The Biden administration aims to fix nursing home understaffing to improve care, but critics are pushing back.
Americans gave nursing homes a D+ for quality of care in a recent Gallup/West Health poll and most said they’d be uncomfortable being admitted into one or admitting a loved one. One reason could be the severe understaffing problems facing the 1.2 million residents in the nation’s 15,000 nursing homes.
The lack of registered nurses (RNs), licensed practical nurses (LPNs) and certified nursing assistants (CNAs) in many nursing homes recently led the Biden administration to propose national minimum staffing requirements.
Improving safety and care
The goal, said U.S. Health and Human Services Secretary Xavier Becerra, is to “improve resident safety and promote high-quality care so residents and their families can have peace of mind.” About one-fifth of all COVID-19 deaths in the United States during the pandemic were at nursing homes.
Currently, 38 states have minimum staffing standards at nursing homes, but many of those standards are low or over 20 years old. Studies have shown that higher nursing-home staffing has been associated with better patient care and health outcomes.
The new rules would provide nursing home residents with a minimum number of hours of care per day. They would also ensure that an RN would be on site 24 hours a day, seven days a week. The administration says 22% of nursing homes would need to hire RNs to meet that requirement. Today, nursing homes must have at least one RN for a minimum of eight straight hours a day and an RN, LPN or LVN (a Licensed Vocational Nurse) on duty 24 hours per day.
The Long-Term Care Community Coalition (LTCCC) , a nonprofit organization seeking to improve the quality of care in nursing homes and assisted living centers, has favored a 24/7 RN requirement for years.
Jasmine Travers, an NYU nursing college assistant professor and co-chair of the staffing committee at Moving Forward, a coalition working to improve nursing-home care, said: “I’m excited the president will be requiring 24 hours-a-day staffing for RNs.”
Will the standards happen?
Exactly how much the proposals would improve resident safety and promote high-quality care — or even ever take effect — is an open question.
The trade group representing primarily for-profit nursing homes, The American Health Care Association, calls the minimum standards “unfathomable.”
Katie Smith Sloan, president and CEO of LeadingAge (an association of nonprofit aging services providers, including nursing homes), said her group is “disappointed” the president moved forward with the proposals “despite clear evidence against them.” She says the cost of implementing the staffing mandate “will cripple nursing homes.”
Others, however, applaud the administration’s efforts.
“This is a step in the right direction,” said Harvard health care policy professor David Grabowski, a noted nursing home analyst. “I wish it had been a bigger step, but the administration deserves a ton of credit for going down this path.”
Terry Fulmer, president of the John A. Hartford Foundation, a philanthropy that seeks to improve care for older adults, said: “staffing ratios are a key lever to help nursing homes offer high-quality, age-friendly care to residents.”
What consumer advocates say
Some long-term care consumer advocates think the proposals don’t go nearly far enough.
Leaders of both the LTCCC and the National Consumer Voice for Quality Long-Term Care said they’re generally disappointed by what the administration has proposed.
LTCCC Executive Director Richard Mollot said: “The basic staffing standard, outside of the 24/7 RN [proposal], is abysmal. It’s well below what every study has shown to be necessary.”
He chastises nursing home leaders who say they can’t afford the proposed minimum standards. “Nursing homes aren’t warehouses,” Mollot said. “There’s absolutely no excuse to ever allow nursing homes to take in residents when they clearly don’t have the staff and the ability to care for them.”
Sam Brooks, director of public policy at National Consumer Voice for Quality Long-Term Care, said: “This rule was designed to bring up poor performers to average, and we disagree that average is the mark of quality in the nursing home sector.”
A history of staffing proposals
Proposals for minimum staffing standards at nursing home aren’t new, though the U.S. government has never adopted any.
The National Academy of Medicine (formerly the Institute of Medicine) called for minimum staffing standards in 1986, and the 1987 Nursing Home Reform Act gave the U.S. government authority to create staffing standards. In 2001, a Centers for Medicare and Medicaid Services (CMS) study said each nursing home resident needed at least 4.1 hours of direct care a day to avoid being at risk of harm.
By contrast, the Biden administration proposals would require 3 hours of care per day — 33 minutes from an RN and 2 hours and 27 minutes from a CNA, who helps residents with tasks of daily living, like eating, bathing and going to the bathroom. Moving Forward calls CNAs the “often underappreciated and undercompensated core of the nursing home workforce.”
Grabowski said he thinks there could be real benefits increasing the proposed minimum staffing standard to at least 3½ hours of care per day.
According to the Biden administration, to meet its proposed hours-per-day standards, 36% of nursing homes would need to hire RNs; 68% would have to hire nurse aides.
What the Biden proposals miss
There’s no specific requirement, however, for LPNs, who provide hands-on patient care and handle administrative tasks like monitoring vital signs, changing bandages and inserting catheters.
That LPN omission concerns some nursing home analysts.
“I worry a little bit with putting in a requirement for RNs and one for CNAs, but ignoring LPNs,” said Grabowski. “Are you going to see LPNs shift to almost zero in a lot of nursing homes and see the facilities staff up to the minimum for RNs and fill up the remaining staff slots with CNAs?”
That’s what happened in Ohio and California after those states adopted Biden administration nursing home standards. A 2015 study Grabowski helped to write found that the overall quality of care rose, but since those states didn’t specify minimum number of hours for RNs, LPNs and CNAs, “we saw a shift away from higher-cost professional staff and toward certified nurse aides.”
Slow rollout and exemptions
The Biden administration’s staffing proposals have a long rollout period before they would take effect — three years for most nursing homes; five years for those in rural areas. “It will really be about seven years, since you have to figure on [time needed for] enforcement,” said Brooks.
Rural nursing homes would be allowed three years to make sure they have RNs onsite 24/7, a year longer than others.
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