Facilities News Policy Spotlight

2024-04-22 Spotlight: Biden administration finalizes controversial minimum staffing mandate at nursing homes

Biden administration finalizes controversial minimum staffing mandate at nursing homes

April 22, 2024
By Tami Luhby

Nursing Home Staffing Mandate Finalized: Balancing Quality Care and Workforce Shortages

The Biden administration has finalized the first-ever federal minimum staffing rule for nursing homes. This controversial mandate aims to address chronic understaffing and improve resident care but faces concerns from the industry about feasibility and potential closures.

Key Points:

  • Minimum Staffing: Nursing homes must provide at least 3.48 hours of daily nursing care per resident, with defined portions from registered nurses (RNs) and nurse aides.
  • Phased Implementation: Rural communities will have more time to comply, and temporary exemptions are available for facilities facing workforce shortages.
  • Industry Pushback: Nursing home operators argue the mandate is unrealistic, citing existing staffing challenges and potential closures.
  • Cost and Workforce Concerns: The industry estimates hiring over 100,000 additional staff at a significant annual cost, while struggling to find qualified candidates.
  • Consumer Advocates Unsatisfied: Some consumer groups believe the minimum staffing level is still insufficient to ensure quality care.
  • Divided Opinions: Legislators are split, with some Democrats supporting the rule and Republicans opposing it due to potential closures.
  • Labor Unions and Consumer Groups Support Mandate: These groups see the rule as promoting resident and worker safety.

Comments about the rule:
Sen. Elizabeth Warren, a Democrat of Massachusetts, has called for the administration to finalize the rule and strengthen it.

“This would help improve the quality of care for residents at the same time that it’s improving conditions for the staff who provide this long-term care,” she said at a hearing of the Senate Special Committee on Aging last week.

Other Democratic lawmakers, including Sen. Bob Casey of Pennsylvania and Rep. Richard Neal of Massachusetts, praised the final rule on Monday, saying it will strengthen patient and worker safety.

The Debate:
The Biden administration argues the mandate is necessary to address widespread understaffing, which can lead to poor resident care. The minimum staffing levels are intended to ensure basic needs are met, resident safety is improved, and staff workload is manageable.

Opponents, primarily the nursing home industry, express concerns about the feasibility of the mandate. They argue the already strained workforce will not be able to meet the increased demand, potentially forcing facilities to close. Additionally, they emphasize the significant financial burden of hiring additional staff.

Looking Forward:
The final rule faces potential legal challenges and will require significant adjustments from the nursing home industry. Addressing workforce shortages through funding for recruitment and training programs is crucial for successful implementation. Balancing quality care for residents with the needs and capacity of the nursing home workforce remains a key challenge.

Fact Sheet: Vice President Harris Announces Historic Advancements in Long-Term Care to Support the Care Economy

The White House
April 22, 2024

Everyone deserves to be treated with dignity and respect and to have access to quality care. That’s why, today, Vice President Harris is announcing two landmark final rules that fulfill the President’s commitment to safety in care, improving access to long-term care and the quality of caregiving jobs. Ensuring that all Americans, including older Americans and people with disabilities, have access to care – including home-based care – that is safe, reliable, and of high quality is an important part of the President’s agenda and a part of the President’s broader commitment to care. Today’s announcements deliver on the President’s promise in the State of the Union to crack down on nursing homes that endanger resident safety as well as his historic Executive Order on Increasing Access to High-Quality Care and Supporting Caregivers, which included the most comprehensive set of executive actions any President has taken to improve care for millions of seniors and people with disabilities while supporting care workers and family caregivers.

Cracking Down on Inadequate Nursing Home Care
Medicare and Medicaid pay billions of dollars per year to ensure that 1.2 million Americans that receive care in nursing homes are cared for, yet too many nursing homes chronically understaff their facilities, leading to sub-standard or unsafe care. When facilities are understaffed, residents may go without basic necessities like baths, trips to the bathroom, and meals – and it is less safe when residents have a medical emergency. Understaffing can also have a disproportionate impact on women and people of color who make up a large proportion of the nursing home workforce because, without sufficient support, these dedicated workers can’t provide the care they know the residents deserve. In his 2022 State of the Union address, President Biden pledged that he would “protect seniors’ lives and life savings by cracking down on nursing homes that commit fraud, endanger patient safety, or prescribe drugs they don’t need.”

The Nursing Home Minimum Staffing Rule finalized today will require all nursing homes that receive federal funding through Medicare and Medicaid to have 3.48 hours per resident per day of total staffing, including a defined number from both registered nurses (0.55 hours per resident per day) and nurse aides (2.45 per resident per day). This means a facility with 100 residents would need at least two or three RNs and at least ten or eleven 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. Many facilities would need to staff at a higher level based on their residents’ needs. It will also require facilities to have a registered nurse onsite 24 hours a day, seven days a week, to provide skilled nursing care, which will further improve nursing home safety. Adequate staffing is proven to be one of the measures most strongly associated with safety and good care outcomes.

To make sure nursing homes have the time they need to hire necessary staff, the requirements of this rule will be introduced in phases, with longer timeframes for rural communities. Limited, temporary exemptions will be available for both the 24/7 registered nurse requirement and the underlying staffing standards for nursing homes in workforce shortage areas that demonstrate a good faith effort to hire.

Strong transparency measures will ensure nursing home residents and their families are aware when a nursing home is using an exemption.

This rule will not only benefit residents and their families, it will also ensure that workers aren’t stretched too thin by having inadequate staff on site, which is currently a common reason for worker burnout and turnover. Workers who are on the frontlines interacting with residents and understanding their needs will also be given a voice in developing staffing plans for nursing homes. The Biden-Harris Administration also continues to invest in expanding the pipeline of nursing workers and other care workers, who are so essential to our economy, including through funding from the U.S. Department of Health and Human Services.

Improving Access to Home Care and the Quality of Home Care Jobs
Over seven million seniors and people with disabilities, alongside their families, rely on home and community-based services to provide for long-term care needs in their own homes and communities. This critical care is provided by a dedicated home care workforce, made up disproportionately by women of color, that often struggles to make ends meet due to low wages and few benefits. At the same time, home care is still very inaccessible for many Medicaid enrollees, with more than three quarters of home care providers not accepting new clients, leaving hundreds of thousands of older Americans and Americans with disabilities on waiting lists or struggling to afford the care they need. The “Ensuring Access to Medicaid Services” final rule, finalized today, will help improve access to home care services as well as improve the quality caregiving jobs through its new provisions for home care. Specifically, the rule will ensure adequate compensation for home care workers by requiring that at least 80 percent of Medicaid payments for home care services go to workers’ wages. This policy would also allow states to take into account the unique experiences that small home care providers and providers in rural areas face while ensuring their employees receive their fair share of Medicaid payments and continued training as well as the delivery of quality care.

Higher wages will likely reduce turnover, leading to higher quality of care for older adults and people with disabilities across the nation, as studies have shown. States will also be required to be more transparent in how much they pay for home care services and how they set those rates, increasing the accountability for home care providers. Finally, states will have to create a home care rate-setting advisory group made up of beneficiaries, home care workers and other key stakeholders to advise and consult on provider payment rates and direct compensation for direct care workers.