Strong Early Pushback to Proposed Staffing Rule

Sep 30, 2023 | Minimum Staffing

News Digest: Staffing Shortages and Perceived Benefits Questioned

Advocates and the industry absorbed and reacted to CMS’ Proposed Rule for Minimum Staffing standards, and quickly shifted into promoting their views.  Many questioned the ability to meet a new mandate in light of a widespread nursing shortage and a lack of funding to increase staffing levels or wages.


The hypocrisy of staffing mandates

Absorbed as you probably are in fighting through the long-term care staffing crisis while parrying a CMS mandate, I wouldn’t blame you for not noticing. But at airports across America, big planes are nearly crashing into each other in the skies and on the ground. And not just once in a while. Nearly all the time.

A recent report by the New York Times identified 46 incidents involving major airlines in July of 2023 alone, and stated that “close calls … have been happening, on average, multiple times a week.” What’s a close call? Well, how about a FedEx plane passing within 100 feet of a Southwest jet with 128 passengers taking off for Cancun? That close.


Tetz, Gary. “The Hypocrisy of Staffing Mandates.” McKnight’s Long-Term Care News, 19 Oct. 2023,


In this corner, long-term care providers …

Don’t be fooled by the public civility. The relationship between long-term care providers and regulators is, by nature, one of shared mistrust.

Providers tend to see regulators as meddlesome at best, business killers at worst. Conversely, regulators tend to see providers as insubordinate at best, people killers at worst. You might say there’s a certain level of built-in tension.

Reminds me a bit of two feuding relatives who must put on a show of unity at a family gathering. The façade can quickly crumble once the drinks start to flow. Well, consider the liquor cabinet officially unlocked.

And this time, it’s the Center for Medicare & Medicaid Services holding the keys.

After months of promising, federal regulators have released a proposal that requires skilled care operators to hire more workers.


O’Connor, John. “In This Corner, Long-term Care Providers ….” McKnight’s Long-Term Care News, 13 Oct. 2023,


Quality does not equate to staffing mandates

I recently returned from the AHCA/NACL national convention and expo, one of my favorite conferences of the year. One reason why it’s a favorite is the recognition of quality in our profession.

There is a 90-minute awards session, recognizing Bronze, Silver and Gold Quality award winners throughout our nation. These are facilities who worked darn hard to achieve quality, measured results, applied for the award, were subject to immense scrutiny using the Baldrige process by a team of examiners, and were awarded for achieving quality. Definitely not an easy feat to accomplish.

There were 399 Bronze winners, 72 Silver winners and two Gold winners. Holy moly! The excitement at the award session was palpable. People cheering, standing, clapping, applauding, some crying tears of joy. It was incredible!

Now picture this: All of this amazing quality was achieved without having an unfounded, unfunded, unrealistic and unachievable staffing mandate in place.


Jacqueline Vance Rnc. “Quality Does Not Equate to Staffing Mandates.” McKnight’s Long-Term Care News, 10 Oct. 2023,


Already losing count of the staffing mandate arguments? You’re not alone

For those of you already a bit frustrated or even disgusted with the hullabaloo surrounding the proposed nursing home staffing minimum rule, look out. It’s about to get even uglier.

To confirm your worst fears, the combatants are starting to resort to that repugnant four-letter word. Yes … math.

Except for the obvious professionals who have to use numbers and calculations in their daily chores, it seems many, if not most, people would rather speak in public in their underwear than deal with them. Journalists, with rare exception, are in that boat.


Berklan, James M. “Already Losing Count of the Staffing Mandate Arguments? You’re Not Alone.” McKnight’s Long-Term Care News, 29 Sept. 2023,


CCRC ratings unlikely to be affected by SNF staffing mandates: Fitch

The minimum staffing rule that most nursing homes will be required to meet within the next three years will add to staffing pressures at continuing care retirement / life plan communities, but it will not affect their ratings, according to a new report from Fitch Ratings.

If the draft rule released earlier this month by the Centers for Medicare & Medicaid Services is implemented as written, non-rural nursing homes will be required to provide a minimum of three hours per patient day of direct care — 0.55 hours of that care by a registered nurse and 2.45 hours by a nurse aide — within three years. Rural nursing homes will have five years to implement the overall hourly rate.

Ratings will not be affected, Fitch said, because although most CCRCs contain a skilled nursing component, they also include other service lines, such as independent living and assisted living, and can adjust the number of skilled nursing beds in service.


Gaivin, Kathleen Steele. “CCRC Ratings Unlikely to Be Affected by SNF Staffing Mandates: Fitch.” McKnight’s Senior Living, 24 Oct. 2023,


Upper Valley nursing homes say federal staffing proposal ignores work force realities

Administrators of Upper Valley nursing homes are balking at proposed changes to federal staffing requirements, which they say would be difficult for them to meet and could put beds offline, reducing the availability of long-term care in the region.

But nursing organizations say it’s not a question of whether to bolster staffing in nursing homes, but how.

The Biden administration has proposed new rules for long-term care facilities that accept payments from the government insurance programs Medicare and Medicaid as a way of improving safety. Outbreaks of COVID-19 during the public health emergency, which ended in May, led to illness and deaths of residents and workers.

But the proposed new rules come as nursing homes are already struggling to meet current staffing requirements.


Doyle-Burr, By Nora. “Upper Valley Nursing Homes Say Federal Staffing Proposal Ignores Work Force Realities.” Valley News, 16 Sept. 2023,


When long-term care becomes a slugfest

If you ever want to see something really wrong, just watch two sides fight when both think they’re really right. It usually isn’t pretty.

That describes the climate created by the nursing home staffing mandate proposed on Friday.

Even before the release, providers had lobbied hard to impress upon rulemakers that there isn’t enough money in the government propped-up system to fund what they want. Nor enough bodies to fill the workstations they desire.

On the other side of the arena stands a crowd of regulators, consumers/voters, labor groups and academics who want more for patients. Some seem to be suspicious of any provider that doesn’t prolong health status indefinitely. Most are pretty adamant that they are going to fight for higher nurse-hours-per-day requirements, and — fair warning — they will have public sentiment on their side.


Berklan, James M. “When Long-term Care Becomes a Slugfest.” McKnight’s Long-Term Care News, 6 Sept. 2023,


Nursing home staffing mandate puts assisted living communities at risk of losing workers, experts say

Assisted living communities are at risk of losing staff members following the first-ever proposed federal staffing mandate for nursing homes, released Friday, according to senior living experts.

Competition for workers, especially nurses and other caregivers, may increase at a time when all providers already face recruiting and retention challenges.

The Centers for Medicare & Medicaid Services released its expected draft rule last week. It calls for US nursing homes to ensure that each resident receives a minimum of 0.55 hours of registered nurse care and 2.45 hours of nurse aide care each day. Nonrural nursing homes would have three years to comply, and rural facilities would have five years. A requirement for around-the-clock registered nurse 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.

Many assisted living providers continue to deal with staffing shortages, whereas others have almost rebuilt their workforce back to pre-pandemic staffing levels, National Assisted Living Center Executive Director LaShuan Bethea told McKnight’s Senior Living.


Bonvissuto, Kimberly. “Nursing Home Staffing Mandate Puts Assisted Living Communities at Risk of Losing Workers, Experts Say.” McKnight’s Senior Living, 24 Oct. 2023,


Timeline a Win, But RN Provision Draws Ire as Nursing Home Industry Reacts to CMS’ Staffing Proposal

Mixed reactions to the nursing home minimum staffing mandate continued to roll in over the weekend – along with an editorial from President Joe Biden – following a first glimpse of the proposal on Friday.

As the president underlined the need for more staff to improve quality, the 24/7 provision for registered nurses (RNs) continued to draw ire from leaders across every corner of the nursing home industry, with advocates calling for more funding. Meanwhile, the lead time given to implement the mandate was seen as a win for the sector by all sides.

In his editorial for USA Today, President Biden said what he has seen from private equity firms informed the structure of the proposed staffing minimum mandate. Specifically, Biden pointed to PE firms “slashing key staff” after buying nursing homes in order to cut costs and make bigger profits, and endangering the safety of residents.


Amy Stulick. “Timeline a Win, but RN Provision Draws Ire as Nursing Home Industry Reacts to CMS’ Staffing Proposal.” Skilled Nursing News, 5 Sept. 2023,


Providers find few silver linings, stew over minimum staffing demands

The initial jolt of the newly proposed nursing home staffing mandate has softened little over the long holiday weekend and now those tasked with making it work — providers — are coming to grips with how to cope.

Despite deep provider resentment over the mandate, there is little doubt it will take some enacted form. Now it comes down to how much provider advocates might get the toughest provisions softened.

Regulators’ call for 24/7 registered nurse coverage in every nursing home — triple the current eight-hour requirement — will take center stage, virtually all stakeholders agree.


Berklan, James M. “Providers Find Few Silver Linings, Stew Over Minimum Staffing Demands.” McKnight’s Long-Term Care News, 5 Sept. 2023,


What New Nursing Home Staffing Rules Would Mean For Residents And Patients

In a long-awaited and highly controversial decision, the federal Centers for Medicare and Medicaid Services (CMS) has proposed that nursing homes provide at least three hours of staff time daily for every patient or resident.

Would it meaningfully improve care at nursing facilities? Not by much.

The rule would require facilities to provide enough staff to deliver 33 minutes (.55 hours) of nursing care and 2 hours, 27minutes (2.45 hours) of nursing assistant time each day. A registered nurse would have to be on site 24/7. Separately, the agency asked for comment on a minimum standard of 3.48 hours.

And in a provision that suggests CMS may be considering an entirely different standard, the agency wants to require states to report what share of Medicaid payments each nursing home spends on direct care workers. That and other reporting eventually could be used to require facilities to dedicate a minimum percentage of their revenue to staffing, rather than (or perhaps in addition to) mandating specific hours.


Gleckman, Howard. “What New Nursing Home Staffing Rules Would Mean for Residents and Patients.” Forbes, 5 Sept. 2023,


Industry Critics Blast ‘Tremendously Unfunded’ CMS Nursing Home Staffing Mandate, Warn of Severe Access Issues

As the nursing home industry finally gets a first look at the long-awaited proposed minimum staffing mandate released early Friday, leaders across the sector say that its most critical aspects deal with implementation timing, a “good faith” provision, and requirements for registered nurses (RNs).

As it stands, the proposed rule has major implications for access issues with about 294,000 nursing home residents at risk of displacement across the sector, according to audit, tax and consulting firm CliftonLarsonAllen (CLA), while operators and nursing home advocates say it is grossly underfunded. This, while the industry still struggles with staffing shortages and as caregiver numbers slowly inch up toward pre-pandemic levels, as highlighted by the federal government’s latest jobs report, also released Friday.


Amy Stulick. “Industry Critics Blast ‘Tremendously Unfunded’ CMS Nursing Home Staffing Mandate, Warn of Severe Access Issues.” Skilled Nursing News, 6 Sept. 2023,

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