Nursing Home Associations Alarmed Over CMS Proposed Rule on Staffing

Sept. 1, 2023
Proposed rule ‘requires nursing homes to hire tens of thousands of nurses that are simply not there,’ says Mark Parkinson, president and CEO of the American Health Care Association

The Centers for Medicare & Medicaid Services (CMS) estimates that approximately 75 percent of nursing homes would have to strengthen staffing in their facilities under a proposed rule that seeks to establish comprehensive staffing requirements for nursing homes—including, for the first time, national minimum nurse staffing standards.

Under CMS’s proposal, nursing homes participating in Medicare and Medicaid would be required to meet specific nurse staffing levels. Nursing homes would need to provide residents with a minimum of 0.55 hours of care from a registered nurse per resident per day, and 2.45 hours of care from a nurse aide per resident per day, exceeding existing standards in nearly all states.

As the long-term care sector continues to recover from the COVID-19 pandemic, CMS said the proposed standards take into consideration local realities in rural and underserved communities through staggered implementation and exemptions processes.

But organizations representing the nursing home industry expressed disappointment with the proposed rule.

Mark Parkinson is president and CEO of the American Health Care Association (AHCA), which represents more than 14,000 nursing homes and other long-term care facilities across the country. “It is unfathomable that the Biden Administration is proceeding with this federal staffing mandate proposal. Especially when just days ago, we learned that CMS’ own study found that there is no single staffing level that would guarantee quality care,” he said in a statement.

“At the very same time, nursing homes are facing the worst labor shortage in our sector’s history, and seniors’ access to care is under threat. This unfunded mandate, which will cost billions of dollars each year, will worsen this growing crisis. It requires nursing homes to hire tens of thousands of nurses that are simply not there,” Parkinson added. “It then penalizes us and threatens to displace hundreds of thousands of residents when we can’t achieve the impossible. Already, hundreds of nursing homes across the U.S. have closed because of a lack of workers. We hope to convince the administration to never finalize this rule as it is unfounded, unfunded, and unrealistic. We will vigorously defend access to care for our nation’s seniors and advocate for common sense solutions to improve quality and strengthen the long-term care workforce.”

Katie Smith Sloan is president and CEO of LeadingAge, an association of nonprofit providers of aging services, including nursing homes. “To say that we are disappointed that President Biden chose to move forward with the proposed staffing ratios despite clear evidence against them, is an understatement. We share the Administration’s goal of ensuring access to quality nursing home care. This proposed rule works against that shared goal. One-size-fits-all staffing ratios don’t guarantee quality, as the Administration’s own Abt research findings made clear. That aside, it’s meaningless to mandate staffing levels that cannot be met. There are simply no people to hire—especially nurses. The proposed rule requires that nursing homes hire additional staff. But where are they coming from? To serve older adults and families, nursing homes must have the resources, including staff, to serve them. Without that, there is no care.”

Smith Sloan said that nonprofit and mission-driven nursing homes will be forced to reduce admissions or even close if the rule is finalized, which will cause older Americans and families to suffer.

Soumi Saha, senior vice president, government affairs, at supply chain and analytics services provider Premier, issued a statement expressing concern “that the agency’s proposal reflects a lack of understanding of the true state of the workforce environment. The implementation of any unfunded staffing ratios in any healthcare setting is preposterous given the current labor challenges that are occurring across the board, but are particularly acute for skilled nursing facilities. While well-intended, mandating staffing ratios will likely leave SNF beds empty due to lack of staff – exacerbating boarding issues at acute facilities and increasing overall costs to the healthcare system.

CMS executives counter that the initiative is focused on improving the lives of over 1.2 million residents who reside in Medicare and Medicaid-certified long-term care facilities. “Today, we took an important first step to propose new staffing requirements that will hold nursing homes accountable and make sure that residents get the safe, high-quality care that they deserve,” said CMS Administrator Chiquita Brooks-LaSure, in a statement.

Under the proposed rule, nursing homes would also be required to ensure a registered nurse is on site 24 hours per day, 7 days per week and to complete robust facility assessments on staffing needs. Facilities would continue to be required to provide staffing that meets the needs of the individual residents they serve, which may require higher levels of staffing above the proposed minimum standards. 

CMS also proposes to require states to collect and report on compensation for workers as a percentage of Medicaid payments for those working in nursing homes and intermediate care facilities. These policies build on CMS’ recent proposals to support compensation for direct care workers in home- and community-based settings and to publish Medicaid data on average hourly pay rates for home care workers. The agency said this enhanced transparency will aid efforts to support and stabilize the long-term care workforce across settings.

Additionally, CMS announced a national campaign to support staffing in nursing homes. As part of the HHS Workforce Initiative. CMS will work with the Health Resources and Services Administration (HRSA) and other partners to make it easier for individuals to enter careers in nursing homes, investing over $75 million in financial incentives, such as scholarships and tuition reimbursement. This staffing campaign builds on other actions by HHS and the Department of Labor to build the nursing workforce.

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