The Staff Time and Resource Intensity Verification (STRIVE) study evaluated the relationship between reimbursement and the actual staffing required to provide care per RUG score.[i] This study was sponsored by the Centers for Medicare & Medicaid Services (CMS) along with a collaboration of consumer advocates, clinicians, and the nursing home industry and others. The extremes were removed such as the very worst facilities or the very best special care facilities. Once they had a representative sample over a geographic area of fifteen states and more than two hundred nursing homes, the study monitored the time that it took to care for residents. They recorded staff times for ADLs, personal care, and all aspects of care received in skilled facilities. They then totaled up and averaged the staff time per RUG score. The study didn't just include Medicare residents. All residents, no matter the pay source, were included. The purpose was to determine the amount of time that nursing home staff spent caring for residents while exercising current care practices.
The STRIVE study has been completed and the new staff time expectations have been released. Just for an example, let's look at the Brian Center of Lexington. Historically, it has had a very low level of staffing. In the November 2011 staffing study, their expected level of staffing based on their RUG scores was 4.55 nhppd while the facility self-reported only 2.84 nhppd. Shouldn't the facility provide staff at or near the expected levels? If a facility is operating at staffing levels that are around half of the expected amounts, it should be no big surprise if the facility delivers poor care. In addition to many private studies, the GAO has also determined that quality of care is related to staffing and not the amount spent by the government as only around half of all funds received by nursing homes were spent on staffing and medical supplies.[ii]
As stated above, subsection .30 of the federal regulations requires enough staff as determined by resident assessments. The resident assessment is the MDS form, which generated a RUG score and in combination with the staff time studies estimated the number of staff needed. Shouldn't the nursing home be required to at least provide staffing close to these expected numbers and at a minimum be forced to increase staff with reimbursement increases? Whenever I depose a managerial employee, and I ask if they are required to increase staff if there is an increase in acuity, they answer "yes". I then ask, "how are you monitoring acuity levels?" I will often get answers such as, "we just have a general feel of what is needed."
In actuality, the corporate owners set staffing numbers to establish a particular level of profitability. The budgets are set annually and adjust quarterly for profitability. However, the adjustments are not focus on costs, census and revenue not acuity. Staffing is by far the largest cost for nursing homes, so this is the area that gets cut the most. Corporate owners have easy access to the RUG information and increasing staffing as reimbursement increases would do the trick. If they don't do this, the residents suffer and are neglected. At Roane Law, our attorneys handle nursing home neglect cases. In fact, to my knowledge, James Roane handles more nursing home abuse and neglect cases than any other attorney in the Greensboro area.
[i] STRIVE study information from Federal Register Vol. 74, No. 153 (August 11, 2009)
[ii] GAO-02-431R Nursing Home Expenditures and Quality