Finding a solution to improve nursing home care

  • Daniel Simmons-Ritchie/PennLive

Do you want to improve nursing home care in Pennsylvania? Advocates and researchers say these are the eight key solutions Pennsylvania could undertake to protect the elderly from dangerous care.


Experts recommend that nursing home residents receive a minimum of 4.1 hours of care per resident per day from direct care staff. This doesn’t mean every resident necessarily needs that much care – some patients will need barely any help and some may need a lot of help – but 4.1 is the recommended average across a home.

In Pennsylvania however, the recommended minimum is only 2.7 hours of care per resident per day. Experts say that’s far too low. Given the intense medical needs of most nursing home residents, facilities that are providing anything less than 3.5 are often providing dangerously low levels of care, experts say.

The single biggest thing that Pennsylvania can do to improve nursing home care, experts say, is to require nursing homes to provide at least 4.1 hours of care per resident per day.

That 4.1 hours should consist of an average of at least 45 minutes of registered nurse care, 33 minutes of licensed practical nurse care and 168 minutes of certified nurse care.


A key problem, advocates and researchers say, is that state regulators in too many states, including Pennsylvania, understate the severity of nursing home violations.

They say that when inspectors visit nursing homes and find problems, such as a medication mistake that causes resident’s death, too often inspectors don’t grade that violation as a severe error.

That’s a problem because under federal regulations the severity of a violation dictates the severity of the resulting punishment. A 2016 PennLive investigation found that Pennsylvania routinely understated the severity of problems that caused resident deaths, meaning the Health Department rarely penalized homes or only fined them a few thousand dollars – a pittance for a major nursing home chain.

Since that reporting, Pennsylvania has issued tougher violation grades but advocates say there’s reason to believe the department is still falling short. A PennLive analysis found that Pennsylvania issued the severest grade of violation, called “immediate jeopardy”, only 35 times in 2017 – still one of the lowest rates in the nation. Because there’s little reason to believe Pennsylvania’s nursing homes are better than those in other states, that discrepancy is likely a result of weak oversight.

North Carolina, for instance, issued 151 immediate jeopardy violations in 2017 despite having nearly a third fewer nursing homes.

In order to ensure that nursing homes are appropriately penalized for serious errors, researchers and advocates say, Pennsylvania’s Department of Health needs to appropriately grade serious violations.


Although the severity of a violation is one of the biggest determinants of the penalty, even when Pennsylvania appropriately grades citations the resulting penalty is often far too small or non-existent.

For instance, PennLive found that of the 104 inspections that led to citations for Golden Living’s former nursing homes in 2017, the state issued penalties in response to 10.

Beyond the small number of sanctions, some sanctions appear unusually lenient. In one case, PennLive found the department fined a Tunkhannock home $15,000 following a medication error that caused a terminally-ill resident to have a narcotic overdose and become unconscious.

Without tougher penalties, advocates say, there is no discentive for unscrupulous nursing home operators to provide low quality care.

Some advocates also suggest more innovative penalties: if a nursing home is part of a chain or larger company, perhaps the agency should directly fine the chain organization or its parent company.


Pennsylvania’s Health Department says it only approves nursing home licenses to operators that can prove they can provide safe care.

However, PennLive discovered that the Health Department has no internal policies to determine what “safe care” is.

Although the department does ask applicants whether any of their other nursing homes have been charged with fraud or have faced state or federal penalties, it doesn’t appear to assess staffing levels, citation numbers or other quality metrics that would help it truly determine whether a new operator has a track record of good care.

In order to ensure that new nursing home operators can live up to their promises, researchers and advocates say the Health Department should create clear policies to assess an operator’s quality. If nursing home operators don’t have a history of good care, they shouldn’t be granted a nursing home license.


In addition to failing to assess the quality track record of new nursing home license applicants, PennLive found that it doesn’t appear that Pennsylvania assesses the financial stability of license applicants either.

That’s particularly salient following the mysterious financial problems of Skyline Healthcare. In April, the New Jersey company suddenly abandoned about 100 facilities across the country, including nine in Pennsylvania. State agencies in affected states, including the Pennsylvania Health Department, took temporary control of those homes in order to protect residents. According to the department, the cost of that takeover was $408,000.

A PennLive review of licensing documents for seven Skyline nursing homes in Pennsylvania found no evidence the department assessed the financial health of the company.

In order to prevent a repeat of Skyline’s problems, advocates says that agencies should require new nursing home applicants to provide proof they have adequate financial resources and aren’t overly leveraged.

If a company can’t prove that it has adequate financial resources, some advocates say that Pennsylvania should require those companies to pay a bond to the agency. If a nursing home operator suddenly abandons its homes, that bond will be used to recoup the cost of temporary management by the state.


An ongoing concern elderly care advocates is that Pennsylvania’s nursing home inspectors don’t thoroughly investigate resident complaints.

In particular, some say, inspectors rarely speak with residents or their families about the complaints they’ve filed. In most cases, they believe that the inspectors simply speak with the nursing home and trust their version of events.

In order to ensure that complaints are thoroughly investigated, advocates believe that inspectors should contact complainants in most situations in order to gain further information about a problem or to check statements made by the nursing home operator.


Although researchers recommend that nursing homes provide at least 4.1 hours of care per resident per day, it remains an open question whether all nursing homes can afford to do that.

State and federal governments are the primary payers for the vast majority of nursing home residents. Residents receiving short-term rehabilitation are generally covered by Medicare, administered by the federal government. Long-term residents are generally covered by Medicaid, administered by state governments.

The problem is that state Medicaid programs, as in Pennsylvania, pay nursing homes far less than federal Medicare – sometimes as much as a third.

Although nursing home advocates and some researchers believe for-profit nursing homes routinely skimp on care in order to paid their profits, there are also genuine concerns about whether Pennsylvania’s Medicaid funding is adequate.

Researchers recommend how much of existing Medicaid and Medicare dollars are going to profit and administrative costs in homes. That would help determine whether Medicaid rates need to be raised and, if staffing standards are also raised, how much additional funding they need to provide those levels.


Many nursing home advocates believe there’s a simple reason so many nursing homes are low quality: they’re pocketing taxpayer dollars and skimping on care.

In order to ensure that nursing homes aren’t sacrificing patient care, researchers say there’s a number of steps that states could take.

The biggest is for Pennsylvania to revise its Medicaid funding formula so that any increases in Medicaid funding are required to go directly to staffing levels. Other states have had success with so-called “pass through” policies.

The other larger change, some say, would be for the federal government to require nursing homes abide by a “minimum loss ratio”. Although the term sounds technical, the concept is relatively simple: all nursing homes would be required to spend only a certain percentage of their revenue on administration and profit.

A similar cap – known as a ‘medical loss ratio’ by policymakers – was placed on health insurers following passage of the Affordable Care Act in 2010. It meant that only 20 percent of an insurer’s revenue could go to profits and administration.


Want to find a good nursing home? Here’s how

It’s not easy to find a good nursing home in Pennsylvania. Most have staffing levels that are far below the levels recommended by experts for safe care. Here’s our quick guide on finding a good facility for your loved one.


There’s a big jumble of different types of senior care and it can get confusing fast. A number of facilities offer some combination of the below.

Personal care homes: Facilities for elderly people who need some help with daily activities, like bathing, dressing and transportation, but don’t need medical care. Personal care homes are not medical facilities and are not required to hire nurses or medical professionals.

Assisted living: The difference between assisted living and personal care homes differ from state to state. In Pennsylvania, assisted living facilities are similar to personal care homes but tend to offer more daily help and some skilled medical care to residents.

Nursing homes: Facilities that provide 24-hour care by licensed professionals. Residents may have intense severe medical needs and require help with almost every aspect of daily living.


There are two pieces of advice most consumer advocates agree upon:

1) Start searching before your loved one needs a nursing home.

2) Visit the homes that you’re considering and tour them.

Having to find a nursing home fast, unfortunately, is a common situation. An older person’s condition can change abruptly. He or she might be managing well alone or with help of family but a bad fall or the onset of dementia can change everything.

It used to be that people were given time to recover in the hospital. That’s no longer true. Hospitals are now under pressure to discharge people as soon as they are medically stable, even though they might need significant nursing care and be far from able to care for themselves, or be cared for by family.

The best nursing homes often have waiting lists. That could mean someone ends up in a poorly rated nursing home. And the family might not know the home is poorly rated until it’s too late.


Your first port of call should be the federal government’s website Nursing Home Compare.

The website rates homes on a five-star scale based on their staffing levels, quality metrics and how many times they’ve been cited by the state for regulatory violations. It can show you nursing homes in your county.

Unfortunately, Nursing Home Compare is not a perfect tool. Because its quality metrics are self-reported, many nursing home researchers don’t put much stock in those numbers. Facilities have been known to bolster their quality metrics in order to bump up their overall star rating.

Broadly speaking, however, Nursing Home Compare’s star ratings can give you a good feel for the best and worst nursing homes in your area.

A better metric to determining the best homes in your area, however, is too look closely at its staffing levels. Staffing is typically considered by nursing home experts as the most important determinant of quality care.

PennLive has created a database of nursing homes and has categorized their staffing based on levels recommended by experts. We recommend comparing our data with what you see on Nursing Home Compare.

Beyond the data, experts recommend asking friends, co-workers, and other acquaintances about their experiences with local nursing homes. Ask them if there’s a home in the area they would avoid or recommend.


Visit the home or homes under consideration. Virtually every expert says this is essential.

Walk around the home: Is it fresh smelling or does it smell of urine?

Visit during meal time: Does the food look appetizing? Do the residents seem to be enjoying their meals? Are residents who need help with eating getting it, or are they staring at their food?

Watch how staff interacts with residents. Are they friendly? Are the residents happy?

Talk to the home’s administrator. Ask about staffing levels. Many nursing homes in Pennsylvania like to say they’re above the state minimum requirement – an average of 2.7 hours of direct care per resident per day – but that requirement is out-of-date and considered far below what’s recommended by experts.

Ideally, a nursing home should provide at least an average of 4.1 hours of direct care per resident per day. This doesn’t mean every resident should get this much care, some residents will have higher needs and some will have lesser needs, 4.1 is just the recommended average across a home.


Ask about the level of staff turnover. High turnover can suggest poor working conditions and low levels of staffing.

Also ask about the use of ‘agency staff’. These are nurses that the home contracts with and often rotate between several nursing homes. If a nursing home makes heavy use of agency staff, they might not be able to become familiar with your loved one, meaning the care they provided is less tailored to their needs.

Other questions: Ask about activities offered to residents. Ask if the facility has a high vacancy rate. If it does, ask why. Ask if there’s a waiting list to get into the home.


Consider whether the home is for-profit or nonprofit. This is a contentious subject, with critics arguing that for-profit homes skimp on staffing to maximize profits. Some studies have found that nonprofit homes have higher staffing levels – probably the single most important factor in providing good care, safety and high quality of life for residents.

But don’t assume all for-profit homes are bad. If it’s a nonprofit home, find out its affiliation. Nonprofit homes are often affiliated with churches or religious organizations.

These are sometimes more “mission” focused, and more inclined to channeling resources toward higher staffing levels and the highest possible level of care. They also might be better positioned to obtain volunteer help, and have a charitable fund to help residents cover their costs.

About this investigation


In 2016, PennLive published ‘Frailing the Frail’, a six-part investigative series that explored major problems in Pennsylvania’s nursing home industry, including the death of 46 residents.

That investigation was prompted in part by a 2015 lawsuit filed by Pennsylvania’s Attorney General against Golden Living and other nursing home chains in Pennsylvania. Three years after that lawsuit and two years after the publication of ‘Failing the Frail’, PennLive wanted to use Golden Living’s nursing homes as a lens to re-examine the state of Pennsylvania’s nursing home industry.

PennLive reporter Daniel Simmons-Ritchie discovered that Golden Living sold the licenses of all 36 of its homes to new operators. And, over eight months, based on interviews with more than a dozen families and residents, and an extensive analysis of state and federal records, PennLive found most of those homes had the same or more citations and lower staffing under new operators than under Golden Living. Two of the operators defended they are dedicated to providing quality care.

The timeliness of PennLive’s reporting was only heightened in April when one of the companies operating Golden Living’s former homes, Skyline Healthcare, went into receivership in Pennsylvania and other states, forcing state agencies to take emergency control of those homes to protect residents. That situation raised new questions about how closely Pennsylvania scrutinizes the financial stability of new nursing home operators.

Beyond that, as Simmons-Ritchie’s reporting progressed, he discovered that Golden Living may still be influencing care inside those homes: The company continues to own the real estate to all 36 of its home and it remains unknown how much control Golden Living may exert over the companies now managing those facilities.

PennLive ultimately concluded that three years after the Attorney General’s lawsuit, Pennsylvania appears to still be failing its frailest citizens.

REPORTING: Daniel Simmons-Ritchie is an investigative reporter with PennLive and the Patriot-News. He has earned state and national awards for work on a variety of subjects, including health care, criminal justice, and the environment.


PROJECT EDITORS: Ron Southwick and Burke Noel

DESIGN & PRODUCTION: Megan Lavey-Heaton

DATA & INTERACTIVES: Nick Malawskey and Daniel Simmons-Ritchie

PHOTOGRAPHY & VIDEOGRAPHY: Dan Gleiter, Mark Pynes, Sean Simmers, and Daniel Simmons-Ritchie

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