‘An Extinction Event’: Industry Leaders Blast Finalized Nursing Home Staffing Mandate

The Centers for Medicare & Medicaid Services (CMS) on Monday unveiled the finalized minimum staffing standards for nursing homes, drawing sharp – and deeply apprehensive – responses from leaders in the sector.

CEOs of nursing home owners and operators and leaders of industry associations were all but unanimous in their reactions; among those who spoke out on Monday, Sabra Health Care REIT (Nasdaq: SBRA) CEO Rick Matros called the rule “unacceptable,” while New Hampshire Health Care Association CEO and President Brendan Williams compared the rule to Star Wars’ “Death Star.”

Katie Smith Sloan, president and CEO of LeadingAge, criticized the rule for not including any support for recruitment and training of needed staff.


“How can providers hire more RNs when they do not exist?” she said in a statement. “Nurse aides, who are the backbone of aging services, are also in short supply – yet again, the rule does not include support to recruit, train and hire more of these critical workers. By the Centers for Medicare and Medicaid Services’ (CMS) estimate, the rule will add to providers’ financial burden – by $43 billion, over 10 years.”

Source: KFF

The American Health Care Association/National Center for Assisted Living (AHCA), representing more than 14,000 nursing homes and other long term care facilities, also harshly condemned the rule.

“This fight is not over,” AHCA President and CEO Mark Parkinson stated. “We will vigorously defend our nursing home members, those they serve, and those they employ. Momentum against the mandates continues to build among both Democrats and Republicans, and we hope to work with lawmakers on more meaningful solutions that would help boost the long term care workforce. For the sake of our nation’s seniors and their caregivers, we must find a better way.”


As this response suggests, the battle over the rule is ongoing. Legal challenges could still be mounted, and political action – particularly should a new administration take the White House – could shape the future.

The rule mandates a minimum of 3.48 hours per resident per day (HPRD) of total staffing, with specific allocations for registered nurses (RN) and nurse aides.

This standard encompasses 0.55 HPRD of direct RN care and 2.45 HPRD of direct nurse aide care. CMS said that facilities can use a mix of nurse staff, including RNs, LPNs/LVNs, or nurse aides, to meet this standard. This is a change from the proposed version of the rule that CMS put forward in Sept. 2023, which called for 3 HPRD of care and excluded licensed practical nurses.

The finalized version translates to facilities with 100 residents needing a minimum of two to three RNs and ten to eleven nurse aides per shift, along with two additional nurse staff members, who could be registered nurses, licensed professional nurses, or nurse aides.

“Many facilities would need to staff at a higher level based on their residents’ needs,” the White House stated in a fact sheet. “It will also require facilities to have a registered nurse onsite 24 hours a day, seven days a week, to provide skilled nursing care, which will further improve nursing home safety.”

Only 19% of nursing facilities currently meet the full complement of staffing standards in the final rule, according to a KFF analysis released Monday. Nearly 60% of facilities meet an interim requirement of 3.48 HPRD, without specific RN and nurse aide allocations.

The rule will be phased in over a period of three to five years, with a longer lead-up time being given to rural nursing homes. Urban facilities would have to meet interim requirements by May 2026 and final requirements by a year later, and rural facilities would have until May 2027 for the interim requirements and until May 2028 for final requirements.

‘Strong and reasonable standards’

The rule’s final version is a response to over 46,000 public comments and will impact nearly 1.2 million residents.

On a call with reporters, a senior administration official said that the government considered the comments, many from operators who opposed the rule, and finalized “strong and reasonable standards” that officials believe all nursing homes can meet.

There are some situations in which nursing homes can apply for exemptions, according to CMS’ fact sheet on the rule. For example, if facilities are located in an area where the RN to population ratio is a minimum of 20% below the national average, they may receive an exemption from the 0.55 RN HPRD and an exemption of up to eight hours per day for the 24/7 on-site RN requirement.

“Alongside the finalization of the 24/7 requirements for registered nurses, we have included some allowances for facilities to have an exemption to that standard for eight hours of that 24/7 RN requirement,” the official said on Monday’s call. “Any nursing home that seeks that exemption would need to have appropriate staff available – either a physician’s assistant, a registered nurse available to the facility by phone or otherwise – during that eight hour period.”

Consumer groups praised certain aspects of the final rule while also pushing for more stringent requirements. For example, the Long-Term Care Community Coalition characterized the overall nursing requirement as too low, but described the 24/7 RN requirement as a strength.

“The benefit of this requirement is that residents will finally have greater access to the 24-hour skilled nursing which, by definition, nursing homes are expected – and paid – to provide,” the LTCCC stated in a brief posted to the organization’s website. “Importantly, CMS is requiring that the RN be in the building, rather than just ‘available’ at a foreign location.”

Industry stakeholders weigh in

The mandate, which has been widely opposed by the nursing home operators in the comment period, has been met with further dissent.

Sabra’s Matros said he expects to see both legal and legislative action to stop the mandate.

The mandate continues to be unacceptable,” he said in an email to Skilled Nursing News. “The nurses don’t exist. This isn’t about quality care. It’s about having a mechanism in place to punish operators for not complying with something it’s impossible to comply with.”

Brian Ellsworth, vice president of public policy and payment transformation at Health Dimensions Group, said that one of his biggest concerns is the ongoing imbalance between the supply and demand for labor in the aging services field.

By the time the staffing rule is fully implemented, the U.S. will be near the end of a 20-year, steep slide in the ratio of number of workers per Medicare eligible beneficiary, going from about 4 workers per beneficiary to 2.5, he said.

“These next five years are the worst part of that slide, with the 75 and older age group projected to grow by about 19%while working age people will remain essentially flat,” he said. “This has profound implications for the costs of the staffing mandate, which are likely to far exceed CMS projections. This will place even greater pressures on state Medicaid programs, many of which are in the process of rebasing their payment systems and moving to the Patient-Driven Payment Model.”

Two solutions to the workforce shortage in the short run could be increasing legal immigration and encouraging greater labor force participation, he said.

“Staffing mandates don’t cure this fundamental economic problem and may, in fact, encourage providers to reduce admissions or shift to other service lines, creating access problems and hospital backups,” he said.

Impacts on rural facilities

To support implementation, CMS has outlined a phased approach, giving non-rural facilities three years and rural facilities five years to meet the staffing requirements. This recognizes the unique challenges faced by rural facilities, particularly in staffing.

The agency also introduced a hardship exemption process, allowing facilities facing staffing challenges due to workforce unavailability to apply for temporary exemptions while demonstrating good faith efforts to hire and retain staff.

Yet this may not be enough, rural stakeholders told SNN.

The New Hampshire Health Care Association (NHHCA) issued a stark warning in response to the mandate, calling the legislation a “death star” for the industry.

“This news is Christmas in April for predatory staffing agencies,” Brendan Williams, CEO of NHHCA said in a press release. “For many nursing homes, it’s an extinction event.”

Williams said that although New Hampshire is a very rural state, even in urban areas like Manchester finding licensed nursing staff is extremely challenging, leading the state to rely heavily on staffing agencies to “an unhealthy degree” even in state-run facilities that offer high wages and union-negotiated benefits.

And small rural nursing homes are having an even harder time, he said.

“They’ve been denying access to care for prospective residents, and these facilities are really the last refuge for those in need,” he said. “The fact is that even they have been unable to accommodate the need that exists, and it’s going to get worse with this mandate.”

His point has been echoed repeatedly over the last months by other providers with a large rural presence, including the Evangelical Lutheran Good Samaritan Society.

Uncertain future

With the fight against the final rule underway, the nursing home industry has some allies on Capitol Hill, including lawmakers from both sides of the aisle who represent rural states.

Sen. John Tester, a Democrat from Montana, joined with Sen. James Lankford, a Republican from Oklahoma, in sending a letter to CMS urging reconsideration of the mandate. That letter, dated Sept. 29, 2023, was signed by other members from both major political parties.

The U.S. House of Representatives’ Ways & Means Committee passed a bill in early March, seeking to prohibit the HHS secretary from finalizing the minimum staffing requirements. And other lawmakers on Capitol Hill also oppose the mandate, and some spoke out on Monday.

“The President’s one-size-fits-all, Washington-knows-best approach to long-term care is an unfunded mandate that will drive up costs and threaten access for patients,” House Energy and Commerce Committee Chair Cathy McMorris Rodgers, a Republican from Washington, stated. “The minimum staff-to-patient ratio is unworkable for nearly 80% of nursing homes, requiring facilities to increase costs for patients or close their doors to new patients.”

Democrat Gwen Moore, a representative from Wisconsin, also recently wrote to CMS, highlighting concerns about the exemption requirements.

“​​My district is a dense urban area that has multiple [long term care] facilities,” Moore wrote. “I am concerned that this proposal may make it harder for facilities in areas like my district that try in good faith to [qualify] for this exemption. And without the ability to get that exemption, it may lead to a facility closure that for many families in my district, would be an extreme hardship to try to locate a new facility that meets the needs of their family member.”

Wisconsin was the setting for the Biden administration’s official rollout of the minimum staffing rule. On Monday, Vice President Kamala Harris traveled to the Wisconsin town of La Crosse, where she was joined by CMS Administrator Chiquita Brooks-LaSure. Harris delivered comments on the staffing mandate, saying that about 75% of federally funded nursing homes are understaffed, according to a report from Wisconsin Public Radio (WPR).

Harris and Brooks-LaSure spoke with health care workers at the Hmoob Cultural & Community Agency. Brooks-LaSure noted that her agency carefully considered comments submitted on the staffing rule from health care workers themselves – some of whom noted that they were feeling compelled to leave health care for jobs in the service industry “where they could earn higher wages without the emotional and physical demands of nursing home care,” WPR reported.

The Biden administration has been at odds with nursing home industry leaders on several issues, and operator executives have reported a combative regulatory environment.

“We’re facing more fines and sanctions, creating a very punitive environment,” Care Initiatives CEO Michael Beal said at the recent Capital & Strategy conference, held by Skilled Nursing News and other WTWH Media publications.

Should the 2024 elections lead to a change in which political party controls the White House, that could alter the fate of the staffing mandate, industry analysts noted on Monday.

Seema Verma, who was CMS administrator during the Trump administration, has been among the critics of the staffing mandate.

“A one-size-fits-all staffing ratio concocted by federal bureaucrats won’t consider differences in a patient’s acuity or local factors, but it will thwart innovation in operational and technological advances that can improve care with existing workforce numbers,” Verma wrote in March 2022.

On Monday, current HHS Secretary Xavier Becerra said the time is right for the staffing mandate, given the increasing number of older adults who need care in these settings.

“We believe that with more and more Americans going to nursing homes, it’s time to make sure that quality is the standard that everyone strives for,” Becerra said in an interview with The Associated Press.

But nursing home leaders themselves have said that they support efforts to enhance quality, and they are not even opposed to a staffing mandate per se – but “the devil is in the details,” as Sam Bechtold, chief investment officer with Utah-based operator Eduro Healthcare, said at the Capital & Strategy conference.

“I’m not against a staffing mandate, and our company’s not against staffing mandates,” he said. “It’s just you’ve got to look at it on a case by case basis, on a state by state basis, instead of trying to blanket-cover the entire United States. Banks, Texas is not New York City, and trying to have the same rules apply across the board just doesn’t make a lot of sense.”

With contributions from WTWH Media Editorial Director Tim Mullaney.

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