On April 22, 2024, the Centers for Medicare and Medicaid Services (“CMS”) announced that it had issued several new rules affecting Medicaid beneficiaries and skilled nursing facilities. Most important to skilled nursing facilities is the new minimum staffing requirements put into place by CMS.
CMS Requires A Minimum of 3.48 Hours of Total Direct Nursing Care
Under the new rule, CMS is requiring all nursing homes that receive federal funding through Medicare and Medicaid to provide a minimum of 3.48 hours of total direct nursing care to residents, of which .55 hours must be provided by a Registered Nurse and 2.45 hours to be provided by nurse aids. CMS clarifies that facilities are able to use any combination of nursing staff (RN, LPN, LVN, or nurse aides) to account for the additional .48 hours needed to comply with the new standards. According to a White House Fact Sheet, this means that a facility with 100 residents would need at least two or three RNs and at least ten or eleven nurse aides as well as two additional nursing staff (which could be registered nurses, licensed professional nurses, or nurse aides) per shift to meet the minimum staffing standards.
CMS Is Finalizing The Requirement for RN to be onsite 24/7
Additionally, CMS indicates it is finalizing the requirement for an RN to be onsite 24 hours a day/seven days a week and that such RN must be available to provide direct resident care (the 24/7 RN can be the Director of Nursing, however, this person must be available to provide direct resident care).
The Biden Administration states that the requirements of the staffing rules will be introduced in phases, with longer timeframes for rural communities and that limited, temporary exemptions will be available for both the 24/7 RN requirement and the underlying staffing standards for nursing homes in “workforce shortage areas that demonstrate a good faith effort to hire”.
The response by nursing home organizations to the new CMS rule has been sharply critical. Mark Parkinson, American Health Care Association president, stated that “[i]t is unconscionable that the Administration is finalizing this rule given our nation’s changing demographics and growing caregiver shortage. Issuing a final rule that demands hundreds of thousands of additional caregivers when there’s a nationwide shortfall of nurses just creates an impossible task for providers. This unfunded mandate doesn’t magically solve the nursing crisis.”
Indeed, the new staffing rules could force closures of skilled nursing facilities. KFF issued an independent study evaluating the implications of the proposed rule last year and found that only 19% of nursing facilities would meet the minimum RN and nursing staff standards and also found that 81% would be required to hire additional nursing staff under the new rule.
Efforts were made in Congress to prevent the implementation of the new CMS rule. Senator Deb Fischer (R-Neb) introduced the Protecting Rural Seniors’ Access to Care Act in December 2023, but the bill failed to advance as a result of a lack of Democratic support. Senator Fischer issued a statement following the implementation of the new staffing standards rules stating: “[t]ime and again, this administration has abandoned rural America, leaving working families and small businesses in the dust. Instead of listening to the overwhelming, bipartisan opposition to this rule, the administration has decided to plow ahead. This misguided rule will devastate nursing homes across this country and worsen the staffing shortages we are already facing.
The Fight For Increased Wages
At the same time, nursing home workers are fighting for increased wages. For example, on April 28, 2024, the Minnesota Nursing Home Workforce Standards Board voted to set minimum wages for nursing home workers at $22 per hour by 2026. These actions create substantial pressure on skilled nursing facilities working to provide their residents quality care.
We will soon begin to see how the new staffing rules affect nursing home facilities and their ability to provide quality care to their residents. Nursing home facilities and organizations are encouraged to document how the new rules affect the care the facilities are able to provide to their residents and reach out to your congress members to voice your concerns.
1 https://www.whitehouse.gov/briefing-room/statements-releases/2024/04/22/fact-sheet-vice-president-harris-
announces-historic-advancements-in-long-term-care-to-support-the-care-economy/
2 https://www.ahcancal.org/News-and-Communications/Press-Releases/Pages/Nursing-Homes-React-to-Staffing-
Mandate-Final-Rule.aspx
3 https://www.kff.org/medicaid/issue-brief/what-share-of-nursing-facilities-might-meet-proposed-new-
requirements-for-nursing-staff-hours/
4 https://www.fischer.senate.gov/public/index.cfm/news?ID=7255648A-BCBE-40FF-BA7C-5CC74EE4534A
5 https://www.startribune.com/minimum-wage-of-22-proposed-for-minnesotas-nursing-home-
workers/600362495/
