Mixed reactions to the nursing home minimum staffing mandate continued to roll in over the weekend – along with an editorial from President Joe Biden – following a first glimpse of the proposal on Friday.

As the president underlined the need for more staff to improve quality, the 24/7 provision for registered nurses (RNs) continued to draw ire from leaders across every corner of the nursing home industry, with advocates calling for more funding. Meanwhile, the lead time given to implement the mandate was seen as a win for the sector by all sides.

In his editorial for USA Today, President Biden said what he has seen from private equity firms informed the structure of the proposed staffing minimum mandate. Specifically, Biden pointed to PE firms “slashing key staff” after buying nursing homes in order to cut costs and make bigger profits, and endangering the safety of residents.

“Research shows that these staffing levels will save lives, provide residents with a higher quality of life and prevent needless suffering,” Biden said in his editorial, referring to 24/7 RN coverage, along with ensuring there are enough nurse aides to provide routine bedside care and other tasks.

“We are working to make sure no nursing home can sacrifice the safety of its residents just to add some dollars to its bottom line,” he added.

It’s telling, he said, that nonprofit nursing homes are three times as likely as for-profit facilities to already satisfy the proposed minimum staffing standard.

Terry Fulmer with the John A. Hartford Foundation called staffing ratios a “key lever,” while adding that this initiative must be “funded and implemented,” with advocacy help from the Moving Forward Nursing Home Quality Coalition.

From the nursing home sector’s standpoint, there were some positives.

Investment analysts for Stifel Financial Corp. noted the proposed minimum staffing requirements weren’t as bad as they had expected, mainly because of the proposed plan to stagger its implementation.

“This is a huge positive from a near-term perspective, since it will take years for these changes to be implemented,” analysts said in a note over the weekend. “This should give operators time to figure out solutions to staffing issues they currently face. And regarding the RN shortage, it will allow for additional graduates to enter the workforce.”

However, Stifel analysts do expect a lot of push back to come from the industry on the proposal’s RN requirements, especially given the continuing workforce shortage.

Clinical complexity and the nursing home staffing mandate

The three main proposals in the nursing home minimum staffing mandate include3.48 hours per resident day, with 0.55 from RNs and 2.45 from certified nursing assistants (CNAs).

The second requirement involved 24/7 RN coverage for each facility. The last piece of the puzzle involves enhanced facility assessment requirements.

The Society for Post-Acute and Long-Term Care Medicine (AMDA) expressed concern about what they called a “fixed ceiling,” and that staffing levels based only on resident-to-worker ratios won’t safely address or meet residents’ needs.

“This critical problem requires a multi-faceted approach, including taking into account the complexity of the population (e.g., facility case-mix), availability of nurses, training programs, as well as innovative models that incorporate telehealth and technology advances to improve efficiencies and access to expertise, and the workplace culture,” the association said in its statement.

AMDA strongly urged CMS to take recommendations from its own study that concluded there was no specific staffing number to improve care.

Delayed implementation

Location, specifically if a facility is in a rural area of the country or not, will dictate implementation – a “big differentiator,” Stifel analysts said.

Non-rural facilities will have 60 days after the publication date of the final rule to meet facility assessment requirements, two years for the RN provision and 3 years for the proposed minimum staffing standard.

Rural facilities will have 60 days, 3 years and 5 years for each of these phases, respectively.

On top of additional time, Stifel analysts noted facilities’ ability to apply for a temporary waiver if they have challenges hiring and retaining certain nursing staff.

“Overall, given the 60-day comment period, an expected 6-18 months to finalize the proposal, and the delayed implementation, the minimum staffing requirements are likely to be implemented in 2026 or 2027 at the earliest,” added Stifel analysts.

AMDA said the delayed implementation, along with a call for “alternative approaches” to meeting resident needs, was “encouraging.” But, CMS needs to still invest more in the post-acute and long-term care workforce. The agency set aside $75 million for staff recruiting, training and retention, but other leaders had said this amount is way below what’s needed.

There isn’t expected to be much change in operator profitability or business models, according to the Stifel note, meaning little impact to rent coverage in the near term. Long-term implications are “opaque,” analysts said.

As SNF operators strive to meet the RN and CNA federal requirements, Stifel analysts wonder if facilities might end up replacing some LPN staffing with lower-cost CNAs, which could also offset higher RN costs.

Straddling state and federal staffing mandates

The federal proposal follows minimum staffing standards being implemented across several states, a situation which is causing confusion among providers..

Washington already has a minimum staffing standard of 3.24 of direct care to each resident, but doesn’t specify which types of staff need to provide care, according to an article published in the Seattle Times.

And as a result, the proposed requirements send a mixed message to nursing homes in states like Washington, with a potential reduction in face-to-face time with higher-skilled nurses as more CNAs are brought on to meet federal requirements.

While nearly all nursing homes in Washington meet state requirements, and state provisions already exceed federal hours, the staff needed for the federal mandate could shift hiring processes.

A nursing home with 100 residents, the report said, would need at least two RNs on staff for each shift and 10 CNAs to meet the proposed federal staffing minimum standard.

The Washington legislature recently approved $215.3 million for nursing homes as part of its Medicaid rate increases, according to the Seattle Times report.