Proposed Federal Rule Would Set Staffing, Transparency Requirements for Nursing Homes

On Sept. 1, the Centers for Medicare and Medicaid Services (CMS) introduced a proposed rule that, for the first time, outlines federal minimum staffing standards for direct patient care in long-term care (LTC) facilities. The rule also would establish new transparency guidelines for the facilities.

The staffing standards are described in terms of direct care hours per resident day, i.e., the total number of hours that each type of nursing staff (registered nurses and nurse aides) provides care to residents, divided by the number of residents.

The proposed rule would:

• Establish minimum nurse staffing levels of 0.55 hours per resident day for registered nurses and 2.45 hours for nurse aides, for a total of three hours per resident day.
• Require a registered nurse to be present on-site 24/7.
• Establish a consistent process for assessing and documenting resource and staffing levels to better govern LTC facilities.

Recognizing the unique challenges rural facilities face, including a diminishing pool of healthcare professionals, the proposal offers a phased implementation strategy that differs between urban and rural settings.

Existing staffing requirements vary at the state level, with 38 states and the District of Columbia having their own minimum standards, potentially leading to differences in care quality at LTC facilities in different states. Arkansas requires a minimum of 3.36 direct care hours per resident day — higher than the proposed federal standards — but LTC facilities can allocate nursing staff flexibly (i.e., there are not separate requirements for registered nurses and nurse aides) to meet that minimum.

Several studies have found that higher levels of nurse staffing were associated with better resident outcomes, such as reduced emergency room visits and fewer health complications. From 2017 to 2018, 75% of nursing homes almost never met the expected registered nurse staffing levels calculated by CMS for its consumer tools Nursing Home Care Compare and the Five-Star Quality Rating System. The COVID-19 pandemic exacerbated pre-existing staffing issues, further straining the resources of many LTC facilities. In response to these challenges, Arkansas, along with several other states, permanently added or expanded minimum staffing requirements.

The proposed rule also would require state Medicaid agencies to publicly disclose percentages of payments to nursing homes and intermediate care facilities for direct care workers and support staff to provide care to people with intellectual disabilities.

The goal of the proposed rule is to encourage a better working environment, improve the overall quality of services offered to residents, and avoid problems like frequent emergency visits and costly hospital stays, which may occur when there is not enough staff to provide quality care.

In conjunction with the proposed rule, CMS announced that it will work with the Health Resources and Services Administration to initiate a national campaign to facilitate easier pathways for individuals to build careers in long-term care through incentives such as scholarships and tuition reimbursements.