‘It’s Not Reality’: Health Dimensions’ CEO on the Ripple Effects of the Nursing Home Staffing Rule

As staffing shortages continue to drive nursing home closures across the U.S, sector leaders such as Erin Hennessey, President and CEO of Health Dimensions Group, are expressing deep concerns about the minimum staffing rule that will only worsen the crisis of access, especially in rural counties where labor is in very short supply.

“There’s no provider that doesn’t want or think that we need more staffing,” said Hennessy. “There’s a disconnect in what Washington thinks will happen if they implement this. Some communities won’t survive … because they can’t find that staff.”

And while rural communities can lean on temporary waivers, urban communities will be limited in their response. “[In urban communities] the only thing you can do is reduce the amount of residents that you take.”


The final 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 the additional 0.48 HPRD.

Rural counties have five years to implement the minimum staffing standards while urban areas are allowed up to three years. Urban counties are defined as those that have a population of 50,000 or more people.


A USA Today analysis revealed that a vast majority of nursing homes in the U.S. fall short of meeting the staffing requirements

If the final rule is implemented, expect a “ripple effect” through the entire continuum, Hennessy said.

“I think our best friend during this needs to be our hospital associations because our inability to care for residents will be their inability to discharge patients to our setting,” she said.

Currently, for HDG, it was “impossible” to fulfill the 24/7 RN requirement in certain communities, she said.

“We calculated that you need about 5 to 6 nurses doing a mix of full-time work to part-time work to be able to cover that. In some places we operate we don’t even have 5 or 6 RNs on staff right now. So my first response was, it’s absurd and we all wish we could have that, but it’s not reality.”

However, since the staffing mandate isn’t expected to go into effect for urban communities until 2027, a lot can change provided the sector perspective is shared and heard, Hennessy said.

“The world will be a different place in three years. So I think that we have a lot of time with our advocacy groups, our trade organizations to really make sure that our story is heard and that our voice is heard. That we’re all on the same side of taking care of residents. We just need to be a little more realistic on how we do it,” she said.

And it’s imperative for nursing home organizations to come up with a game plan soon via facility assessments that need to be completed in 90 days following the finalization of the rule in April. “So we’re all going to be taking a pretty close look at our organizations this summer and understanding what we’re going to need,” she said.

Hennessy shared her views in a conversation with Scott Tittle, managing director at VIUM Capital, in VIUM’s latest podcast.

For many industry insiders, there is enough time for advocacy efforts to provide a viable path forward for all parties.

“There’s a lot of opportunity on the advocacy side. We have several general elections to go, the bills moving through Congress, there’s litigation to be filed. So hopefully at the end of this, despite all the hard work that’s going to be needed, the right solution comes out,” said Tittle, who added that the sector wasn’t against minimum staffing ratios.

That said, he said, “It just has to be reasonable, realistic and funded. There has to be a recognition that there’s a significant cost there that’s got to come from somewhere. And with the fact that this whole thing is unfunded is just tremendously concerning.”

The staffing mandate will certainly increase the price of care at SNFs, Hennessy said.

“I worry about the parts of the sector that can’t dictate their own pricing,” she said. “And what happens to Medicaid patients where you don’t have as much control over your rates and then you have managed care coming in? What do you do in settings where you don’t have as much control over your rates?”

At the end of the day, the final rule might end up impacting those most in need, who can’t afford to pay privately, Hennessy noted.

“Buildings are going to close and we’re going to have counties, many counties in this country, they’re just not going to have a nursing home in their county, and they’re gonna have to travel a long ways to get the care they need,” Tittle said.

It is unrealistic to expect that some of the residents’ care will be diverted to other segments of long-term care, Hennessy said.

“I think it’s kind of an illusion that skilled nursing won’t be in demand,” she said. “The diseases and the chronic illness that our seniors have, it’s always going to be a part of it. I think the government doesn’t understand how many skilled beds are going to be needed for this wave of people coming our way.”

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