On September 1, 2023, the Centers for Medicare and Medicaid Services (CMS) released the Notice of Proposed Rule Making (NPRM), which aims to establish minimum staffing standards to address the safety and quality concerns for the 1.4 million residents receiving care in Medicaid and Medicare certified long-term care (LTC) facilities. As written in the summary of the NPRM, “Numerous studies, including our new research study as well as existing literature, have shown that staffing levels are closely correlated with the quality of care that LTC facility residents receive, and with improved health outcomes.”

While advocates like VOYCE are excited to see CMS step up to make these changes, we have concerns with the proposed rule.

Key factors include:

  • Nursing homes would be required to provide 3 hours of direct care per resident per day. This requirement includes .55 hours of Registered Nurse (RN) care and 2.45 hours of Certified Nurse Aide (CNA) care. In 2001, a CMS study found that 4.1 hours of direct care per day was necessary to avoid “compromised care that placed residents at a risk of harm.”
  • Facilities would be required to have an RN on staff 24 hours a day, an increase from the current requirement of 8 hours per day.
  • There is no proposed standard for Licensed Practical Nurse (LPN) care hours.
  • Facilities could be eligible for waivers to allow them not to comply with this rule if they meet specific criteria. These criteria include location where the supply of health staff is insufficient, the next closest long-term care facility is 20 or more miles away, good faith efforts to hire (recruitment and retention plans), and demonstrated financial commitment (documentation of financial expenditures on staffing).
    • Exclusions from eligibility for the waiver include being a special focus facility, having citations in the last 12 months for widespread insufficient staffing with actual resident harm, a pattern of insufficient staffing with actual resident harm, or immediate jeopardy related to staffing, and failure to submit staffing data to the Payroll Based Journal.
  • Implementation of this rule would be over a 3-year period.

As the Long-Term Care Community Coalition describes, “nursing home residents need a minimum of 4.1 total care staff hours per resident day (HPRD) to receive sufficient clinical care and avoid unnecessary harm, according to a landmark 2001 federal study.”

Their data on staffing for the first quarter of 2023 finds:

  • The median U.S. nursing home provided 3.59 total nurse staff HPRD. This is 35 minutes higher than the 3.0 hours per resident day minimum proposed by CMS.
  • Nursing homes turned over more than half their staff within 12 months. The median total nursing staff turnover is 52.9%, including 50% RN turnover. This suggests we do not have a staffing shortage but perhaps a “good job” shortage.

Read the personal comments below from Michelle Gralnick, a Residents’ Rights Advocate and Private Care Manager.

“Ask lay people or professionals alike about the state of nursing home care, and they will inevitably include the words ‘staff shortages’ in their comments about what is causing the lack of correct and complete care services provided by the facility in which they reside or work.

 ‘Staff shortages’ has been used as an explanation since before the COVID-19 pandemic; for me, those words have lost any true meaning. Yes, we are told there is a nationwide staffing shortage in residential care communities. As if this factual explanation excuses the industry from finding solutions to the myriad of concerns, problems, complaints, and mistakes being made within the walls of the “homes” into which families entrust their loved ones.

Isn’t it time for those facility owners and administrators to figure out a way to adapt to this new reality, to create and evolve new staffing configurations, hiring incentives, training mechanisms, and professional development opportunities to attract and keep employees? To step up and see where the breakdowns are, what “holes” need to be filled, and how the procedures they maintain as “how we do things” aren’t getting those things done?

If we – privately or through Medicare and Medicaid coverage – are being asked to pay for quality care, ought we not receive quality care? And isn’t the obligation of the provider to ensure that they satisfy the terms of the contract under which they accepted their residents?

No one wants to be the ‘squeaky wheel,’ the ‘troublemaker,’ or the ‘constant critic.’ Certainly not the resident who must depend upon the kindness of strangers for their care and fear reprisals. Not the family member who knows that staff are doing what they cannot or will not do. Even the volunteer and professional advocates who seek solutions are frequently limited by State laws.

So, who does that leave? Who should residents and families contact to report concerns and request assistance and resolution? We are told it is the Division of Health and Senior Services, whose employees are also overwhelmed due to – you guessed it – staff shortages.

Who has the authority, the power, and the financial resources to implement change? To mandate standards and to monitor compliance? Theoretically, the owner. But is their goal health care or fiscal profits?

This leaves us with our government officials. Local, State, and Federal, whom we have elected to represent the needs of citizens – their constituents. We must share our concerns with them: raising awareness, making requests, demanding change. We need to be monitoring how they vote; we need to be attending hearings and testifying about our experiences; and we need to give voice to those who cannot speak for themselves.

William Arthur Ward wrote, ‘If you can imagine it, you can achieve it.’ Let’s use our creativity and commitment to be agents for change so that ‘staff shortages’ become an obstacle we’ve overcome.”

How You Can Help

To comment on CMS’ Notice of Proposed Rule Making to propose a minimum staffing standard, visit National Consumer Voice’s website for their step-by-step instructions for commenting. All comments are due by November 6, 2023. We encourage you to make your voice heard and continue to help amplify residents’ voices.

Sources: The National Consumer Voice, The Long-Term Care Community Coalition, U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services

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