CMS Finalizes Historic Nursing Home Staffing Standards to Protect Residents and Enhance Accountability
In a monumental step towards ensuring the safety and well-being of nursing home residents, the Centers for Medicare & Medicaid Services (CMS) has finalized the Minimum Staffing Standards for Long-Term Care (LTC) Facilities and Medicaid Institutional Payment Transparency Reporting rule.
This groundbreaking regulation, informed by over 46,000 public comments, aims to significantly reduce the risk of unsafe and low-quality care in nearly 1.2 million Medicare and Medicaid-certified long-term care facilities across the nation.
The final rule introduces comprehensive minimum nurse staffing requirements, mandating a total nurse staffing standard of 3.48 hours per resident per day (HPRD), which includes at least:
- 0.55 HPRD of direct registered nurse (RN) care
- 2.45 HPRD of direct nurse aide care
The rule also requires an RN to be onsite 24/7 to provide skilled nursing care. To account for unique workforce challenges, the rule provides a staggered implementation timeframe and possible exemptions for qualifying facilities.
Additionally, states will be required to report on the percentage of Medicaid payments spent on compensation for direct care workers in nursing facilities and intermediate care facilities for individuals with intellectual disabilities.
Key Takeaways:
- Minimum total nurse staffing standard of 3.48 HPRD, including 0.55 HPRD of RN care and 2.45 HPRD of nurse aide care
- A new requirement for an RN to be onsite 24/7 to provide direct resident care
- Staggered implementation timeframe based on geographic location and possible exemptions for qualifying facilities
- Enhanced facility assessment requirements and evidence-based care planning
- Medicaid Institutional Payment Transparency Reporting to promote public transparency on direct care worker compensation
- $75 million investment in a national nursing home staffing campaign to increase the number of nurses in nursing homes
Keep reading for a more in-depth analysis and discussion of this impactful regulation.
Minimum Nurse Staffing Standards
CMS has finalized new minimum nurse staffing standards to address the persistent concern of inadequate staffing in long-term care (LTC) facilities, requiring a minimum of 3.48 hours per resident per day (HPRD) of total direct nursing care.
This includes at least 0.55 HPRD provided by registered nurses (RNs), 2.45 HPRD by nurse aides, and the remaining 0.48 HPRD by any combination of RNs, licensed practical nurses (LPNs), licensed vocational nurses (LVNs), or nurse aides, while expecting facilities to adjust staffing levels above these minimums based on resident acuity and individual care needs, which shall be determined through updated facility assessments.
Adjusting On-Site Requirements for RNs
CMS is finalizing the requirement for LTC facilities to have an RN onsite 24 hours a day, seven days a week.
This is a significant change and may be costly for facilities due to the significant increase in hours per day.
The RN must consistently be available to provide direct resident care and help mitigate and reduce the likelihood of preventable safety events, particularly during evenings, nights, weekends, and holidays, as residents in these facilities have increasingly complex medical needs that require substantial resources and care provided or supervised by an RN.
Upgrading the Facility Assessment Requirement
To ensure that LTC facilities are making thoughtful, informed staffing plans and decisions focused on meeting resident needs, CMS is finalizing several requirements to strengthen the facility assessment process.
Facilities must use evidence-based methods when care planning for their residents, including those with behavioral health needs, and assess the specific needs of each resident, adjusting as necessary based on significant changes in the resident population.
The facility assessment process must include input from nursing home leadership, management, direct care staff, residents, resident representatives, and family members.
Facilities are also required to develop a staffing plan to maximize recruitment and retention of staff, consistent with President Biden’s April Executive Order on Increasing Access to High-Quality Care and Supporting Caregivers.
Regulatory Flexibility
CMS recognizes that some LTC facilities may face temporary challenges in meeting the final minimum staffing standards due to external circumstances, such as local workforce unavailability.
To address this, CMS is offering a proposal for hardship exemptions, with modifications that apply in limited circumstances to the HPRD and 24-hour, 7 days a week onsite RN requirements.
LTC facilities may qualify for a temporary hardship exemption if they are located in an area where the supply of RN, NA, or total nurse staff is insufficient to meet area needs, as evidenced by the applicable provider-to-population ratio being a minimum of 20% below the national average.
Facilities may receive exemptions from specific staffing requirements (3.48 HPRD total nurse staffing, 0.55 RN HPRD, or 2.45 NA HPRD) based on the corresponding workforce ratio in their area.
To receive a temporary hardship exemption, eligible LTC facilities must provide documentation of good faith efforts to hire and retain staff, as well as their financial commitment to staffing.
Facilities granted an exemption must post notices of their exemption status and provide this information to current and prospective residents.
However, facilities are not eligible for an exemption if they have failed to submit data to the Payroll-Based Journal System, have been identified as a Special Focus Facility, or have been cited for widespread or harmful insufficient staffing within the preceding 12 months.
Exemptions are valid until the next standard recertification survey and may be extended if the facility continues to meet the exemption criteria.
How Implementation Will Occur
To give LTC facilities time to comply with the proposed minimum staffing requirements, CMS is implementing the minimum nurse staffing requirements for all non-rural facilities in three phases over a three-year period.
Non-Rural Facility Phases
The following is currently being finalized for non-rural facilities:
Phase 1
Within 90 days of the final rule’s publication, facilities must meet the facility assessment requirements.
Phase 2
Within two years of the final rule’s publication, facilities must meet the 3.48 HPRD total nurse staffing requirement and the 24/7 RN requirement.
Phase 3
Within three years of the final rule publication, facilities must meet the 0.55 RN and 2.45 NA HPRD requirements.
Rural Facility Phases
The following is required for facilities in rural areas – which is defined by the Office of Management and Budget:
Phase 1
Within 90 days of the final rule publication, facilities must meet the facility assessment requirements.
Phase 2
Within three years of the final rule publication, facilities must meet the 3.48 HPRD total nurse staffing requirement and the 24/7 RN requirement.
Phase 3
Within five years of the final rule publication, facilities must meet the 0.55 RN and 2.45 NA HPRD requirements.
$75 Million National Nursing Home Campaign
In September 2023, CMS announced an investment of over $75 million to launch a national nursing home staffing campaign aimed at increasing the number of nurses in nursing homes and enhancing residents’ health and safety.
The campaign will provide financial incentives, such as tuition reimbursement, for nurses who commit to working in qualifying nursing homes or oversight roles with state inspection agencies. Additionally, the campaign will streamline the process for individuals to become nurse aides by simplifying enrollment in training programs and placement in nursing homes.
The campaign will also promote awareness of the various career pathways available in the nursing field, targeting recruitment of all types of individuals, from NAs to LPNs/LVNs and RNs.
CMS will partner with states to bolster nurse recruitment by investing funds to improve nurse aide training information and increase the number of available financial incentives, while also collaborating with other partners to amplify impact.
CMS is currently conducting comprehensive research to inform the program’s structure and plans to release additional information and a resource hub later this year, with financial incentives expected to be distributed starting in 2025.
Medicaid Institutional Payment Transparency
The Medicaid Institutional Payment Transparency Reporting provisions, finalized in this rule, aim to promote public transparency regarding the percentage of Medicaid payments spent on compensation for direct care workers and support staff in nursing facilities and intermediate care facilities for individuals with intellectual disabilities (ICFs/IID), which serve about 1.5 million people annually.
These provisions complement similar requirements in the Ensuring Access to Medicaid Services final rule, which mandates states to report on the percentage of Medicaid payments spent on direct care worker compensation for certain home and community-based services, ultimately providing a comprehensive view of Medicaid spending on the direct care workforce across both institutional and community-based settings.
Key Takeaways from the Medicaid Institutional Payment Transparency Reporting Provisions include:
- New institutional payment reporting requirements require states to report to CMS the percentage of Medicaid payments for services in nursing homes and ICFs/IIDs that are spent on compensation for direct care workers (such as nurses and therapists) and support staff (such as housekeepers and drivers who transport residents). These requirements are applicable regardless of whether a state’s LTSS delivery system is fee-for-service or managed care.
- Support for quality care and worker safety by excluding travel, training, and personal protective equipment (PPE) costs from the calculation of the percentage of Medicaid payments used for compensation. Excluding the costs of training, travel, and PPE from the calculation will help nursing facilities and ICFs/IIDs continue to invest in these critical activities and items without fear of these costs being deducted from their spending on direct care workers and support staff compensation.
- Indian Health Service and tribal health programs subject to 25 U.S.C. 1641 are exempt from reporting requirements.
- Both states and CMS must make the institutional payment information reported by states available on public-facing websites.
RN Staffing Assistance in California and Southern Florida
The new staffing regulation may seem daunting to some long-term care facilities.
If you want to get ahead of this new regulation and prepare your facility for long-term success, partnering with a premier nurse staffing agency like NurseRegistry can help.
We streamline nurse staffing and are equipped with over 500 nurses. That means you facility can receive an RN exactly when you need them.
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