Safer Staffing?

“Research shows that these staffing levels will save lives, provide residents with a higher quality of life and prevent needless suffering.”

–Biden said in his editorial for USA Today, referring to 24/7 RN coverage, along with ensuring there are enough nurse aides to provide routine bedside care and other tasks.

CMS released a proposed rule to establish staffing standards among the nation’s nursing homes. Biden’s recent staffing proposals for minimum safe staffing would require facilities to provide enough direct care staff to deliver 33 minutes (.55 hours) of registered nursing care. That translates to one registered nurse for every 44 residents. But that is below what the average nursing home already provides, which is 0.66 hours per resident, a 1:36 ratio, federal records show.

The rule would require 2 hours, 27 minutes (2.45 hours) of certified nursing assistant time each day. While the federal government sets no specific staffing requirements for nurse aides, the average home already provides 2.22 nurse aide hours a day, a ratio of about 1:11.

Separately, the agency asked for comment on a minimum standard of 3.48 hours. A study commissioned by CMS last year analyzed staffing requirements ranging from 3.3 to 3.88 daily care hours per resident.

A 2001 CMS report based on the 1995-1997 STM Study recommended between 4.1 and 4.85 hours. Many experts and consumer advocates recommended CMS require at least 4.1 staffing hours per patient per day. The second requirement involved 24/7 RN coverage for each facility.

Nonprofit nursing homes are three times as likely as for-profit facilities to already satisfy the proposed minimum staffing standard.

“We are working to make sure no nursing home can sacrifice the safety of its residents just to add some dollars to its bottom line.”

-President Biden added.

CMS is seeking feedback on the 231-page proposal until November 6. Right now, nursing homes that are reimbursed by Medicare and Medicaid are required to provide staffing levels that are “sufficient” to meet residents’ needs, and there are no laws that set a minimum number of staff members or hours of care provided per day. The agency wants to require states to report what share of Medicaid payments each nursing home spends on direct care workers.

Most researchers conclude that low staffing causes neglect, burnout, and poor quality. Higher RN staffing levels are linked to fewer pressure ulcers and other infections; less pain, dehydration, and weight loss; and reductions in hospitalizations. See summary of safe staffing by UCSF professor and leading expert Charlene Harrington here. Nursing schools have had to turn away tens of thousands of would-be students annually for lack of qualified teachers.

Exemptions to the minimum standards will be available when all four of the following criteria are met:

• Workforce is unavailable, or the facility is at least 20 miles from another long-term-care facility;
• The facility is making a good faith effort to hire and retain staff;
• The facility provides documentation of its financial commitment to staffing; and
• The facility has not failed to submit Payroll Based Journal (PBJ) data.

Medicare and Medicaid spent $95 billion for 1.2. million residents on nursing home care and retirement community care in 2021, according to CMS.