Biden administration proposes new standards to boost nursing home staffing

Reviewed by Megan Craig, M.Sc.Sep 1 2023

The nation's most thinly staffed nursing homes would be required to hire more workers under new rules proposed on Friday by the Biden administration, the greatest change to federal nursing home regulations in three decades.

The proposed standard was prompted by the industry's troubled performance earlier in the coronavirus pandemic, when 200,000 nursing home residents died. But the proposal falls far short of what both the industry and patient advocates believe is needed to improve care for most of the 1.2 million Americans in nursing homes.

The proposal, by the Centers for Medicare and Medicaid Services, would require all facilities to increase staff up to certain minimum levels, but it included no money for nursing homes to pay for the new hires.

CMS estimated that three-quarters of the nation's 15,000 homes would need to add staff members. But the increases at many of those facilities would be minor, as the average nursing home already employs nurses and aides at, or very close to, the proposed levels.

"The standards are a lot lower than what a lot of experts, including myself, have called for over the years," said David Grabowski, a professor of health care policy at Harvard Medical School. "There are some real positives in here, but I wish the administration had gone further."

The government said it would exempt nursing homes from punishment if they could prove that there was a local worker shortage and that the facilities had made sincere efforts to recruit employees.

"Fundamentally, this standard is wholly inadequate to meet the needs of nursing home residents," said Richard Mollot, the executive director of the Long Term Care Community Coalition, an advocacy group based in New York.

Executives in the nursing home industry said that without extra money from Medicare or Medicaid — the two federal insurers that pay for most nursing home care — the requirement would be financially unattainable.

"It's meaningless to mandate staffing levels that cannot be met," Katie Smith Sloan, the president and chief executive of LeadingAge, an association that includes nonprofit nursing homes, said in a statement. "There are simply no people to hire — especially nurses. The proposed rule requires that nursing homes hire additional staff. But where are they coming from?"

The new staffing standard would require homes to have daily average nurse staffing levels amounting to at least 0.55 hours per resident. That translates to one registered nurse for every 44 residents. But that is below what the average nursing home already provides, which is 0.66 hours per resident, a 1:36 ratio, federal records show.

At least one registered nurse would have to be on duty at all times under the proposed plan — one of the biggest changes for the facilities, as they currently must have nurses for only eight consecutive hours each day.

The proposed rule also calls for 2.45 nurse aide hours per resident per day, meaning a ratio of about one aide for every 10 residents. While the federal government sets no specific staffing requirements for nurse aides, the average home already provides 2.22 nurse aide hours a day, a ratio of about 1:11.

"The federal minimum staffing standards proposed by CMS are robust yet achievable," the agency said in a statement. "The proposal also makes clear that the numerical staffing levels are a floor — not a ceiling — for safe staffing."

Registered nurses are at the top of the chain of command at nursing homes, overseeing assessments of residents and handling complex clinical tasks. Nurses delegate more straightforward clinical roles to licensed practical nurses.

Certified nurse assistants, often called nurse aides, are generally the most plentiful in a nursing home and help residents with basic needs like bathing, getting out of bed and eating.

On average, registered nurses make $37 an hour while licensed practical nurses earn $28 an hour, according to CMS. Aides often start at minimum wage or slightly above, earning $17 an hour on average.

"People have more choice," said Tina Sandri, the chief executive of Forest Hills of DC, a nursing home in Washington, D.C., referring to nursing home staff. "They can go to hospitals and make more and do less than they do here in a nursing home."

"We've lost staff to hospitals that had $20,000 signing bonuses," she added, "and as a nonprofit, we can't compete with that."

Nursing home officials say they cannot afford to pay higher wages because state Medicaid programs reimburse them too little. Patient advocates, however, note that some for-profit homes are providing substantial returns to investors.

Medicare and Medicaid spent $95 billion on nursing home care and retirement community care in 2021, according to CMS. The agency estimated that the new standards would cost homes another $4 billion in three years, when all homes except those in rural areas would need to comply. Rural homes would have five years.

Ellen Quirk, a retired certified nurse assistant in Hayes, Virginia, recalled that sometimes she would care for all of the residents on a single floor in the nursing home, which could be 20 or more people, by herself. It's challenging for an aide to care for more than five to seven people at a time, she said.

"If it's more than that, then things aren't done properly," Quirk, 63, said. "Things are skipped over, like a bath or changing them every couple of hours or feeding them properly."

"I've seen patients that roll over and fall out of bed," she added. "Sometimes they get bed sores because beds are saturated in urine for hours and hours."

The nursing home industry has been pressing federal and state governments to pay for a bevy of enticements to long-term care workers, including educational subsidies for those who have worked in nursing homes, loan forgiveness and career opportunities for certified nursing assistants working toward their nursing degrees.

The administration said it would offer $75 million in scholarships and tuition as part of the new proposal. The administration is accepting comments for the next 60 days before it finalizes the new standard.