Biden administration proposes minimum staffing standards for nursing homes

The Centers for Medicare & Medicaid Services (CMS) has made good on President Joe Biden’s word during the 2022 State of the Union with new proposed staffing requirements for nursing homes.

The proposed rule, issued Friday, includes for the first time national minimum nurse staffing standards that have been broadly opposed by the long-term care industry.

It would require nursing homes participating in Medicare and Medicaid to provide a minimum of 0.55 hours of care from a registered nurse per resident per day, as well as 2.45 hours of care from a nurse aid per resident per day—a bottom floor that CMS estimates three quarters of nursing homes would need to increase hiring to achieve. Facilities would also be required to have at least one registered nurse onsite at all times.

“Establishing minimum staffing standards for nursing homes will improve resident safety and promote high-quality care so residents and their families can have peace of mind,” Department of Health and Human Services Secretary Xavier Becerra said in the announcement. “When facilities are understaffed, residents suffer. They might be unable to use the bathroom, shower, maintain hygiene, change clothes, get out of bed or have someone respond to their call for assistance. Comprehensive staffing reforms can improve working conditions, leading to higher wages and better retention for this dedicated workforce.”

The news has gained quick condemnation from industry groups.

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 statement that the proposal is "unfounded, unfunded and unrealistic" as it "requires nursing homes to hire tens of thousands of nurses that are simply not there." 

Katie Smith Sloan, president and CEO of LeadingAge, an association of nonprofit aging service (including nursing homes) providers, said that disappointment with the proposed policy “is an understatement.”

“Nonprofit and mission-driven nursing homes will be forced to reduce admissions or even close if this rule is finalized—a needless outcome that will cause older Americans and families to suffer,” she said in a statement.

CMS said it is still soliciting public comment on “alternative policy options” surrounding the minimum nurse staffing standards, as well as feedback on whether to add a total nurse staffing standard of 3.48 hours per resident per day.

It’s also proposing a soft onramp once the staffing requirements are finalized. Long-term care facilities in non-rural areas would be given three years to come into full compliance, CMS said, while rural facilities would have three years to meet the 24/7 onsite registered nurse requirement and five years to meet the rest of the staffing requirements.

CMS said it is also cognizant of instances in which “external circumstances may temporarily prevent a facility from achieving compliance despite the facility’s demonstrated best efforts.”

As such, the proposed rule would allow long-term care facilities to be exempted from the requirements if they can demonstrate workforce unavailability in their area and good faith hiring and retention efforts.

Other items in the proposed rule include updates strengthening the requirements for annual facility assessments—for instance, by requiring that long-term care facilities include facility staff input during the assessments—and provisions that give more insight into how nursing facilities and intermediate care facilities for individuals with intellectual disabilities are spending Medicaid funds.

“CMS is proud to be leading the President’s initiative to improve the lives of over 1.2 million residents who reside in Medicare and Medicaid-certified long-term care facilities, and those who will need that care in the future,” CMS Administrator Chiquita Brooks-LaSure said in the announcement. “Today, we took an important first step to propose new staffing requirements that will hold nursing homes accountable and make sure that residents get the safe, high-quality care that they deserve.”

The administration paired the proposal with word that it would be increasing enforcement and oversight of existing staffing standards and use of taxpayer funds. To increase the supply of workers, the White House also outlined more than $75 million HHS and the Health Resources and Services Administration will be investing toward scholarships and tuition reimbursement for those training to work in nursing homes.

The long-term care industry has long railed against staffing requirements they say are financially unreasonable and not guaranteed to increase quality.

Shortly after the Biden administration outlined its nursing home playbook in early 2022, for instance, the AHCA penned a letter to the federal government highlighting the hundreds of thousands of workers lost during the pandemic and warning that staffing requirements would force facilities to limit care “or close altogether.”

In Friday morning’s statement, LeadingAge’s Sloan said that the $75 million toward workforce training “while a huge need, to be sure … is simply not enough at this point.”

Sloan and Parkinson both pointed to a leaked, government-funded study from earlier this week that critics and advocates alike said makes a weak case for the staffing requirements.

“One-size-fits-all staffing ratios don’t guarantee quality, as the Administration’s own … research findings made clear,” she said. “…The Biden White House in 2022 set out to create policy based on research. If neither study nor practice nor reason guide our federal regulations, how can CMS justify them?”

CMS’ official announcement leaned on a different study published by the Office of the Assistant Secretary for Planning and Evaluation, which highlighted lower median wages for nursing assistants than other entry-level jobs across dozens of states. The agency said that the provisions included in its proposed rule, including the staffing minimums, can help drive better pay and conditions for these workers.

Liz Shuler, president of labor organization AFL-CIO, applauded the proposal as a boon for residents and workers alike.  

"Corporations long have prioritized cutting costs rather than shoring up safety for health care workers and the people who rely on these life-sustaining services," she said in a statement. "Workers continue to bear the brunt of the care economy crisis and are stretched thin by a severe lack of resources. Care workers are egregiously underpaid and deeply undervalued, and it’s past time they receive good pay and dignity on the job."