How Can Facilities Get Ready for Minimum Staffing Requirements?

Nov 12, 2023 | Minimum Staffing, Nursing HPRD & Turnover

News Digest: Resolving Staffing Shortages Is Key to Compliance with Mandate

PBJ data and labor force participation data illustrate the challenge for the senior care industry to add staff to the required levels.  Various studies and interpretations of minimum rules show that compliance will be an expensive proposition and significant effort.


U.S. News Ranking Exposes Critical Staffing Shortages at Nursing Homes, With Only 5% Meeting CMS Proposal’s Requirements

The U.S. News & World Report’s 2024 Best Nursing Homes ratings released Tuesday reveals that only fewer than 5% of nursing homes across the country will meet both the current federal staffing requirements and the newly proposed standards by the Biden administration.

The report comes on the heels of the end of the comment period for the Centers for Medicare & Medicaid Services’ (CMS) minimum staffing proposal for the skilled nursing sector, during which stakeholders accumulated more than 45,000 comments, many in opposition to the mandate.


Shelby Grebbin. “U.S. News Ranking Exposes Critical Staffing Shortages at Nursing Homes, With Only 5% Meeting CMS Proposal’s Requirements.” Skilled Nursing News, 14 Nov. 2023,


Proposed nursing home staffing mandate would hurt senior living providers ‘fishing from the same pool’ of workers

Even though the staffing mandate proposed by the Centers for Medicare & Medicaid Services directly would apply only to nursing homes, senior living providers as well as providers across the rest of the aging services continuum would be affected because they are “fishing from the same pool” of workers, LeadingAge President and CEO Katie Smith Sloan said Monday.

The bottom line, she said, speaking at the opening session of the LeadingAge Annual Meeting, is that the proposal simply is not viable. “There are just not enough people to hire,” Sloan said.

The CEO said that the proposed standard for nursing homes, as written, would require 90,000 additional nurses and nurse aides at a cost of approximately $7.1 billion annually.


Bonvissuto, Kimberly. “Proposed Nursing Home Staffing Mandate Would Hurt Senior Living Providers ‘Fishing From the Same Pool’ of Workers.” McKnight’s Senior Living, 9 Nov. 2023,


Analysis Reveals the Effects the CMS Staffing Proposal Would Have on Nursing Homes

The Centers for Medicare and Medicaid Services’ (CMS) new proposed rule has generated lots of discussion within the senior care industry. The rule, which we covered last month, would establish new requirements for registered nurse and nurse aide staffing levels in nursing homes. It also requires nursing homes to have a RN on duty 24/7. Designed to establish stronger staffing requirements, the rule also establishes new Medicaid reporting requirements.

KFF, an independent source for health policy research, polling, and journalism, has released a brief examining the share of nursing facilities that might meet the proposed new staffing requirement. Alice Burns, associate director of KFF’s Program on Medicaid and the Uninsured, sat down with iAdvance Senior Care to discuss the brief and what its findings mean for the nursing home industry.


Cerulli, Paige. “Analysis Reveals the Effects the CMS Staffing Proposal Would Have on Nursing Homes.” I Advance Senior Care, 3 Nov. 2023,


Unfunded mandate leaves staffing ‘puzzle’ unsolved: researchers

Two preeminent skilled nursing researchers are calling for significant changes to a proposed federal staffing mandate that would build on “the rule’s strengths while addressing shortcomings and minimizing unintended consequences.”

In the short term, Harvard healthcare policy expert David Grabowski, PhD, and Scripps Gerontology Center Fellow John Bowblis (pictured), PhD, urged the Centers for Medicare & Medicaid Services to use a total nurse-hour measure to ensure that licensed practical nurses remain a core component of daily nursing home care.

In the long-term, the researchers encouraged CMS to shorten its implementation window and take a harder look at system-level challenges in paying for nursing home care.


Marselas, Kimberly. “Unfunded Mandate Leaves Staffing ‘Puzzle’ Unsolved: Researchers.” McKnight’s Long-Term Care News, 31 Oct. 2023,


Nursing home shortages ‘biggest public policy issue’ for state, nation: Virginia provider exec

As the threat of a federal mandate inches closer to reality, nursing homes in Virginia are reporting major difficulties finding qualified staff.

A recent survey from the Virginia Health Care Association/Virginia Center for Assisted Living of its members found that 31% of respondents said they had “few to no applicants” for open positions. And 91% of respondents said they have vacancies for certified nursing assistants — a role that makes up a significant part of the recently proposed federal staffing mandate.


Marselas, Kimberly. “Nursing Home Shortages ‘Biggest Public Policy Issue’ for State, Nation: Virginia Provider Exec.” McKnight’s Long-Term Care News, 31 Oct. 2023,


(Opinion) Federal mandate for nursing staff ‘undermines access to care’

In 2016, well before an apocalyptic global pandemic wreaked havoc on our nation’s health care workforce, the Obama Administration acknowledged that mandating nursing home staff ratios would have the effect of “stifling innovation, and would not result in the improved quality and person-centered care that we seek in facilities.”

Further, the Obama Administration warned, presciently, in rejecting a suggested 24/7 registered nurse (RN) requirement, that “geographic disparity in supply could make such a mandate particularly challenging in some rural and underserved areas.”

In its inexplicable efforts to resurrect what the Obama Administration rejected, the Biden Administration commissioned a study finding no “clear evidence basis for setting a minimum staffing level” and warning “nursing homes are currently very challenged in hiring and retaining direct care workers, because of workforce shortages and competition from higher-paying agency positions.”


Williams, Brendan. “(Opinion) Federal Mandate for Nursing Staff ‘undermines Access to Care’ – NH Business Review.” NH Business Review, 23 Oct. 2023,


‘Sirens Going Off’: Providers Warn of Mass Closures, Vast Nursing Home Deserts Due to Staffing Mandate

As nursing homes closures continue across the country, “nursing home deserts” are expanding, and the proposed federal staffing mandate is expected to exacerbate the problem.

This is despite attempts to make the potential policy change easier for providers in rural markets, which are especially vulnerable to access issues. Operators in these areas point to the 24-hour RN requirement as being especially devastating.

Nate Schema, CEO with the Evangelical Lutheran Good Samaritan Society, says the organization’s facilities located in “deep rural communities” will struggle the most with the 24-hour RN rule.


Amy Stulick. “‘Sirens Going off’: Providers Warn of Mass Closures, Vast Nursing Home Deserts Due to Staffing Mandate.” Skilled Nursing News, 19 Oct. 2023,


Skilled Nursing Operators Put ‘Pedal to the Metal’ to Increase RN Staffing in Light of Federal Mandate

The recently proposed federal nursing home staffing mandate includes the requirement that all facilities have a registered nurse on staff around the clock, every day of the week. Operators are taking some early steps to prepare for this requirement even as they rally against this aspect of the mandate, arguing that 24/7 RN staffing will be impossible for certain facilities.

In particular, providers are mobilizing to hire more RNs or training licensed practical nurses (LPNs) for the role, executives at regional and national nursing home chains said at Skilled Nursing News’ recent RETHINK conference in Chicago.

For companies with facilities in both rural and urban areas, the staffing proposal’s sweeping standards are a source of particular concern.


Zahida Siddiqi. “Skilled Nursing Operators Put ‘Pedal to the Metal’ to Increase RN Staffing in Light of Federal Mandate.” Skilled Nursing News, 17 Oct. 2023,


AHCA CEO: Nursing Home Policy Nightmare Just Starting, Business Nightmare Persists — But Clinical Nightmare Over

The “clinical nightmare” created by Covid-19 has come to an end, but the “business nightmare” related to the pandemic is ongoing, and the “policy nightmare” has only just begun.

That’s according to Mark Parkinson, CEO and president of the American Health Care Association/National Center for Assisted Living (AHCA/NCAL), the largest nursing home provider association in the United States.

“What’s keeping me up right now is the policy nightmare,” Parkinson said Monday at the AHCA/NCAL Annual Convention and Expo, taking place in Denver. “ … The proposed staffing rule is an overreaction — a poor reaction to a horrible crisis that we all experienced.”


Tim Mullaney. “AHCA CEO: Nursing Home Policy Nightmare Just Starting, Business Nightmare Persists — but Clinical Nightmare Over.” Skilled Nursing News, 2 Oct. 2023,


First state analysis shows mass closures under ‘catastrophic’ federal staffing proposal

A proposed federal staffing mandate would force an estimated 4,000 skilled nursing beds out of service in Michigan, according to an analysis by the state’s largest nursing home advocacy group.

The Health Care Association of Michigan surveyed its members and accessed facility statistics through the American Health Care Association’s LTC Tracker to find that 71% of facilities in the state would not meet the proposed staffing rule for certified nurse aides. In addition, 41% of facilities would not be able to meet the requirement to provide 0.55 hours of direct care by a registered nurse and “almost no” facilities are capable of having an RN on duty 24/7.


Towhey, Jessica R. “First State Analysis Shows Mass Closures Under ‘Catastrophic’ Federal Staffing Proposal.” McKnight’s Long-Term Care News, 25 Sept. 2023,

Kaiser health news

What Share of Nursing Facilities Might Meet Proposed New Requirements for Nursing Staff Hours?

…This issue brief analyzes the percentage and characteristics of facilities that would meet the rule’s proposed requirements for the minimum number of RN and nurse aide hours to better understand the implications of the rule. The analysis does not evaluate facilities’ ability to comply with other requirements, including the requirement to always have a registered nurse on duty 24/7 or the ability to meet the new reporting and assessment requirements due to data limitations (see methods). The analysis uses Nursing Home Compare data, which include 14,591 nursing facilities (97% of all facilities, serving 1.17 million or 98% of all residents) that reported staffing levels in August 2023.

  • Among all nursing facilities, fewer than 1 in 5 could currently meet the required number of hours for registered nurses and nurse aides, which means over 80% of facilities would need to hire nursing staff.
  • 90% of for-profit facilities would need to hire additional nursing staff compared with 60% of non-profit and government facilities.
  • The percentage of nursing facilities that would meet the requirements in the proposed rule varies from all in Alaska (100%) to nearly none in Louisiana (1%).


What Share of Nursing Facilities Might Meet Proposed New Requirements for Nursing Staff Hours? | KFF.” KFF, 27 Oct. 2023,


KFF: Fewer Than One in Five Nursing Homes Could Meet Federal Staffing Proposal

Fewer than one in five facilities would currently meet the required number of hours for RNs and CNAs as set forth in the federal minimum staffing proposal, with more than 80% of the facilities nationwide needing to hire more nursing staff.

This is according to an analysis published by KFF on Monday.

Interestingly, almost half of the skilled nursing facilities (SNFs) currently meet the registered nurse (RN) requirements, while only 28% cover the minimum hours for certified nursing assistants (CNAs).


Amy Stulick. “KFF: Fewer Than One in Five Nursing Homes Could Meet Federal Staffing Proposal.” Skilled Nursing News, 18 Sept. 2023,


Nearly 450K Residents at Risk of Displacement if Mandate is Enacted, As Access Issues Compound

As nursing homes limit admissions due to ongoing labor challenges, residents can expect a mounting access crisis, with some U.S. counties being turned into “nursing home deserts.”

This is according to a report released Wednesday by the American Health Care Association (AHCA), which notes that nearly 450,000 residents will be displaced if a potential minimum staffing mandate were to be enacted. These estimates are based on if SNFs had to comply with a 4.1 hours per resident day staffing minimum.

“Too many of our nation’s seniors are having to look farther and wait longer for the long-term and post-acute care they need. These are sobering numbers and should serve as a wake-up call to policymakers to help nursing homes rebuild,” said Mark Parkinson, president and CEO of AHCA/NCAL.


Amy Stulick. “Nearly 450K Residents at Risk of Displacement if Mandate Is Enacted, as Access Issues Compound.” Skilled Nursing News, 23 Aug. 2023,


Analysis warns few nursing homes could now meet 3.5 staffing hours per day

A national analysis finds that nearly half of US nursing homes would not meet a daily, 3.5-hour nurse staffing requirement and just 29% would meet a standard of 4.0 hours.

The work from KFF exposes the challenge that nursing homes will have if the long-anticipated federal staffing mandate from the Centers for Medicare & Medicaid Services requires 4.1 hours of direct care per resident per day, as some sector observers have predicted.

National nursing home advocates and providers in nearly every state have been warning that severe workforce challenges will hinder compliance, if not make it impossible.


Towhey, Jessica R. “Analysis Warns Few Nursing Homes Could Now Meet 3.5 Staffing Hours per Day.” McKnight’s Long-Term Care News, 22 Aug. 2023,


KFF: Only 29% of Nursing Homes Would Meet 4-Hour Federal Staffing Mandate

Ahead of the federal nursing home minimum staffing ratio proposal, a KFF analysis released Friday suggests that less than a third of the nation’s nursing homes would even come close to meeting forthcoming minimum staffing requirements.

The analysis from KFF found nearly all facilities would meet a 2.5 or fewer hour per resident day (HPRD) staffing requirement, while 85% of SNFs say they could handle 3.0 HPRD. Worryingly, close to half, or 45% of SNFs say they could not meet a 3.5 HPRD requirement, and only 29% would meet 4.0 HPRD.

Moreover, there was a “wide variation” across the country, KFF found, if facilities were required to meet staff levels exceeding 3.0 HPRD.


Amy Stulick. “​​KFF: Only 29% of Nursing Homes Would Meet 4-Hour Federal Staffing Mandate.” Skilled Nursing News, 14 July 2023,

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