Nursing Home Staffing Requirements
Currently, federal law requires nursing homes under the Centers for Medicare and Medicaid Services (CMS) to provide 24-hour licensed nursing care sufficient to “meet nursing needs of residents.”
Recently, the Biden administration announced reforms to help improve the quality of care in nursing facilities and the safety of residents.
Part of these reforms is ensuring that every nursing home has adequate staff members who are sufficiently trained to deliver excellent nursing home care to all residents. The Department of Health and Human Services (HHS) developed and implemented these new regulations.
What Are the Current Minimum Staffing Requirements in Nursing Homes?
The CMS requires nursing homes to have “sufficient nursing staff to meet residents’ needs.” However, the agency does not set specific guidelines on minimum staffing requirements, and regulations vary from state to state. There is no minimum number of direct care hours per resident day or a particular ratio of nursing home staff to residents.
In 2001, the CMS recommended the following daily minimum direct care hours per resident per shift:
4.1 hours of total direct nursing time for each resident
2.8 hours of direct care from certified nursing assistants
0.75 hours from registered nurses
0.55 hours from vocational or licensed practical nurses
These minimum daily standards are only recommendations and are not enforced by the agency.
Moreover, the federal government does not require nursing homes to meet a minimum staffing requirement or have a registered nurse (RN) or licensed nurse on all shifts. According to federal regulations, a nursing facility must have an RN on duty at least eight hours per day, seven days a week. Still, they do not specify that these hours must be allocated to direct care for residents.
According to a USA TODAY report, about 75% of nursing homes in the US had fewer RNs and nurse aides in 2021 than the expected number under Medicare regulations. However, only 4% were cited by state inspectors, and penalties for violators was sparse.
Researchers also found that sufficient nursing staff is the most prominent indicator of resident wellness.
What Happens When There Are Insufficient Registered Nurses and Other Staff Members in a Nursing Facility?
Vague minimum staffing requirements leave many facilities in the country understaffed. Multiple studies show that higher nursing home staffing levels are associated with better care, allowing staff members to focus on one resident at a time.
Conversely, insufficient nursing home staffing increases the risk of harm, including injuries such as:
Pressure ulcers
Broken bones
Spinal cord trauma
Contusions and lacerations
Burns
Overdose
Death
The lack of sufficient staff and staffing hours also makes way for the poor quality of life for residents, often demonstrated by:
Lack of personal hygiene
Poor psychosocial well-being
Unintentional weight loss
Recurring infections and other illnesses
Dehydration
What Can We Expect Under the New Nursing Home Reforms?
The widespread staffing crisis has worsened in recent years, highlighting significant issues within the nursing home industry already suffering from chronic understaffing.
On February 28, 2022, President Biden announced a set of reforms to improve the standard of care for nursing home residents. A fundamental initiative under the administration’s strategy is to set new minimum staffing requirements to ensure “every nursing home provides a sufficient number of staff who are adequately trained to provide high-quality care.”
According to the White House, CMS will conduct a new study to identify the level of staffing required to ensure proper care in nursing facilities and propose new regulations within a year.
Additionally, the agency issued a Request for Information (RFI) as part of its recently released Fiscal Year 2023 Skilled Nursing Facility Prospective Payment System Proposed Rule, aiming to obtain information from the public to help develop new federal requirements for minimum staffing.
Nursing Homes Are Expected to Face More Challenges with Upcoming Staffing Requirements
The American Health Care Association (AHCA), representing over 14,000 nursing homes in the US, found that meeting staffing standards according to the federal minimum staffing requirement will cost facilities $10 billion yearly to hire sufficient staff to meet the needs of all residents.
“This report makes it crystal clear that increasing staffing standards in nursing homes require substantial and consistent government resources. Even then, nursing homes would have the impossible task of finding another 187,000 nurses at a time when vacant positions sit open without applicants for months on end,” said Mark Parkinson, the CEO and President of AHCA.
Furthermore, the association states that 18% of residents may be at risk of displacement as facilities are forced to reduce their capacities to meet the minimum requirement for direct care staff.
Increasing the number of direct care staff and staffing hours could positively impact total and intermediate care for residents. Even so, the budget needed to raise staffing to the federal level would likely increase operating costs for nursing homes, increasing the risk of more budget cuts and closures. New rules would also increase training costs and make it more difficult for facilities to find capable nurses, nurse aides, and other nursing home employees.
Ultimately, new requirements would affect vulnerable residents the most, potentially making it harder for seniors and disabled individuals to get the care they need.
“Every nursing home wants to hire and develop more caregivers, but they can’t do it alone. An enforcement approach will not solve this long-term care labor crisis. We urge the Administration and Congress to put forth meaningful aid and policies that will help us recruit and retain the dedicated caregivers our nation’s seniors deserve,” said Holly Harmon, RN, from AHCA.
Potential Benefits for Nursing Home Residents
On a more positive note, increasing the number of nursing staff and direct care hours per resident will help ensure quality care in nursing facilities.
With enough staff, facility residents will receive more supervision and care from occupational therapists and registered, vocational, and licensed practical nurses, helping prevent pain, injury, and illness.