The enhanced facility assessment requirements — effective within 60 days of finalization — add new documentation obligations around staffing plans and resident acuity that must align with ongoing PBJ reporting practices.
“The proposed rule consists of three core staffing proposals: 1) minimum nurse staffing standards of 0.55 hours per resident day (HPRD) for Registered Nurses (RNs) and 2.45 HPRD for Nurse Aides (NAs); 2) a requirement to have an RN onsite 24 hours a day, seven days a week; and 3) enhanced facility assessment requirements. The proposed rule also includes a staggered implementation approach and possible hardship exemptions for select facilities. This proposed rule results from a multi-faceted approach aimed at determining the minimum level and type of staffing needed to enable safe and quality care in LTC facilities. This effort included… reviewing recent years of Payroll-Based Journal System staffing data.”
Citation: Centers for Medicare & Medicaid Services. “Medicare and Medicaid Programs: Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting (CMS 3442-P).” Centers for Medicare & Medicaid Services, 1 Sept. 2023. https://www.cms.gov/newsroom/fact-sheets/medicare-and-medicaid-programs-minimum-staffing-standards-long-term-care-facilities-and-medicaid
Nursing home staffing rule ‘balanced and achievable,’ CMS official says
“Overall, we believe that these proposals are balanced and achievable, but I want to remind everyone that this is a proposed rule,” Richards said. “We believe that all staff, including LPNs, are vital to the care that residents receive on a daily basis. We expect long-term care facilities to continue considering all staff when determining the staffing and resource needs based on the facility assessment. Our goal, as we have said throughout, was to identify the type and minimum staffing levels needed to establish a broadly applicable floor across all long-term care facilities that would significantly reduce the risk of unsafe and low-quality care.”
— McKnight’s Long-Term Care News, September 15, 2023
If you recognize the first part of the title of the blog post, then we share the same taste in movies! The well-known phrase (which I modified slightly), “If you build it, he will come,” comes from my favorite movie, Field of Dreams, in which the main character, Ray Costello (played by Kevin Costner), builds a baseball field in order to bring his father’s favorite baseball player, Shoeless Joe Jackson, back to life. My version, “if you require it, they will come,” doesn’t refer to something quite as exciting, but it’s what the Centers for Medicare & Medicaid Services (CMS) aims to do with its new proposal to require long-term care (LTC) facilities to institute specific nurse staffing ratios.
“CMS still expects that 12,639 additional RNs and 76,376 additional nurse aides will be needed to meet the agency’s proposed HPRD requirements, before accounting for any exemptions. CMS stated in the proposed regulation that ‘some facilities may be challenged in hiring and retaining nursing staff such as registered nurses and certified nursing assistants due to local workforce unavailability, while others may need to improve pay and job quality in order to attract and retain staff, given competition from higher-paying positions or alternate career paths.'”
— JD Supra (McDermott+), September 8, 2023
CMS Proposes Minimum Staffing Requirements and Enhanced Facility Assessments for Nursing Homes
“According to CMS estimates, approximately 75% of nursing homes would have to increase their staffing levels to meet these requirements at a cost of about $40.6 billion over 10 years. CMS also noted that the proposed RN requirement is higher than every state requirement and only lower than the District of Columbia, and that the proposed NA requirement is higher than all existing standards based on September 2022 data. CMS explicitly noted that the enhanced facility assessments are intended to ‘guard against any attempts by [facilities] to treat the minimum staffing standards . . . as a ceiling, rather than a floor’ and that minimum staffing standards ‘are only the beginning.'”
— Crowell & Moring LLP, September 8, 2023
Long Term Care Facilities Face Mandatory Minimum Staffing Requirements
“Facilities that fail to submit required data to CMS’s Payroll-Based Journal System will also be ineligible for a hardship exemption. The proposed rule notes that facility compliance with staffing requirements will be published on the Care Compare website, including whether a facility has obtained a hardship exemption.
As proposed, the RN and NA HPRD requirements would establish a floor that is independent of a facility’s patient case-mix. In other words, no facility would be permitted to operate below .55 RN HPRD and 2.45 NA HPRD, and if the acuity needs of residents in a facility require a higher level of care, a higher RN and NA staffing level would be required.”
— The National Law Review (Sheppard, Mullin, Richter & Hampton LLP), September 6, 2023
Raising the Floor: CMS Proposes New Nurse Staffing Requirements for Long-Term Care Facilities
“The Proposed Rule responds to chronic understaffing concerns in the post-acute setting, which was exacerbated by the COVID-19 public health emergency, and attempts to ‘improve[] the likelihood that [the 1.4 million LTC facility] residents in the U.S. are provided safe, high-quality care, and that workers have the support they need to provide high-quality care.’
While the impact of the Proposed Rule would be state-dependent, as some states have no laws on point while others have similar laws to the Proposed Rule, it imposes substantial costs on LTC facilities, managers, owners, and other stakeholders.”
— Ropes & Gray LLP, September 6, 2023
CMS issues first-ever nursing home staffing mandate
“US nursing homes would have at least three years to provide a minimum of 3.0 hours per patient day of direct care, 0.55 hours of that by a registered nurse and 2.45 hours by a nurse aide, under a first-ever proposed federal staffing mandate released this morning.
Non-rural nursing homes would have three years to comply with some elements of the rule, with rural facilities given five years to get up to speed on the overall hourly rate.
A requirement calling for 24/7 RN coverage, triple the current standard, would go into effect two years after the rule is finalized for urban providers, with another year granted to rural providers.
The proposal does include an option for hardship waivers, an element providers had pleaded for given the sector’s ongoing workforce crisis.”
— McKnight’s Long-Term Care News, September 1, 2023
CMS Issues Proposed Minimum Staffing Rule
CMS released the proposed minimum staffing rule this morning (see their press release and fact sheet). The rule is mostly what we expected. Our pre-rule campaign had an impact, but there are still major problems with the rule. If finalized, large portions of the sector would be out of compliance. On top of that, there is no funding to implement these mandates. For this and other reasons you can count on a vigorous AHCA campaign to continue to shape and/or stop this rule.
“Is this paid for? NO. There is no funding for the additional expense of these nurses and nurse aides. Obviously, this is a major flaw of the proposal. There is $75 million for some scholarships and tuition reimbursement programs to help grow the workforce, but nothing to fund these new requirements.
CMS’s own estimate is that the total cost over 10 years will be $40.6 billion with an average annual cost of $4.06 billion.”
— AHCA/NCAL, September 1, 2023
“Additionally, CMS announced a national campaign to support staffing in nursing homes. CMS will work with the Health Resources and Services Administration (HRSA) and other partners to make it easier for individuals to enter careers in nursing homes, investing over $75 million in financial incentives such as scholarships and tuition reimbursement.
This staffing campaign builds on other actions through the HHS Health Workforce Initiative, including the recent announcement that HRSA awarded more than $100 million to train more nurses and grow the nursing workforce.”
— Florida Hospital News and Healthcare Report, September 1, 2023
