Meeting state minimums does not guarantee federal F725 compliance, meaning facilities must evaluate staffing against both the numeric floor and the dynamic, resident-acuity-based federal standard, while also preparing for enhanced facility assessment obligations embedded in the proposed CMS mandate.
‘Only the Beginning’: Staffing Mandate Assessments May Push Operators to the Brink
Beyond minimum staffing requirements, operators may need to prepare for updated assessment requirements, which leaders say will be a “core” aspect of the mandate, along with the 24-hour registered nurse (RN) requirement.
“While we propose to require all LTC facilities (subject to exemptions) to comply with the minimum nursing staffing requirements, … those minimum standards are only the beginning,” the Centers for Medicare & Medicaid Services (CMS) wrote in the mandate proposal.
CMS wants nursing homes to go beyond meeting the minimum staffing thresholds, to appropriately staffing for the needs of their resident population, including their acuity levels, cultural and clinical needs. CMS’s proposed staffing mandate calls for Medicare and Medicaid-certified nursing homes to provide a staffing equivalent of 3 hours per resident per day (PRPD), with 0.55 hours of care from registered nurses (RNs) and 2.45 hours of care from certified nursing assistants (CNAs).
— Skilled Nursing News, November 16, 2023
According to nursing home advocates, New York’s Department of Health sent out its first set of letters to nursing home providers on Wednesday.
Penalties assessed can be as much as $2,000 a day, and the letters are meant to give nursing homes a warning of violation of the staffing mandate, with labor information being based on Payroll Based Journal (PBJ) data.
The Department of Health is issuing these initial determination letters to providers showing them how they came up short on CNAs, RNs or LPNs, said Stephen Hanse, president and CEO of New York State Health Facilities Association. Penalties assessed can be as much as $2,000 a day, and the letters are meant to give nursing homes a warning of violation of the staffing mandate, with labor information being based on Payroll Based Journal (PBJ) data.
— Skilled Nursing News, August 3, 2023
Nurses, Not Policymakers, Should Determine Appropriate Staffing Levels
Though a handful of state legislatures are considering mandating nurse-to-patient staffing ratios, government mandates are not the answer to nurse staffing, the American Organization of Nursing Leadership (AONL) has declared.
“Staffing is a complex decision based on the experience and clinical expertise of the nurse, care team, resources, and patient needs,” AONL said in a prepared statement. “Organizational leaders, nurse managers, and direct care nurses, not policymakers, should collaboratively align staffing with patient needs.”
“Mandated nurse staffing standards remove real-time clinical judgment and flexibility from nurses. Government-mandated ratios do not account for an individual patient or the healthcare team’s needs in an ever-changing environment, nor do they account for the variability among healthcare organizations.”
— HealthLeaders Media, July 18, 2023
As many skilled nursing facilities are falling short of expected federal requirements for adequate nursing staff, the shortage has led to a failure to promote the well-being of residents and to burnout and low retention for current staff.
According to a recent staffing report by the Long Term Care Community Coalition, data provided by the federal government reveals that U.S. nursing homes had an average of only 3.61 total nurse staff hours per resident day (HPRD) in the fourth quarter of 2022. This falls significantly below the threshold necessary to ensure the proper care and support of residents.
Alaska tops the nation with 6.0 total nurse staff HPRD, with only 8 other states making it above the requirement of 4.1 HPRD proposed by the Biden Administration’s forthcoming minimum staffing mandate. The report analyzed the payroll-based journal data from the Centers for Medicare & Medicaid Services (CMS) for every nursing home across the country, as mandated by reporting requirements.
— Skilled Nursing News, July 14, 2023
With Federal Staffing Proposal Near, States Also Working Toward Minimums
State lawmakers are showing an appetite for mandatory healthcare staffing rules, with new nursing home-specific or tough hospital proposals on the table in at least four additional states.
CMS announced last year it would pursue a national minimum staffing level for nursing homes to ensure resident safety and quality of care. A month later, the American Health Care Association issued a report showing that it would cost up to $11 billion per year and require nursing homes to hire approximately 187,000 nurses. The report found that just 6% of nursing homes had 4.1 hours of care per patient per day, a figure floated for at least a decade after an academic study.
— McKnight’s Long-Term Care News, January 23, 2023
A Word of Warning: Beware of Staffing Ratio Violations
In July 2022, IDPH issued nursing home staffing ratio violations, with huge penalties, for the January – March 2022 quarter, citing deficiencies in meeting the state’s minimum staffing requirements. After providers were up in arms about the penalties, which clearly would have bankrupted many facilities outright, it was clearly discovered that IDPH’s staffing ratio calculations were incorrect. In other words, IDPH utilized incorrect census information and staffing information from PBJ reporting or from facility reports that were outdated. Facilities also must make sure the facility’s PBJ reporting (which the government uses to assess staffing) is accurate and take steps to correct incorrect PBJ reports now.
— McKnight’s Long-Term Care News, November 21, 2022
Nearly Half of States Now Using Medicaid to Boost Direct-Care Pay
At least 19 states are actively implementing strategies to address direct care worker wages through reporting and/or enforcement mechanisms, a report issued this week by the National Governors Association Center for Best Practices found.
“Although many healthcare providers have received rate increases through temporary federal COVID-19 relief and state funding, only a limited number of states have policies to ensure funds are passed on to direct care workers.”
Medicaid is the largest payer for facility-based and home and community based settings care, paying for 42.1% of all long-term services and supports in 2020.
— McKnight’s Long-Term Care News, November 4, 2022
SNF Operators in Favor of Staffing Standards But Not Without Funding, Role Expansion
Ahead of a federal minimum staffing ratio to be proposed for the nation’s nursing homes, data continues to show a shortfall of available staff to meet such requirements.
Many operators are in favor of higher staffing levels, but not without state or federal funding to hire and retain the appropriate level of staff. Others hope the types of positions counted in a staffing minimum will be expanded beyond registered nurses (RNs), licensed practical nurses (LPNs) and certified nursing assistants (CNAs).
A recent Pulse survey conducted by Skilled Nursing News showed that 40% of respondents who operate in a state where staffing mandates are in place are unable to meet those requirements. Nearly 67% of survey respondents said they would also like to see other positions considered in creating a minimum staffing standard. About 94% of nursing homes would need to increase staffing levels just to be in compliance with a 4.1 minimum staffing ratio, according to CLA data.
— Skilled Nursing News, October 9, 2022
Ask the Nursing Expert: Does Meeting State Minimums Satisfy Federal F725 Requirements?
Q: If we meet state-level staffing minimums, will we have sufficient staff under F725, Sufficient Nursing Staff?
A: Meeting state minimums does not guarantee compliance with federal staffing standards.
States with minimums require a specific number of staff, while the federal rule is more dynamic; more nursing staff may be necessary to meet federal mandates.
Meeting state minimums does not guarantee compliance with federal staffing standards. Federal regulations require facilities to “have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.”
States with minimums require a specific number of staff, while the federal rule is more dynamic; more nursing staff may be necessary to meet federal mandates. State surveyors also use the Payroll Based Journal system to examine staffing, so ensure PBJ data is submitted timely and accurately.
— McKnight’s Long-Term Care News, October 7, 2022
