After receiving criticism as being lax, the Pennsylvania Department of Health has increased the number of citations given for inadequate staffing in Philadelphia-area nursing homes over the last two years.

The agency cited facilities 12 times last year for violations of staffing rules, up from six in 2016 and no more than two in any of the previous eight years.

The citations are for not meeting the minimum of 2.7 hours per day of direct nursing care per patient, not having a registered nurse on duty when required, or more broadly not having enough staff to meet the needs of patients as defined in their care plans.

When facilities miss the 2.7-hours-per-day requirement — which advocates have long criticized as too low — they are typically in the 2.5- or 2.6-hours-per-day range.

"Facilities should budget higher, recognizing that their call-out rates are usually significant," which will put them under the requirement, said David Hoffman, a nursing home expert and former federal prosecutor. "The facilities that budget at 2.7 should get slammed."

Belle Haven Healthcare & Rehabilitation Center in Quakertown was cited in 2014, 2016, and 2017 for inadequate staffing. Officials with the facility's owner, Guardian Elder Care of Brockway, Pa., did not respond to a request for comment.

Also cited for lack of staffing was St. Francis Center for Rehabilitation & Healthcare in Darby Borough, which had its license revoked after an inspection last year and now has a provisional license. The state later fined the facility $675,750 for a wide range of violations.

Russ McDaid, president of the Pennsylvania Healthcare Association, a nursing home trade group in Harrisburg, downplayed the increase. He cited the Health Department's policy change in July 2015 to allow anonymous complaints after they were prohibited for three years.

"We know that that's yielded a strong uptick in complaints in nursing facilities, and we know that virtually all of them are accompanied by a complaint visit of some type. Seeing it go from six to 12, year over year, across 189 facilities, I wouldn't characterize as a significant uptick," he said, referring to the number of nursing homes in Bucks, Chester, Delaware and Montgomery Counties and Philadelphia.

The mix of reasons for surveys that resulted in citations for inadequate nursing has not changed much over the years. It has been split pretty evenly between licensure or recertification surveys and surveys in response to complaints.

The Health Department did not respond to questions about what caused the increase in citations, which do not seem to have fines attached, according to a roster of penalties dating to early 2014. "Our priority is making sure that the deficiency is corrected. Civil penalties may be issued at a later time than the sanction," department spokeswoman April Hutcheson said.

A 2016 Pennsylvania auditor general's report criticized the department as not doing enough to ensure sufficient nursing staffing levels. That report mentioned a federal suggestion of a 4.1-hours-per-day minimum for nursing care and noted that Pennsylvania's minimum was set in 1999.

At a Feb. 23 meeting in Germantown called by State Sen. Art Haywood (D., Phila.-Montgomery) on how the state handles care complaints, the state's long-term-care ombudsman, Margaret Barajas, said her office received 1,724 complaints last year, with 574 of them related to staffing.

What she said she hears from nursing home residents: "It's not the staff's fault. There's just not enough."