Nursing Home Staffing Regulations, Proposals Clash With Financial, Operational Realities

As the White House considers stricter federal staffing minimum requirements, regulations in some parts of the country are bowing to the realities of the skilled nursing industry’s workforce crisis.

Providers in states from Virginia to New York are pushing back on the requirements they say threaten their ability to provide the best care for residents. The Georgia Health Care Association (GHCA) opposes implementing a “one size fits all” approach to regulating its providers’ staffing levels.

“A mandated increase in staffing minimums increases the risk of providers basing hiring practices upon the ‘warm body’ model,” Tony Marshall, president and CEO of the GHCA, told Skilled Nursing News. “This would exponentially increase the potential for abuse, neglect and exploitation.”


Pennsylvania offers a clear example of a state that has granted more leeway to providers on staffing minimums, while still pushing for higher hours per patient day (HPPD).

As the state passed its historic 17.5% Medicaid reimbursement increase set to go into effect next year, lawmakers also backed off efforts to raise the minimum HPPD staffing requirement from 2.7 to 4.1.

Instead, providers compromised and agreed to gradually raise the minimum to 3.2 by 2024, after the Medicaid reimbursement increase goes into effect, offering some optimism for the future.


“It doesn’t mean that there won’t be more work, it doesn’t mean that we won’t still be focused on workforce development,” Zach Shamberg, CEO and President of the Pennsylvania Health Care Association (PHCA), told SNN. “But we believe that we can get there next year, and 2024 as well.”

Pennsylvania as a model

Within the next year, the Centers for Medicare & Medicaid Services (CMS) is expected to study the level and type of staffing needed at skilled nursing facilities and propose a new standard.

However, nursing home providers have expressed concern over this plan, saying that while they would like to have higher staffing ratios, they are facing a dearth of job applicants and insufficient reimbursement levels to raise wages or take other steps to build the workforce. Meanwhile, the Centers for Medicare & Medicaid Services (CMS) has proposed slashing SNF Medicare reimbursement rates for 2023.

But while CMS is moving to cut reimbursements, states are able to tap into federal funds to support nursing home operators. Pennsylvania allocated $131 million in American Rescue Plan funds for its Medicaid increase.

And Pennsylvania’s approach to the issue stands out for how the state tied its rate increases to staffing and care expectations, including a requirement that operators spent 70% of the new funds on bedside care. This move helped gain the support of the Service Employees International Union (SEIU), as part of an “unorthodox” coalition with the state’s providers, Shamberg said.

He believes the rate increase will “help providers in the months and years to come investing in this workforce, and hopefully building a more robust workforce pipeline.”

Pennsylvania provides one model for how federal nursing home reform might be accomplished most fruitfully, by tying care standards to payments and finding common ground for employers and labor. But there is also a concern about whether national staffing minimums are a good idea at all.

“As service models vary from community to community, it is difficult to use a one-size-fits-all approach,” said GHCA’s Marshall.

He also expressed concern over how staffing minimums are being determined.

“Standards of care and evidence-based practice are ever evolving, and reliance on older staffing studies and resource verification models should be limited,” he said. “By now, we have come to understand that a rule or mandate does not guarantee quality of care or life for beneficiaries.”

But he is heartened by some recent action in Georgia, including 2021 state legislation allowing certified medication aides (CMAs) to work in skilled nursing centers.

“This allows an additional step in a career pathway that we feel is vitally important to reinforce and promote,” said Marshall. “Further, utilization of CMAs allows nurses to spend more time at the bedside and practice at the top of their license, which we believe will promote satisfaction and retention.”

Creative benefits and partnerships

The CMA measure in Georgia points to the importance of giving providers flexibility and authority to make the skilled nursing sector a more attractive career option. And while the federal government remains gridlocked, much of this action also is occurring at the state level.

Nearly “every piece of legislation” that the PHCA has recently advocated is related to workforce, Shamberg said. Specific measures include making pathways for temporary nurse aides to become CNAs, compelling Pennsylvania to join the Nurse Licensure Compact, and expanding the ability of nurses to utilize online training.

“Everything we’ve done at the state level here in Harrisburg has really gone to building our workforce, building our workforce pipeline, and developing our workforce — not just today or tomorrow, but in the years to come.”

In the meantime, Shamberg noted that Pennsylvania providers have begun offering “creative” benefits to attract employees, including:

  • Being flexible with shift preferences and offering shift differentials
  • Retention and recruitment bonuses
  • Transportation services to and from the workplace
  • Weekly or daily paychecks
  • Compensating employees for their daycare services

Marshall noted that many Georgia providers are also offering many of the same creative benefits to attract and retain staff, such as the more frequent pay schedules. He added that GHCA members are also recruiting and training foreign staff, training temporary nurse aides to become permanent, and tackling employee stress levels with benefits like “quiet rooms that promote sensorial calm.”

Last month, Georgia Governor Brian Kemp also formed a Healthcare Workforce Commission to develop strategies curbing the workforce crisis, with GHCA as a member.

All these actions could inform eventual federal policy as CMS and other agencies work to implement the Biden reform package — and they are also sorely needed, given that the labor crisis is not abating any time soon.

“We need to make workforce development a priority, and not just in Pennsylvania, but in every state throughout the country, and at the national level,” Shamberg said.

By Sloane Airey

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