New Jersey lawmakers begrudgingly advanced a proposal Thursday to establish firm staff-to-patient ratios for frontline nursing home care, despite strong objection from industry leaders who called the requirements “unachievable” and warned that some facilities would be forced to halt admissions to comply.
But elder advocates testified that staff shortages are often linked to substandard care, an issue that has been magnified by the coronavirus pandemic, which took a significant toll on vulnerable residents in New Jersey’s long-term care facilities. Almost half of the state’s nearly 14,300 lab-confirmed COVID-19 deaths are connected to its nursing homes, state figures show.
While several members suggested the measure was far from perfect, the Assembly appropriations committee voted 7-4 along party lines to pass the bill, the latest — and possibly most controversial — element in a legislative package based on recommendations by consultants from Manatt Health. The Senate Health, Human Services and Senior Citizens Committee approved a companion version of the bill on Monday.
As drafted, the proposal (A-4652/S-2712) — championed by Assemblywoman Angelica Jimenez and Sen. Brian Stack (both D-Hudson) — would limit the responsibilities of frontline nursing assistants to just six residents at a time during the day, up to 10 on the evening shift and a maximum of 14 overnight, with some flexibility over what professionals can be deployed in this role. It also establishes a 16-member task force to study the nursing home workforce, which suffers from low pay, high turnover and limited opportunities for advancement.
On Wednesday Gov. Phil Murphy signed into law four related bills, which provide pay relief to certified nursing assistants (CNAs), strengthen emergency planning around long-term care and increase public oversight of the industry. The state Department of Health has already implemented other Manatt recommendations to establish widespread regular COVID-19 testing among nursing home residents and staffers, beef up infection control mechanisms and prepare for the state’s 372 nursing homes to reopen safely to visitors.
But AARP and other advocates have long stressed the critical nature of sufficient staffing; proposals to establish ratios in state law date to 2015, at least. Several other states, including Delaware, have such laws, labor leaders note. Currently, staffing levels are dictated by state regulation that requires each resident receive a certain amount of daily care.
‘Not enough qualified staff’
“Most of the complaints that we receive boil down to the simple fact that there are not enough qualified staff in many facilities to provide direct, thorough, hands-on care to help residents with their most basic needs,” New Jersey Long-Term Care Ombudsman Laurie Facciarossa Brewer told the committee; as advocate for residents in these facilities, her office receives some 9,000 complaint calls a year.
“Indeed, at the height of New Jersey’s pandemic, already thin staffing levels were stretched to the breaking point, and in many facilities, staffing and quality of care fell away entirely,” she added. Of the almost 198,400 COVID-19 cases diagnosed in New Jersey, some 38,500 involve nursing home staff and residents.
According to 1199SEIU United Healthcare Workers East, which represents some 8,000 nursing home workers here, New Jersey was in the bottom 10% of states for CNA staffing levels before the coronavirus hit. Facciarossa Brewer said that at the height of the pandemic, caregivers were left to tend to as many as 70 residents on their own in certain extreme cases.
“Today, despite nearly 160 nursing facilities reporting current outbreaks, our union is now seeing layoffs among CNAs,” 1199’s Bryn Lloyd-Bollard testified Thursday. “This is short-sighted and dangerous, especially as we consider the need to bolster the workforce, not shrink it, as we head into the flu season.”
But industry representatives said that, good intentions aside, the math doesn’t work. New Jersey’s nursing homes are already short some 1,800 certified nursing assistants, or CNAs, and the legislation as drafted would require these facilities to hire another 1,500 full-time caregivers at an estimated cost of $70 million annually, according to LeadingAge New Jersey & Delaware, which represents more than 140 nonprofit homes in the two states.
“So, if you want to establish unachievable benchmarks that not-for-profit, mission driven, nursing home providers are unable to achieve because of the workforce shortage of frontline professionals, vote for this bill,” LeadingAge president and CEO James McCracken, told lawmakers. “We need achievable goals that improve care and do not jeopardize the safety of residents.”
McCracken, who previously served as New Jersey’s long-term care ombudsman, “implored” lawmakers to let the industry develop a nursing assistant workforce before enacting a statutory staffing requirement; he also urged them to allow operators to count registered nurses toward the ratio, without limiting their scope of practice. As drafted, the bill permits other professionals, like nurses, to be counted as CNAs if they sign in as such and only perform the related duties.
Jonathan Dolan, president and CEO of the Health Care Association of New Jersey, which represents long-term care facilities of all kinds, called the proposal a “costly, impracticable, and unfunded mandate.” He labeled it “far worse” than past staffing ratio bills (including the initial Senate version), which called for ratios of 1:8 during the day, 1:10 in the evening and 1:16 overnight.
“Because of the current and documented workforce shortage, there will be a feeding frenzy among nursing centers as they compete against each other, with the centers with the most resources hiring away staff from other centers,” Dolan said. With an “improbable-to-achieve ratio,” he said the measure would prompt facilities to suspend admissions. “This action would create a denial of access to the care that so many of New Jersey’s most vulnerable citizens require,” he added.
Assemblyman Gary Schaer (D-Passaic), who said he had been tasked with trying to bridge the gap between stakeholders but failed to make much progress, lamented that a “substantial divide” remained between the groups. He conceded he was “not happy with this bill at all,” but noted, “We must take action. The issue, of course, is what action to take.”