Minimum Nursing Home Staffing Standards: A Good Start, But Not Quite There

The pandemic shone a troubling spotlight on the unnecessary suffering resulting from substandard conditions in nursing homes. On Sep 6, 2023, the Centers for Medicare and Medicaid Services (CMS) published a proposed rule for their widely anticipated minimum staffing requirements for long-term care facilities. A 2022 Nursing Home Staffing study that was convened to inform the development of these requirements followed an urgent plea from the Biden Administration and National Academies of Sciences, Engineering, and Medicine’s Committee on the Quality of Care in Nursing Homes for every nursing home to provide a sufficient number of staff so that the quality of care and safety in nursing homes might be addressed.

The proposed requirements.

An abundance of qualitative interviews, surveys, listening sessions, and comments from the public yielded the following staffing requirements:

1. Minimum staffing hours per resident day (HPRD) for registered nurses (RNs)—0.55 HPRD—and nurse aides (NAs)—2.45 HPRD. Outside of these hours, sufficient additional nursing personnel, such as licensed practical nurses (LPNs) and licensed vocational nurses (LVNs), and other clinical and non-clinical staff
2. The adoption of a 24/7 onsite RN requirement
3. Transparency to the amount of Medicaid funds that are spent on compensation for direct care workers and support staff
4. An enhanced facility assessment requirement that includes:
   1. Clarifying that facilities must use evidence-based methods when care planning for their residents
   2. Assessing the specific needs of each resident in the facility and to adjust as necessary based on any significant changes in the resident population
   3. Requiring facilities to develop a staffing plan to maximize recruitment and retention of staff
   4. Including the input of facility staff

In addition to the posting of these requirements, the administration also provided guidance on their implementation. Guidance included:

• Phases for which nursing homes would need to implement the requirements
• Length of time nursing homes had to implement the requirements based on their geographical location
• Waivers that nursing homes could apply for if they were deemed to be in an area where the workforce was unavailable to meet these requirements and good faith efforts were shown by the nursing home to hire and retain staff

Why these requirements matter.

We applaud the effort of the administration to establish minimum staffing requirements. This step marks a significant achievement for the following reasons:

1. The required 24-hour presence of an RN has been long advocated for in recognizing the impact of the RN’s presence on the quality of care residents experience including decreased hospitalizations, lower incidence of pressure ulcers, and increased resident satisfaction.
2. Several nursing homes have been operating at critically minimal staffing levels for years calling for the necessity of some form of staffing level floor.
3. Publicly displaying nursing homes that have not met minimum staffing standards has the promise of holding nursing homes more accountable and will allow the public to make a more informed decision in where they choose to receive care.

The realities of today’s long-term care environment.

However, despite these wins, the requirements in their totality don’t embrace the realities of long-term care in today’s environment. For example, although the requirements acknowledge the increased complexity of care needs for the population in long-term care, this is not reflected in the newly required minimum total nursing HRPD, lack of inclusion of LPNs in the minimum staffing HPRD, provision of waivers to nursing homes unable to meet requirements, and limited support in ensuring nursing homes are able to meet minimum staffing HPRD. Below we expound upon these limitations.

The floor for minimum staffing hours per resident day is not high enough.

There was a recommendation from a study completed by CMS more than 20 years ago that found a level of staffing hours in which quality of care for residents was no longer improved. At that time, the recommendation for minimum nurse staffing was 4.1 HPRD, inclusive of RNs, LPNs, NAs. The most recent 2022 Nursing Home Staffing Study found that a total nurse (RN, LPN, NA) staffing level between 3.8 HPRD and 4.6 HPRD would be adequate to keep rates of omission of activities of daily living and clinical care below ten percent.

Yet, the newly proposed minimum staffing requirement is significantly lower than either of these recommendations. In order to implement a staffing plan that ensures a team can provide quality resident-centered care, the HPRD must be increased to include a minimum of .55 hours of RNs, and a minimum of at least 3.25 hours of LPNs and NAs to reach the minimum of 3.8 hours recommended by the recent Nursing Home Staffing Study. Another option is to apply the increase to a combined hours of RNs and LPNs, keeping NAs separate and maintaining the requirement of the 24-hour RN presence. This would allow for a dedicated RN for resident care at all times, but also an emphasis on employing the LPN to support that RN.

LPNs are integral to resident care and need to be reflected in total nursing hours.

Research conducted on long-term care nurse staffing has included a team of NAs, LPNs, and RNs, yet the 3.0 hours in the administration’s proposed requirements only includes RNs and NAs. The proposed requirements do not reflect LPNs in the HPRD.

The addition of the LPN provides a licensed nurse to amplify the presence of nursing at the bedside and ensures that the RN has adequate support to focus on the assessment of the resident as opposed to everyday maintenance tasks that can be performed by the LPN. It is necessary for LPNs to be included in the minimum staffing requirements to realize the quality-of-care outcomes found by RNs.

It’s not about nursing homes not wanting to invest in staffing to meet requirements, but about actually finding the staff given significant supply challenges.

The recommendation recognizes that the pipeline for nurses to long-term care is quite small and proposes additional funding for nursing education to increase the number of RNs. However, there is no focus on supporting the education and recruitment of NAs; if the salaries of RNs and NAs in LTC remain 10-20% less than RNs and NAs working in acute care and other settings, these workers will migrate to higher paying jobs. The same is true for the increased competition between nursing homes and agencies when it comes to pay. Nursing homes have lost their ability to compete for staffing because of the price-gouging that has taken effect in the industry. Lastly, low attraction to jobs in long-term care yields a limited supply of people going into this area.

To adequately reimburse the industry for the proposed minimum level of staffing at a competitive wage, a state and federal financial plan must be implemented. In the past, this has come through mechanisms such as wage pass throughs and Medicaid Incentive Payment Programs. Other approaches to addressing the supply of RNs, LPNs, and NAs through state and federal means include investing in immigration reform, providing financial support to schools that graduate people who pursue jobs in long-term care, and bolstering emergency workforce programs. A detailed recruitment plan along with support and resources must accompany any final minimum staffing standard requirements.

There needs to be less focus on allowing for waivers to be submitted and more focus on the provision of support for nursing homes to meet staffing standards.

A significant responsibility of recruitment and retention of a nonexistent workforce has been placed on nursing homes themselves. Prior to the proposed requirements, 96% of 400+ nursing homes surveyed reported some level of staffing shortages, and 72% of these nursing homes reported being very or somewhat concerned that they will have to close because of staffing shortages. Moreover, regarding the complexity of the residents’ needs, nursing homes should not be solely tasked to make the assessment of additional staff needs—this was the nature of the previous requirement and it has yet to be implemented across nursing homes.

Making nursing homes a better place to work.

There needs to be support for changing the culture of nursing homes to make them a better place to work so that staff can be retained and beds do not have to close. Currently there is legislation to enable culture change in nursing homes through improving the structural environment and promoting person-centered care. Moving this bill out of its current stage and passing it needs to be a priority.

With regards to transparency of Medicaid payments and the percent that goes to direct care, this should be public information to hold nursing homes accountable to how much they are investing into the workforce.

Next, more direction needs to be provided to nursing homes on when to increase staffing minimums in light of the care needs of more complex residents and, finally, while waivers may indeed be necessary, more stipulations around the waivers need to be implemented. For example, decreasing admissions, closing units, and/or provision of support by CMS for nursing homes that despite their best efforts cannot meet staffing minimums.

In conclusion, we commend all of the work that has been done so far to ensure that residents receive the care they need and deserve, and we emphasize the importance of prioritizing what is still needed.

1. Appropriateness of minimum nurse staffing ratios in nursing homes. (2001, December 24). Report to Congress: Phase II Final, Volume I. Prepared by Abt Associates Inc. https://theconsumervoice.org/uploads/files/issues/CMS-Staffing-Study-Phase-II.pdf
2. cms.gov/files/document/nursing-home-staffing-study-final-report-appendix-june-2023.pdf