Nursing homes need more staff – and more supervision – after reports of poor conditions

According to an investigation by The (Springfield) Republican, residents of the Highview of Northampton nursing home reported mold on the walls and long waits for care.

At the Pioneer Valley Health and Rehabilitation Center in South Hadley, state officials called for an investigation after reports of unsanitary conditions and unpaid wages, the Daily Hampshire Gazette reported. On Monday, the attorney general placed that home and two others under the same ownership into receivership, citing dangerous understaffing, back pay and poor quality of care, including improper medical management of a patient’s diabetes.

The New York Times analyzed nursing home staffing levels in five states, including Massachusetts, that mandate a certain number of hours of care per resident. The Times found that the rules were often ignored without consequence, and that understaffing led to deplorable conditions. (Tara Gregorio, president of the Massachusetts Senior Care Association, which represents nursing homes, told the editorial board that 144 facilities, 42 percent, were below minimum staffing standards as of the end of 2023.)

While it’s tempting to call for stricter oversight—and existing penalties for understaffing should certainly be enforced—one can’t blame nursing homes alone. Staffing shortages are plaguing the entire health care sector and, indeed, the entire economy. While there needs to be more oversight of nursing home financial management, the state should also help nursing homes recruit and retain more staff.

This is especially important as the federal government prepares to implement new staffing standards for nursing homes. Massachusetts already requires more staff than the federal requirement, but the federal law will require more hours from registered nurses, who are already in short supply.

Fortunately, the Massachusetts House passed a bill last November that would address oversight and staffing, and the Senate passed a similar bill on Thursday.

The problem is that formal legislative sessions end on July 31, and there are differences among the bills that need to be reconciled. Lawmakers need to identify provisions they agree on — particularly policies around nursing home oversight and staff — and quickly pass a bill to begin transforming an industry that leaves too many seniors languishing in substandard conditions.

How did the industry get to this point in the first place?

The nursing home industry blames low Medicaid reimbursement rates on staffing issues. Gregorio said 70 percent of nursing home residents receive their care through MassHealth, the state’s Medicaid program. Although the Legislature has increased nursing home reimbursement rates since the pandemic, Gregorio said the rates are still below the cost of care. With insufficient revenue, nursing homes can’t compete with wages offered by hospitals, temporary nursing agencies or non-nursing services.

There’s no question that nursing homes are struggling financially. According to the Center for Health Information and Analysis’ 2024 annual report, the median margin for a state nursing home in 2022 — a measure of revenue and expenses — was negative 3 percent, meaning more than half of the state’s nursing homes are operating at a loss.

And COVID-related factors have led to turnover in health care. Employment in nursing homes and assisted living facilities in 2022 was 14 percent below 2018 levels, according to the Massachusetts Health Policy Commission. The Massachusetts Senior Care Association said 17 percent of nursing home jobs, or 4,200 positions, are vacant.

Still, staffing problems can’t be blamed solely on Medicaid rates. Nursing homes choose how to spend their money, and not all of them prioritize patient care. In June, Attorney General Andrea Joy Campbell reached a $4 million settlement with Next Step Healthcare, which operates 16 nursing homes in Massachusetts. Campbell alleged that Next Step “put profits before care” by intentionally understaffing nursing homes.

Massachusetts requires nursing homes to spend 75 percent of their revenue on direct care or lose Medicaid money. In fiscal year 2023, 38 of 342 nursing homes fell below that threshold, according to a report from MassHealth.

National reports identify a trend of nursing homes paying inflated prices to entities — often a landlord or management company — with whom they share ownership. A report published by the National Bureau of Economic Research found that real estate and management transactions involving a “related party” increased costs by 42.4 percent and 24.6 percent, respectively. A 2023 report from the National Consumer Voice for Quality Long-Term Care cited the example of Life Care Centers of America, which operates nursing homes across the country, including Massachusetts. Between 2018 and 2020, Life Care Centers paid related entities $1.2 billion for costs such as rent and management fees, $140 million of which was profit. Life Care Centers’ nursing homes were understaffed.

And even with the industry’s challenges, there are models for high-quality nursing home care. The Peabody-based nonprofit Legacy Lifecare was founded in 2018 to provide management services to nine nursing homes and other health care facilities. Its affiliated nursing homes, all nonprofit, generally score above average on federal assessments with staffing levels that exceed state minimums, even though funding, like most nursing homes, comes primarily from Medicaid and Medicare.

Legacy Lifecare CEO Adam Berman said homes are struggling to find staff in a tight labor market, but the company is keeping staffing levels high to avoid a spiral of overworked employees leaving. A key factor in the organization’s success, Berman suggests, is its nonprofit status. “It really helps that we don’t have shareholder return expectations,” Berman said. (According to its 2022 tax form, the organization has nine managers earning six-figure salaries.)

Institutions like Legacy Lifecare show what is possible and what state lawmakers should be pushing for.

The legislation provides more money for nursing home staff and more accountability to ensure the money is used properly, in line with recommendations made in 2020 by a task force of state nursing facilities.

The House bill addresses staffing issues by directing the state to establish training programs to help nurses climb the career ladder. It creates a new role of certified medication assistant, who can administer non-narcotic medications. Both the House and Senate bills would update the MassHealth reimbursement formula to more accurately reflect the cost of care.

The House and Senate bills would also address oversight. When licensing a nursing home or approving a change of ownership, the Department of Public Health would have more authority to investigate the owners’ litigation history, financial standing and long-term care history — including records of management companies and any entity with at least a 5 percent ownership stake. When nursing homes violate state law, DPH would be able to pursue more administrative sanctions, including hiring a temporary manager. The bills would increase civil penalties for abuse and neglect.

Elderly people living in poor quality nursing homes with insufficient staff cannot wait until next year to take action.

Editorials represent the views of the Boston Globe Editorial Board. Follow us @GlobeOpinion.