LTSS Evolve: Standing Up for Change

February 15, 2024

LTSS Evolve: Standing Up for Change 

LeadingAge PA members weigh in on staffing ratios



According to CMS provider data, over 3,000 Pennsylvania nursing home beds have been delicensed over the last decade. Even more concerning? 84% of those beds were delicensed within just the last four years. The alarming rate of this downward trend is already continuing into 2024, and if that’s not enough? Many licensed beds have also sat empty over the last year because providers don’t have the funding or workers they need to fill them, especially since increased state staffing minimums went into effect in July 2023. 

LeadingAge PA members are abundantly committed to quality. Our nursing home members boast above-average CMS star ratings in both overall quality and staffing-related measures. However, the overly prescriptive ratios that came along with the July staffing mandate, as well as unnecessarily strict interpretation of how to calculate those ratios by the PA Department of Health (DOH), meant many of our members only had one choice to remain in compliance without sacrificing quality: turn away residents. 



When we launched LTSS Evolve last spring, the July implementation of the new staffing requirements was rapidly approaching. Our members were in full preparation mode, doing everything they could to hire and retain the qualified staff they would need to comply with the new regulations, despite ongoing workforce challenges and instability in Medicaid reimbursement rates that make it nearly impossible to compete with other industries for needed workers.  

It became clear that finding relief from overly strict application of this mandate was not only the topic of the hour, but a perfect example of the heart of LTSS Evolve. It was a looming regulatory requirement that, while well-intentioned, would prove to be overly burdensome and siphon valuable resources away that could be better allocated to providing true quality care. Not to mention the access issue our state is facing with the number of beds being stripped away from older Pennsylvanians in need.

It should be noted that the higher staffing standards on their own were not inherently objectionable to many LeadingAge PA members. Many were already going above the required minimum per patient day (PPD) hours. But because of the way DOH calculated the ratios, providers had to “round up” to whole shifts, even when their actual census didn’t demand it. While these extra hours did not contribute a meaningful difference in quality of care, it forced the providers to make unnecessary and difficult decisions that resulted in wasted resources. It prevented providers from filling beds or forced them to pull investment from other shifts or positions where the residents could have been more positively impacted. 

With that understanding in mind, we knew this nuanced issue showed how even a well-intentioned requirement can negatively impact resident experience. How did we know? We listened to what

LeadingAge PA nursing home providers had to say: 

  • “We’ll have to consider cutting back on activities and other supplemental staff during the day who really benefit our residents in order to cover the cost of an additional, unnecessary nurse on night shift (while residents are sleeping).” 

  • In order to make it work the first month of the ratios, “our nursing management team worked 390 overtime hours on the front-line nursing schedule. They’re going to burn out at this pace. How is that good for resident care?” 

  • “When the staffing ratios came out, we had to further reduce our census to 40 (out of 50 licensed beds), impacting our revenue and ability for the hospitals to discharge patients to available beds.” 

With a rapidly growing list of real-world implications unfolding before us, this issue became one of our first priorities for LTSS Evolve.  




This endeavor, like all LTSS Evolve priorities, was not to create loopholes. Not to save money. Not to skimp on resident care. But to preserve some of the flexibility providers need to structure their staffing models in a way that most appropriately meets the needs of their unique resident population. Limiting census to comply with overly struct interpretation of the rations could not be the answer, so we got to work.

We compiled the experiences of our members. We held heartfelt conversations with leaders within the Department of Health and other stakeholders, helping to demonstrate the unintended consequences of the strict application of the regulations: 

  • Older adults were being turned away from quality nursing homes. 

  • Hospital backlogs were further exacerbated.  

  • Providers could no longer accommodate part-time shifts for students or allocate hours to the times of day when residents need the most care.  

  • Salary costs were being unnecessarily diverted to positions and shifts that did not benefit residents at the expense of those that do. 

And with this effort? Our first LTSS Evolve win. The Department heard the concerns. They saw the negative impacts older adults were facing. And they listened to our proposed solutions as they implemented updated guidance (effective Jan. 1, 2024) to change the way ratio requirements are to be calculated, which restored some flexibility to providers. 

Are there still challenges? Yes. Is access to care still at risk? Yes. Our advocacy continues and is multi-pronged. But this flexibility marks a shift. A shift toward listening. Toward common sense. Toward working together to truly evolve the way we care for seniors in Pennsylvania. 

We’ve still got work to do. But we’re starting to change the narrative. We’re starting to shift the mindset. We’re starting to ignite change within the aging services ecosystem and evolve the way care is delivered and regulated in Pennsylvania. Watch what happens next.  


Did you miss our first LTSS Evolve blog posts? Catch up here and here