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State Legislators Aim to Boost Number of Nursing Assistants at Homes

Industry advocates estimate cost of increased staffing at $123 million, but bill has support of union

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The question of how many certified nursing assistants must be employed by New Jersey nursing homes is at the center of a brewing dispute over a proposed bill.

The labor-backed bill, A-4636/ S-2878, would require nearly all state nursing homes to increase the number of CNAs -- staff members who help patients take care of many of their basic activities like eating and bathing -- who work each shift. Assembly members Angelica M. Jimenez (D-Bergen and Hudson), Joseph A. Lagana (D-Bergen and Passaic), and Raj Mukherji (D-Hudson) and Sen. Brian P. Stack (D-Hudson) introduced the measure.

The legislators argue that by requiring at least one CNA for every six to 14 residents, depending on the time of day, the bill, would be more easily enforceable because it would be less complicated than current regulations and bring a greater sense of security to residents and family members. But industry advocates are pushing back, arguing that the proposal will cost state nursing homes $123 million annually at a time when they’re under increased financial pressure. They also say that it would create an additional problem by taking away flexibility from nursing home managers

While the federal government sets standards for the number of registered nurses and licensed practical nurses -- jobs that require higher levels of training than CNAs -- it leaves it up to states to set CNA minimums. New Jersey’s current minimum standards are based on a multipart formula that varies depending on the condition of patients and covers all staff members who directly provide care to residents. Critics of the current approach say these standards are unnecessarily complex, making them more difficult for regulators to enforce.

If the bill becomes law, nearly all nursing homes would have to raise their staffing levels within days of it going into effect. For example, from April to June of this year, only 11 of 366 nursing homes would have met the bill’s mandate of at least one certified nursing assistant for every six patients during day shifts, according to state Department of Health data (information wasn’t available for six other homes).

Jimenez said in a statement that she’s hopeful that the new standards would improve nursing home service. “In turn, this will hopefully provide greater peace of mind for both residents and their loved ones,” she said.

Lagana added: “Mandating specific certified nursing assistant-to-resident ratios will create more precise, enforceable standards. Ultimately, this will raise the bar for the standard of care throughout nursing homes in New Jersey.” Service Employees International Union Local 1199, which represents some CNAs, has been a leading voice in support of the bill.

“The experience of certified nursing assistants over the last couple of years is that the work is getting harder” as a rising share of nursing home residents are older and sicker, union spokesman Bryn Lloyd-Bollard said. He added that 1199 officials believe that the bill “will go a long way toward fixing this urgent issue.”

Lloyd-Bollard noted that nonprofit advocacy organization Families for Better Care gave New Jersey nursing homes an “F” for the number of direct-care staffing hours per resident, ranking the state 43rd in the country. The overall grade for the homes was a “B” -- good for 18th nationally -- when factors such as the number of complaints against homes was taken into account.

“Nursing homes in the state of New Jersey receive a significant amount of money from taxpayers and it’s important that this money is invested in the front-line staff of nursing homes, who are responsible for providing the direct care at the bedside,” he said.

But Jon Dolan, president and CEO of nursing industry trade group the Health Care Association of New Jersey, described the bill as an unfunded mandate of $123 million. He said nursing home managers know how best to devote staffing resources to meet patient needs.

“We have to leave some decisions to the business,” Dolan said, noting that the federal government recently issued a massive overhaul of Medicaid and Medicare nursing-home regulations, but didn’t impose CNA minimum staffing levels. He noted labor’s role in pushing the bill and compared it to direct legislative involvement in medical decisions.

“You don’t tell a heart surgeon how to cut and sew,” Dolan said, adding that staffing decisions should be based on clinical evidence and the industry’s best practices. “This is an arbitrary, capricious, labor-focused mandate that has not been thought through” or included industry input.

Dolan expressed a willingness to work with policymakers on ways to address the needs of CNAs, including ways to increase their pay.

Dolan emphasized that while CNAs are “the most important employees directly involved” in patient care, the higher-level needs of increasingly ill patients often require care from licensed practical nurses, not CNAs.

Dolan also questioned how the nursing homes would pay for the increase, considering that insurers are seeking to cut and not increase payments to nursing homes. He described his association’s members as “chronically underfunded,” adding that the state is among the lowest in the country in its ratio of Medicaid to Medicare payments. Most nursing home care is reimbursed through Medicaid.

Lloyd-Bollard responded that “many facilities are making millions of dollars in profits, and they need to make sure before the owners skim off the top of that that they’re investing in their workforce.” He also noted that seven other states, including Delaware, based their CNA staffing minimums on standards that are similar to those in the bill, rather than the more complicated standards that the state currently uses.

The Assembly version of the bill has been referred to the Assembly Human Services Committee, while the Senate version has been referred to the Senate, Human Services, and Senior Citizens Committee.

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