With federal staffing proposal near, states also progressing toward minimums

Aug 3, 2023 | State Mandates & Medicaid, Minimum Staffing

News Digest: States also pursuing minimum staffing policies

While CMS considers implementing a minimum staffing rule for Medicare (ultimately issued September, 2023), a number of state legislatures have taken up the responsibility to ensure facilities in their state start meeting minimum levels even sooner than the potential federal mandate.

These articles detail state initiativees being developed while the world waits for CMS’ new rules.


‘A Microcosm’: States Push Minimum Staffing Mandates on Nursing Homes in Pennsylvania, NY as Providers Notified of Violations

As the nursing home sector nervously awaits a potential federal minimum staffing mandate, several states are implementing similar mandates of their own, with New York issuing initial letters of violation of state policy this week.

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.

August 3, 2023


Siddiqi, Zahida. “‘A Microcosm’: States Push Minimum Staffing Mandates on Nursing Homes in Pennsylvania, NY as Providers Notified of Violations.” Skilled Nursing News, Aug. 2023, skillednursingnews.com/2023/08/a-microcosm-states-push-minimum-staffing-mandates-on-nursing-homes-in-pennsylvania-ny-as-providers-get-notified-of-violations.


Nurses, Not Policymakers, Should Determine Appropriate Staffing Levels

  • A handful of state legislatures are considering mandating nurse-to-patient staffing ratios.
  • California is the only state to establish minimum RN-to-patient ratios in every hospital unit, though other states have differing ratio rules.
  • Health system leaders, nurse managers, and direct care nurses—not policymakers—should determine correct staffing, AONL says.

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.”

July 18, 2023


July, Analysis |. by Carol Davis |. “Nurses, Not Policymakers, Should Determine Appropriate Staffing Levels.” HealthLeaders Media, www.healthleadersmedia.com/nursing/nurses-not-policymakers-should-determine-appropriate-staffing-levels.


With federal staffing proposal near, states also progressing 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 $10 billion per year (since increased to $11 billion) 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. 

January 23, 2023


Towhey, Jessica. “With Federal Staffing Proposal Near, States Also Progressing Toward Minimums.” McKnight’s Long-Term Care News, 23 Jan. 2023, www.mcknights.com/news/with-federal-staffing-proposal-near-states-also-working-toward-minimums.


A word of warning: Beware of staffing ratio violations

We are all waiting to see the possibility of proposed rules over federal minimum staffing ratios in nursing homes.

But with possible federal minimum staffing ratios looming, let’s make sure the government calculates staffing ratios right!  After all, one state recently experienced incorrect calculations for nursing home staffing levels, and facilities that sit back and wait for the government to work out proper calculations may be frightened to learn of the potential legal and public implications.

[P]roviders need to pay attention and not readily accept government calculations.  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.  

November 21, 2022


Bilimoria, Neville. “A Word of Warning: Beware of Staffing Ratio Violations.” McKnight’s Long-Term Care News, 19 Nov. 2022, www.mcknights.com/blogs/guest-columns/a-word-of-warning-beware-of-staffing-ratio-violations.


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,” the report stated. “The direct care workforce represents a critical component of the United States employment market, yet pay remains low. States have taken a variety of actions through provider rate increases and minimum wage policies through the Medicaid program as two strategies to address recruitment and retention.”

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. 

November 4, 2022


Bush, Joe. “Nearly Half of States Now Using Medicaid to Boost Direct-care Pay.” McKnight’s Long-Term Care News, 4 Nov. 2022, www.mcknights.com/news/nearly-half-of-states-now-using-medicaid-to-boost-direct-care-pay.


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).

The current federal requirement does not provide a specific daily minimum standard, rather, it states that nursing homes must provide “…sufficient nursing staff to attain or maintain the highest practicable … well-being” of every resident.

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. About 56% of respondents to SNN’s survey said they operate in a state that requires staffing minimums.

October 9, 2022


Stulick, Amy. “SNF Operators in Favor of Staffing Standards but Not Without Funding, Role Expansion.” Skilled Nursing News, 10 Oct. 2022, skillednursingnews.com/2022/10/snf-operators-in-favor-of-staffing-standards-but-not-without-funding-role-expansion.


Ask the Nursing Expert - State vs Federal Staffing Minimums

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.

Each surveyor will observe and interview to consider nurse staffing; if they find issues, surveyors then investigate further. These investigations may uncover resident care or safety issues linked to insufficient nurse staffing.

State surveyors also use the Payroll Based Journal system to examine staffing, so ensure PBJ data is submitted timely and accurately.

October 7, 2022


Stewart, Amy. “Ask The Nursing Expert.” McKnight’s Long-Term Care News, 7 Oct. 2022, www.mcknights.com/print-news/ask-the-nursing-expert-23.

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