November 30, 2000

Dear Friend of Nursing Home Residents:

We have now received notice that the Florida Agency for Health Care Administration will again begin having hearings around the State to obtain input from citizens regarding a proposed minimum staffing requirement for nursing homes, and the use of part time people to feed nursing home residents.

The first hearing will be in Miami on December 5th at 10:00 a.m.  The hearing will be held in the Manchester Building of the Koger Center,  8355 N. W. 53rd Street (adjacent to the Doral Country Club) in the 2nd floor Medicaid Conference Room.  Hearings will be held in other cities following that, but exact dates and locations have not been provided.

We thought you might like to know the background and history of these issues, as we understand them.

For many, many years, and up to the present time, the State’s staffing requirement has been that a nursing home must provide .6 hours of licensed staff time (RN or LPN) and 1.7 hours of direct staff time (nursing aides) per day per resident. 

There was no requirement as to how many actual people had to be on duty throughout the day and night.  This allowed a nursing home to have adequate or close to adequate staffing during the morning hours, and practically none the rest of the day and night, and still meet the State regulation. 

Although there has simultaneously been a Federal requirement that there must be sufficient staff (of whatever number) to meet the needs of the residents, this Federal rule requires  a subjective determination, and it has been totally  impossible to insure sufficient 24 hour staffing on a consistent basis to meet the basic needs of residents. 

The present staffing rule has  been in place since 1972 (albeit in a slightly re-written form), and is less than the staffing required in the original nursing home licensure rule adopted in 1962,  even though the  acuity (severity of the illness) of nursing home residents has greatly increased due at least in part to the shortened period of time patients now remain in the hospital after serious illness or surgery, and the insufficient amount  of home health care or community based care which has been available.

The nursing home industry’s staffing practice has caused huge numbers of complaints to the State of understaffing (several thousand annually) which family members believe has caused poor care and unnecessarily endangered the health and well being of nursing home residents as a whole. 

Poor quality  care is believed to be the source of many  serious and life-threatening  but primarily preventable conditions such as pressure sores, falls with broken bones, and untimely death from malnutrition, dehydration,  serious infections, etc.  These are things which have engendered the numerous nursing home law suits which I am sure you have heard about. In addition, they result in huge medicare and medicaid expense which could be lessened.

Many families believe that if the staffing situation was improved the care would improve greatly and many of these unnecessary and preventable illnesses could be eliminated, greatly reducing pain and suffering of the residents,  preventing their untimely death, greatly reducing the number and level of nursing home law suits,  and resulting  in major savings of  medicare and medicaid funds. 

In recognition of the serious impact of understaffing, the Florida Legislature passed a nursing home reform act in the 1998 session, requiring the Agency to establish new minimum staffing requirements. 

In furtherance of that mandate, the Agency held hearings on this subject around the State over a period of months and ultimately, last summer,   the Agency announced it  proposed to adopt the following staffing ratios by shift:  from 7 a.m. to 3 p.m. 1 nurse  (RN or LPN)  to 30 residents and 1 aide (CNA) to 10 residents;  from 3 p.m. to 11 p.m. 1 nurse to 40 residents and 1 aide to 15 residents;  and from 11 p.m. to 7 a.m. 1 nurse to 60 residents and  1 aide to 20 residents.

Protests came from all over the State that it was impossible for one nurse or one aide to take care of these large numbers of residents.    There were also some other provisions about how the numbers were to be counted and how it would be construed, that caused  the nursing home industry to challenge the proposed rule.   These combined protests caused the Agency to finally withdraw its proposal shortly after its final hearing in July. 

Because the Agency does have a legislative mandate to promulgate staffing rules, it will now begin new hearings, starting from scratch, with the first hearing to be held on December 5th, as noted above.

You may be aware that the Governor’s Task Force on Long Term Care has also been holding hearings around the state on numerous nursing home issues, including the staffing issue.  During those hearings there were some  specific  recommendations made for staffing. 

The specific recommendations that seemed most appropriate and minimally necessary for reasonable care of nursing home residents were  as follows:

 From 7 a.m. to 8 p.m.:
 1 nurse to 10 residents and 1 aide to 6 residents

From 8 p.m. to 7 a.m.:
 1 nurse to 15 residents and 1 aide to  10 residents

*with administrative staff not to be counted as “aides” or “nurses” in this ratio, and appropriate supervisory, administrative, housekeeping, maintenance and dietary staff to be on duty 24 hours a day.

The presenter explained that this position was garnered  after considerable research and interviews with residents, caregivers, nursing home staff, students in nursing schools, participants in adult day care centers and their families, and from personal experiences.  It also took into consideration,  the fact that there is already  established in Florida an  adult day care ratio of 1 staff member to 6 participants without Alzheimer’s, and 1 staff member to 3 participants with Alzheimer’s. 

In view of the obvious increased acuity of those in  nursing homes over those in adult day care centers, how can the staff be less? 

The  Agency will also hear testimony on whether to allow part time staff to assist residents with eating.  While this proposal sounds good, many individuals with personal nursing home experience have expressed concern that it is a bandaid approach to the overall staffing problem, and should not be allowed.  It also raises other serious issues, including  questions of  sufficient standardized training, supervision, liability,  documentation, etc. Numerous advocacy groups, both in Florida and elsewhere around the country, have  expressed strong concern over this proposal and have urged that it be turned down.

If you (or anyone you know) feel these are important issues, or if  you (or anyone you know) have had some personal experience with staffing problems in nursing homes, you may wish to attend the hearing as individual citizens.  Information on the dates after the Miami hearing will be provided as soon as possible. 

Since the Agency is requesting specific recommendations as to numbers, if you wish to use the numbers previously recommended to the Task Force, as high lighted above, please feel free to do so.

If you, or anyone you know, would like to have input on these issues but cannot attend a hearing, you can make written comments, if done at an early date, giving specific recommendations for numbers of staff and your opinion of whether or not there should be part time people feeding residents, to:

  Mr. Richard Kelly
  Agency for Health Care Administration
  2727 Mahan Drive, Mail Stop #33
                Tallahassee, Florida 32308
                Fax: 850-410-1512
  e-mail:  kellyr@fdhc.state.fl.us

IF YOU PREVIOUSLY GAVE WRITTEN COMMENTS IN TERMS OF YOUR PERSONAL EXPERIENCES, BUT DID NOT GIVE A SPECIFIC RECOMMENDATION OF NUMBERS OF STAFF YOU BELIEVE ARE APPROPRIATE (AS WE UNDERSTAND WAS THE CASE IN MOST INSTANCES) YOU CAN TAKE A COPY OF YOUR PRIOR LETTER, AND ATTACH A COVER SHEET WHICH MIGHT SAY SOMETHING LIKE THIS:

I RECOMMEND STAFF IN THESE NUMBERS:   (GIVING THE NUMBER YOU RECOMMEND) BASED IN PART ON MY PERSONAL EXPERIENCE AS OUTLINED IN THE ATTACHED
LETTER.

ALSO, I DISAGREE WITH HAVING PART TIME PEOPLE FEEDING RESIDENTS IN NURSING HOMES.

ALTERNATELY, IF YOU DON’T HAVE A COPY OF YOUR PRIOR LETTER YOU COULD REFER TO IT, AND GIVE YOUR SPECIFIC RECOMMENDATIONS.

IF YOU WISH TO SEND A COPY OF YOUR COMMENTS TO ME THEY CAN BE PRESENTED IN PERSON AT A HEARING WE WILL ATTEND.

If you would like to have additional information regarding these two important issues, which impact every family at one time or another,  please contact me as soon as possible.

     THE NIGHT WATCHMAN EDITOR
     P. O. BOX 13553
     TAMPA, FL 33681-3553

     E MAIL: nightwatchman@ij.net 
     (that’s i j (for internet junction) .net