Anne Clauss hates to imagine what her mother would have endured at a nursing home in Langhorne if she or another relative hadn’t visited daily during her stay from 2017 to 2018.

One evening Clauss found her mother at the end of a hallway facing away from her room, where she had been stuck for a few hours, another resident told her. Other times, staff — whom she called underpaid and overworked — forgot to bring her mother her meals.

Her mother died at a hospital in 2018. But that experience prompted the Levittown resident to comment in favor of a Pennsylvania Department of Health proposal to increase the homes’ minimum level of direct care to 4.1 hours daily per patient, up from the current 2.7 hours.

“I hope regulations can be updated to help our elderly live out their lives well cared for and treated respectfully,” Clauss wrote to the Independent Regulatory Review Commission, which will review the comments and eventually hold a public hearing. It’s not clear how quickly the commission will act.

Monday is the deadline for public comments, which can be sent to irrchelp@irrc.state.pa.us.

The effort to revise Pennsylvania’s nursing home regulations began after a 2016 report by Auditor General Eugene DePasquale that cited the Health Department for being inconsistent when evaluating compliance with staffing requirements.

The effort is coming to a head during the COVID-19 pandemic in which over 13,000 people have died in Pennsylvania’s nursing homes.

The 150 comments received through Thursday were heavily weighted toward industry — not counting 753 copies of a form letter from Service Employees International Union supporting the proposal. Of 150 signed comments, only 27 were from individuals, advocates, and union representatives who favored more staffing.

In their objections, industry representatives said they can’t hire enough workers because of a worker shortage economy-wide and they can’t afford it because Medicaid rates are too low and haven’t risen in seven years.

Ken Beiler, executive director of Wesley Enhanced Living at Stapeley in Germantown, said that during the week of Aug. 9, his facility had 21 confirmed interviews with job candidates. “Of those 21, one person showed up for their interview,” he wrote.

The base rate for Medicaid works out to about $8 an hour, said Natalie Ferrebee, whom LinkedIn identifies as division director of payer relations for SavaSeniorCare, which operates Broomall Nursing & Rehabilitation Center. Because of that low Medicaid rate, Ferrebee called it “unrealistic” to think that “providers will be able to increase wages and staffing levels.”

Estimates for how much nursing homes lose daily on a Medicaid resident ranged from an average of $50 at the seven Pennsylvania facilities run by Ohio-based HCF Management Inc. to $154.35 at Homewood at Martinsburg, a continuing care retirement community near Altoona.

A few individuals who work in nursing homes supported higher staffing, including a director of nursing in Bucks County who called 2.7 hours per day “disgraceful.”

A repeated argument in industry comments — taken from talking points provided by the Leading Age trade group, one commenter said ― was that 4.1 hours of daily care “does not necessarily equate to quality of care.”

“That’s insulting and dumb,” wrote Donovan Carper, a nursing home administrator at Moravian Manor in Lancaster County. Carper said that quality is complex, involves training, data analysis, and leadership.

While more hours of care per day do “not equate quality by itself, a lack of caregivers almost certainly guarantees a compromise in quality due to short cuts, misses, near misses, errors, increased stress, burnout, etc.,” he wrote.

Advocates for more nursing care also said the increase to 4.1 hours per day is not enough.

The new regulation must also prohibit any decrease in the number of hours by ancillary staff, wrote the Center for Advocacy for the Rights and Interests of the Elderly and Community Legal Services of Philadelphia.

That recommendation was based on findings by the Center for Medicare Advocacy that nursing homes — when faced with higher minimum staffing requirements alone — tended to shift housekeeping and other non-direct care tasks to nursing assistants, effectively undoing the intended result, the two advocacy groups said.

For 20 years experts have been recommending 4.1 hours per day of care per patient as a benchmark for ensuring better outcomes.

During the first three months of this year, 163 of Pennsylvania’s 681 nursing homes already provided at least 4.1 hours of care per day, according to federal data from the Long Term Care Community Coalition. The median amount of care — which means half provided more and half provided less — was 3.45 hours per day, which indicates that the proposed increase would be smaller than going from 2.7 hours to 4.1 hours.

States surrounding Pennsylvania have minimums ranging from 2.25 in West Virginia to 3.67 in Delaware. New York has no minimum, requiring only “sufficient staffing,” though proposed legislation would establish a minimum of 4.85 hours per day for every patient.

“There is no question that 2.7 hours of direct care is not enough, and we urge the department to stand firmly behind their proposed shift to 4.1 hours per resident per day,” the two advocacy groups said.