CMS to Boost Nursing Home Staffing Requirements to Impossible Levels

Kaiser Health News reported that the Biden Administration is proposing new staffing standards for nursing homes. The new standards were prompted by assumptions that inadequate staffing led to the death of nearly 200,000 nursing home residents from Covid. I’m not convinced these data points are related but that never stopped government officials from using a natural disaster to boost regulations.

The proposal, by the Centers for Medicare and Medicaid Services, would require all facilities to increase staff up to certain minimum levels, but it included no money for nursing homes to pay for the new hires.

Around two-thirds of nursing home stays are paid for by Medicaid and some others by Medicare. Well over half of nursing home residents rely on Medicaid, while Medicare only covers a limited number of lifetime nursing home days. Medicare nursing home stays are usually while recuperating after hospital care. Medicare does not cover nursing home stays for seniors who no longer can perform activities of daily living like cooking, eating, cleaning, bathing, dressing and so on.

CMS estimated that three-quarters of the nation’s 15,000 homes would need to add staff members. But the increases at many of those facilities would be minor, as the average nursing home already employs nurses and aides at, or very close to, the proposed levels.

Some facilities will get waivers if they can show there are shortages of available workers and they have tried to recruit more but were unsuccessful. The problem is the worker shortage is behind a lot of nursing home problems. Workers willing to work in nursing homes are in short supply and those willing to work in nursing homes can now demand more money than minimum wage.

The biggest problem with the new proposed rule is that is will require a registered nurse be on staff 24/7. That is roughly three times the hours that most nursing homes have RNs on staff. Evenings and weekends require substantial pay premiums. The rule would also require 2.45 hours of nursing assistants per resident, for a staffing ratio of about 1 nursing assistant to 10 residents.

Not everyone is happy with the new standard. Those facilities struggling with higher labor costs and worker shortages will have a more difficult time making ends meet.

“It’s meaningless to mandate staffing levels that cannot be met,” Katie Smith Sloan, the president and chief executive of LeadingAge, an association that includes nonprofit nursing homes, said in a statement. “There are simply no people to hire — especially nurses. The proposed rule requires that nursing homes hire additional staff. But where are they coming from?”

On the other hand, some advocates lobbied for even tougher standards.

“Fundamentally, this standard is wholly inadequate to meet the needs of nursing home residents,” said Richard Mollot, the executive director of the Long Term Care Community Coalition, an advocacy group based in New York.

Why would some nursing homes lobby for higher standards? There are distinct levels of service in the nursing home community. Some cater to Medicaid patients and are spartan in amenities, while others cater to affluent self-pay residents and are expensive (i.e. $10,000 to $12,000 a month). If the expensive ones can raise costs of their lower-cost rivals it reduces competition.

In a post from last January, I wrote about nursing homes closing in large numbers, saying:

MarketWatch even compared being a nursing home staffer to walking dogs for a living. Its conclusion was that dog walking is more rewarding, both financially and in terms of job satisfaction.

Some local community colleges and nursing homes in Western Colorado are working together to create programs to train more workers. Nursing homes are offering internships with coursework credit at local colleges towards certification. I imagine Colorado would have more success with this type of program than states with less scenery and fewer outdoor activities. Also, Grand Junction has a population of 67,000 people. That’s a veritable metropolis compared to some places that need nursing home workers.