Staffing mandate's shaky future impedes industry preparation

The latest piece of the nursing home staffing rule is set to take effect in 2025, but nursing homes are caught between preparing for a rule that may not remain on the books and finding solutions to their immediate workforce shortages. 

The Centers for Medicare and Medicaid Services in April finalized an unprecedented rule setting minimum staffing levels nursing homes must maintain. To comply, facilities will need to have enough staff to provide at least 3.48 hours of nursing care per resident per day, including at least 0.55 hours from a registered nurse. 

Related: When CMS takes aim at the worst nursing homes, it often misses

The rule is not accompanied by federal funding, but in tandem with the rule, CMS also announced a $75 million tranche of funding for a staffing campaign the agency said would begin in 2025 to "increase the number of nurses in nursing homes, thereby enhancing residents’ health and safety." The agency released limited new information on the campaign in mid-December, though a CMS spokesperson did not comment when asked for additional details on how the $75 million will be used. 

CMS' staffing rule has received sustained blowback from a bipartisan group of lawmakers on Capitol Hill, and experts are skeptical the rule will remain intact under the incoming Trump administration. 

So nursing homes are confronted with a conflict: whether, or how, to prepare for an active regulation that’s increasingly that might not survive the political vitriol it’s fomented.  

Some nursing homes are preparing for the rule. Jodi Eyigor, director of nursing home quality and policy for the nonprofit nursing home trade group LeadingAge, said in an email that nursing facilities are working to step up staffing to meet CMS’ requirements, though they’re waiting for more information from the agency on the staffing campaign. 

“We eagerly anticipate release of additional information on the CMS staffing campaign, but we and our members are mindful that there is no silver bullet for this issue,” Eyigor said.

Other groups are channeling their efforts into blocking the regulation. Clif Porter, president and CEO of the American Health Care Association/National Center for Assisted Living, another nursing home trade group, said AHCA is pushing for “more meaningful workforce solutions” than the staffing rule. 
 
“We are optimistic that a Trump administration would rescind the unrealistic staffing mandate, but there are still multiple paths for Congress and the courts to address this issue as well,” Porter said in an email.

Mostly, facilities are focused on their immediate, day-to-day staffing shortages rather than compliance with the staffing rule, said David Grabowski, a professor of healthcare policy at Harvard University, since those requirements won’t go into effect until 2026, if at all.

Plenty of challenges are impeding nursing homes from increasing their staffing, on both a current basis and in facilities' longer-term preparations for CMS' new staffing requirements, experts said. 

The agency estimates it will cost the sector around $4.3 billion per year to hire enough staffers to comply with the rule. Nursing home groups and some researchers have said CMS’ decision not to fund the staffing rule denies the industry the tools it needs to meet the mandate's requirements. 

Tamara Konetzka, a professor of public health sciences at the University of Chicago, said CMS’ decision not to fund the mandate was likely a political one, given the current challenges of drawing funding out of Congress. 

But that means the regulation doesn’t come with any support for facilities that already struggle with staffing shortages. It also tests the theory that there is already money in the system that nursing facilities could allot to staffing if they chose to. 

“People have long said that nursing homes hide profits in various ways, use related-party transactions, that there's money in the system, and that if we force them to, nursing homes will find the money for staffing. To me, it's really unclear whether there's enough money in the system,” Konetzka said. 

Plus, prevailing Medicaid rates for nursing home staffing aren’t high enough to make working in the nursing home space appealing, she said. 

“These are long-term macroeconomic trends, compounded by the fact that these are difficult jobs,” Konetzka said. “In times of low unemployment, if nursing homes are paying people minimum wage or a little bit more for pretty difficult jobs, and people can go get jobs in retail or in a hospital that pay more, I'm not sure that investing in campaigns to increase the long-term care workforce in less than a very well-funded, ongoing effort is really going to make a difference.” 

Both Konetzka and Grabowski noted nursing homes’ ongoing reliance on staffing agencies to fill their rosters. That strategy grew in popularity during the COVID-19 pandemic, but while that demand has dwindled, nursing facilities are still leaning on contract nurses more than they used to, Grabowski said. Contract nurses are usually paid higher rates than staff nurses are, which puts a strain on facilities' finances, he said. 

There’s also a lot that CMS hasn’t made clear about the staffing campaign, Grabowski said, including what the $75 million fund will be used to pay for, which strategies for increasing nursing home staffing the agency will focus on as part of the campaign, and when the funding will be available in 2025. 

A CMS spokesperson said the information it plans to release on the staffing campaign will cover ways to connect workers with nursing home staffing vacancies, tuition reimbursement options for registered nurses, and details on training options. The agency's new website for the staffing campaign, which launched Dec. 16, contains limited details on those topics. CMS launched a website with resources on a free training to become a certified nurse assistant the same day. 

Nursing home groups are still looking to the government for more, though.

Janine Finck-Boyle, LeadingAge's vice president of health policy, said the organization is looking forward to learning more about how CMS intends to connect with prospective workers, explain potential financial incentives and "generally entice jobseekers to apply for employment in the aging services sector." 

Holly Harmon, senior vice president of quality, regulatory and clinical services at AHCA/NCAL, said the group is similarly waiting for more information on financial incentives, and noted that "policymakers must invest significant resources and advance meaningful policy changes" to build out a strong workforce pipeline.