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Establishing a federal minimum staffing requirement will help ensure there is adequate staff to care for those living in nursing homes. To that end, evidence-based staffing thresholds are needed at the levels determined necessary to ensure adequate care.
We urge CMS to recognize and include the role of LPNs/LVNs in the final rule establishing minimum nursing home staffing standards. This could be done by establishing a minimum licensed nursing standard (HPRD) that includes a specific RN HPRD minimum with the difference made up of LPN/LVN or RN time as determined by the individual nursing home.
We strongly support a final rule that would strengthen the staffing requirements by requiring:
- The care provided by a licensed nurse should be set at 1.4 hours per resident day (HPRD), with at least 0.75 of that provided by an RN. CMS should determine a LPN specific standard to meet part or all of the remainder of the licensed nurse requirement.
- The care provided by a CNA should be 2.8 HPRD.
CMS proposed a requirement for licensed nurses that includes a minimum of 0.55 HPRD of care from RNs. While this proposal is better than no standard, the 2023 Abt study supports a significantly higher staffing standard that would be far more protective of both residents and workers.
For decades, health researchers, geriatricians, nurses, and other clinical experts have recommended minimum nurse staffing requirements to improve the quality of care at nursing homes. As far back as 2001, the Centers for Medicare & Medicaid Services (CMS) noted the “strong and compelling” evidence for having minimum staffing levels. Moreover, a blue-ribbon panel convened by the National Academy of Science, Engineering, and Medicine (NASEM) noted in its 2022 report that increasing overall nurse staffing has been a consistent and longstanding recommendation for improving the quality of care in nursing homes.
Minimum standards are intended to ensure that staffing will not fall to a level that would be harmful to residents. Over 20 years ago an in-depth, evidenced-based CMS study found that each nursing home resident required at least 4.1 hours of direct care each day to avoid compromised care that placed residents at risk of harm.
Unfortunately, this proposed rule would implement a standard of care well below the 4.1 hours of care. While AAJ strongly supports the intent of this proposed rule, the proposed regulations as currently drafted will endanger rather than protect the lives of residents in long-term care facilities.
The need for a federal minimum staffing standard in our nation’s nursing homes is clear. As explained in the NPRM, a large body of evidence shows that higher levels of direct care staffing in nursing homes are associated with improved quality of care and resident health outcomes.
We also believe the available evidence, including the staffing study that CMS recently commissioned, point to a reasonable basis for higher minimum standards than proposed in the NPRM. Specifically, the following minimum staffing standards are both attainable and would improve outcomes for residents:
- CNA – 2.8 HPRD.
- RN – 0.75 HPRD.
The June 2023 Nursing Home Staffing Study Comprehensive Report (the Report), which CMS commissioned Abt Associates to conduct, offers several levels of possible HPRD standards that are higher and more impactful. While the proposal of 2.45 HPRDs for NAs mirrors the highest option in the Report, CMS’ proposal of 0.55 HPRDs for RNs is scaled back, falling between the medium and higher options in the Report. We recommend that CMS finalize a higher minimum HPRD threshold for RNs given the important role they serve and the available evidence that shows quality and safety increase with RN staffing levels.
While the agency may be attempting to strike a balance between establishing appropriate and reasonable standards and addressing challenges related to the cost of additional staffing and workforce shortages, the AGS believes a higher minimum staffing requirement is necessary to ensure quality and safety. It also would better keep pace with states that have established minimum staffing requirements, several of which already exceed the proposed standards. Further, higher staffing standards would enhance the quality of the positions that are available to NAs and RNs by lessening the existing burdens on the existing workforce.
ANA urges CMS to create a total staffing standard that retains the proposed HPRD ratios for RNs and NAs with an additional HPRD standard specific to LPNs.
We know that having an RN in person and onsite 24/7 in LTC facilities is important for patient care quality and safety. LTC facilities require the active contributions and clinical expertise of RNs at all times to ensure the delivery of skilled quality care for patients. As such, ANA urges CMS to finalize its proposal to require an in-person 24/7 RN presence in LTC facilities.
However, while well-intentioned, the proposed minimum staffing standards for RNs, certified nurse assistants (“CNAs”) and licensed practical nurses (“LPNs”) are too low to protect this critically vulnerable population. As explained below, unintended consequences of the Proposed Rule would include incentivizing many for-profit nursing homes to reduce staffing, which would increase harm to vulnerable residents. We strongly recommend that CMS adopt a minimum requirement of 4.1 hours per resident day (“HPRD”), comprised of 2.8 HPRD for CNAs, .75 HPRD for RNs, and .55 HPRD for LPNs.
However, CMS seems to overlook the critical finding from the 2001 Study that at levels below 4.1 HPRD care in nursing homes is compromised. It is undeniable that as staffing increases in nursing homes, so do quality and safety outcomes.
A 0.55 RN hours per resident per day (hprd) and 2.45 certified nursing assistant hprd standard is much too low to ensure resident safety and quality care. We do not agree with CMS, that a 3.00 total direct care staff hprd standard will force 75% of nursing homes to hire more staff. Most facilities have more than 3.0 hprd staffing. Rather than hire more staff, we expect the proposed rule could induce facilities to reduce staff.
The bottom line is 3.0 hprd is unsafe, low quality care. CANHR recommends the new rule require a total of 4.2 hprd for all direct care staff and 1.4 hprd licensed nurse direct care hours (excluding nurses performing administrative functions), 0.75 of which has to be RN hours. CMS itself cites its 2022 Abt study in finding that at least 1.4 direct care hprd is needed from nurses in order to provide minimally safe and high quality care.
Other labor challenges can be solved, as evidenced by the difference in staffing between for-profit facilities and nongovernmental nonprofit facilities. Average staffing for the latter already meets or exceeds the 4.1 HPRD. Both types of facilities receive the same reimbursement from public programs, but revenue is allocated differently.
The Center sees no justification in the proposed rule supporting the low nurse staffing ratio and standards that CMS proposes if the goals of staffing ratios are (as they should be) meeting residents’ actual clinical needs, minimizing delayed or omitted clinical care, and respecting residents’ quality of life and rights. The proposed staffing ratios violate the mandate of the 1987 Nursing Home Reform Law that – ‘It is the duty and responsibility of the Secretary to assure that requirements which govern the provision of care in skilled nursing facilities under this subchapter, and the enforcement of such requirements, are adequate to protect the health, safety, welfare, and rights of residents . . . .’
The inadequate staffing ratios and levels proposed by CMS fail to protect residents’ “health, safety, welfare, and rights.”
CMS’s 2001 staffing report, calling for 4.1 HPRD, should have been the starting point for the 2023 study.
The 3.0 HPRD in the proposed rule is even lower than staffing levels met by nursing facilities during the pandemic, when staffing shortages were rampant.
Although we strongly support CMS’s effort to establish minimum staffing standards for NHs, we recommend higher mandatory minimum staffing standards than CMS has proposed, along with specific guidelines for staffing levels based on resident acuity. The regulations as proposed are weak, have many potential negative unintended consequences and risk normalizing staffing levels associated with poor quality of care.
Research has shown that in the absence of national NH staffing standards, many facilities, especially for-profit facilities, have routinely maintained low levels of staffing. Establishing federal staffing standards may ensure that facilities provide adequate care to residents, but this is contingent upon what staffing standards are established.
Requiring nursing homes to freeze admissions when they fail to meet minimum staffing regulations is a common method used in nursing homes across the country. This should be one method of enforcement. Another method for handling new admissions when there has been a determination that staffing level regulations are not met, those new admissions should not be eligible for reimbursement until staffing levels have been in compliance for at least the previous six months.
RNs, LPNs/LVNs, and CNAs each have important roles in the provision of quality care to residents. A staffing standard should address total direct care for residents. These staffing levels are supported by decades of research and by the 2023 Staffing Study commissioned by CMS last year.
We commend the Administration for proposing minimum nursing staffing standards. The NPRM represents a paradigm shift in nursing home oversight to promote quality of care. At the same time, we strongly urge CMS to strengthen the proposed minimum nurse staffing standard, as detailed below. These proposed changes will increase the likelihood that the minimum staffing standard reaches the goal laid out in the original 2001 Abt study: to meet the requirements of the NHRA by identifying “staffing thresholds below which quality of care was compromised and above which there was no further benefit of additional staffing concerning quality.”
With respect to direct care, we strongly support a final rule that would strengthen the staffing requirements by requiring:
- The care provided by a licensed nurse should be set at 1.4 hours per resident day (HPRD), with at least 0.75 of that provided by an RN. CMS could choose to allow the facilities to meet the remainder of the licensed nurse requirement (.65 HPRD) with LPNs or RNs, or could mandate that time be met solely by LPNs; and
- The care provided by a CNA should be 2.8 HPRD.
These staffing levels are more protective of residents and direct care staff and, consequently, are more likely to meet both the statutory goals of the NHRA and the goals of the NPRM.
CMS has proposed a CNA HPRD staffing minimum that would place all residents at risk of harm. CMS relies heavily on the CMS-commissioned 2023 Abt Study in its proposal to establish a 2.45 CNA HPRD. This reliance is unfortunate because, in selecting the 2.45 HPRD, CMS ignores significant evidence that these staffing levels will result in significant levels of omitted care. The staffing recommendations from the 2023 study notably are not based on the foundational federal requirement that all nursing facilities provide “nursing services and specialized rehabilitative services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident.”
To ensure resident health and safety, it is incumbent on CMS to strengthen the final rule by: 1) implementing phased in minimum staffing requirements that include a total minimum staffing level of at least 4.2 hours per resident per day (HPRD), 2.8 HPRD of certified nurse aide and assistant (CNA) care, and 1.4 HPRD of licensed nursing care, a minimum of which must be fulfilled by 0.75 HPRD of registered nurse (RN) care; 2) adopting timestamped staffing data reporting requirements to ensure oversight of a 24/7 onsite RN staffing requirement; and 3) expanding reporting requirements to provide taxpayer accountability and transparency on all spending on compensation for nursing staff.
Higher staffing levels result in lower mortality rates, fewer rehospitalizations and emergency room visits, as well as reduced incidents of infections, pressure ulcers, weight loss, and dehydration. Strong staffing standards also promote resident independence as patients receive adequate training and assistance to improve activities of daily living. Finally, nursing homes with higher staffing levels have fewer deficiencies cited.
A recent Department of Health and Human Services (HHS) Office of Inspector General (OIG) report that examined the deadly impact of COVID-19 on nursing home residents recommended that CMS establish minimum staffing requirements. Finally, a joint investigation by the Senate Committee on Finance and the Senate Special Committee on Aging evaluated a series of HHS OIG nursing home audits finding that understaffing at nursing homes contributes to inadequate emergency preparedness, leaving older adults and people with disabilities vulnerable to extreme weather events. It is clear that a staffing standard will help improve care and save lives.
It is notable, however, that average staffing for nongovernmental nonprofit facilities already meets or exceeds the 4.1 hours per resident day standard identified in the 2001 study by Abt Associates and, according to the 2023 Abt Associates study, provided 43 minutes more per resident day than for profit homes. The example of the non-profit facilities — which receive the same reimbursement as their for-profit counterparts — demonstrates that achieving adequate staffing is possible.
We are dismayed that CMS is proposing a 3.0 HPRD standard, that is known to cause residents harm and poor health and safety outcomes. This clearly appears to violate CMS’s own mission statement, which states: “The CMS Innovation Center fosters healthcare transformation by finding new ways to pay for and deliver care that can lower costs and improve care.”
By proposing a staffing standard that is lower than required to avoid harm to residents (4.1 per CMS’s own study), CMS is failing in its mission to foster a method to improve care.
We recommend adopting a national standard of at least 4.1 HPRD along with 24‐7 RN requirements. IF CMS adopts a lower standard than 4.1 HPRD, we request that CMS include language that will prevent states that have a higher HPRD standard from reducing their standard or allowing facilities to utilize a national lower standard.
These strengths of the NPRM notwithstanding, NASW believes that CMS’s laudable goals will not be reached unless the proposed nurse staffing standards are strengthened significantly. CMS has proposed that nursing homes provide 3.0 hours per day of resident care (hours per resident day, or HPRD): 2.45 HPRD of nurse aide care and 0.55 HPRD of RN care. The proposed standard does not require either LPN–LVN HPRD or total nurse staffing levels.
NASW is concerned that CMS’s proposed nurse staffing minimums are well below those found to be necessary more than 20 years ago.
Absent setting robust standards for safe staffing at the level recommended in CMS’ prior time-motion study published in 2001 and in subsequent similar analyses, the National Committee is gravely concerned that well-established patterns of chronic understaffing will continue in many nursing homes. Such homes should not continue to receive reimbursement and a “free pass” from federal officials who are charged with ensuring that every beneficiary receives safe care. Rather, nursing homes should be held accountable at a national level for providing good care, every day, to every resident, in every state in the county.
[D]ecades of research, including the 2023 Staffing Study, demonstrate the relationship between better health outcomes and higher RN staffing levels… Despite this evidence, CMS has proposed a minimum staffing standard for RNs that is too low. CMS’s justification for this RN level is that it is higher than every state’s minimum RN staffing standard. However, and importantly, CMS has proposed a minimum standard well below the current national average of .67 HPRD of RN care.
CMS has proposed a CNA HPRD staffing minimum that would place all residents at risk of harm. CMS relies solely on the 2023 Study in its proposal to establish a 2.45 CNA HPRD. In selecting the 2.45 HPRD, CMS ignores significant evidence that this will result in significant levels of omitted care for residents.
This proposed rule will begin to hold long-term care facilities, such as nursing homes, accountable for dangerous industry practices including the use of insufficient staffing that puts residents in harm’s way. Further, establishing a minimum staffing standard will help advance the quality of direct care jobs in long-term care facilities by ensuring that nursing assistants—who are disproportionately low-paid women of color—have a more manageable and reasonable workload so that they are empowered to do their important jobs sustainably and well.
Adequate staffing levels are achievable: Average staffing for nongovernmental, nonprofit facilities already meets or exceeds the 4.1 hours per resident day standard identified in the 2001 CMS study by Abt Associates. While for-profit facilities do not yet typically meet this standard, this failure is not due to any difference in reimbursement but because of how for-profit facilities choose to allocate their revenue. The Administration should not forego policies that would improve the quality of care simply because one industry segment—for-profit facilities— refuses to address a workforce problem of its own creation.
For decades, PHI has advocated for minimum staffing standards that would foster reasonable workloads and promote safety while ensuring the delivery of quality care to nursing home residents. The need for strong staffing standards is even more clear today, given the ever-increasing acuity of residents and the evidence that NAs support, on average, 13 residents per shift (and more, in many cases). The current, less prescriptive federal staffing requirement is not stringent enough to protect LTC facility residents or the staff that care for them. Thus, the proposed standards, which create a floor rather than a ceiling, are a critical step towards lessening NAs’ untenable workloads, safeguarding their health and well-being, improving their job satisfaction, and strengthening care continuity and quality for LTC facility residents.
SEIU strongly supports the proposed alternative structure that includes a total nurse staffing standard; however, we believe this standard should be 4.1 HPRD. In 2001, a widely referenced, CMS sponsored study determined 4.1 HPRD was a threshold “below which quality of care was compromised.” It is important to note that the 2001 study defined quality in terms of numbers of hospital transfers for preventable causes, pressure ulcers, residents experiencing weight loss, incidences of skin trauma, and other critical clinical care indicators. These indicators are linked to severe declines in quality of care for residents.
Given that nursing home residents need more care now than they did in 2001, it follows that safe staffing standards should now be at or above the level determined safe in 2001. Both qualitative and quantitative findings from the June 2023 Nursing Home Staffing Study and Comprehensive Report commissioned by CMS and carried out by Abt Associates show that increased staffing levels improve quality and safety in nursing homes.
CMS current proposal of only 2.45 hours per resident day (HPRD) of CNA care is too low and “staffing below 2.45 HPRD for CNAs does not improve safety and quality of care.” (NPRM, p. 61263). Further, CMS does not provide an explanation as to why a higher level of care was not adopted. This lack of information is troubling considering since the 2023 study that the 2.45 HPRD is based on documents that there are significant increases in safety outcomes for patients above the 2.45 CNS HPRD staffing level.
Select comments from individuals
I agree that a minimum staffing level should be implemented, without it corporations will not implement the change. Nurses and direct care workers cannot safely meet any residents need at a 2.8 ppd (minimum standard in my state). Higher minimum standards will help promote staff attendance, provide better care, along with promoting a safer home for the community.
Without strict regulations on PPD executive staff will not support the nursing team providing direct care.
CMS is tragically proposing that federal nursing home minimum nursing home staffing be set at 3.0 hours per resident per day (HPRD) when federal staffing data show that U.S. nursing homes’ staffing is already well above that level (3.63 total nurse staff HPRD in Q1 2023) and far below the 4.1 HPRD residents require for their care needs to be met based on CMS studies more than 20 years ago!!!
Inadequate staffing in nursing homes is cruel and inhumane and does not provide care that can be delivered appropriately with dignity and compassion. In the 2000s, CMS recommended more than what is being recommended here – only 3.1 hours/per staff. The standard should be no less than 4.1 hours/per day.
A robust staffing standard is crucial to ensure that nursing home residents receive appropriate care. For decades, studies show that higher staffing levels are associated with better care and lower staffing levels result in harm and death of residents. Understaffing in nursing homes is correlated with abuse, dropped nursing home residents, preventable falls, facility closures, bedsores, neglect, and violations of human dignity. During the current coronavirus pandemic, self-reported nurse staffing shortages were correlated with a 10.5 percent increase in deaths of residents.
A strong federal minimal nursing home staffing standard would also benefit nursing home employees. Nursing home staff are disproportionately women, people of color, and immigrants. Staff shortages can result in burnout, exhaustion, sickness, injuries, and other adverse effects. Nursing home workers risk injury when understaffing forces them to move a resident who should be moved by two employees.