Biden admin finalizes industry-opposed staffing requirements for nursing homes

Editor's note: This story was updated after the final rule was issued Monday afternoon.

The Biden administration finalized a controversial nursing home staffing rule today that includes the more stringent requirements floated in last September’s proposal.

As previewed by Vice President Kamala Harris’ office Monday morning, the final rule unveiled later in the day requires facilities receiving Medicare and Medicaid funding to have a total nurse staffing standard of 3.48 hours per resident per day. Below that bar are also ratio requirements for registered nurses (0.55 hours per resident per day) and nurse aides (2.45 hours per resident per day), and a requirement for at least one registered nurse to be onsite 24 hours a day.

“This means a facility with 100 residents would need at least two or three [registered nurses] 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,” Harris’ office wrote in a fact sheet release. “Many facilities would need to staff at a higher level based on their residents’ needs.”

The proposed rule from September included the ratio requirements for registered nurses and nurses aides, with the 3.48 hours per resident per day total framed as an “alternative” standard the administration was exploring.

Monday's final rule also requires nursing homes to develop a staffing plan to maximize recruitment and retention, and strengthens annual facility assessments "to improve the planning and identification of the resources and supports that are needed to care for residents based on their acuity during both day-to-day operations and emergencies," the Department of Health and Human Services (HHS) said in a release.

The impending requirements are expected to force a hiring increase across most long-term care providers, where the administration and researchers alike have said chronic understaffing has worsened the quality of care. HHS said it received and considered more than 46,000 public comments on the rule that often referenced poor care experiences due to understaffing in nursing homes.

"This will help ensure that millions of people have access to high-quality health care and that the dedicated workers who provide care to our loved ones are fully valued for their work,” HHS Secretary Xavier Becerra said in a statement.

Long-term care industry groups have opposed last year’s proposal in full force, arguing that long-term care employers are largely grappling with a shortage of clinical workers and won’t be able to afford the administration’s requirements. A study released last year, for instance, estimated that the rule as proposed would force 102,000 additional nurse hires at a cost of $6.8 billion, which was over 50% higher than the government’s cost estimate.

“It is unconscionable that the administration is finalizing this rule given our nation’s changing demographics and growing caregiver shortage,” Mark Parkinson, president and CEO of the American Health Care Association (AHCA), which represents over 14,000 nursing homes and long-term care facilities, said in a Monday statement. “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.”

Soumi Saha, senior vice president of government affairs at Premier Inc., said it shares the administration's quality concerns but is "deeply concerned" that Monday's final rule could lead to financial strain that worsens bed capacity in long-term care facilities and subsequently worsens boarding at acute facilities.

The industry’s concerns are shared in part by Congress. Just last week the Senate Committee on Aging held a hearing in which lawmakers acknowledged the impact that staffing shortages have on care. The comments and responses to witnesses, particularly on the Republican side of the aisle, suggested more support for bills targeting clinical workforce training and pay or local-level requirements as opposed to a federal staffing mandate.

“We need innovation at the state and local levels to meet this increased demand,” Sen. Mike Braun, R-Indiana, the committee’s ranking member, said. “We don’t need the federal government forcing a one-size-fits-all approach.”

Harris’ office noted that the final rule’s requirements will be introduced in phases. Rural communities will have longer time frames to come into compliance and temporary exemptions for the total and role-specific standards will be available “for nursing homes in workforce shortage areas that demonstrate a good faith effort to hire.”

The administration is supporting the effort with investments in training nursing and care workers, including a $75 million national nursing home staffing campaign. It is also finalizing another rule on Monday that will flesh out home care services by requiring that at least 80% of Medicaid payments for home care are used to fund workers’ wages.

More than 1.2 million people receive care in a Medicare- and Medicaid-certified nursing home, according to the administration.

Still, Parkinson said in his statement that AHCA intends to use the “momentum against the mandates … among both Democrats and Republicans” to develop legislative alternatives to the administration’s staffing policy.