- The HHS announced its highly anticipated proposed rule on Friday, which sets staffing requirements, including minimum nursing staffing levels, for nursing homes nationwide.
- The proposal would require nursing homes to provide three hours of care per resident, per day, with 0.55 hours coming from registered nurses. The rule also stipulates that at least one registered nurse be on duty at all times. CMS estimates approximately three quarters of nursing homes would have to strengthen staffing in their facilities in order to comply with the proposed rule.
- Federal nursing home staffing laws have not been updated since 1987. President Biden promised to establish staffing minimums and answer decades-old concerns about unsafe staffing levels when he announced the Action Plan for Nursing Home Reform during the State of the Union address last year.
The COVID-19 pandemic had an outsized impact on the nursing home industry, killing over 200,000 residents and isolating thousands more as efforts to contain the virus resulted in reduced contact with the outside world. Nursing home workers left the industry in droves due to burnout, low wages and increased stress associated with caring for vulnerable populations during a public health emergency.
While healthcare worker advocate groups have long argued that increasing staffing levels are associated with higher-quality patient care, staffing standards in almost every state remained low through 2021. The COVID pandemic fueled demand for highly skilled, well trained professionals and brought the issue to regulators’ attention.
The proposed rule, if passed, will be the first federal law of its kind. Currently, the Nursing Home Reform Act of 1987 requires homes to have “sufficient” staffing, but lacks guidance for how states ought to interpret that standard.
The proposal released on Friday is lower than suggestions from a 2001 landmark study, funded by CMS, which proposed an average of 4.1 hours of nursing care per resident per day to ensure quality care.
However, a new CMS-funded study, released in draft form this week, concluded that there is “no obvious plateau at which quality and safety are maximized” and made no specific recommendations for staffing minimums. The CMS has since retracted the study, noting that it had been published in error, following a report from KFF Health News.
Labor and management stakeholders have pointed to the conflicting studies to criticize the new proposal. Nursing advocates argue the proposed rule does not go far enough to secure safe staffing, while nursing home groups say a one-size-fits-all approach is not an appropriate solution.
Staffing reform advocates, including Richard Mollot, executive director of the Long Term Care Community Coalition, a nonprofit organization dedicated to improving nursing home quality, continue to promote the 2001 recommendations.
Mollot applauded the proposed requirement for 24-hour registered nurse supervision. However he told Healthcare Dive via email that the three hour per day requirement “flies in the face of decades of research and experience in our nation’s nursing homes, all of which indicate that at least 4.1 hours of nursing care are required just to meet the basic clinical needs of residents.”
Other stakeholders argued the current proposal was overly burdensome for providers. Mark Parkinson, CEO and president of the American Health Care Association, a non-profit representing 14,000 facilities including nursing homes, said in a statement it was “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.
Parkinson noted that requiring additional staffing during a continued nursing labor shortage would jeopardize patients’ access to care.
“It requires nursing homes to hire tens of thousands of nurses that are simply not there,” Parkinson said. “It then penalizes us and threatens to displace hundreds of thousands of residents when we can’t achieve the impossible.”
Despite Parkinson’s concerns about hiring, some estimates suggest that most nursing homes already reach the suggested staffing minimums. A July analysis from KFF found that 85% of facilities could currently offer three hours per resident day with existing staff.
The proposed guidance also includes parallel initiatives, including increased oversight for nursing home facilities through more inspections and audits. CMS also announced an investment of over $75 million in financial incentives, such as scholarships and tuition reimbursement, to build the future nursing workforce.
The proposed rule will now enter a public comment period.