Changes in minimum-staffing requirements for Pennsylvania nursing homes have some local providers and advocates concerned for the future of the facilities entrusted with providing care for aging seniors.

The state implemented new staffing requirements in 2023, and the federal government followed suit by instituting its own changes last year, with those changes being phased in over the next few years.

Although there is a phasing-in process, some on the front lines worry the new staffing requirements, combined with what they’re calling a workforce crisis and insufficient funding from Medicaid and other sources, could create a perfect storm at the worst possible time, as the baby boomer generation continues to age and need more services.

Chuck Quinnan, chief governmental affairs officer with LeadingAge PA, an advocacy association that represents more than 400 mission-driven aging services providers in Pennsylvania, said he believes the impact of staffing mandates during a workforce and funding crisis will mean more older Pennsylvanians will be unable to access care when and where they need it.

And it appears that plenty of them will need it at some point. The Pennsylvania Health Care Association estimates that about 7 of every 10 people currently turning 65 will require long-term care and they will receive care for an average of three years.

According to the association, Pennsylvania has about 700 nursing homes. The same organization notes that Medicaid pays for nearly half the costs, Medicare pays for 23% and a similar percentage is covered by families out-of-pocket. The median annual cost for a semiprivate room in Pennsylvania ranges from about $84,000 to about $151,000.

The current state staffing regulations, which became law in 2023, require a certain ratio of nurses to residents and 3.2 hours per resident, per day of total clinical staffing — up from 2.7 hours per resident, per day. But the new federal regulations would require all nursing homes that receive federal funding through Medicare and Medicaid to have 3.48 hours per resident, per day, including a defined number of registered nurses and nurse aides.

David Fenoglietto, president and CEO of Lutheran SeniorLife, said his organization and most others are meeting existing staffing requirements.

“But at times it becomes difficult when you look over the horizon and see where those hours per patient each day increase,” he said. “With increased regulation, oftentimes it’s worrisome as to what the future will be for the providers.”

Fenoglietto, whose organization includes three Butler County facilities — Advanced Care Center in Butler Township, St. John Specialty Care Center in Mars and Passavant Retirement Community in Zelienople — said he’s fine with the current 3.2-hour level. The concern is the specific complexion, or makeup, of the staffing when the number rises to 3.48 and the fact that reimbursement levels likely won’t increase to cover those rising costs.

“The demand is increasing, reimbursement is flat, and the requirements are becoming more onerous,” he said. “In the senior-living field, these are unreimbursed mandates to increase staffing levels. As we’re looking toward the future with a lack of funding to support these continued administrative increases, the quality of care will continue to be a focused priority.”

The new staffing requirements would mean a facility with 100 residents would need at least two additional registered nurses or nurse aides per shift, according to Jonathan Szish, a spokesman for Presbyterian SeniorCare Network, which manages Sherwood Oaks in Cranberry Township. Sherwood Oaks, which is owned by UPMC Senior Communities, has about 350 residents.

Sherwood Oaks and other similar facilities also would require a registered nurse on-site, around the clock, seven days a week, to provide skilled nursing care.

Quinnan said his organization understands that everyone wants more staffing.

“But the reality is,” Quinnan said, “workers simply don’t exist.”

Quinnan also said specific ratios of the types of workers to the resident population take away much-needed staffing flexibility. “It makes it hard to leverage and maximize your resources where they’re needed during the day,” he said.

Specifically, Quinnan said forcing nursing homes to have an arbitrary number of staff on hand during the third shift is problematic.

“It really gets down to that one-size-fits-all mandate really doesn’t equate to ensuring quality of care,” he said. “It really has exacerbated this access-to-care crisis.”

Keith Frndak, president and CEO of Concordia Lutheran Ministries, agreed mandated staffing levels don’t mesh with the reality of the situation, particularly during evening and overnight hours.

“I have to say that someone was clearly playing hooky during math class,” he said of whoever devised the new staffing ratios. “This requires a complex analysis — not simple addition. It’s well-intended, but it will end up backfiring.”

Frndak said from about 8:30 p.m. on, 90% of nursing home patients are in bed and their need for care drops off by about 60%. So, he said, the need for additional staffing overnight is “clearly a waste that will cause consequences somewhere else that I believe won’t be good for patients.”

“We and others will do our part to take care of people,” said Frndak, whose company has nine skilled nursing facilities, including Concordia at Cabot, which averages about 140 patients per day. “We’ve been doing that for 140 years, and we’ll continue to do that.”

But Frndak said the financial ramifications might cause facilities such as his to adjust the expenses related to things like food services, social services and activities. He said Concordia doesn’t want to do any of those things, but when specific guidelines are mandated by regulatory agencies, “you have to make adjustments.”

Like the others, Frndak said there are simply not enough workers to meet the new mandates.

“When you impose regulations that cause you to have to hire more (people) when they’re not there, it causes an inflationary cycle that’s unintended,” he said.

Quinnan said the workforce crisis is not a new phenomenon and, in fact, it dates back more than 15 years.

“We were talking then about the ‘silver tsunami’ and the aging baby boomers,” he said. “This keeps getting talked about like it’s new, but these aren’t new crises. It’s just exacerbated by a global pandemic and an artificial mandate.

“While it may be well-intended, it could, in many ways, end up hurting those they’re designed to try to help.”

Quinnan said that in 2019, the Pennsylvania Long-Term Care Council estimated Pennsylvania would need 37,000 more direct-care workers by 2026, not accounting for vacancies due to people leaving their jobs. Then came the pandemic, and an ongoing shortage of funding, “and this has formed an access to care crisis.”

As of July, there were 81,825 nurse aides available to work in the state — a 15% decrease compared with active records from 2019.

The current workforce shortage has forced many nursing homes in Pennsylvania to leave available beds unfilled. According to a LeadingAge PA survey of nursing homes conducted in October 2023, more than half the respondents said they had to refuse admissions and limit their census — despite having licensed beds available — to comply with new state staffing ratios that went into effect July 1, 2023.

One provider in Cambria County told LeadingAge PA it has had an entire wing closed since the pandemic “and the ratios have essentially placed all plans to reopen that wing on hold.”

In the same survey, an average of 1 in 4 available beds was out of use, with up to 60% of beds sitting empty despite constant referrals and long waiting lists.

Survey respondents said if the new federal mandate moves forward without change, nearly two-thirds of them will need to further limit their census and more than 15% said they would have to either close or sell.

According to Szish, more than two dozen nursing homes in Pennsylvania have closed in the last four years and 2,588 beds have been decertified due to current funding shortages and the workforce crisis, leaving only about 85,000 beds left in a state where more than 2.2 million people are 65 years old or older.

Szish said Presbyterian SeniorCare Network and similar providers simply don’t receive enough Medicaid funds to overcome staff challenges, pay employees competitive wages and increase access to care for older adults — and another unfunded mandate will only worsen the situation.

As a result, 21 LeadingAge state affiliates have joined a lawsuit with 20 state attorneys general to overturn the new federal nursing home staffing mandate, which was issued by the Centers for Medicaid and Medicare Services.

Garry Pezzano, LeadingAge PA president and CEO, said the new federal mandate overlooks the fact that nursing homes in Pennsylvania and throughout the nation have their hands full with the current workforce shortage.

“An unfunded federal mandate will only further exacerbate the consequences we are seeing as a result of an inadequate and broken Medicaid reimbursement system: closures, sales and reduced access to care,” Pezzano said.

He said even if the new federal mandate were fully funded, there are not enough workers.

“It’s a human capital issue,” he said. “You can’t mandate qualified workers into existence.”

LeadingAge PA estimates the new federal mandate, if unchanged, would require nursing homes across the country to hire 27,000 additional RNs and 78,000 full-time nurse aides at a cost of $7 billion.

Fenoglietto said in addition to looking to LeadingAge PA for help getting the word out, providers can talk with legislators about the unfunded component of the staffing increase. In the meantime, he said his organization will continue to provide services to the 300 or so people in its three Butler County facilities.

“We’re a mission-driven, faith-based organization, and our mission is to serve frail older adults, persons in need,” Fenoglietto said. “Our mission is to serve, so we continue to keep this as part of our portfolio.”

He noted others haven’t been able to continue, pointing out the sale of several facilities in the Pittsburgh area.

“They’re wonderful providers that continue to serve persons in need, but they were unable to have a strategic plan for this model of skilled nursing,” he said.

Quinnan said he and others would like to see leaders address the workforce issue in what he called “a very intentional way.”

“There’s no silver bullet,” he said. “But we can try to get these careers in front of young adults at an earlier age to get them interested. Whether that’s high school credits for volunteering or working, or allowing nursing students to test as (certified nursing assistants). If you’re a nursing student in college and you have the required coursework that allows you to take the CNA test, you could work in a nursing home while going to school, and it could spark a passion that could lead to a career.”

This article first appeared in the November edition of Butler County Business Matters.