LPN omission from CMS’ staffing mandate worries nursing homes

Many of the nation's 15,000 nursing homes are trying to figure out the role for their licensed practical nurses under a proposed staffing mandate recently announced by the Biden administration.

LPNs, who make up about 13% of nursing home staff and as much as 75% of clinical staff at some facilities, were omitted in the proposal the Centers for Medicare and Medicaid Services announced Sept. 1. The proposed mandate would require nursing homes to provide three hours of care per resident, per day, with 0.55 hours of care coming from registered nurses and 2.45 hours of care coming from certified nursing assistants.

No mention is made of LPNs, who provide most of the hands-on care in skilled nursing facilities. Their absence in the proposed rule worries the industry, particularly given the overall staffing challenges in healthcare.

Related: CMS' proposed nursing home staffing mandate explained

Excluding LPNs from the proposal undervalues the clinicians and “demonstrates how minimum staffing requirements are inherently flawed and archaic health care policy,” the American Health Care Association said in a statement.

LPNs are trained to perform routine clinical tasks such as taking patients’ vital signs, administering medication, inserting catheters and dressing wounds–all under the supervision of a registered nurse, according to the American Nurses Association. They generally receive 12 months of training at a vocational school or community college and are licensed following the completion of an exam.

By contrast, RNs work directly with physicians and must complete two to four years of accredited training before receiving a state license. The median annual salary for LPNs is about $55,000 compared with $81,000 for RNs, according to the Bureau of Labor Statistics.

In many nursing homes, LPNs perform clinical tasks and often oversee certified nursing assistants, who perform more personal duties for patients such as bathing and feeding. RNs also perform clinical tasks, but typically serve in more supervisory roles such as managing care teams, infection control, education and training.

At three nursing homes Lifespark operates in the Minneapolis area, LPNs account for 70% of the clinical staff. The St. Louis Park, Minnesota-based company has relied more heavily on LPNs in recent months due partly to the shortage of RNs, said Amanda Johnson, vice president of operations for senior living.

If the CMS proposal is adopted as proposed, Lifespark may have to “reassign” LPNs to lower-paid CNA positions or cut staff if it has to hire more RNs to comply with the mandate, Johnson said.

“There could be a handful of positions (eliminated) just from a financial standpoint because adding those hours of RNs would be a huge financial burden that is unfunded,” Johnson explained.

Shannon Slowinski is an LPN at Lifespark’s Woodbury Senior Living Facility’s nursing home in Woodbury, Minnesota. She has worked as an LPN for nearly two decades and said she would take a lesser position as a CNA if she had to, but she wants to remain in her current role. 

“To take a pay cut would be hard, so I would have to consider going back to school to become an RN,” Slowinski said. “I’m 46 years old. I’m at that point in my life where I could still do it, but I’m happy as an LPN.”

Even some supporters of the proposed staffing mandate think CMS needs to consider LPNs in the final rule. Leslie Frane, executive vice president of Service Employees International Union, called the proposal an “historic step forward” for skilled nursing care, but also said CMS should address  “the important role that LPNs play in skilled nursing facilities.”

In announcing the proposal, CMS said it seeks comments on alternative policy options for nursing home staffing standards. The comments must be submitted to the Federal Register by Nov. 6.