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Government Reports Nursing Home Staffing Is Inadequate

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JULY 31, 2000 VOLUME 8, NUMBER 5

In 1990 Congress became concerned about the quality of care in American nursing homes. The Department of Health and Human Services was directed to prepare a report on nursing homes by the beginning of 1992. Last week DHHS finally sent the first part of that report to Congress a little over eight years late. Maybe it took so long because the figures on nursing home care are so bad.

Nursing home operators and patient advocates tend to disagree on many things, but central to their differences is the appropriate level of staffing required to operate safe and healthy nursing homes. The DHHS report to Congress attempts to determine minimum and optimal staffing levels in nursing homes.

DHHS reviewers tried three different methods to determine the appropriate staff-patient ratios for nursing homes. They considered the numbers proposed in professional journal articles. They also considered “outcome” measures like injury and death rates, and compared them to staff ratios.

Finally, the reviewers conducted “time-motion” studies in an attempt to determine how many staff hours are required to adequately care for each nursing home resident. While the literature review was not very helpful, the other two measures provided strong arguments for a minimum staffing level.

The report proposes a minimum staffing level of 2.0 hours of aides for each resident day. In other words, one full-time aide position should be filled for every four patients in the facility.

According to the report, there should also be one full-time RN on staff for every 40 residents, and a combination of RNs and LPNs at the level of about one for every ten patients. Of course, those staff members need to be spread across shifts to provide 24-hour coverage as necessary.

How do nursing homes stack up against those minimum requirements? Poorly, as it turns out. More than half (54%) of nursing homes studied now fall below the minimum staffing level for aides, and about a third fall below the minimum standards for professional staff. That is for minimum standards: the figures are much bleaker when compared to optimum levels.

According to DHHS it would be much better if RN and LPN rates were considerably higher. The agency recommends that RNs should be hired at the rate of one for every 18 residents, and the combination of RNs and LPNs should total one for every 8 patients. Between half and two-thirds of all nursing homes fall below those preferred staffing levels.

Why are staffing levels so low? One culprit is the federal government itself. Vigorous budget-cutting by Congress has resulted in a record rate of bankruptcies in the industry. More on that problem, and the early Republican response to the report, in next week’s Issues.

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Robert B. Fleming


Robert Fleming is a Fellow of both the American College of Trust and Estate Counsel and the National Academy of Elder Law Attorneys. He has been certified as a Specialist in Estate and Trust Law by the State Bar of Arizona‘s Board of Legal Specialization, and he is also a Certified Elder Law Attorney by the National Elder Law Foundation. Robert has a long history of involvement in local, state and national organizations. He is most proud of his instrumental involvement in the Special Needs Alliance, the premier national organization for lawyers dealing with special needs trusts and planning.

Robert has two adult children, two young grandchildren and a wife of over fifty years. He is devoted to all of them. He is also very fond of Rosalind Franklin (his office companion corgi), and his homebound cat Muninn. He just likes people, their pets and their stories.

Elizabeth N.R. Friman


Elizabeth Noble Rollings Friman is a principal and licensed fiduciary at Fleming & Curti, PLC. Elizabeth enjoys estate planning and helping families navigate trust and probate administrations. She is passionate about the fiduciary work that she performs as a trustee, personal representative, guardian, and conservator. Elizabeth works with CPAs, financial professionals, case managers, and medical providers to tailor solutions to complex family challenges. Elizabeth is often called upon to serve as a neutral party so that families can avoid protracted legal conflict. Elizabeth relies on the expertise of her team at Fleming & Curti, and as the Firm approaches its third decade, she is proud of the culture of care and consideration that the Firm embodies. Finding workable solutions to sensitive and complex family challenges is something that Elizabeth and the Fleming & Curti team do well.

Amy F. Matheson


Amy Farrell Matheson has worked as an attorney at Fleming & Curti since 2006. A member of the Southern Arizona Estate Planning Council, she is primarily responsible for estate planning and probate matters.

Amy graduated from Wellesley College with a double major in political science and English. She is an honors graduate of Suffolk University Law School and has been admitted to practice in Arizona, Massachusetts, New York, and the District of Columbia.

Prior to joining Fleming & Curti, Amy worked for American Public Television in Boston, and with the international trade group at White & Case, LLP, in Washington, D.C.

Amy’s husband, Tom, is an astronomer at NOIRLab and the Head of Time Domain Services, whose main project is ANTARES. Sadly, this does not involve actual time travel. Amy’s twin daughters are high school students; Finn, her Irish Red and White Setter, remains a puppy at heart.

Famous people's wills

Matthew M. Mansour


Matthew is a law clerk who recently earned his law degree from the University of Arizona James E. Rogers College of Law. His undergraduate degree is in psychology from the University of California, Santa Barbara. Matthew has had a passion for advocacy in the Tucson community since his time as a law student representative in the Workers’ Rights Clinic. He also has worked in both the Pima County Attorney’s Office and the Pima County Public Defender’s Office. He enjoys playing basketball, caring for his cat, and listening to audiobooks narrated by the authors.