a third of the nursing homes meet or exceed the goal of 4.1 hours, not all of them satisfied the ratios outlined in this year’s legislation for different tiers of staff. The bill followed in the footsteps of a 2001 Centers for Medicare and Medicaid Services report that also recommended a minimum of 4.1 hours of direct care per resident per day, where 0.75 hours of care are provided by registered nurses, 0.5 by licensed practical nurses and 2.8 hours by certified nursing assistants.

“When we say 4.1 hours, that is really probably on the low side, because that [CMS report] was done in 2001. The needs of residents have absolutely increased, and they’ve become much more medically complex,” said Robyn Grant, director of public policy at the National Consumer Voice for Quality Long-Term Care, an advocacy group based in Washington D.C. “We have many more residents now with dementia. There are more individuals who need supervision and monitoring. So if anything, that number is lowballed. And despite that, there’s still amazing pushback.”

Costs, recruitment remain a challenge

The high cost of increasing staff is one of the most common arguments against mandating 4.1 or more hours of direct care.

“Every single time you talk about raising staff, it’s, ‘Well, if we got higher reimbursement, then we could hire more staff,’” Grant said.

That was the case in Connecticut, where the Office of Fiscal Analysis estimated it would cost at least $200 million to bring all nursing homes in line with the proposed minimum of 4.1 hours.

When the bill was revised to require three hours of direct care, that estimate fell to $600,000 to $1 million, because so many nursing homes already were exceeding the three-hour minimum. Legislators cited the lofty expense as a reason the bill was amended.

In states where cost is a sticking point, Grant said, the nursing home industry should disclose how state and federal contributions are being used, and she encouraged policy makers to review that information.

“If the money is going primarily to direct care and they are still struggling, then that is one thing,” she said. “But if it’s going to administrative costs, that’s a completely different story. And it’s not that they need more money, it’s that they need to spend it differently.”

About 30% of total revenues in Connecticut go to salaries and wages for registered nurses, licensed practical nurses and aides providing direct care to residents, a CT Mirror analysis found. That's in line with national trends — typically states spend about 25% to 35% of their revenues on direct care, said Charlene Harrington, professor emeritus at the School of Nursing at the University of California, San Francisco.

Another key reason why a 4.1-hour mandate has fueled resistance is difficulty with recruitment and retention of workers at nursing homes.

A study by the American Health Care Association and National Center for Assisted Living in June found that 94% of nursing homes and 81% of assisted living facilities surveyed had a staff shortage in the last month. The organization defines staff shortage as meaning that on more than one occasion a facility could not fill all shifts without asking employees to work overtime or extra shifts, or without resorting to a temporary staffing agency.

The group surveyed 616 nursing homes and 122 assisted living facilities across the country. More than half of the facilities are actively trying to fill vacant positions for certified nursing assistants, licensed practical nurses, registered nurses, dietary staff and housekeeping, the study noted.

In Connecticut, many nursing home operators say they are having trouble recruiting or retaining staff. Amid the pandemic, the homes lost candidates to jobs in less risky or better paying professions.

“You really have to be careful and cautious about saying that something is achievable in an environment where there would be very serious questions about whether the staffing is available,” said Matthew Barrett, president and CEO of the Connecticut Association of Health Care Facilities. “If Connecticut moved to a very aggressive minimum staffing requirement and decided they were going to fund it, [there’s a question of] whether or not it actually could be achieved because there simply isn't a workforce – a trained workforce – available to work in our nursing homes.”

Exploring solutions

As proponents of higher minimum staffing prepare for another push at the legislature, they are examining ways to work around the stumbling blocks.

In Connecticut, some nursing home operators have already taken steps to incentivize job candidates, including offering more pay and bonuses for certain positions, such as certified nursing assistants.

“If you look right now, there are all kinds of bonuses. I mean, we never have seen bonuses to be a CNA,” said Painter, the state’s long-term care ombudswoman. “Companies are offering all kinds of things to incentivize individuals to take these roles, and hopefully [the public health department] is doing work on the CNA certification and training and looking at how we can keep people engaged.”

For those “who volunteered to be temporary nursing aides during the pandemic – make sure they are appropriately certified,” she said. “How do we keep them engaged and bring new people in to meet the three-hour [requirement] and then push for 4.1?”

Many employees who work in the industry are drawn to caregiver jobs or enjoy being around elderly people, advocates said. But they questioned whether more could be done to help staff move up the chain once they are inside.

“I don’t think there are really clear career ladders,” said Doroghazi, the associate director of AARP Connecticut. “I am not aware of any formal programs within the state that would say, ‘Hey, you’re a really terrific CNA, let’s support you in becoming a registered nurse.’ You can go a lot of places with a health care career, but how many folks that begin in these entry level positions move on?”

Grant, the public policy director at National Consumer Voice, said companies that are not paying well should offer better wages and benefits to help increase staff. But the problem goes beyond money – how nursing homes treat their workers will also have a big effect on retention, she noted.

“It’s a huge issue,” Grant said. “Things like pairing a new nurse aide with somebody who’s experienced; good mentoring; good supervision. There are a number of approaches that have been shown to have an impact. But whenever we suggest those, it falls on deaf ears.”

Any future increases in the Medicaid reimbursement rate should be tied to direct care and not go toward other expenses, she added. Medicaid covers the cost of roughly 70% of all nursing home care provided in Connecticut.

Among the facilities, competition for prospective employees has never been more intense, industry officials said. As the state emerges from the pandemic, nursing homes are losing workers to factories and big box stores, where pay is the same or better and working conditions aren’t as strenuous. The facilities have also faced a diminished reputation for the high number of coronavirus deaths among residents, though leaders say that perspective is unfair.

“The confidence of the public and the confidence of the workforce was undermined because of the really challenging experience that we had, not just in Connecticut but across the country,” Barrett said. “The really difficult outcomes ... we experienced early on in the pandemic were largely attributed to the fact that the science and the medical community had nursing homes ... treating the virus like it was spreading like the flu.”

Barrett warned that it will take time and funding to build up the workforce.

“We are moving to the other side of the pandemic, and we have fiercer competition for jobs paying similarly,” he said. “So the ability to pay for the quality workforce that you want is probably the issue that rises above all other issues.”

Jenna is CT Mirror’s Health Reporter, focusing on health access, affordability, quality, equity and disparities, social determinants of health, health system planning, infrastructure, processes, information systems, and other health policy. Before joining CT Mirror Jenna was a reporter at The Hartford Courant for 10 years, where she consistently won statewide and regional awards. Jenna has a Master of Science degree in Interactive Media from Quinnipiac University and a Bachelor or Arts degree in Journalism from Grand Valley State University.

Kasturi was CT Mirror’s data reporter. She is a May 2020 graduate of the Columbia Journalism School’s master’s program in data journalism and holds a degree in comparative literature from Brown University, where she was editor-in-chief of the student newspaper. Prior to joining CT Mirror, Kasturi interned for publications in India.