New Nursing Home Staffing Rules: Will They Help?
The Biden administration aims to fix nursing home understaffing to improve care, but critics are pushing back
Americans gave nursing homes a D+ for quality of care in a recent Gallup/West Health poll and most said they'd be uncomfortable being admitted into one or admitting a loved one. One reason could be the severe understaffing problems facing the 1.2 million residents in the nation's 15,000 nursing homes.
The lack of registered nurses (RNs), licensed practical nurses (LPNs) and certified nursing assistants (CNAs) in many nursing homes recently led the Biden administration to propose national minimum staffing requirements.
Improving Safety and Care
The goal, said U.S. Health and Human Services Secretary Xavier Becerra, is to "improve resident safety and promote high-quality care so residents and their families can have peace of mind." About one-fifth of all COVID-19 deaths in the United States during the pandemic were at nursing homes.
Currently, 38 states have minimum staffing standards at nursing homes, but many of those standards are low or over 20 years old. Studies have shown that higher nursing-home staffing has been associated with better patient care and health outcomes.
"This is a step in the right direction. I wish it had been a bigger step, but the administration deserves a ton of credit for going down this path."
The new rules would provide nursing home residents with a minimum number of hours of care per day. They would also ensure that an RN would be on site 24 hours a day, seven days a week. The administration says 22% of nursing homes would need to hire RNs to meet that requirement. Today, nursing homes must have at least one RN for a minimum of eight straight hours a day and an RN, LPN or LVN (a Licensed Vocational Nurse) on duty 24 hours per day.
The Long-Term Care Community Coalition (LTCCC) , a nonprofit organization seeking to improve the quality of care in nursing homes and assisted living centers, has favored a 24/7 RN requirement for years.
Jasmine Travers, an NYU nursing college assistant professor and co-chair of the staffing committee at Moving Forward, a coalition working to improve nursing-home care, said: "I'm excited the president will be requiring 24 hours-a-day staffing for RNs."
Will the Standards Happen?
Exactly how much the proposals would improve resident safety and promote high-quality care — or even ever take effect — is an open question.
The trade group representing primarily for-profit nursing homes, The American Health Care Association, calls the minimum standards "unfathomable."
"Staffing ratios are a key lever to help nursing homes offer high-quality, age-friendly care to residents."
Katie Smith Sloan, president and CEO of LeadingAge (an association of nonprofit aging services providers, including nursing homes), said her group is "disappointed" the president moved forward with the proposals "despite clear evidence against them." She says the cost of implementing the staffing mandate "will cripple nursing homes."
Others, however, applaud the administration's efforts.
"This is a step in the right direction," said Harvard health care policy professor David Grabowski, a noted nursing home analyst. "I wish it had been a bigger step, but the administration deserves a ton of credit for going down this path."
Terry Fulmer, president of the John A. Hartford Foundation, a philanthropy that seeks to improve care for older adults, said: "staffing ratios are a key lever to help nursing homes offer high-quality, age-friendly care to residents."
What Consumer Advocates Say
Some long-term care consumer advocates think the proposals don't go nearly far enough.
Leaders of both the LTCCC and the National Consumer Voice for Quality Long-Term Care said they're generally disappointed by what the administration has proposed.
LTCCC Executive Director Richard Mollot said: "The basic staffing standard, outside of the 24/7 RN [proposal], is abysmal. It's well below what every study has shown to be necessary."
He chastises nursing home leaders who say they can't afford the proposed minimum standards. "Nursing homes aren't warehouses," Mollot said. "There's absolutely no excuse to ever allow nursing homes to take in residents when they clearly don't have the staff and the ability to care for them."
Sam Brooks, director of public policy at National Consumer Voice for Quality Long-Term Care, said: "This rule was designed to bring up poor performers to average, and we disagree that average is the mark of quality in the nursing home sector."
A History of Staffing Proposals
Proposals for minimum staffing standards at nursing home aren't new, though the U.S. government has never adopted any.
"There's absolutely no excuse to ever allow nursing homes to take in residents when they clearly don't have the staff and the ability to care for them."
The National Academy of Medicine (formerly the Institute of Medicine) called for minimum staffing standards in 1986, and the 1987 Nursing Home Reform Act gave the U.S. government authority to create staffing standards. In 2001, a Centers for Medicare and Medicaid Services (CMS) study said each nursing home resident needed at least 4.1 hours of direct care a day to avoid being at risk of harm.
By contrast, the Biden administration proposals would require 3 hours of care per day — 33 minutes from an RN and 2 hours and 27 minutes from a CNA, who helps residents with tasks of daily living, like eating, bathing and going to the bathroom. Moving Forward calls CNAs the "often underappreciated and undercompensated core of the nursing home workforce."
Grabowski said he thinks there could be real benefits increasing the proposed minimum staffing standard to at least 3½ hours of care per day.
According to the Biden administration, to meet its proposed hours-per-day standards, 36% of nursing homes would need to hire RNs; 68% would have to hire nurse aides.
What the Biden Proposals Miss
There's no specific requirement, however, for LPNs, who provide hands-on patient care and handle administrative tasks like monitoring vital signs, changing bandages and inserting catheters.
That LPN omission concerns some nursing home analysts.
"I worry a little bit with putting in a requirement for RNs and one for CNAs, but ignoring LPNs," said Grabowski. "Are you going to see LPNs shift to almost zero in a lot of nursing homes and see the facilities staff up to the minimum for RNs and fill up the remaining staff slots with CNAs?"
That's what happened in Ohio and California after those states adopted Biden administration nursing home standards. A 2015 study Grabowski helped to write found that the overall quality of care rose, but since those states didn't specify minimum number of hours for RNs, LPNs and CNAs, "we saw a shift away from higher-cost professional staff and toward certified nurse aides."
Slow Rollout and Exemptions
The Biden administration's staffing proposals have a long rollout period before they would take effect — three years for most nursing homes; five years for those in rural areas. "It will really be about seven years, since you have to figure on [time needed for] enforcement," said Brooks.
Rural nursing homes would be allowed three years to make sure they have RNs onsite 24/7, a year longer than others.
Lisa Harootunian, associate director of the health program at the Bipartisan Policy Center, thinks that timetable will give nursing homes the time they need to meet the staffing requirements.
"You don't waive regulations on an airplane or on a bus. We're talking about safety here. If you can't provide high-quality care, why are you in business?"
The proposals would also let nursing homes apply for hardship exemptions. "There will be nursing homes that despite their best efforts will not be able to meet the minimum staffing requirements and will have to apply for the waivers," said Travers.
Critics worry the waivers will amount to a giant loophole, allowing many nursing homes to escape the new rules.
"We oppose all waivers," said Brooks, of the National Consumer Voice for Quality Long-Term Care: "This is a matter of human dignity. You don't waive regulations on an airplane or on a bus. We're talking about safety here. If you can't provide high-quality care, why are you in business?"
To avoid an avalanche of waiver exemption applications, Grabowski said, the U.S. government could give some nursing homes extra money to put toward staff.
Staffing Shortages at Nursing Homes
Nursing home trade groups say meeting the staffing proposals isn't possible given the shortage of nurses and nurse aides and high turnover rates. The median among nursing home assistants in nursing homes is nearly 100%, according to the Paraprofessional Healthcare Institute, or PHI.
"There simply aren't enough people to hire. Nursing homes are being forced to reduce admissions or even close when they can't fill their employee rosters."
"The shortage of workers, not only in nursing homes, but also home- and community-based settings, is a major issue that needs to be tackled right now," said Harootunian. "This shortage was exacerbated in the past few years through the COVID-19 pandemic."
Said Smith Sloan: "There simply aren't enough people to hire. Nursing homes are being forced to reduce admissions or even close when they can't fill their employee rosters."
Over half of nursing homes in 2022 limited new patient admissions, citing staffing shortages, and the U.S. has at least 600 fewer nursing homes now than six years ago, according to a Wall Street Journal analysis.
Low Pay Hampers Hiring
But consumer advocates say hiring problems are due to low wages and working conditions and a lack of training. According to CMS, registered nurses make $37 an hour, on average, LPNs earn $28 an hour and aides frequently start at $17 an hour, which is close to the $15 minimum wage.
"Over time, we haven't paid nursing homes, and financed nursing home care, in a way to encourage strong staffing models."
Travers acknowledged "challenges" attracting RNs to nursing homes, noting the need to pay them "a more appropriate wage to be competitive." Grabowski noted that during the pandemic, many nursing home RNs, LPNs and CNAs left for jobs at places like WalMart, Amazon and McDonald's.
To improve recruitment and training, the Biden proposals would invest over $75 million in scholarships and tuition reimbursement.
Harootunian wants Congress and the administration to improve recruitment and retention of nursing home workers – including immigration reform — so the facilities can meet the proposed requirements.
Is Medicaid Reimbursement Too Low?
Nursing home representatives also say Medicaid, the federal/state program that's the primary payer for 62% of nursing home residents, doesn't reimburse facilities enough to pay higher wages.
Critics say that nursing homes' lack of financial transparency means no one knows whether the facilities can afford to pay higher wages.
The Biden proposal would require state Medicaid agencies to report the percent of payments for Medicaid-covered services spent on compensation. "We see that as a nice first step into transparency," said Brooks.
What Happens Next
CMS is accepting comments about its proposals until Nov. 6 and will decide on a final rule after.
"We're going to fight as much as we can to get the proposals to a place that's safe for residents. This is a once-in-a-lifetime opportunity for nursing home residents," said Brooks, whose group will offer comments to make the proposed standards tougher. "We're not going to give up."
With critics fighting the staffing mandates and consumer advocates pushing to strengthen them, independent analysts expect the proposals will likely take effect, and pretty much as is.
"I don't think they're going to get tougher," said Harootunian.
The Root Problem for Nursing Homes
Grabowski maintains that although staffing is "a huge problem" at nursing homes, it's not the root problem.
"Over time, we haven't paid nursing homes, and financed nursing home care, in a way to encourage strong staffing models," he said. "And we haven't always held nursing homes' feet to the fire. We haven't held them accountable to taxpayers."
Grabowski hopes the Biden administration's staffing proposals are "a starting point, but not a finishing line."