Minimum nursing home staffing standards established in final rule

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The Centers for Medicare and Medicaid has issued a final rule requiring nursing home staffing standards.

Nursing homes participating in Medicare and Medicaid programs are required to provide residents with a minimum total of 3.48 hours of nursing care per day, which includes at least 0.55 hours of care from a registered nurse per resident per day, and 2.45 hours of care from a nurse aide per resident per day.

Nursing homes will need to have a registered nurse on site 24 hours per day, seven days per week, to help mitigate against preventable safety events and deliver critical care to residents at any time.

The locations are being required to conduct a stronger annual facility assessment than current ones 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. This process will need to include participation from direct care workers and others.

CMS will also require states to collect and report on the percent of Medicaid payments that are spent on compensation for direct care workers and support staff delivering care in nursing facilities and intermediate care facilities for individuals with intellectual disabilities. 

To increase transparency and accountability, CMS will publicly report the data reported by states, and states will also be required to report this data for each facility on a state-operated website.

WHY THIS MATTERS

Under the final rule, facilities will need to develop a staffing plan to maximize recruitment and retention. 

Lack of staff and funding to hire more employees, who often work for low wages, have been the main issues when CMS released its proposed minimum staffing rule in September.

CMS said Monday that it is developing a $75 million national nursing home staffing campaign to increase the number of nurses in nursing homes, thereby enhancing residents' health and safety. 

Through this campaign, CMS will be providing financial incentives for nurses to work in nursing homes, the agency said, without giving specifics.

American Hospital Association EVP Stacey Hughes said, "This final rule could lead nursing homes to reduce capacity or close outright, including those that are otherwise high performers on quality and safety metrics. The loss of these nursing home beds could adversely impact patients who have completed their hospital treatment and need continuing care in nursing facilities. The AHA has already documented rising lengths of stay for hospital patients in need of skilled post-acute care, with patients waiting days, weeks or even months for post-acute care placements. As those patients continue to occupy hospital beds, other patients awaiting elective surgeries or other scheduled procedures may find their care disrupted because there is no bed for them in the hospital. Even more troubling, this final rule could lead to delays in urgent medical care as patients coming into hospital emergency departments may experience longer waits as EDs and inpatient beds are occupied by patients awaiting nursing home placements."

The final rule could exacerbate the already serious shortages of nurses and skilled healthcare workers across the care continuum, Hughes said. 

Premier's SVP of government Affairs Soumi Saha called the rule an unfunded mandate.

" …the healthcare sector is still in a historic workforce crisis, with long-term care facilities hardest hit with not enough beds available to meet current demands. As such, Premier is deeply concerned that today's final rule implements an unfunded staffing ratio mandate in LTC facilities that will only exacerbate this schism and lead to nursing home beds remaining empty due to staff shortages, worsening boarding issues at acute facilities and escalating healthcare system costs," Saha said. 

The vast majority of nursing facilities will need to hire more staff to comply with the final rule, KFF said, releasing new analysis on the same day as the final rule. Fewer than 1 in 5 (19%) nursing facilities currently meet the minimum staffing standards set out in the final requirements of the federal rule released by CMS, the report said. Nearly 60% of facilities currently meet the overall staffing requirement of 3.48 hours per resident day, which had been set as the interim requirement in the rule.

"CMS adopted staffing standards that are similar to the staffing requirements in the rule proposed last year, which included minimum staff levels of 0.55 registered nurses and 2.45 nurse aide hours per resident day. The final requirements of the rule maintain these staff levels, and add an overall staffing requirement of 3.48 hours per resident day. The rule also requires a registered nurse on staff 24 hours per day, 7 days per week," KFF said.

THE LARGER TREND

CMS said nursing home direct care workers are often women of color who typically earn low wages, rarely receive health and retirement benefits, and experience high injury rates. 

"The Biden-Harris Administration believes that by improving working conditions and wages, improvements in the recruitment and retention of direct care workers will follow, enabling nursing staff to provide safer, higher quality care to all residents within nursing homes," CMS said. 

Over 1.2 million residents receive care in Medicare- and Medicaid-certified nursing homes each day. 

CMS said it received and considered more than 46,000 public comments on this rule from various stakeholders, including residents and their family members, workers, advocates, and the industry. 

Many of these comments highlighted how – without sufficient staff – residents do not receive necessary care, including baths or trips to the bathroom, and experience preventable safety events, such as pressure ulcers and falls.

Email the writer: SMorse@himss.org