CMS Study Undercuts Potential Nursing Home Minimum Staffing  Mandate

The White House’s ambitious plans for a federal nursing home staffing mandate might have hit a snag due to the inadvertent online release and subsequent removal of a study commissioned by the Centers for Medicare & Medicaid Services (CMS).

KFF Health News first reported on the study on Tuesday, after which CMS removed the report, which was compiled by Abt Associates, from the agency’s website.

CMS has long advocated for higher staffing standards. In a report issued to Congress in 2001, CMS recommended a daily minimum standard of 4.1 hours of total direct care nursing time per resident: 2.8 hours from certified nursing assistants (CNAs); 0.75 hours from registered nurses (RNs); and 0.55 hours from licensed practical/vocational nurses.

However, the fresh staffing study did not explore what CMS previously called optimal minimum staffing levels. Instead, researchers exclusively looked at staffing thresholds below the ones deemed ideal in the prior federal assessment. Still, researchers said that elevated staffing levels would result in reduced hospitalizations and emergency room admissions, faster care delivery, and a decrease in instances of care omission.

The study indicated that no solitary staffing measure could ensure high-quality care – a stance which many leaders in the skilled nursing industry, mired with a staffing crisis, have long endorsed.

“Recent literature underscores the relationship between nursing home staffing and quality outcomes, such as reduced pressure ulcers, emergency department visits, rehospitalizations, and outbreaks and deaths related to COVID-19,” researchers wrote. “However, it does not provide a clear evidence basis for setting a minimum staffing level.”

The study assessed four minimal staffing thresholds, each of them falling beneath the 4.1 staff hours per day considered optimal in the previous report. The uppermost level was 3.88 staff hours per day, while the minimum was 3.3 daily hours of staffing.

David Grabowski, a professor of health care policy in the Department of Health Care Policy at Harvard Medical School, told Skilled Nursing News that researchers studied thresholds that are lower than what is necessary, but still higher than the levels maintained by many nursing homes.

“All four of the ‘what if’ minimum staffing scenarios proposed in the study would raise staffing in some share of facilities and improve quality,” he said. “That is a great development. However, all of these thresholds fall below what many experts including myself believe is optimal. Thus, if CMS moves forward with one of these “what if” scenarios, nursing home care in the US will be ‘better but still not well.’ In other words, we will have work left to do.”

Jonathan Blum, CMS’ principal deputy administrator and COO, told KFF that the 478-page report had been erroneously posted, and that it was in fact a draft. 

“CMS’s proposal is being developed using a rigorous process that draws on a wide range of source information, including extensive input from residents and their families, workers, administrators, experts, and other stakeholders,” Blum said. “Our focus is on advancing implementable solutions that promote safe, quality care for residents.”

In a statement provided to SNN, Blum confirmed the study was prematurely released and declined to offer more details of the official release date of potential staffing regulation saying, “We look forward to releasing our proposals, as well as the Nursing Home Staffing Study, soon.”

Blum also emphasized that CMS sees links between staffing levels and quality of care. “CMS is committed to holding nursing homes accountable for protecting the health and safety of all residents, and adequate staffing is critical to this effort,” he said.

Currently, CMS’ regulation is pending review within the Office of Management and Budget.

Specific findings

The highest staffing level studied by researchers in the leaked draft was 3.88 hours, at which approximately 0.6% of residents might experience delayed care, and 0.002% might not receive necessary care. This level could potentially reduce annual emergency room visits by 14,800 and Medicare patient hospitalizations by 12,100, researchers said.

The report, which was primarily conducted between May and December 2022, estimated that over 11,000 of the nation’s 15,200 nursing homes would need to recruit additional staff, incurring an annual cost of $5.3 billion, to achieve this level.

On the lower end, the 3.3 hours per resident day could raise the percentage of residents with delayed care to 3.3% and those without needed care to 0.04%.

To meet this lower level, more than 50% of nursing homes would need to expand staffing, incurring an extra annual cost of $1.5 billion. Furthermore, the sector would need to hire nearly 200,000 new workers, in addition to the 190,000 positions lost since the pandemic’s onset.

“The relationship of staffing with quality and safety varies by staff type,” researchers wrote. “Quality and safety consistently increase with RN staffing levels but only at the highest levels of nurse aide staffing. There is no consistent relationship of quality and safety with LPN staffing. There is a negative correlation between LPN and RN staffing, indicating that nursing homes with higher LPN staffing levels tend to have lower RN staffing levels.”

Industry stakeholders react

Ruth Katz, senior vice president of policy at LeadingAge, the association of nonprofit providers of aging services, told SNN that she’s interested to see how the research, which was inconclusive, could be translated into a proposed rule that would mandate an effective staffing ratio that will improve care for residents and their families.

“In February 2022, the President wisely determined to base any staffing ratios on research,” she said. “The report he commissioned said there is no single staffing level that would guarantee quality care. Policy should be based on evidence.”

Zach Shamberg, president and CEO of the Pennsylvania Health Care Association, said that while much time and resources have been spent on debating “arbitrary” staffing numbers, providers are just trying to care for residents and their specific needs.

“The argument for this staffing mandate has done nothing but turn residents into statistics and assume projections on outcomes,” he said. “We agreed with CMS in 2016 when they proclaimed that a one-size-fits-all approach wasn’t best for providing care. And we agree with them today that it still isn’t.”

Shamberg added that residents have varying needs for care, and they should be treated as such.

“Our elected and appointed leaders need to stop devaluing the specific needs of seniors and adults with disabilities and start being more productive in supporting their care,” he said.

Nursing home operators said the leaked draft understated views they have been long advocating.

“If CMS proceeds with an unfunded one-size-fits-all minimum staffing mandate, our nation’s seniors living in rural areas will pay the price,” Nate Schema, president and CEO of the Evangelical Lutheran Good Samaritan Society, told SNN, adding that there simply weren’t enough workers to fulfill requirements for potential minimum staffing regulation. “Increased staffing requirements will not create the caregivers we need to fill open positions. Setting unattainable staffing ratios will result in seniors having fewer options for care close to home due to closures and reduced admissions.”

Schema instead urged CMS to reconsider a proposed minimum staffing rule and focus on both funding and strengthening programs to attract, retain and grow the long-term care workforce.