CNA: Patient and LVN: Patient ratio's in an ALF??

Valarie7979 · May 31, 2010

It's true---there is no specific caregiver to patient ratio for assisted living facilities. However, there are regulations for ALF's in California under Title 22, which calls these facilities "Residential Care Facilities for the Elderly". This is from the Department of Social Services, Community Care Licensing Division in California.

What these regulations say is there must be sufficient numbers of personnel to meet the needs of the clients. This type of "regulation" is then open for interpretation about "needs" and whether they are met or not. Here is a site where you can take a look at the regulations: CALA California Assisted Living Association These are in PDF format, and are lengthy. So if you click on Part III, and then navigate to page 17, you will see the regulations for Personnel Requirements. Part IV has the regulations about what types of patients can or cannot be cared for.

RCFE's, or assisted living facilities are supposed to be surveyed by the Department of Social Services, but because of budget cuts in California, I don't know if these are taking place on an annual basis. I also don't know if the surveys that are done are useful in changing the facilities "ways". These facilities are under a "social" model expectation, not a "medical" one (like a skilled nursing facility).

The problem with most ALF's is that elderly patients often lose function and health as time goes on. Otherwise they would be at home, right? And many patients are kept in the facility far longer than they should be. This could be because Administration does not want to the census to fall; and/or the family is not willing to move the patient for any number of reasons (but usually financial). ALF's are not compensated enough to provide skilled nursing care 24/7, unless they have a sliding scale type of billing for level of care needs (private pay).

I don't know what to tell you. Its not going to get better any time soon. You might want to consider another line of nursing. I worked many years in SNF's and nursing homes and it is still very frustrating even with solid regulations about staffing.

Or, you can choose to "get involved" and find ways to make your legislators understand the problems that are typically encountered in these facilities. Changes need to be made. Either increase the revenue and staffing expectations, or enforce regulations that prevent the facility from keeping and caring for people that need a higher level of care.

neutrophil · May 31, 2010

Hi, well I can't say that I read all of your letter, it was long. I got the message. I am an LVN, I was a med tech at an assisted living facility, an LVN, or RN, will never medicate PO meds like a med tech. Two different set of rules. RCFE's governed by the department of social services, some dementia units also. SNF's governed by the department of health. Different set of rules. A caregiver and a CNA are very similar. An LVN and RN, are also very similar. There are different scope of practice for each. I can tell you the problems that happen in SNF's due to under staffing. But it is long. Well, good question, your answer is involved with bureacracy and may not have the answer you want, or an appropriate answer. Do the best you can, your residents need it. Good luck.

groovahgrl · Jun 4, 2010

I'm in VA, and our laws are similar. There is no defined ratio for staffing in Assisted Living. The industry as a whole is moving toward longer stays in ALFs, with stays in skilled nursing facilities on a more short term basis for rehabilitative purposes. VA law is clear about what we cannot accept, but it is a VERY short list. So it is common to have non-ambulatory residents who require total care. This is becoming the norm now with Assisted Living. We too have hospice residents, paraplegics, advanced Parkinson's residents, not to mention the variety of mental disorders (depression, schizophrenia, bipolar disorder.)

Indeed, the definition of Assisted Living has evolved over the years. The word "assisted" refers to the resident's needs for assistance with their ADLs and ambulation and transferring are ADLs. When I hire CNAs I always ask in the interview "What do you think Assisted Living is? How do you think it's different from a nursing home?" Many older CNAs will say they are looking for a setting with less lifting. I think a lot of CNAs believe that working in an ALF is "easier" because they assume that our residents only need help with housekeeping, meal prep and meds.

Your facility sounds much like mine. My CNAs also have to assist during mealtime, deliver mail, collect trash & laundry, AND assist with (and sometimes lead) up to three recreational activities daily, AND they have to do it all with a smile! We work in a four story ALF that holds 45 assisted living residents and 20 dementia residents.

For the 45 assisted living residents our staff is as follows: 1 LPN, 1 med tech (who also has to take on her own group of residents), and 3 CNAs. On occasion the LPN will assist with hands on care when necessary.

The CNAs have to keep a shift log throughout the day that tracks their every movement. They have to write down on their log what they are doing all day. For instance, if they go to assist room 123 with a shower from 10:12 am to 10:45am, they would write that down on their log. This allows us to go back and cross reference to see how much interaction they are having with the residents. We are also able to monitor the calls for assistance through our paging system to see how long it takes for calls to be answered.

This gives us a good idea of whether or not we are adequately staffed. We also pay attention to how much time our aides "goof off": smoke breaks, social visits to the front desk, hanging out in the nurses' station, chatting in the hallways, etc.

I am lucky that I work in a place that is family owned and operated and they really do have the residents' best interest at heart. But before we hire on new staff they still want to see the data that proves we need that additional person.

Maybe if you and your co-workers could start keeping track of your day, for a week or so, and then bring it to management. Management is used to hearing CNAs complain that they need more help (which it sounds like you need at least one more CNA), but management is more likely to listen if you can show them the data.

Give them proof in black and white that the residents and the staff are suffering as a result. Maybe mention that the shortage in staff can lead to extra staff & resident injuries which can cost the company a lot of money. If you have residents that require 2 people to transfer them, but two people aren't available and one person attempts it on their own and they both end up on the floor, it's bad for everyone. The company has to pay out workman's comp for who knows how long, plus replace the staff person in most instances until they are able to return to work, not to mention having to explain to the family why their loved one had to be sent out to the hospital. Or what about staff turnover from burnout. It costs money to have to advertise, recruit, and train new staff members to replace the ones that quit because they were overworked. Remember that ALFs are still businesses. You have to appeal to their business sense. If it makes sense financially to have an additional staff person, more than likely they will consider it.

GOOD LUCK!!

jennakay89 · Jun 4, 2010

thank you all for your input.

groovahgrl: that is a great idea. We complain and complain and complain and management does not seem to care. We will have to step it up and show them the data. We use walkie talkies that they too carry at all times, so they hear how many calls we are getting and that it takes up to 20 minutes to get to a resident, even when they presss their emergency pendant. But we will step it up and record specific data to present to them. Thanks for your advice!

Emilyktee · Mar 3, 2015

I know this is an old post lol, but god I could have written this myself. I am putting up with the SAME thing currently. I notice you're from Southern California. So am I....could be the same place!! hahaha

Finestnurse, Lpn · Sep 14, 2016

Im in Ohio and we also have no regulations on staffing ratio. I work in a 15 million dollar facility that is beautiful and well-maintained. Some of our memory impaired residents think they are in a Hotel and the male caregivers are bellhops! Residents and families drain their lifesavings by paying thousands upon thousands of dollars monthly for rent. They receive inadequate care for what they pay in my opinion. We are always understaffed and when fully staffed, assuming everyone shows up that day, its still NOT ENOUGH! Ive seen so many elderly shell out their retirement savings until they are completely broke. Than guess what? You have to move out! Its so sad. We do keep residents until end of life if at all possible. They push hospice care to keep the rooms full. We take pretty much anyone that doesnt need IV's (which hh ususlly hired to come in and do), no feedings through pegtubes although we can flush to keep patent and this also can be done by family or outside agency along with regular feedings. We have a STRICT policy against feedings in our dining room which everyone is STRONGLY encouraged to attend 3 times a day. Feedings must be done in apts. And you cant move in requiring hoyer lifts but if needed during the course of your occupancy we usually can use than. Wounds not expected to heal within 180 days, i think, must be monitored by outside agencies. Oh, no ventilators and rarely have i seen suctioning.

Thats pretty much our rules. Staffing depends on what shift. Caregivers do everything from restaurant style serving to laundry to bathing and toileting. They are constantly busy as are lpns.

And still never enough time to do all that needs done PROPERLY. Never in a million years could anything be accomplished BY THE BOOK standards.

I would recommend keeping your loved one at home, taking the money you spend on AL and pay for private duty care instead. It would probably save you money. And you would receive better care most likely.