DHHS Eagle graphic
ASL Header
Mission Nav Button Division Nav Button Grants Nav Button Testimony Nav Button Other Links Nav Button ASL Home Nav Button
US Capitol Building
HHS Home
Contact Us
dot graphic Testimony bar

This is an archive page. The links are no longer being updated.

Statement on Nursing Home Staffing by Helene Fredeking
Senior Advisor, Division of Outcomes and Improvement
Center for Medicaid and State Operations
Health Care Financing Administration

Before the Senate Special Committee on Aging
November 3, 1999

Chairman Grassley, Senator Breaux, distinguished Committee Members, thank you for inviting me to discuss our efforts to improve quality of care for America’s 1.6 million nursing home residents and to address the issue of nursing home staffing levels.

Protecting nursing home residents is a priority for this Administration and our Agency. Through the Medicare and Medicaid programs, the federal government provides funding to the States to pay for care and protect resident safety.

In 1995, the Clinton Administration began enforcing the toughest nursing home regulations ever. They have brought about measurable improvement. However, our report to Congress and GAO investigations have shown that much more needs to be done. That is why President Clinton last July announced a major new initiative to increase protections for vulnerable nursing home residents and crack down on problem providers. Since then, we have worked diligently with your Committee, States, providers, advocates, residents, and their families, to implement and build upon this initiative.

We also are conducting a comprehensive study to help determine what the appropriate level of staffing in nursing homes should be, and whether minimum nursing home staffing ratios may be in order.

This study is critical to our efforts to improve oversight and ensure safety and high quality care for vulnerable nursing home residents. We expect to have the first phase of this report completed by this coming summer.


We have made substantial progress in implementing many facets of this nursing home initiative, announced by President Clinton in July of last year.

  • We issued new protocols for conducting nursing home surveys which specifically address areas where there have been significant problems, including hydration, nutrition, and pressure sores. These protocols, released in July 1999, are vital to guiding and training State surveyors and will assure a new level of consistency of surveying among the States.

  • We provided training and guidance to States on the President’s nursing home initiative, including enforcement, use of quality indicators in the survey process, survey tasks in the areas of medication review, pressure sores, dehydration, weight loss, and abuse prevention.

  • We required States to evaluate all complaints alleging actual harm within 10 days. Last month we issued detailed guidance on how to conduct such evaluations and prioritize complaints. Key staff from each of our regional offices will be meeting with State survey agencies to discuss these guidelines and facilitate sharing of best practices in complaint management.

  • We identified facilities in each State for more frequent inspection and intense monitoring, based on results of most recent annual inspections and any substantiated complaints during the previous two years. States have begun monitoring these facilities more frequently.

  • We vigorously encouraged States to impose sanctions on facilities that do not comply with health and safety regulations.

  • We urged States to impose especially close scrutiny and immediate sanctions for facilities that demonstrate "yo-yo" compliance by fixing problems temporarily, only to be cited again in subsequent surveys.

  • We instructed States to stagger surveys and conduct a set amount on weekends, early mornings, and evenings.

  • We required States to revisit facilities in person to confirm that violations have been corrected before lifting sanctions.

  • We issued regulations that enable States to impose civil money penalties for each serious incident.

  • We have been working with the Department of Justice to improve referral for potential prosecution of egregious cases in which residents have been harmed.

  • And we are testing an abuse intervention campaign in 10 States, with posters and other printed messages in nursing homes to inform residents and families about the signs of abuse and how to report it.

We also are taking steps to protect residents from any disruptions or dislocations in facilities that may be experiencing financial or other difficulties. We have made clear that filing for Chapter 11 bankruptcy does not diminish a facility’s responsibility to provide residents with high quality care and a good quality of life. We issued monitoring protocols designed to help State surveyors and ombudsmen uncover early warning signals that might indicate the possibility that a facility in financial difficulty will fail to continue providing quality care to residents. And we developed a management contingency plan spelling out responsibilities of State and federal governments so we can respond quickly and effectively if a facility’s financial situation places resident health or safety at risk.

To improve consistency in how these efforts are implemented across the country, we have established a workgroup that includes key central and regional office staff. This workgroup is promoting clear and consistent communication among all involved staff. And it is specifically addressing areas where inconsistencies have been identified.

We also continue to target our efforts toward increasing nursing home accountability by making information on each facility’s care and safety record available to residents, their families, care givers, and advocates. We have launched a new Internet site, Nursing Home Compare at www.medicare.gov, which allows consumers to compare survey results and safety records when choosing a nursing home.


Some evidence suggests that staffing levels and staff-to-patient ratios may be an important contributing factor to some nursing home problems. However, there is as yet little systematic evidence available to substantiate such a link for specific ratios. That is why further study is so critical.

We are conducting a study and developing a report to Congress that will help to determine the appropriateness of establishing minimum caregiver-to-resident ratios. We have faced challenges in conducting this study, in part due to the paucity of preexisting data on the subject. However, we are on track and expect to provide the first phase of this report to Congress in the summer of 2000.

With the assistance of our contractor, Abt Associates, we expect to analyze two years of data from nearly all nursing homes in Ohio, New York, and Texas, representing approximately 2,700 facilities that are home to over 240,000 Americans. Our study focuses on three key areas:

  • Whether staffing ratios improve care;
  • Whether minimum nurse staffing ratio requirements are appropriate; and
  • The potential cost and budgetary implications of minimum ratio requirements.

In developing the study, we have met, and continue to meet, with a variety of individuals, including consumer groups, labor organizations, and industry representatives.

We also have established an external Technical Expert Panel to provide us with independent advice in analyzing the data. This expert panel will review our study design and provide ongoing assistance to us throughout the study process.

We were careful to select those experts who we believed could be objective and who had not publicly staked out a prior position on the appropriateness of minimum staffing ratios. While all the panelists are expert in long-term care, they represent very different disciplines that we viewed as critical to our study, including nursing and qualitative research, quality indicators, clinical expertise, and cost analysis.

Once we are confident that we have reliable and meaningful data on staffing, we will include information about staffing levels at individual nursing facilities on our Nursing Home Compare web site. We know there are concerns about the accuracy of the staffing data available to us today. We have research underway to help us get better data. And we feel it is essential to wait until we are certain the data are not flawed or misleading before they are posted.


We continue to move forward on both our comprehensive nursing home initiative and our study of nursing home staffing. We greatly appreciate the assistance provided to us in these efforts by resident advocates, labor and trade groups, other experts, and this Committee. And we look forward to consulting further with you when our staffing study is complete on how to interpret and act upon its findings. I thank you again for inviting us to this forum, and I am happy to answer any questions.

Privacy Notice (www.hhs.gov/Privacy.html) | FOIA (www.hhs.gov/foia/) | What's New (www.hhs.gov/about/index.html#topiclist) | FAQs (answers.hhs.gov) | Reading Room (www.hhs.gov/read/) | Site Info (www.hhs.gov/SiteMap.html)