When she heard her great grandmother calling for her aunt from the bedroom, Simmons strode into the room, hopped up on the hospital bed and helped to turn and change the 84-year-old the way she had seen the women in her family do many times.

Forty-seven years later, that's still the way she operates as a certified nursing assistant in the Mississippi nursing home she serves. 

“When you walk in that door, every resident is your patient,” Simmons said.

Despite her dedication and more than 30 years of experience, she is only making $17 an hour at the nursing home where she currently works. In order to make ends meet, she works two jobs between 6 a.m. and 5 p.m., sometimes working overtime until 10 at night. She says some nights she gets out of work and sits in her car for an hour and a half because she's too drained to move.

“I feel helpless. I feel exhausted,” she said. “But I know I got to keep going because who else is going to do it? If the people with the hearts give up, there's going to be no one left for the people in there who are just forgotten about.”

Simmons never considered going back to school to become a registered nurse. What she loves about her job is being a familiar and reliable face for her residents. A CNA is responsible for providing the majority of hands-on resident care, and is often the person a nursing home resident sees the most on any given day.

“I don't just want to be pushing pills,” Simmons said. “I want to let them talk to me. A lot of the residents tell me things that their families don't even know about them.”

Poor pay and high turnover are among the reasons Simmons believes new federal staffing requirements in nursing homes will be, in effect, meaningless.

“Where are they going to get the staff from?” Simmons asked. “People are not doing it because they're underpaid, and they can't feed their families on that kind of money.”

That's in line with the national trend: Over the first quarter of 2023 – from January to March – less than 1% of skilled nursing facilities in the U.S. met the draft rule's two core standards of provider care.

After signing the executive order in September, Biden accepted public comment through Nov. 6. The Centers for Medicare and Medicaid Services is the agency responsible for reviewing the more than 40,000 comments and writing the final rule – which hasn't happened yet and can take anywhere from months to years. Sixty days after the final rule is published in the Federal Registrar, the first phase in a staggered implementation process will begin.

Falling Short: Rebuilding elderly care in rural America

Rural nursing homes across the country, already understaffed, face significant new federal staffing requirements. With on-the-ground reporting from INN's Rural News Network and data analysis assistance from USA TODAY and Big Local News at Stanford University, eight newsrooms explore what the rule change would look like for residents in communities across America. Support from The National Institute for Health Care Management (NIHCM) Foundation made the project possible.

The proposal, which comes at the heels of a years-long battle nursing home lobbyists waged against reform, outlines minimal standards. For example, the draft rule mandates 2.45 hours of CNA care and .55 hours of RN care per resident per day. That's less than the 2.8 hours and .75 hours recommended by a CMS landmark 2001 study – even though residents' needs have gotten more complex over the last two decades with more people living longer.

The proposal also mandates having an RN on duty 24-7. Current regulations mandate having 24-7 care, but allow the position to be filled by licensed practical nurses, who are used more frequently because their salaries are lower than those of RNs. The proposal does not have a requirement for LPN care, leaving experts worried nursing homes will simply replace LPNs with other staff.

“The 24-hour staffing requirement is good, as long as they make that in addition to the administrative nurses,” explained gerontologist and national nursing home expert Charlene Harrington. “But the other requirements they propose are just shockingly low. And that's partly because the nursing homes have been lobbying against these standards for over a year and a half. So, all these advocates and the experts are very upset about it.”

The only two skilled nursing homes in Mississippi already meeting the not-yet imposed standards are Reginald P. White and James T. Champion nursing facilities – sister organizations of East Mississippi State Hospital, one of the state's two psychiatric hospitals. The two Meridian nursing homes met the staffing minimums every day of the 91-day second quarter of 2023.

These homes receive about 20% of their funding from the state, according to Mississippi Department of Mental Health Planning and Communications Director Adam Moore. That's in addition to the funding they receive from Medicaid and Medicare, as well as personal insurance and private pay.

Kevin Walker, administrator of Reginald P. White Facility, and Judd Nance, administrator of James T. Champion Facility, were surprised to learn they met the new requirements every day between April and June.

“We probably try to staff a little heavier than most nursing homes do, but we think we're short all the time,” Nance said.

Any nursing facility participating in Medicaid or Medicare reimbursement is required by law to provide services that “attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident,” as dictated by the Nursing Home Reform Act of 1987.

Richard Mollot, the executive director of Long Term Care Community Coalition – a national nonprofit dedicated to advocating for residents of nursing homes and their families – says that when it comes to laws, the Nursing Home Reform Act is unique because it focuses on the customer – in this case, the resident.

“Most laws focus on the industry itself,” Mollot said. “For instance, all car manufacturers are expected to meet specific miles-per-gallon efficiency or have certain safety features. Nursing homes, on the other hand, are required to provide the staffing, supplies, and services to assure that every resident is able to attain and maintain their highest practicable well-being as an individual, based upon a comprehensive assessment of the person and a care plan that includes not only clinical needs, but the resident's cultural background, goals, and personal preferences, too.”

Currently, states are in charge of regulating staffing in nursing homes. Some states have no staffing minimums, while the ones that do keep the requirements very low. In Mississippi, regulations require there to be at least a ratio of one CNA for every 15 residents during the day, and 25 residents at night – despite the fact that studies have shown one CNA for every six to eight residents during the day and 11 to 13 at night is optimal. 

Even these suboptimal regulations are rarely enforced, according to Harrington, due in part to a national shortage of inspectors. States are required by the U.S. Department of Health and Human Services to conduct annual surveys and certifications of nursing homes receiving Medicaid and Medicare. In Mississippi, 54% of nursing home state surveyor positions were vacant in 2022, and 44% of the working surveyors had less than two years of experience.

“Enforcement is very weak, especially on staffing,” said Harrington. “We'd like to see CMS really crack down on the nursing homes that don't have enough staff, and maybe put a hold on admissions until they have enough staff. If they're not actually able to hire staff they shouldn't be able to admit patients.”

In previous nursing homes, Simmons says she witnessed bathroom requests going unanswered and continent residents being diapered out of convenience.

The results can be devastating. Residents who are confined to bed and unable to go to the bathroom not only suffer low morale, but can also develop concurrent urinary tract infections. In the elderly, these infections can cause delirium and exacerbate dementia. Those who try to get up on their own may suffer falls, broken bones and concussions as a result.

“You see residents with UTIs and falls and stuff because they're crying out for help to go to the bathroom in the middle of the night and they fall because they have to go to the bathroom and they're told to go to the bathroom in their briefs,” Simmons said. “Who wants to be sitting somewhere with a wet brief on? It's humiliating. And it's unacceptable.”

According to Mollot, it's a violation of the Nursing Home Reform Act, and one that could be resolved with adequate staffing.

“Nursing homes claim that diapering residents is necessary because they don't have enough staff to respond to call bells or implement resident-centered toileting practices,” Mollot said. “But if you think about it, that is pretty outrageous. In effect, facilities are admitting that they are taking in and retaining vulnerable human beings for whom they have neither the ability nor intention of providing decent care. Why do we accept the warehousing of millions of vulnerable Americans every year?”

Simmons says she has been let go twice, in two different states, shortly after filing incident reports to Occupational Safety and Health Administration and to the staffing agency she was contracted with.

But Simmons is resolved to continue advocating for the residents she serves and hopes that in time, higher pay and more stringent regulations will lead to better working environments for staff and quality of life for residents in nursing homes.

“I don't care if they fire me from every job,” she said. “When I know something is not right, I'm going to stand up for it. And can't nobody stop me from doing that.”

This article first appeared on Mississippi Today and is republished here under a Creative Commons license.