Completely Out of Touch: Biden’s Minimum Staffing Proposal Comes as Skilled Nursing Reels From Labor Crisis

As state and federal policymakers clamor to set nursing home minimum staffing standards – most recently in the Biden administration’s expansive reform proposals – leaders in the space are asking a pointed question: Why now?

The industry has already lost nearly 238,000 caregivers in the last two years – an issue that has only been inflamed by the pandemic.

While the nursing home industry has seen modest job growth the last two months, adding 5,400 hires from December 2021 to February, the sector is far behind other health care fields in employment recovery.

Nursing home operators have offered hiring bonuses, increased wages, better benefit packages and job flexibility – all with varying degrees of success – to both hire new workers and retain current staff.

Since the White House released its fact sheet on Feb. 28 outlining the proposed reforms, little is known about what the staffing requirement might look like in its final form.

The Centers for Medicare & Medicaid Services is expected to conduct a study to determine the level and type of staffing needed, and propose a new standard within one year, the agency confirmed during a stakeholder call on March 10.

Will Harris, senior advisor, Office of the CMS Administrator, said during the call that the government agency understands staffing increases “won’t happen overnight” as they look to take a holistic approach to improving the long-term sustainability of the nursing home workforce.

Still, many in the industry are scratching their heads at the timing of this proposal, how it’s going to be paid for and where the workers are going to come from – at a time when prospective candidates are in short supply.

In a virtual news conference just a few days after the Biden proposals were announced, American Health Care Association President and CEO Mark Parkinson called the minimum staffing requirement “unrealistic and not possible.”

CareTrust REIT (Nasdaq: CTRE) CEO David Sedgwick, also a former nursing home administrator, told Skilled Nursing News late last week that the current labor environment is the toughest he’s seen in his 20 years in the business. CareTrust’s portfolio includes 160 SNFs.

“At a time where labor costs are as high as they are and great staff is in as short supply as it is, to then try to pound the sector with the hammer of minimum staffing ratios and things like that just seems completely out of touch with realities on the ground,” Sedgwick said.

The skilled nursing staffing landscape

Calls from lawmakers for the implementation of nursing home staffing minimums is not a new phenomenon.

CMS, in a report issued to Congress in 2001, recommended a daily minimum standard of 4.1 hours of total direct care nursing time per resident: 2.8 hours from certified nursing assistants; 0.75 hours from RNs; and 0.55 hours from licensed practical/vocational nurses.

Despite that report being issued more than two decades ago, there is no minimum number of direct care nurse and nursing assistant hours per resident per day required by the federal government.

Instead, the federal requirement states that nursing homes must provide “…sufficient nursing staff to attain or maintain the highest practicable … well-being” of every resident.

Nursing home staffing was also a component in various versions of the Build Back Better Act, which is now effectively stalled in Congress.

The Biden administration argued in its fact sheet that the adequacy of a nursing home’s staffing is the measure most closely linked to the quality of care residents receive, citing a September 2020 study of Connecticut nursing homes.

The study found that increasing registered nurse staffing by 20 minutes per resident day was associated with 22% fewer confirmed cases of COVID-19 and 26% fewer COVID-19 deaths.

But industry leaders such as Parkinson have repeatedly noted studies that show nursing home COVID deaths are tied most closely to community spread. And, nursing home operators are in fact eager to increase staffing levels but unable to find workers.

Roughly 28% of nursing facilities reported at least one staffing shortage, according to a Kaiser Family Foundation analysis of the most recent data from the Centers for Disease Control and Prevention’s National Healthcare Safety Network. 

While the most recent rate is slightly lower than its peak during the week of Jan. 23 when 33% of nursing homes reported a shortage, the current rate is higher than in May 2020 when 22% of nursing facilities reported at least one type of staffing shortage, the analysis noted.

The degree to which the staffing shortage has impacted facilities also varies widely by state, according to the KFF analysis. The most recent data showed that in 10 states at least half of nursing facilities reported one or more staffing shortages.

The five states with the greatest number of facilities reporting shortages include Alaska (73%), Minnesota (64%), Kansas (59%), Washington (59%) and Wyoming (57%), the analysis noted.

On the opposite end of the spectrum, the five states with the lowest number of facilities reporting shortages include California (3%), Connecticut (4%), Massachusetts (9%), Texas (10%) and New Jersey (10%).

Unsurprisingly, the labor shortage is related to financial duress in the sector, as operating expenses increase.

Norcross, Ga.-based nursing home operator PruittHealth reported a $260 million revenue hit since the early days of the pandemic and an estimated $102.1 million in Medicaid underfunding.

Since March 2020, PruittHealth has spent $23.4 million in workforce retention, and another $38 million on other staffing costs such as sick leave, hazard pay and agency staffing.

One thing that may stand in the way of recovery for SNF operators like PruittHealth, according to CEO Neil Pruitt Jr., is Biden’s proposed industry reforms. He said, as evidenced in their company report, the industry needs a helping hand, not a “hand slap.”

Pruitt recently told Skilled Nursing News that while he is open to the idea of minimum staffing standards, there needs to be a way to pay for it.

“In this report, we have $102 million in Medicaid underfunding, and that’s just with existing staff. So if you add a requirement on top of that, what are the financial proposals to help pay for it? Second, where are we going to get the nurses?” he said.

Pruitt said while serving on the Board of Regents of the University System of Georgia, he’s seen firsthand the limited number of nurses out there, let alone ones who are interested in working in long-term care.

One way PruittHealth has tried to combat the staffing shortage is by hiring as many as 1,000 international nurses and certified nursing assistants.

States take on staffing minimums

Despite continuing workforce shortages across the country, several states have pushed to establish or increase already existing mandated minimum staffing hours.

Pennsylvania Gov. Tom Wolf has proposed increasing the minimum staffing standard in nursing homes from 2.7 hours per patient per day to 4.1 hours.

When the measure was first proposed last July, state officials estimated it would cost around $180 million to achieve that goal. State officials are working on revising that number but the new figure has not yet been released, according to PHCA President and CEO Zach Shamberg.

This proposal was a stark contrast from the Pennsylvania Health Care Association’s estimation that it would require closer to $800 million in funding and an additional 7,000 workers.

“It doesn’t make sense for the environment and it doesn’t make sense for the operating reality that every provider throughout Pennsylvania faces,” Shamberg told SNN.

Shamberg acknowledged that while minimum staffing requirements have a place in the skilled nursing industry, any conversation about the possibility needs to include the frontline “experts” and providers.

“What we are attempting to do is to ensure in Pennsylvania that we’re able to provide access to care and we have the appropriate number of staff members for our seniors in nursing homes who are going to need a specific level of care,” Shamberg said.

In December of last year, the state association proposed that the governor and state department of health allocate $200 million in American Rescue Plan funding to long-term care to incentivize coming to work and staying in the field.

In the long-term, Shamberg said the industry needs to promote careers in long-term care not only in college or high school, but even to middle schoolers.

“Pennsylvania has one of the oldest populations in the country – these jobs are going to be here, this career ladder is going to be available for anyone who wants to begin climbing. We just need to get younger Pennsylvanians interested in these careers as soon as possible,” he told SNN.

Virginia, Rhode Island and New York are among the states that have delayed legislation to change staffing minimum requirements within their borders.

There are 18 states, including Virginia, that don’t require nursing homes to have a minimum number of staff hours per resident day, according to a December report released by the National Consumer Voice for Quality Long-Term Care.

New York Gov. Kathy Hochul put the mandate on hold in January 2022 amid the omicron surge, while Rhode Island Gov. Dan McKee signed an executive order the same month to delay a law that would fine nursing homes for failing to comply with minimum staffing requirements.

In Florida – which currently requires 3.6 hours of direct care per resident per day – the legislature earlier this month passed a bill that reduced the minimum hours of care provided by certified nursing assistants, from 2.5 to 2.0.

The new law allows other health care professionals, such as mental health workers and physical therapists, to help meet those hours.

The bill alleviates some of the pressures related to hiring CNAs when the pickings are slim – without sacrificing patient care, according to Florida Health Care Association (FHCA) director of communications Kristen Knapp.

“Our facilities are hiring, they are offering sign-on bonuses, they are incentivizing their current workers with contests, recruitment contests to try to find staff, people just aren’t applying for these positions,” Knapp told SNN.

While the bill has yet to be signed by Florida Gov. Ron DeSantis, he recently said during a ceremony to mark the end of the 2022 legislative session that there will be “a lot of nursing homes that are very, very happy,” according to a Florida Politics report.

The state’s budget will include a Medicaid rate increase of $293 million for nursing center care, or approximately $419,000 per care center. Funds will take effect on Oct. 1 with the next annual rate setting, according to Knapp.

As a condition of the rate increase, all nursing center employees must be paid at least $15 an hour. This will be implemented by requiring providers to enter into a supplemental wage agreement with the Agency for Health Care Administration to ensure compliance.

“This appropriation will produce higher wages and better benefits, which in turn will help our care centers attract new workers and incentivize current staff to remain in their positions,” Knapp wrote in an emailed statement.