The nursing home industry has another weapon in its arsenal to fight against a pending federal staffing minimum regulation: A report the Centers for Medicare and Medicaid Services itself commissioned that falls short of recommending the government mandate more nurses to improve quality.
The report by research firm Abt Associates came to light Tuesday when KFF Health News reported that CMS briefly made the document publicly available, only to withdraw it. Abt Associates did not advocate a specific staffing minimum in its findings, which nursing home groups assert reinforces the industry's argument that one-size-fits-all approach to staffing is infeasible.
The American Health Care Association seized on the report and likened its conclusions to the nursing home sector's long-held position opposing staffing minimums.
“This report confirms what we’ve been saying for more than a year—that an arbitrary staffing mandate is not feasible and will not equate to higher quality care. There needs to be a comprehensive approach to staffing beyond numbers, acknowledging that each resident and facility is unique,” AHCA President and CEO Mark Parkinson said in a news release Wednesday.
The snafu about the report is the latest complication for CMS' long-awaited, and long-delayed, proposed rule that would mandate how many nurses per resident must be on duty at skilled nursing facilities.
In February 2022, President Joe Biden announced during the State of the Union address that his administration would take this historic step, partly in response to the devastation that COVID-19 wreaked on nursing home employees and residents.
CMS vowed to issue a draft regulation this February but was already behind its self-imposed schedule when it submitted the proposed rule to the White House Office of Management and Budget on May 30. The OMB disclosed on its website Thursday that it completed its analysis of the regulation on Tuesday, clearing it for CMS to publish at any time.
CMS Principal Deputy Administrator and Chief Operating Officer Jonathan Blum gave no indication that the agency is backing off its plans in a statement that KFF Health News published Tuesday.
“CMS is committed to holding nursing homes accountable for protecting the health and safety of all residents, and adequate staffing is critical to this effort,” Blum told KFF Health News. “CMS’ proposal is being developed using a rigorous process that draws on a wide range of source information, including extensive input from residents and their families, workers, administrators, experts and other stakeholders. Our focus is on advancing implementable solutions that promote safe, quality care for residents.”
CMS hired Abt Associates to conduct a study to identify a minimum staffing standard that would inform its rulemaking. But the company did not make recommendations that the agency set a staff-to-resident ratio or offer evidence that quality rises or falls depending on how many nurses are on duty. Instead, the report merely echoes previous research that generally associates higher staffing levels with superior quality.
Moreover, Abt Associates stopped short of repeating its own guidance to CMS from two decades ago. The agency paid the company for a similar study in 2001 that recommended CMS require a minimum of 4.1 hours per resident day. Yet in its new paper, Abt Associates reviewed the effects of less-stringent staffing minimums, the toughest being 3.88 hours per resident day.
LeadingAge executives argued that these findings don't support CMS' stated goal to improve nursing home quality. “Policy should be based on evidence. We’re interested to see how this inconclusive research could be translated into a proposed rule that would mandate an effective staffing ratio that will improve care for residents and their families,” Senior Vice President Ruth Katz said in a statement on Tuesday.
The National Consumer Voice for Quality Long-Term Care, a patient advocacy organization, characterized the report as rushed and incomplete, and demanded that CMS proceed with its proposal. "Every day, residents in the vast majority of nursing homes are not receiving quality care in a safe environment, or experiencing quality of life because there are not enough staff. Efforts to establish an effective standard must go forward. It is unacceptable that anything less—including the status quo—be allowed to continue," a spokesperson wrote in an email.
The nursing home industry also used the report to highlight other items on its policy agenda, such as Medicaid reimbursements and a longstanding nursing shortage that worsened during the pandemic.
“If we want to improve the quality of care in our nation’s nursing homes, we should be talking about investing in training and reversing chronic underfunding of Medicaid, not arbitrary, unfunded staffing ratios,” said Nate Schema, president and CEO of Sioux Falls, South Dakota-based Evangelical Lutheran Good Samaritan Society, which operates 139 nursing homes in 22 states.
AMDA–The Society for Post-Acute and Long-Term Care Medicine, which represents physicians and other practitioners who specialize in post-acute and long-term care, sees the Abt Associates findings as evidence that the problems facing the nursing home industry are too complicated to be solved by staffing minimums, said Dr. Victoria Walker, who chairs its public policy steering committee.
“It should be obvious that we all really want good, high-quality care for people in nursing homes, and it would be nice if it were as simple as finding a clear-cut answer in these studies that we could base future practice on, but I think it’s just not that simple,” Walker said.