Patient advocates say new nursing home staffing rules fall short

You may have heard (or even written about) the new minimum staffing standards for nursing homes, finalized on April 22.

“Controversial” is only one of many adjectives that has been used to describe the regulations, which require a minimum of 3.48 hours of nursing care per day, per resident, from both nurses and nurse aides in any facility which receives Medicare or Medicaid funding. Every nursing home must also have an RN on site at all times.

“The new rules from the Centers for Medicare & Medicaid Services are the most substantial changes to federal oversight of the nation’s roughly 15,000 nursing homes in more than three decades,” wrote Jordan Rau of KFF Health News. “But they are less stringent than what patient advocates said was needed to provide high-quality care.”

The new rules will be phased in over the next three years. Rural facilities will have five years to comply. The American Hospital Association criticized what it called CMS’s “one size fits all staffing rule that will create more problems than it solves.”

Katie Smith Sloan, president and CEO of Leading Age, the association of nonprofit providers of aging services, including nursing homes, said the Biden administration mischaracterized aging services providers and repeated incendiary descriptions of care delivered in nursing homes as the White House promoted the final rule’s rollout. Sloan said a lack of qualified workers and support needed for recruitment, training, and retention pose significant obstacles to providers’ ability to comply with the mandate.

Meanwhile, patient advocates argue the rules don’t go far enough.

Why it matters

The new mandates provide an opportunity for journalists to report on specific staffing situations in local nursing home facilities and to speak with residents or families to analyze needs and learn about possible solutions within the community.

Nursing homes are experiencing severe staffing shortages nationwide and struggle to hire qualified personnel. It’s still not clear how they will comply with these mandates when it’s so hard to recruit and retain staff. An American Hospital Association report puts the onus on the COVID-19 pandemic for struggles in rebuilding the nursing home workforce. The AFL-CIO, which represents some nurses and aides’ unions, blames poor Medicaid and Medicaid reimbursement rates, which affect how much facility owners can pay their staff, particularly in rural areas.

A survey by the advocacy organization National Consumer Voice for Quality Long Term Care found that 88% of nursing home residents said their facility did not have adequate staff to meet their needs. This is an important first step in ensuring that all residents have their care needs met. However, 3.48 hours per resident per day is a minimum and not a ceiling. Federal law requires that each facility have sufficient staff to meet the needs of all residents. Most residents will require care that exceeds the 3.48 hours, the organization said in a statement. They urged CMS to “institute strong staffing requirements based on the acuity (care needs) of each resident.”

According to an analysis from KFF released April 22, only about one in five (19%) nursing facilities meet the new minimum staffing standards. They used Nursing Home Compare staffing data from March 2024 and compared staffing levels from July to September 2023.

Meanwhile, a May 2 report from The Long Term Care Community Coalition shows that as of the fourth quarter of 2023:

Six in 10 (60%) of U.S. nursing homes would have met the new 3.48 hours per resident per day requirement
Only one in four (26%) nursing homes are providing at least 4.1 hours per resident per day, the minimum amount of time needed to ensure that residents receive basic clinical care.

These figures are based on payroll-based journal data on nurse staff — RN, LPN, CNA — and non-nurse staff, including medical directors, therapists, and activities staff.

“While we applaud President Biden’s dedication to resident safety and dignity, the final CMS rule falls significantly short of what numerous studies have indicated is necessary for basic clinical care. While it may offer relief to residents in facilities with very low staffing, it jeopardizes residents in those with higher staffing levels, since those operators are now incentivized to decrease their staffing to the new federal standard,” the organization said in a statement.

Industry groups promise a legal fight to stop the mandates and are also working with some members of Congress to undo the requirements. Otherwise, some say they may have to close their doors, leaving thousands of vulnerable, frail older adults, those with severe disabilities, and their families, scrambling to find affordable alternatives.