CMS' own study appears to question proposed staffing standards

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On September 1, the Centers for Medicare and Medicaid Services proposed minimum nursing standards for nursing homes, days after Kaiser Health News published a study commissioned by CMS that said there was "no single staffing level that would guarantee quality care."

The June study was reportedly posted accidentally and pulled by CMS on August 29, the same day the KFF story ran.

Providers have been bracing for a staffing standard to be released since President Joe Biden, in his 2022 State of the Union address, called for Medicare to set higher standards for nursing homes. The White House said at the time that CMS would be establishing minimum nursing home staffing requirements and conduct research to determine the level and type of staffing needed, releasing a proposed rule within one year. 

Concerns have already been raised about the released proposal, based in part on CMS's own commissioned study. A proposed 60-day comment period on the proposed rulemaking ends on November 6.

The American Hospital Association voiced concerns over how the rule would affect hospitals already facing discharge delays due to patients waiting for long-term care facility beds to become available.

"Fewer nursing home beds could adversely impact hospital patients who are denied the specialized care they are prescribed when they must stay, sometimes months, in hospital beds awaiting discharge to post-acute care settings," said Ashley Thompson, senior vice president, Public Policy Analysis and Development for the AHA. "This could become especially dire in rural and underserved communities. The AHA has already documented rising lengths of stay for hospital patients in need of skilled post-acute care."

One of the main concerns of the proposal is the aspect of a 24/7 nursing staffing requirement, according to Reverence founder and CEO Lee Hudson Teslik, who works with providers on workforce issues.

In its rulemaking, CMS said it was interested in comments regarding the feasibility for each LTC facility to have an RN on site 24 hours a day, seven days a week, including possible alternatives to the proposal. Under certain conditions, including lack of available nurses, CMS said it would consider a temporary hardship exemption.

Another issue is financial. CMS offers no money for facilities to meet the minimum staffing level mandate.

An estimated three-quarters of nursing homes in the country would be required to hire more workers under the proposed rule, according to the KFF report.

The CMS study estimates that the total costs of additional staffing to meet a minimum staffing requirement would range from $1.5 to $6.8 billion, depending on the structure and option.

The study also said simulation modeling results show that the percentage of delayed or omitted clinical care decreases appreciably with increased licensed nurse (RN, LPN) staffing levels.

WHY THIS MATTERS

The staffing standard came in answer to the troubling number of nursing home resident deaths from COVID-19. 

By July 30, 2020, 362,000 people in virtually every U.S. nursing home were infected with the virus, representing about 8% of all cases in the country. At least 62,000 nursing home residents had died of COVID-19, representing 41% of all COVID-19 deaths nationally.

An estimated 200,000 nursing home residents had died as of February 2022, according to KFF.

THE LARGER TREND

The labor shortage that was exacerbated by COVID-19 shows no signs of slowing down as baby boomers both retire and need more care, Teslik said. 

But the staffing mandate is only one piece of the picture for providers, he said. There's a range of factors that contribute to good patient outcomes. 

"What is becoming clear," he said, "is just having more people is not going to yield better results."

Twitter: @SusanJMorse
Email the writer: SMorse@himss.org