KFF: Fewer Than One in Five Nursing Homes Could Meet Federal Staffing Proposal

Fewer than one in five facilities would currently meet the required number of hours for RNs and CNAs as set forth in the federal minimum staffing proposal, with more than 80% of the facilities nationwide needing to hire more nursing staff.

This is according to an analysis published by KFF on Monday.

Interestingly, almost half of the skilled nursing facilities (SNFs) currently meet the registered nurse (RN) requirements, while only 28% cover the minimum hours for certified nursing assistants (CNAs).


Katie Smith Sloan, president and CEO of LeadingAge, said the KFF data “reinforces two truths.”

One, not all nursing homes are the same, and the other, the workforce crisis is real.

“Nurses are in short supply — and not just in nursing homes. CMS’ proposal raises very real challenges for the whole health care sector. The end result is older adults and families’ access to care is in jeopardy,” Smith Sloan said in a statement.


Key issues to watch, KFF noted, include “muted” effects from the proposal, considering hardship exemptions CMS has on the table for facilities still struggling to recruit and retain staff. On top of exemptions, it’s unknown whether future federal budgets will have adequate funding to enforce the new staffing standards.

“A recent report from the U.S. Senate found widespread understaffing at nursing facility survey agencies,” KFF authors said. “A related uncertainty is how CMS will enforce the 24/7 RN requirement. Current data show how many RN hours each facility has but not when those hours occur each day.”

It’s unclear how this statistic will be identified in existing data, since RNs often work overlapping shifts, not covering all 24 hours.

Costs related to the staffing proposal would be $40 billion in the 10 years after the final rule takes effect, CMS has said. Such costs will likely be passed on to residents and their families, KFF said. In 2020, residents and families paid $45 billion in out-of-pocket costs for nursing home care and other institutional long-term care services. Meanwhile, Medicaid spending was nearly $54 billion in 2020, which is about twice the amount than traditional Medicare, KFF found.

“The cost of implementing the staffing requirements have already been raised as a major concern from the nursing home industry among others, despite calls for stronger requirements from resident advocates,” KFF authors said in the analysis. “Changes made to the staffing requirements in response to stakeholder concerns and comments on the rule could affect how many or few nursing facilities will be able to comply.”

The organization said it’s important to note that the staffing mandate doesn’t initially take into account patient acuity. Staffing standards are applied “irrespective of patient characteristics,” KFF authors said.

If proposed staffing levels were enforced to account for resident health and frailty, virtually no nursing facilities would meet the proposal’s requirements, KFF found. Among 14,591 facilities, only 38 would meet case-mix adjusted staffing levels. Most facilities’ case-mix staffing levels are lower than their reported staffing levels, according to KFF.

There will be an assessment process to determine case mix adjustments, which would identify facilities needing a higher level of staffing depending on the higher health or functional needs.

“In the proposed rule, CMS solicited feedback as to whether the agency should consider using case mix adjustment when assessing compliance with the minimum staffing requirements of 0.55 RN HPRD and 2.45 nurse aide HPRD rather than relying only on the facilities’ unadjusted/self-reported hours of care,” the KFF analysis noted.

The organization’s statistics are slightly different from what was estimated by the Centers for Medicare & Medicaid Services (CMS); KFF says this is likely due to the federal agency taking the 24/7 RN rule into account.

“Neither KFF nor CMS account for the hardship exemptions in the estimates nor is it clear what share of the facilities that do not meet minimum standards would apply and qualify for a hardship exemption,” according to the KFF analysis.

Another finding from KFF: 90% of for-profits would need to hire staff compared to 60% of nonprofit and government facilities.

Nursing homes’ ability to meet the federal proposal varies wildly by state as well, with some states already having a minimum staffing mandate in place, KFF authors said. All properties in Alaska, for example, would meet requirements. Virtually none of nursing homes in Louisiana – 1% – would meet the requirement, according to the KFF analysis.

In more than half of states, less than a quarter would be able to meet the required nursing hours per resident day, KFF found.

“The proposal raises very real challenges for the whole health care sector, and actually jeopardizes access to care for older Americans. No state will be immune from the harm,” added Smith Sloan.

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