New Legislation
On April 22, 2024, the Centers for Medicare & Medicaid Services (CMS) affirmed its commitment to hold nursing homes accountable for providing high-quality care for the nearly 1.2 million residents living in long-term care facilities by issuing the Minimum Staffing Standards for Long-Term Care (LTC) Facilities and Medicaid Institutional Payment Transparency Reporting final rule.
The rule was motivated by the high number of deaths seen during the pandemic of COVID-19 outbreaks due to inadequate nursing staffing levels and is the most significant federal rule to affect the over 15,000 nursing homes in several decades.
Additionally, it is well-studied that the profit incentive is linked to low staffing because for-profit homes operate with lower staffing and more quality deficiencies (violations) than nonprofit and publicly owned facilities. Facilities with the highest profit margins have been found to have the poorest quality.
Added Requirements
LTF facilities must now meet the following staffing ratios:
- Nursing homes that receive funding through Medicare and Medicaid must provide the staffing equivalent of at least 3.48 hours of nursing care per resident, per day.
- This includes 0.55 hours of care from a registered nurse and 2.45 hours from a nurse aide daily.
- A registered nurse also must be on site 24 hours a day, seven days a week, to provide skilled nursing care at the facilities.
Implementation Concerns
While the CMS ruling will go a long way to addressing patient safety and quality in LTCs, only 1 in 5 current nursing facilities would meet the staffing requirements stated in the final rule.
80% of the nation’s 15,000 nursing homes will need to hire more staff to come into compliance with the mandate, costing the industry an estimated $43 billion over ten years.
LTCFs in urban settings will need to fill approximately 10,500 RN positions (a 9.7% increase) and 35,300 NA positions (a 9.9% increase) to comply with the staff standards, and 3,267 LTCFs will need to hire RNs to meet the 24-hour standard.
The American Health Care Association (AHCA), a national lobbying group representing more than 14,000 long-term care providers, issued a statement calling the rule “an unreasonable standard”, stating new staff requirements could lead to nursing home shutdowns and the displacement of residents to the national shortage of nurses and clinical providers.
LTC Malpractice Claims Related to Staffing
- Pressure ulcers: Nursing home residents who are immobile are at risk of developing pressure ulcers. Understaffing leads to vague turning and repositioning of residents, increasing the risk of ulcer complications osteomyelitis, and sepsis.
- Infection Control: Understaffing leads to poor infection control practices, as seen during the pandemic with COVID 19 outbreaks.
- Malnutrition: Understaffing can result in inadequate assistance with eating and drinking, leading to malnutrition and dehydration. Residents may not receive adequate assistance in preparing meals and are at increased risk of neglect with low staffing levels.
- Medication errors: Nursing home residents typically require multiple medications, often with complex dosing schedules. Understaffing can lead to missed medication doses for diseases such as diabetes, hypertension, and coronary artery disease, leading to serious complications.
- Falls and injuries: Understaffing can result in delayed response times when residents require help getting up or moving around, increasing the risk of falls
Takeaways
Among all nursing facilities, fewer than 1 in 5 could currently meet the required number of hours for registered nurses and nurse aides, which means over 80% of facilities would need to hire nursing staff.
90% of for-profit facilities would need to hire additional nursing staff.
The percentage of nursing facilities that would meet the requirements in the proposed rule varies from all in Alaska (100%) to nearly none in Louisiana (1%).
Implementation of the new staffing requirements will cost LTCFs $43 billion over 10 years.
While the new CMS staffing requirement will aim to deliver the safety and quality that nursing homes deliver to residents, the implementation will be challenging. With over $43 billion in added staffing costs -with LTCs responsible for this added cost – and challenges already in the healthcare industry in finding trained medical providers, it is unclear how most LTCs will be able to meet this standard.
Expect an increasing number of LTC shutdowns, especially in for-profit entities that will no longer be able to increase profit margins with lean staffing in the coming decade. The downstream effect may be seen in more patients accessing hospitals and emergency rooms to access care, leading to adding additional stress to the hospital systems.
While CMS’s new standards are ambitious, innovations utilizing hospital-at-home solutions and remote technology to help address the cost and staffing constraints may also need to be added to meet this new standard.
