Nursing homes warned the Biden administration's higher staffing minimums, released Monday, could force them to focus on clinical positions at the expense of other needed staff and lack the necessary funding.
Patient advocates, however, were pleased the administration boosted the minimums to 3.48 hours of care per resident, per day, from the proposed 3.00 hours. Registered nurses will provide .55 hours of care under the final rule, while nurses aides will provide 2.45 hours of care, and the additional .48 hours of care can be provided by any combination of clinical staff, such as registered nurses, nurses aides or licensed practical nurses. The final rule requires nursing homes to have a registered nurse on-site at all times, as well.
Related: Biden administration increases nursing home staffing minimums
The Centers for Medicare and Medicaid Services also finalized an enhanced facility assessment that requires nursing homes with sicker patients to staff at higher levels. However some nursing homes may qualify for a temporary hardship exemption from the requirement if they can prove there is a workforce shortage.
The staffing minimum will be phased in over three years, with the facility assessment requirement going into effect 90 days after the rule is published. The 3.48 total staffing requirement and the requirement for a registered nurse on-site at all times will be phased in within two years of the rule’s publication. The .55 registered nurse and 2.45 nurses aide staffing requirements will be phased in within three years. Nursing homes in rural areas will phase in the requirements over five years.
Nursing homes lobbied aggressively against the mandates and trade organizations, including LeadingAge and the American Health Care Association, argued staff shortages would make it difficult for many operators to meet the minimums and could force some nursing homes to limit patient access.
Evangelical Good Samaritan Society, which operates 132 skilled nursing facilities across seven states, has more than 1,500 job openings, according to President and CEO Nate Schema. He said the mandate will force the nonprofit to focus on filling clinical positions at the expense of other positions that are also important to residents.
“Now, instead of trying to meet the needs of patients from a psychosocial standpoint, by hiring additional activities staff or hiring additional spiritual ministry staff, I have to hire very specific categories to meet the rules of this regulation,” Schema said. “It completely blows up how our staffing model works today.”
In advance of the final staffing rule, CMS proposed a 4.1% reimbursement increase to nursing homes in fiscal 2025. But some operators said that pay increase is unlikely to cover additional staffing.
“Without the funding to meet the mandate, it merely exacerbates an already difficult economic and regulatory environment for those of us charged with the care of our seniors,” said Scott LaRue, president and CEO of ArchCare which operates seven nursing homes in metropolitan New York City. “Passing legislation that sounds good in a public forum, yet lacks the funding required to implement, is not progress.”
But during a nursing home roundtable in LaCrosse, Wisconsin, Monday, Vice President Kamala Harris and CMS Administrator Chiquita Brooks LaSure said the regulation will ensure better working conditions for nursing home staff, as well as better care for patients.
“For residents, more staff will mean fewer ER visits potentially, more independence for families,” Harris said. “It’s going to mean peace of mind in terms of your loved one being taken care of. For caregivers, it’s going to mean more time with their patients, less burnout and lower turnover.”
Patient advocacy groups said the mandate is an important first step in improving care quality for an estimated 1.2 million people receiving services in approximately 15,000 Medicare and Medicaid-funded skilled nursing facilities.
“There has never been a federal minimum staffing standard for nursing home residents and we applaud the administration for doing it, but there is still work to be done,” said Sam Brooks, director of national policy at the National Consumer Voice for Quality Long-Term Care. “We’ve got to make sure the needs of all residents are met and the minimum doesn’t become a ceiling and that we are looking at each resident and each resident’s needs individually.”
