Nurse Staffing Rule Slammed By Both Industry And Advocacy Groups

Dive Brief:

• The Biden administration published its final long-term care facilitity staffing standards rule on Monday, following months of controversy. Neither patient advocates nor long-term care groups are satisfied with the final offering.
• The rule requires facilities to provide 3.48 hours of care per resident per day — up from three hours the CMS proposed in September. At least 0.55 hours of care must come from registered nurses, and facilities are also required to have an RN onsite and on duty at all times.
• Long-term care groups blasted the rule, calling it imprudent during a nationwide staffing shortage, while patient advocacy organizations say the rule doesn’t go far enough to safeguard quality.

Dive Insight:

The Biden administration issued the rule in an effort to address quality concerns that were exposed during COVID-19 pandemic lockdowns, when long-term care residents were isolated from their families and more vulnerable to care deficiencies.

Regulators pointed to research in the rule, including a June study commissioned by the CMS, which suggests higher staffing levels are associated with improved health outcomes for patients and potentially lower staff turnover.

The final rule will be phased in over three years for non-rural facilities and within five years for rural facilities. Non-rural facilities will be required to meet the 3.48 hour total staffing requirement and 24/7 RN requirement within two years. Facilities will not have to hit the 0.55 RN care threshold until three years after the rule’s publication date. 

The CMS said in the final rule that 79% of facilities will have to increase staffing to meet the new standards, while KFF estimates 81% of facilities will have to hire additional staff. The CMS predicted it could cost the industry anywhere from $1.5 billion to $6.8 billion to meet the targets.

Some facilities may qualify for exemptions, but “only in limited circumstances,” according to the rule.

Facilities will be exempt if they can prove there is a local workforce shortage and that they have made a “good faith effort to hire and retain staff,” including providing documentation of financial efforts to hire. Care organizations that receive exemptions will be required to notify current and prospective residents of their exempt status, according to the rule.

The administration struggled to generate enthusiasm for the rule since it was announced. The proposed rule garnered nearly 50,000 public comments, many of which decried the rule as too stringent or too lax.

Industry groups and politicans penned letters in opposition to the rule. Last month, the House Ways and Means Committee advanced a bill attempting to block the CMS from finalizing its proposal.

Mark Parkinson, CEO and president of the American Health Care Association, a nonprofit representing 14,000 facilities, slammed the mandate in a statement issued Monday, calling it “unconscionable” to finalize the rule amid what he says is a caregiver shortage.

“This unfunded mandate doesn’t magically solve the nursing crisis,” Parkinson said. 

Nursing home and provider groups have argued that facilities cannot fund further hiring efforts. In a Monday statement, the American Hospital Association said that care facilities could fold under financial pressure to meet the standards.

However, previous research — including a March study from UCLA and Lehigh University — have said nursing homes may be reporting inflated cost estimates to hide profits and appear less able to comply with quality initiatives. 

CMS also raised reimbursement rates for nursing homes for 2025 to 4.1% in March, providing some financial cushion for hiring.

Other stakeholders are concerned about the rule’s impact on rural providers, even with the allotted exemptions. 

“Time and again, this administration has abandoned rural America,” said Sen. Deb Fischer, R-Neb., in a statement. “Instead of listening to the overwhelming, bipartisan opposition to this rule, the administration has decided to plow ahead. This misguided rule will devastate nursing homes across this country and worsen the staffing shortages we are already facing.”

Patient advocacy groups also expressed frustration with the final rule, saying it fell short of the standards they think are necessary to protect care.

“Consumer Voice recognizes that this is an important first step in ensuring that all residents have their care needs met,” said patient advocacy group National Consumer Voice for Quality Long-Term Care in a statement. “However, 3.48 HPRD is a minimum and not a ceiling.” 

The Long Term Care Community Coalition, a nonprofit organization dedicated to improving nursing home quality said, “the final CMS rule falls significantly short of what numerous studies have indicated is necessary for basic clinical care.”

The LTCCC warned that the new standard could jeopardize care for some residents in facilities that are currently higher staffed because “those operators are now incentivized to decrease their staffing to the new federal standard.”