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LeadingAge Pennsylvania President on State of SNFs One Month Into Staffing Mandate

Analysis  |  By Jasmyne Ray  
   August 09, 2023

Facilities negotiated the staffing minimum, but finding staff remains an issue.

A staffing mandate for Pennsylvania nursing homes went into effect in July, and facilities are already feeling the strain.

Former Gov. Tom Wolf proposed a staffing requirement of 4.1 PPD (per patient day) for the state's nursing homes. Many facilities called the proposal untenable, so Wolf's administration struck a compromise: a minimum staffing requirement of 2.87 PPD, in exchange for a $300 million increase in Medicaid funding.

This compromise came with additional accountabilities, said Garry Pezzano, president and CEO of the Pennsylvania chapter of LeadingAge, a community of nonprofit, mission-driven aging services providers.

"One of the accountabilities being that 70% of the Medicaid [funding] spent in skilled nursing facilities would go directly to the bedside," he told HealthLeaders. "And then there was also some very specific staffing ratios that were put into place."

While the compromised staffing ratio decreased from 4.1 PPD to 2.87 PPD, this would be only for the first year—2023, with the mandate going into effect July 1. For the second year—which would be 2024— the PPD will go up to 3.2 PPD, unless another Medicaid increase is approved for that year's budget.

Each sector of healthcare has been affected by the workforce shortage, with aging services like skilled nursing facilities and home health providers struggling even more. A staffing mandate, Pezzano said, is the last thing they need right now.

After polling LeadingAge Pennsylvania's skilled nursing facility members—about 150 in total—34% said they have beds on hold,  meaning that they have a certain number of beds available but can't admit residents because they don't have enough staff.

About 55% of members said they were having to turn away hospital transfers. The average length of stay in Pennsylvania's hospitals is increasing by one and two days, according to Pezzano.

"[That’s] significant because it's not the least-restrictive placement for the resident and it's more costly for an older person to be in acute care," he said.

"That means they're not getting the rehabilitation they need. They're not getting the socialization they need and they're not getting the mobility that they need. Then, it's more costly, so it becomes an access issue."

Some 83% of members are using temporary nurses from staffing agencies, which are notoriously expensive. In addition to the mandate compromise, the state's nursing homes were successful in getting legislators to place quality measures over agency staffing, namely by  requiring them  to register with the state.

However, no changes were made to the pay rates that staffing agencies can charge.

As for how facilities are managing operations with the mandate now in effect, Pezzano said it varies by location. In some areas of the state, they're able to hire the staff they need, and some member facilities have said that they're seeing staff who previously left return to the facility.

"What a mandate does is it treats everyone the same, and not all providers are the same in regard to even their physical space, or their ability to find staff, and most importantly, the acuity of their patients," Pezzano said.

"When you lose that flexibility as a clinical operator, as a clinical team, it kind of forces you into a situation that you know is ultimately going to impact your ability to care for patients."

HealthLeaders has previously reported on the anticipated influx of older adults needing some type of aging service by 2030. With the persisting workforce shortage, strain of staffing minimums, and lack of young healthcare workers interested in working in the post-acute space, there's pressure on skilled nursing facilities to provide the care that people will need.

LeadingAge Pennsylvania began an initiative called Long Term Services and Supports (LTSS) Evolved, where they've begun looking at ways to create more efficiencies in practice by affecting antiquated and more cumbersome legislative health policies. They're also involved in state efforts, urging Gov. Josh Shapiro to create an office of health workforce innovations and reform, and looking at immigration reform to see how foreign workers can bolster their workforce.

"We're stepping through this at the moment, but we continue to look at these disruptors and forward-looking ways of solving the workforce crisis because there are not enough people," Pezzano said.

"You're not going to get enough people and there literally is not enough money to throw at it,” he said. “Staffing mandates that are unfunded and unsupported are just making the situation worse."

“Staffing mandates that are unfunded and unsupported are just making the situation worse.”

Jasmyne Ray is the revenue cycle editor at HealthLeaders. 


Facilities compromised with state legislators to decrease the initial proposed staffing minimum from 4.1 PPD to 2.87, with a $300 million Medicaid funding increase.

34% of LeadingAge PA member facilities have beds on hold because they don't have enough staff.

83% of member facilities are using staffing agencies to supplement their nursing staff, which adds to their expenses.

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