Nursing homes with the nation’s smallest staffs will be required to hire more workers under new rules proposed Friday by the Biden administration, the biggest changes to federal nursing home regulations in three decades.
The proposed standard was prompted by the industry’s troubled performance early in the coronavirus pandemic, when 200,000 nursing home residents died. But the proposal falls short of what both industry and patient advocates believe is needed to improve care for most of the 1.2 million Americans in nursing homes.
The proposal, by the Centers for Medicare and Medicaid Services, would require all facilities to increase staffing to some minimum level, but it would not include money for nursing homes to pay for new hires.
CMS estimates that three-quarters of the nation’s 15,000 homes will need to add staff members. But the increases at many of those facilities would be small, because the average nursing home already employs nurses and aides at, or very close to, the proposed levels.
“The standards are lower than what many experts, including myself, have been calling for in recent years,” said David Grabowski, a professor of health care policy at Harvard Medical School. “There are some real positives here, but I hope the administration goes further.”
The government said it would exempt nursing homes from punishment if they could prove there was a local labor shortage and the facilities made a sincere effort to recruit employees.
“Fundamentally, this standard is completely inadequate to meet the needs of nursing home residents,” said Richard Mollot, the executive director of the Long Term Care Community Coalition, an advocacy group based in New York.
Nursing home industry executives say that without additional money from Medicare or Medicaid — the two federal insurers that pay for most nursing home care — the need will not be met financially.
“It makes no sense to mandate staffing levels that cannot be met,” Katie Smith Sloan, the president and chief executive of LeadingAge, an association of nonprofit nursing homes, said in a statement. “There are no people to hire – especially nurses. The proposed rule would require nursing homes to hire additional staff. But where are they coming from?”
The new staffing standard will require homes to have a daily average nurse staffing level of at least 0.55 hours per resident. That translates to one registered nurse for every 44 residents. But that’s less than what the average nursing home already provides, which is 0.66 hours per resident, a 1:36 ratio, federal records show.
At least one registered nurse would have to be on duty at all times under the proposed plan – one of the biggest changes for the facilities, as they currently must have nurses on duty for eight consecutive hours per day.
The proposed rule also calls for 2.45 nurse aide hours per resident per day, meaning a ratio of approximately one aide for every 10 residents. Although the federal government does not set specific staffing requirements for nurse aides, the average home already provides 2.22 nurse aide hours a day, a ratio of about 1:11.
“The federal minimum staffing standards proposed by CMS are robust but achievable,” the agency said in a statement. “The proposal also clarifies that numerical staffing levels are a floor — not a ceiling — for safe staffing.”
Registered nurses are at the top of the chain of command in nursing homes, overseeing assessments of residents and handling complex clinical tasks. Nurses delegate more direct clinical duties to licensed practical nurses.
Certified nurse assistants, often called nurse aides, are usually the most numerous in a nursing home and help residents with basic needs such as bathing, getting out of bed and eating.
On average, registered nurses earn $37 an hour while licensed practical nurses earn $28 an hour, according to CMS Aides often start at minimum wage or slightly higher, earning $17 an hour in usually
“People have more choices,” said Tina Sandri, the chief executive of DC’s Forest Hills, a nursing home in Washington, referring to nursing home staff. “They can go to hospitals and do more and do less than they do here in a nursing home.”
“We’ve lost staff at hospitals that had a $20,000 signing bonus,” he added, “and as a nonprofit, we can’t fight that.”
Nursing home officials say they can’t afford to pay higher wages because state Medicaid programs pay them too little. Patient advocates, however, note that some for-profit homes provide significant returns to investors.
Medicare and Medicaid will spend $95 billion on nursing home care and retirement community care by 2021, according to CMS. The agency estimates that the new standards will cost homes another $4 billion over three years, when all those homes other than those in rural areas must comply. Rural homes will have five years.
Ellen Quirk, a retired certified nurse’s assistant in Hayes, Va., recalled that she would sometimes take care of all the residents on a nursing home floor, which could be 20 or more people, by herself. It is difficult for an aide to take care of more than five to seven people at a time, he said.
“If it’s more than that, then things aren’t being done properly,” Ms. Quirk, 63. “Things get skipped, like bathing or changing them every two hours or feeding them properly.”
“I’ve seen patients roll over and fall out of bed,” he added. “Sometimes they get bed sores because the beds are saturated with urine for hours and hours.”
The nursing home industry is pressuring federal and state governments to pay for a bunch of lures to long-term care workers, including educational assistance for those who have worked in nursing homes, loan forgiveness and career opportunities for certified nursing assistants working toward their nursing degrees.
The administration said it would offer $75 million in scholarships and tuition as part of the new proposal. The administration is accepting comments for the next 60 days before it finalizes the new standard.
Jordan Rau is a senior correspondent at KFF Health News in Washington, DC