On April 22, the Centers for Medicare & Medicaid Services (CMS) finalized a rule with new minimum nurse staffing requirements in long-term care (LTC) facilities, despite strong pushback from industry stakeholders to the proposed rule when it was announced.
The new total nurse staffing standard is 3.48 hours per resident day (HPRD), which must include at least 0.55 HPRD of direct registered nurse (RN) care and 2.45 HPRD of direct nurse aide care. Facilities may use any combination of nurse staff (RN, licensed practical nurse [LPN] and licensed vocational nurse [LVN], or nurse aide) to account for the additional 0.48 HPRD needed to comply with the total nurse staffing standard.
This means a facility with 100 residents would need at least two or three RNs and at least 10 or 11 nurse aides as well as two additional nurse staff (which could be registered nurses, licensed professional nurses, or nurse aides) per shift to meet the minimum staffing standards.
CMS is also finalizing enhanced facility assessment requirements and a requirement to have an RN onsite 24 hours a day, seven days a week, to provide skilled nursing care.
CMS said it expects LTC facilities to use the updated facility assessment to determine whether their staffing needs to be set above these minimums, based on resident acuity and individual care needs. LTC facilities may qualify for a temporary hardship exemption from the minimum nurse staffing standards and the 24/7 RN requirement only if they meet certain criteria for geographic staffing unavailability, financial commitment to staffing, and good faith efforts to hire.
The American Health Care Association (AHCA), representing more than 14,000 nursing homes and other long-term care facilities across the country that provide care to approximately 5 million people each year, expressed dismay with the final rule.
In a statement, AHCA President and CEO Mark Parkinson, said, “We are extremely disappointed and troubled that the Biden Administration is resolved to issue this unfunded staffing mandate despite overwhelming concerns from experts, stakeholders, and policymakers on both sides of the aisle. While it may be well intentioned, the federal staffing mandate is an unreasonable standard that only threatens to shut down more nursing homes, displace hundreds of thousands of residents, and restrict seniors' access to care.
"It is unconscionable that the Administration is finalizing this rule given our nation's changing demographics and growing caregiver shortage. Issuing a final rule that demands hundreds of thousands of additional caregivers when there's a nationwide shortfall of nurses just creates an impossible task for providers. This unfunded mandate doesn't magically solve the nursing crisis.”
Parkinson stressed that AHCA would continue to work with members of Congress on “more meaningful solutions that would help boost the long-term care workforce. For the sake of our nation's seniors and their caregivers, we must find a better way.”
In a statement, Stacey Hughes, American Hospital Association executive vice president, said, "The AHA strongly believes that a skilled, caring workforce is integral to delivery of high-quality, safe care. Yet, the process of safely staffing any healthcare facility is about much more than achieving an arbitrary number set by regulation. It requires clinical judgment and flexibility to account for patient needs, facility characteristics and the expertise and experience of the care team. CMS’ one-size-fits-all minimum staffing rule for nursing homes creates more problems than it solves and could jeopardize access to all types of care across the continuum, especially in rural and underserved communities that may not have the workforce levels to support these requirements.
"This final rule could lead nursing homes to reduce capacity or close outright, including those that are otherwise high performers on quality and safety metrics. The loss of these nursing home beds could adversely impact patients who have completed their hospital treatment and need continuing care in nursing facilities. The AHA has already documented rising lengths of stay for hospital patients in need of skilled post-acute care, with patients waiting days, weeks or even months for post-acute care placements. As those patients continue to occupy hospital beds, other patients awaiting elective surgeries or other scheduled procedures may find their care disrupted because there is no bed for them in the hospital. Even more troubling, this final rule could lead to delays in urgent medical care as patients coming into hospital emergency departments may experience longer waits as EDs and inpatient beds are occupied by patients awaiting nursing home placements.”
Supply chain and analytics services provider Premier Inc.’s statement also expresses concern. It noted that the healthcare sector is still in a historic workforce crisis, with long-term care (LTC) facilities hardest hit, with not enough beds available to meet current demands. “Premier is deeply concerned that today’s final rule implements an unfunded staffing ratio mandate in LTC facilities that will only exacerbate this schism and lead to nursing home beds remaining empty due to staff shortages, worsening boarding issues at acute facilities and escalating healthcare system costs.”
