Thousands of nursing homes would have to add workers under Biden plan to make them safer

WASHINGTON − Nearly all nursing homes would have to boost staffing under regulations proposed Friday by the Biden administration that would set the first nationwide minimums for nurse and aide care.

The president tied poor care in nursing homes to corporate greed and said these standards are a critical step toward improvement.

“As a country, we’re delivering a clear message to the nursing home industry: No more padding profits on the backs of residents and nurses,”  he wrote in an editorial for USA TODAY. “If you tell families you’ll take care of their loved ones, then follow through.”

Over the first 90 days of 2023, only 141 of the nation’s nearly 15,000 skilled nursing facilities met the registered nurse and certified aide standards in the draft rule, according to a USA TODAY analysis. And those proposed staffing requirements are less stringent than federal recommendations in place since 2001 despite residents having increasingly complex needs.

Minimums like those proposed are intended to limit resident neglect or delays in care. Fulfilling individual care plans, which would continue to be required, often demands even more staffing, research has shown.

Commending advocacy work by union health care workers who have pushed for more staffing for years – most of them women of color — SEIU International President Mary Kay Henry also applauded the proposed regulations.

“In the absence of a federal staffing standard, nursing home workers have endured complete physical, mental and emotional exhaustion due to understaffed shifts and unsafe working conditions, and nursing home residents have been robbed of the quality care and quality of life they deserve,” Henry said.

If finalized and adequately enforced, the mandatory staffing rules would be one of the most significant updates to nursing home regulations since they were created in the 1970s. While some of the changes could take effect in a few months, the bulk of the rules would not go into effect for three years and some five years.

“I am disappointed about the long ramp-up period,” said David Grabowski, a professor of health care policy at Harvard Medical School. “This has been long overdue.”

Biden’s proposal was criticized by advocates for nursing home residents for apparent loopholes while industry trade groups argued the staffing minimums would be impossible to meet.

Stacy Sanders, counselor the Health and Human Services Secretary, said the administration would consider all public comments submitted before early November, but defended the draft regulations as written.

“Our standard is both strong and achievable,” she said. “The status quo is unacceptable.”

Most nursing homes would not meet the new standards

Over the first 90 days of 2023, only 141 of the nation’s nearly 15,000 skilled nursing facilities met two core standards in President Joe Biden’s staffing proposal, according to a USA TODAY analysis.

Yoonserk Pyun | USA TODAY

Slow to act

For decades, federal and academic researchers have found staffing levels to be the single best predictor of quality nursing home care.

Yet, the Centers for Medicare and Medicaid Services, which regulates nursing homes that accept public health insurance – including Medicare – has never required a specific number of nurses and aides. Instead, the agency has made recommendations that few facilities followed.

Even if the new staffing minimums are approved, enforcement continues to be a top concern.

A USA TODAY investigation found that although nursing homes have for years submitted daily staffing data to federal officials, they rarely are punished for violating the existing guidelines and rules.

Penalties were unusual even at facilities where inspectors noted low staffing while investigating avoidable deaths, broken bones, days without help getting out of bed and hours sitting in feces, among other violations. Fines are even rarer.

Three new rules anchor the nursing home staffing proposal

Existing rules require nursing homes to provide “sufficient” staffing to meet all needs outlined by individual care plans, a standard that would continue. The proposed regulations would make three primary revisions. Nursing homes would need to:

  1. Have a Registered Nurse (RN) on duty 24/7. Current rules require 24/7 care but allow a Licensed Practical Nurse (LPN) to meet the requirement.

  2. Ensure RNs provide a daily average of at least 0.55 hours of care to each resident. RNs write individual care plans, monitor changes in condition and write orders for treatment carried out by other licensed nurses and aides.

  3. Ensure Certified Nursing Assistants (CNAs, or aides) provide a daily average of at least 2.45 hours of care to each resident. Aides assist residents with “activities of daily living” such as toileting, bathing and eating.

“This standard will certainly help residents in those bottom-of-the-barrel facilities,” said Richard Mollot, executive director of the Long Term Care Community Coalition, a nonprofit that advocates for nursing home residents.

But he, like some researchers, worry that not including minimum requirements for licensed practical nurses (LPNs) or establishing a total care rule could backfire, with nursing homes opting to cut staff positions not explicitly governed by the regulations.

USA TODAY investigation Many nursing homes are poorly staffed. How do they get away with it?

“Over and over again, we have seen the industry take every opportunity possible to cut staffing to decrease costs and increase profits,” Mollot said. “CMS is opening the door to increased levels of abuse and neglect for the large majority of nursing home residents. Anyone who cares about nursing home residents, or even just the appropriate use of taxpayer funds, should be outraged.”

The Biden administration wants to set a minimum nurse staffing standard for nursing homes.

The Biden administration wants to set a minimum nurse staffing standard for nursing homes.

Proposal could cost businesses billions

The federal government spends nearly $90 billion a year on Medicaid and Medicare stays at nursing homes − many of them run by companies that report double-digit profit margins.

A study conducted to develop the new regulations estimated that increasing staff levels could save taxpayers about $500 million a year in fewer emergency room visits, hospitalizations and other services.

But industry groups argue the proposed rules would cost more money without improving care, saying numeric requirements do not line up with the complexities of providing health services.

“We hope to convince the administration to never finalize this rule as it is unfounded, unfunded and unrealistic,” wrote Mark Parkinson, president and CEO of the American Health Care Association, the nation’s largest trade association for nursing home operators and owners.

The federal study estimated the new rules could cost nursing homes as much as $5.1 billion annually to increase staffing. That does not include the administration’s call for higher wages and better working conditions.

The president and CEO of LeadingAge, an association for aging services providers, said that even if the proposed regulations made sense their members still could not meet them.

“There are simply no people to hire – especially nurses,” Katie Smith Sloan said.

Nation will need more health care workers

Nursing homes today employ about 135,000 RNs and 450,000 CNAs nationwide, in addition to LPNs and other staff. The federal study estimated that the proposed rule would require facilities to hire another 12,600 RNs and 76,000 CNAs, increases of 9% and 17% respectively.

Smith Sloan called on federal and state officials to reform immigration policies, increase payments from Medicaid and Medicare to match delivery costs, and expand health care training programs if they want to increase staff numbers.

“Nursing homes have for too long been ignored and underfunded,” she said.

Union officials disagreed with industry leaders about the reasons skilled nursing facilities struggle to hire and retain workers.

“Our country doesn’t have a shortage of good nursing home workers—just a shortage of good nursing home jobs,” AFL-CIO President Liz Shuler said.

Median pay for CNAs in 2019 was lower than other entry level jobs in most states, according to the U.S. Department of Health and Human Services. Nursing homes also often pay nurses and aides less than hospitals and other care settings, which complicates recruitment.

In addition to the draft regulations, the Biden administration said Friday it is spending more than $75 million on financial incentives to boost the workforce, such as scholarships and tuition reimbursement.

Grabowski, the Harvard researcher, emphasized that improving the quality of care in nursing homes will not be solved by a single policy.

“The work is just starting,” he said.

This article originally appeared on USA TODAY: Biden proposes first-ever nursing home staff minimums

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