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Iowa nursing homes’ staffing levels are among the nation’s worst


Iowa nursing homes’ staffing levels are among the nation’s worst

Apr 16, 2024 | 6:27 pm ET
By Clark Kauffman
Iowa nursing homes’ staffing levels are among the nation’s worst
Des Moines' Fleur Heights care facility has Iowa’s worst record of compliance with requirements for sufficient staffing levels in nursing homes. Over a nine-month period between May 2023 and February 2024, the home was cited, but never fined, five times for insufficient staff. (Photo by Clark Kauffman/Iowa Capital Dispatch)

Last October, state inspectors visited Des Moines’ Fleur Heights Center for Wellness and Rehabilitation to investigate a backlog of 14 complaints alleging substandard care.

While one inspector watched, a male resident of the home called out from his bed, “Help me.” A worker reportedly turned off the man’s call light and left, telling the man she was busy.

“I’m a human being, I need help,” the man told the inspector. The man switched his call light back on and after 15 minutes another worker allegedly came in, asked what he needed, switched off the light, and left.

Later the same morning, the man was parked in his wheelchair outside his room, with the call light out of reach. At the man’s request, the inspector switched on the light. A half-hour later, an aide allegedly went into the man’s room, turned off the light and left.

In their report, the inspectors noted there had been no director of nursing on the Fleur Heights payroll for three months, and there weren’t enough workers on hand to get residents out of bed, serve meals or assist those who needed help eating.

Residents complained of waiting more than two hours for their call lights to be answered. A registered nurse who worked for the home told inspectors the staffing levels were “terrible.” At times, the inspectors reported, the home had just four nurse aides on duty to care for 81 residents.

Iowa violations far above the national average 

Fleur Heights has Iowa’s worst record of compliance with a federal requirement that nursing homes maintain “sufficient” staffing levels to care for residents.  Over a nine-month period between May 2023 and February 2024, the home was cited, but never fined, five times for insufficient staff — more than any other facility in the state.

According to data from the Centers for Medicare and Medicaid Services, 14% of Iowa’s 422 nursing facilities were cited for insufficient staffing in fiscal year 2023. That’s more than double the national average, which was 5.9%.

Only five other states – Hawaii, Michigan, Montana, New Mexico and Oregon — had a worse record of compliance with the sufficient-staffing requirement. Iowa’s neighboring states of Nebraska, South Dakota, Wisconsin and Missouri had no more than 2% to 6.8% of their facilities cited for insufficient staffing in 2023.

Iowa nursing homes’ staffing levels are among the nation’s worst
Gov. Kim Reynolds is a Republican and Iowa’s first female governor. (Photo courtesy of the governor’s office)

Nationally, insufficient staffing has long been recognized as the single biggest contributor to poor quality care in nursing homes. Over the past year, the Biden administration has called for the approval of a new rule that would establish, for the first time, specific minimum staffing levels for care facilities that collect taxpayer money through Medicare or Medicaid.

That proposal has faced stiff opposition from industry lobbyists and many state and federal Republicans, including Gov. Kim Reynolds.

Last November, Reynolds and 14 other Republican governors sent Biden a letter saying the nursing home industry was facing a workforce crisis, particularly in rural areas. The governors predicted that minimum staffing levels would “force over 80% of facilities nationwide to hire more staff” and result in many of them closing.

Proposed rule criticized as too weak

The proposed rule has also faced pushback from advocates for seniors who say the administration, to appease the industry, has watered down the proposal to such an extent it would have little impact.

The Center for Medicare Advocacy, for example, has noted that it calls for facilities to provide about a half-hour of care each day per resident by a registered nurse and another two and a half hours a day by a nurse aide. That’s a lower level of staffing than what the federal government itself said was necessary in 2001.

In addition, the three-hour care requirement is lower than the average staffing level of 3.76 hours that U.S. nursing facilities currently provide and which the Center for Medicare Advocacy calls “grossly inadequate.”

The rule also provides exemptions for facilities that claim they’re unable to meet the three-hour standard, and it allows for phased-in implementation over several years at rural facilities.

Still, conservatives in Congress are opposing the new rule, saying it would drive facilities into bankruptcy.

Iowa nursing homes’ staffing levels are among the nation’s worst
U.S. Rep. Randy Feenstra is a Republican from Iowa’s 4th District. (Photo by Iowa Legislature)

Last month, the U.S. House Ways and Means Committee approved a bill, H.R. 7513, called the “Protecting America’s Seniors’ Access to Care Act,” that prohibits the Secretary of Health and Human Services from promulgating any nursing home staffing standards either now or in the future.

The committee approved the measure on a largely party-line vote of 26-17, with Iowa’s Rep. Randy Feenstra joining other Republicans who backed the bill.

“Every health care provider in my district — I have 36 counties — tells me how difficult it is to find nursing staff,” Feenstra said at the time. “This (staffing) rule would be absolutely devastating to this sector that is already struggling to find staff to provide the highest level of care possible.”

Studies: Profits are being concealed

Industry officials don’t dispute that additional staff would improve care, but argue that the cost of an expanded workforce – assuming the necessary workers could be found — would be prohibitive.

For example, the lobbying organization LeadingAge Iowa, which represents many Iowa care facilities, says the Biden administration’s proposed rule would cost its members $5.39 million per year. Iowa nursing homes, the organization says, are already operating on a -5% operating margin and aren’t making any money.

Others disagree with the industry’s claims of poverty. A new study by researchers at UCLA and Lehigh University reports that nursing homes have engaged in a widespread form of financial maneuvering called “tunneling” to appear less profitable to regulators.

The process involves care facilities paying inflated prices for goods and services that are supplied by commonly owned companies. The study’s authors reported “evidence of widespread tunneling” through inflated rent and management fees doled out to affiliates.

“Extrapolating these markups to all firms’ related party transactions, our estimates suggest that in 2019, 63% of nursing home profits were hidden and tunneled to related parties through inflated transfer prices,” the report states.

Separately, the Long-Term Care Community Coalition published a report in December that was based on its own analysis of the detailed cost reports the care facilities themselves provide the federal government.

The coalition concluded that while the industry reports profit margins of less than 1%, a more realistic figure that takes into account certain expenses and depreciation is 8.84%.

“Too many seniors and families accept substandard care and inhumane conditions because their nursing home tells them that they cannot afford to hire more staff,” said Richard Mollot, executive director of the coalition and co-author of the study. “This study provides important evidence showing that nursing homes get plenty of money — they are just not being held accountable for using it appropriately.”

Violations continue to be cited

If the new rule is not approved, the current standard that imposes a vague and relatively hard to enforce standard of “sufficient” staffing will remain in place.

In December, a few months after the Fleur Heights nurse complained of “terrible” staffing levels, the state inspectors returned to the facility to investigate six additional complaints — and they again cited the home for having insufficient staff.

In this instance, the inspectors said, the lack of staff had contributed to an assault when a resident of the home attacked a female resident in the dementia unit. According to the inspectors, the woman had been calling for help during the attack but there was no nurse in the unit and two aides who were on duty were inside the nurses’ station and couldn’t hear the screams for help. The victim sustained a serious injury that resulted in a trip to the hospital and six staples in her head to close a laceration, according to inspectors.

In January, the state inspectors were back at Fleur Heights to investigate more complaints. Again, they cited the home for insufficient staffing. Inspectors noted that some of the residents had “dull and greasy” hair,” with workers explaining there wasn’t enough staff to provide baths and showers. Some residents had gone three weeks without being bathed, inspectors reported.

A few weeks later, in February, inspectors returned to Fleur Heights, this time in response to four complaints. Again, the facility was cited for insufficient staff, with residents complaining they had to wait up to a few hours for call lights to be answered. The shortage of staff also resulted in meals and medications being delayed, workers told inspectors.

At the close of the inspection, the home’s administrator said the facility, which is a for-profit venture owned by Kevin Babb and Dr. Robert Conner, was making plans to hire more staff.

The facility, however, already has a three-star rating for staffing levels on CMS’ five-star scale.

In fact, when LPN care is combined with care delivered by RNs, Fleur Heights’ staffing levels greatly exceed the nursing care standards that the Biden administration’s proposed new rule would impose.