For SNF operators, the proposed rule carries direct implications for Payroll Based Journal (PBJ) reporting requirements, Five Star staffing ratings, and compliance cost exposure, particularly the 24/7 RN provision and the exclusion of LPNs from qualifying staffing hours.
As it stands, the proposed rule has major implications for access issues with about 294,000 nursing home residents at risk of displacement across the sector, according to audit, tax and consulting firm CliftonLarsonAllen (CLA), while operators and nursing home advocates say it is grossly underfunded. This, while the industry still struggles with staffing shortages and as caregiver numbers slowly inch up toward pre-pandemic levels, as highlighted by the federal government’s latest jobs report, also released Friday.
“Only 19% of SNFs would be able to meet mandate requirements, Rutledge said, while 81% would not. About 98,000 additional nursing FTEs would be required, a cost today of $6.6 billion… Absent the money and labor availability, the only other mechanism that one could leverage to meet the staffing mandate is to remove residents to get up to the 3.0 hours per patient day.”
— Skilled Nursing News, September 1, 2023
Providers Find Few Silver Linings, Stew Over Minimum Staffing Demands
Regulators’ call for 24/7 registered nurse coverage in every nursing home — triple the current eight-hour requirement — will take center stage, virtually all stakeholders agree.
“‘I can’t help but to feel it’s going to 100% reduce access, and it’s going to require our seniors to go farther for care,’ Schema said. ‘I think of our building in Bloomfield, NE. It’s a 5-star building. They run a staffing ratio of 3.1 [hours]. We’re trying to figure out how we could staff that 24/7 with an RN. It’s untenable.'”
— McKnight’s Long-Term Care News, September 5, 2023
What New Nursing Home Staffing Rules Would Mean For Residents And Patients
And in a provision that suggests CMS may be considering an entirely different standard, the agency wants to require states to report what share of Medicaid payments each nursing home spends on direct care workers. That and other reporting eventually could be used to require facilities to dedicate a minimum percentage of their revenue to staffing, rather than (or perhaps in addition to) mandating specific hours.
“Harvard University’s David Grabowski, who authored many of these studies, calls low staffing a ‘symptom’ but ‘not a root cause’ of nursing home problems… A new report by the consulting firm Abt Associates added to the ambiguity by concluding this: ‘There is no obvious plateau at which quality and safety are maximized or cliff below which quality and safety steeply decline.'”
— Forbes, September 5, 2023
Timeline a Win, But RN Provision Draws Ire as Nursing Home Industry Reacts to CMS’ Staffing Proposal
As the president underlined the need for more staff to improve quality, the 24/7 provision for registered nurses (RNs) continued to draw ire from leaders across every corner of the nursing home industry, with advocates calling for more funding. Meanwhile, the lead time given to implement the mandate was seen as a win for the sector by all sides.
“The Society for Post-Acute and Long-Term Care Medicine (AMDA) expressed concern about what they called a ‘fixed ceiling,’ and that staffing levels based only on resident-to-worker ratios won’t safely address or meet residents’ needs… AMDA strongly urged CMS to take recommendations from its own study that concluded there was no specific staffing number to improve care.”
— Skilled Nursing News, September 5, 2023
When Long-Term Care Becomes a Slugfest
If you ever want to see something really wrong, just watch two sides fight when both think they’re really right. It usually isn’t pretty.
That describes the climate created by the nursing home staffing mandate proposed on Friday.
“Even before the release, providers had lobbied hard to impress upon rulemakers that there isn’t enough money in the government propped-up system to fund what they want. Nor enough bodies to fill the workstations they desire. On the other side of the arena stands a crowd of regulators, consumers/voters, labor groups and academics who want more for patients.”
— McKnight’s Long-Term Care News, September 6, 2023
Assisted living communities are at risk of losing staff members following the first-ever proposed federal staffing mandate for nursing homes, released Friday, according to senior living experts.
Competition for workers, especially nurses and other caregivers, may increase at a time when all providers already face recruiting and retention challenges.
“‘No matter where an assisted living community sits on this continuum, a federal minimum staffing mandate threatens to take away the essential staff on which these communities depend to provide high-quality care for hundreds of thousands of residents,’ Bethea said.”
— McKnight’s Senior Living, September 6, 2023
Upper Valley Nursing Homes Say Federal Staffing Proposal Ignores Work Force Realities
Administrators of Upper Valley nursing homes are balking at proposed changes to federal staffing requirements, which they say would be difficult for them to meet and could put beds offline, reducing the availability of long-term care in the region.
“‘There’s just not enough registered nurses in the workforce right now to be in compliance with the regulation,’ Labore said… ‘The rules kind of undo everything we’ve been working so hard to combat since COVID,’ Lagos said.”
— Valley News, September 16, 2023
CCRC Ratings Unlikely to Be Affected by SNF Staffing Mandates: Fitch
“The minimum staffing rule… will add to staffing pressures at continuing care retirement / life plan communities, but it will not affect their ratings, according to a new report from Fitch Ratings… ‘Should these inflationary pressures persist beyond the next two years, [life plan communities] may encounter resistance from residents to the substantial rate increases that may be required to offset the added cost pressure.'”
— McKnight’s Senior Living, September 21, 2023
Already Losing Count of the Staffing Mandate Arguments? You’re Not Alone
For those of you already a bit frustrated or even disgusted with the hullabaloo surrounding the proposed nursing home staffing minimum rule, look out. It’s about to get even uglier.
To confirm your worst fears, the combatants are starting to resort to that repugnant four-letter word. Yes … math.
Except for the obvious professionals who have to use numbers and calculations in their daily chores, it seems many, if not most, people would rather speak in public in their underwear than deal with them. Journalists, with rare exception, are in that boat.
— McKnight’s Long-Term Care News, September 29, 2023
In This Corner, Long-Term Care Providers…
Don’t be fooled by the public civility. The relationship between long-term care providers and regulators is, by nature, one of shared mistrust.
Providers tend to see regulators as meddlesome at best, business killers at worst. Conversely, regulators tend to see providers as insubordinate at best, people killers at worst. You might say there’s a certain level of built-in tension.
Reminds me a bit of two feuding relatives who must put on a show of unity at a family gathering. The façade can quickly crumble once the drinks start to flow. Well, consider the liquor cabinet officially unlocked.
— McKnight’s Long-Term Care News, October 10, 2023
Quality Does Not Equate to Staffing Mandates
I recently returned from the AHCA/NACL national convention and expo, one of my favorite conferences of the year. One reason why it’s a favorite is the recognition of quality in our profession.
There were 399 Bronze winners, 72 Silver winners and two Gold winners. Holy moly! The excitement at the award session was palpable. People cheering, standing, clapping, applauding, some crying tears of joy. It was incredible!
“All of this amazing quality was achieved without having an unfounded, unfunded, unrealistic and unachievable staffing mandate in place… you mean people can achieve quality without meeting impossible staffing ratios?”
— McKnight’s Long-Term Care News, October 10, 2023
The Hypocrisy of Staffing Mandates
“It’s truly disorienting to see regulators and politicians attempt to solve a different staffing crisis by actually investing resources in recruiting and education, rather than reflexively legislating. What happened to their tried and true long-term care model — ignore a crippling nationwide labor shortage, stoke public outrage and simply roll out a magical unfunded mandate?”
— McKnight’s Long-Term Care News, October 19, 2023
