A lack of sufficient nursing home staffing, or understaffing, threatens the nation’s 1.2 million nursing home residents. Residents who do not receive the care they need can experience falls, dehydration, malnutrition, and bedsores. They are also more vulnerable to abuse and neglect.
A historic nursing shortage is affecting long-term care facilities nationwide. According to the U.S. Chamber of Commerce, drivers of the shortage include pandemic burnout, a low retention rate, and inadequate nursing school capacity.
The American Health Care Association’s (AHCA) 2024 State of the Sector Report highlights the impact of the nursing shortage on long-term care facilities. A staggering 99 percent of nursing homes have open jobs, and 89 percent have open listings for registered nurse (RN) positions. Seventy-two percent report lower workforce levels than before the pandemic.
In April 2024, the Centers for Medicare & Medicaid Services (CMS) issued a new rule seeking to combat understaffing. The regulation, known as the Minimum Staffing Standards for Long-Term Care (LTC) Facilities and Medicaid Institutional Payment Transparency Reporting rule, sets the standards for how much time nurses must spend caring for long-term care residents. The rule applies to Medicare- and Medicaid-certified long-term care facilities. It follows the CMS’ 2023 announcement that it plans to invest millions of dollars in financial incentives for people to become nurses who work in nursing homes.
Minimum Staffing Requirements
Under the new regulation, long-term care facilities must provide at least 3.48 hours of nursing care per resident per day. This includes at least 0.55 hours of direct registered nurse (RN) care and 2.45 hours of direct nurse aide care per resident per day.
For the remaining hours, nursing homes may use any combination of nursing staff, such as RNs, licensed practical nurses (LPNs), and licensed vocational nurses (LVNs). When residents require more than this base level of care, the CMS expects facilities to meet these needs.
Payment Transparency
The regulation also finalized provisions to increase public transparency regarding Medicaid payments for services in nursing facilities, including what is spent to compensate direct care workers and support staff.
States must report the percentage of Medicaid payments for nursing facility services to the CMS. They must also report how much facilities spend compensating direct care workers and support staff.
Additional Changes
The CMS finalized additional requirements aimed at protecting long-term care residents. One provision requires an RN to be on site at all times. (Previously, long-term care facilities had to have an RN on site for eight consecutive hours every day.) The intent is to help increase resident safety, especially when regular staff are less available, such as evenings, nights, weekends, and holidays.
The CMS is also strengthening the facility assessment requirement. This means that facilities must evaluate, on an ongoing basis, what resources are essential to addressing the specific needs of their residents. Assessments must incorporate input from nursing home leadership and plans to maximize staff recruitment and retention.
Certain facilities may be eligible to seek exemptions from some of these requirements. Facilities in some rural areas where few nurses live may have trouble obtaining staff, for example.
Gradual Implementation
Recognizing that it may take some time for nursing homes to reach compliance with the new staffing requirements, CMS is implementing the rule gradually through a staggered approach across two to five years.
- By August 10, 2024 (90 days after the rule’s publication), all Medicare and Medicaid long-term care facilities must meet the assessment requirements.
- Facilities must provide 3.48 hours of daily nursing care and the round-the-clock RN requirement within two years. (Long-term care facilities in rural areas will have three years to comply.)
- Facilities have three years to meet the 0.55 RN and 2.45 hours of direct nurse aide care requirements. (Those in rural locations will have five years.)
Facilities that fail to comply with the new federal regulations could face monetary penalties, have their residents transferred elsewhere, lose payment for Medicare and Medicaid services, or other consequences.
Responses to the New Rule
The nursing home staffing mandate has sparked controversy. While some see the rule as remedying understaffing problems, others believe that it will reduce nursing home access. Most nursing facilities do not currently meet the standards.
The Kaiser Family Foundation Health News highlighted criticism among nursing home officials, who worry about the cost of staffing more nurses as well as the availability of nursing staff in light of the shortage.
Some are concerned that the rule could hurt other care facilities, like assisted living, making it harder for them to retain staff, too. Another point of contention is that the mandate does not include providing facilities with additional funding to meet the new staffing requirements. One industry leader called the new mandate “an extinction event” for long-term care facilities.
Others praised the change. U.S. Sen. Bob Casey (D-PA) applauded the rule on his website. “This rule, which both establishes staffing minimums and improves enforcement of nursing home violations,” he stated, “is an important step towards ensuring that all nursing homes are providing the care that all residents need and deserve.”
However, not all legislators support the rule. For one, U.S. Sen. Deb Fischer (R-NE) introduced the Protecting Rural Seniors Access to Care Act in December 2023 when the staffing standards were initially proposed. “This mandate from the Centers for Medicare and Medicaid Services would force many facilities to reduce their number of patients or even close their doors for good,” she said in a news release at the time.
More recently, U.S. Rep. Michelle Fischbach (R-MN) introduced another bill, the Protecting America’s Seniors’ Access to Care Act, which aims to block the CMS from enforcing the new staffing requirements.
