The CMS Staffing Mandate: What to Know and How to Prepare Your Nursing Facility

April 18, 2023
April 19, 2023
Polaris Group
April 19, 2023

Proposed mandates, the potential impacts, and initial steps your facility can take to get ready for this new ruling.

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In February 2022, the White House released a 21-point reform plan that included a first-ever, federal staffing mandate for nursing homes. After nearly a year of study, the proposed rule is expected to be released in May requiring a minimum staffing mandate that may be as high as 4.1 hours per resident day (HPRD).

Why are staffing mandates being proposed?

It may seem odd that a staffing mandate is being released at a time when nursing homes are facing continued staffing shortages. In a recently released LeadingAge survey, 67% of nursing home administrators noted no improvement in labor issues in the last year and 92% were still facing significant staffing shortages.

However, the proponents of the staffing mandate note that maintaining a minimum level of staffing will lead to improved quality of care for residents. This rationale is based on research that finds higher RN staffing levels are associated with fewer adverse resident outcomes and higher levels of total direct care staffing also are associated with improved outcomes.

Prior to the pandemic, federal regulation required 0.30 staffing hours per resident per day (HPRD). However, enormous state-level variation exists in minimum staffing requirements. Some states explicitly require a minimum number of staff hours per resident day, while other states require nursing homes to provide direct care staff 24 hours per day, seven days per week, without an explicit number of hours per resident requirement.

Importantly, newer research finds that the staffing hours per resident per day requirements are actually less predictive of resident outcomes than daily fluctuations in staffing level. In a study published in JAMA, researchers found that two facilities with the same average staffing achieve different quality of resident care and survey ratings in association with the day-to-day variation in staffing. This finding suggests that minimum staffing requirements do not reflect nursing home quality as well as the day-to-day variability in staffing levels.

Opponents of the staffing mandate note that staffing mandates are focused on bodies rather than resident outcomes. Further, in certain states like New Mexico, Medicare reimbursement rates are far below the daily cost of resident care. Minimum staffing mandates only worsen the gap between expenses and revenue and could potentially create situations where they could no longer continue to operate.

What does this staffing mandate mean for residents, staff, and facilities?

For residents, the staffing mandate is proposed to enhance quality care as higher staffing levels are associated with better outcomes for residents. However, if facilities do not have the staff to support residents, people coming from the hospital to nursing homes may be denied admission. The result: patients and families may find much greater difficulty securing sub-acute nursing and rehab needs. This may even lead to families having to take a loved one home to provide care on their own – a dangerous situation for the patient and their caregivers.

For staff, facilities may turn to existing staff to pick up additional hours and shifts. While this may mean extra income for the staff member, the downside is overload and burn-out which ultimately can contribute to worse resident outcomes.

For facilities already facing a staffing crisis, a 4.1 hour per patient day mandate without additional funding support may accelerate nursing home closure rates. Because of the lack of nursing staff supply, facilities are unlikely to achieve the mandate, despite their best efforts to hire qualified staff.

How to prepare for staffing mandate implementation

To be sure, there are many lingering questions about the exact ruling that will come forward later this spring. In the meantime, we need continued advocacy such that nursing homes and policymakers work together to develop and implement comprehensive solutions. Approaches could include increasing funding for nursing homes, improving recruitment and retention of staff, and investing in technology and training to improve the quality of care provided.

The team at Polaris Group Consultants can also be a resource for staffing solutions. Approaches such as outsourcing the MDS coordinator position can free up existing MDS staff to work the floor, as well as ensure that your facility gets reimbursed fully for what you deserve. With both interim and permanent staffing positions available, Polaris can be your partner to ensure your facility meets the staffing mandate requirements.

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