In general, respondents' concerns about staffing related to quantity and quality.
Staffing Levels. Nearly every respondent in every state had concerns about staffing levels in residential care settings, noting that even with highly trained, competent staff, insufficient staffing would compromise the quality of care. All acknowledged that low pay, lack of benefits, lack of a career ladder, poor management and oversight, and, in some cases, an unpleasant work environment made it very difficult to recruit and retain staff and that general workforce shortages exacerbated the problems.
Most felt it would be difficult to impossible to increase staffing at current Medicaid reimbursement rates. On the other hand, some felt that states needed to have a better picture of what care actually costs in residential care settings before simply putting more money into them.
A few said that staffing regulations needed to be based on care needs and not fixed staff-to-resident ratios. In North Carolina, prior to 2000, adult care homes could have one personal care aide for 50 residents on the night shift. Although this was changed to one aide for 30 on the night shift and 1 for 20 on the day shift, one provider stated that 1 aide for 20 residents is "totally insufficient" if residents have heavy care needs. There was agreement that North Carolina needs an improved assessment form and improved methods to determine the level of care people need.24
Staffing Qualifications and Training. Many respondents in every state had concerns about staffing qualifications, some noting that the basic quality problem was staff not knowing and not recognizing signs of need. They noted that many residents are very old, with major health problems and cognitive impairment, and many if not most residential care staff are not adequately trained to provide good care for this vulnerable population.
Respondents in all the states expressed concerns specifically about staff qualifications to administer and manage complex medication regimes, noting that many residents have cognitive impairment and need assistance in this area. In North Carolina, several expressed concerns about medication errors and said there was inadequate nurse or pharmacy supervision. Many noted the need for additional training, and some mentioned the need for certification to be able to dispense and administer medications. Others were concerned about the lack of training to monitor the effects and side effects of medications.
In North Carolina, several expressed concern that new regulatory requirements for increased staff training were not being enforced, and in Wisconsin some providers expressed considerable concern about the additional cost of training requirements.
24. The state has projects under way to address both issues.