AHCA/NCAL: Nursing Home Staffing Rule Will Cost $6.5B Annually, Require 102,000 Extra Clinicians, Displace a Quarter of Residents

The nursing home minimum staffing rule is estimated to cost the industry a staggering $6.5 billion per year, and would require an additional 102,000 clinicians, according to a new analysis released Thursday by the American Health Care Association and National Center for Assisted Living (AHCA/NCAL).

To fulfill the rule’s requirements, more than 77,000 certified nurse aides (CNAs) and 24,000 registered nurses (RNs) will need to be hired.

In terms of access, nearly one-quarter of residents are at risk of displacement as facilities will be forced to reduce census to comply with the mandate, or close altogether. That’s more than 290,000 residents affected by the rule, the AHCA/NCAL analysis states.


Following the finalized federal minimum staffing mandate last month, AHCA/NCAL conducted this analysis of the minimum staffing rules that are set to be published in the Federal Register on Friday. The association’s analysis includes cost estimates and an expected number of additional clinicians.

The Centers for Medicare & Medicaid Services (CMS) settled on a minimum of 3.48 nursing staff hours per resident per day (HPRD), including 2.45 hours from nurse aides and 0.55 hours from registered nurses (RNs).

Nursing homes will also be required to have an RN on site 24 hours per day. Four out of five nursing homes can’t meet the 24/7 RN requirement, AHCA/NCAL found. Breaking down the rule further to account for specific nurse categories, half of facilities can’t meet the 0.55 RN HPRD requirements and 70% can’t meet the 2.45 HPRD requirement.


“What our new analysis confirms is what we’ve been saying for years: An unfunded, one-size-fits-all minimum staffing mandate for nursing homes would be impossible to meet and only threatens to limit access to care for our seniors,” AHCA/NCAL President and CEO Mark Parkinson.

AHCA/NCAL used staffing, cost and facility data from the federal government, including CMS’ Payroll Based Journal, Medicare Cost Reports and Care Compare.

Additional key findings included the fact that only 6% of nursing homes currently meet all requirements in the rule. And, there’s a strong correlation between Medicaid census and compliance – those that predominantly serve residents on Medicaid are less likely to meet the mandate, AHCA/NCAL found. The chronically underfunded payment source reimburses nursing homes at 86% of actual costs.

Generally, location and revenue source are main determinants of whether or not a nursing home can meet the new staffing requirements, according to the analysis.

Nursing homes have been facing a historic labor shortage only made worse by the pandemic – while other health care sectors increased their workforce by 5% to 11% compared to February 2020, nursing homes still need to recover more than 7% of its workforce, or nearly 125,000 workers to get to pre-pandemic levels.

Nearly every nursing home in the country would be considered out of compliance, said Parkinson, and exemptions are “basically impossible” to obtain, It would take nursing homes two years to get to pre-pandemic levels at its current pace, which includes “unprecedented efforts” to attract more staff, according to the analysis.

“It demonstrates how out of touch Washington bureaucrats are with reality. Nursing homes have been doing everything they can to recruit and retain more caregivers, but the available labor force is not there,” said Parkinson.

The Biden administration ignored concerns and finalized the rule, continued Parkinson, despite growing bipartisan concern in Congress that the mandate is not the right path forward.

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