Nursing home leaders convened in Washington, D.C., on Tuesday to present a unified stance against the federal staffing mandate, which they argue could exacerbate existing challenges in long-term care facilities. 

The gathering follows a Congressional Briefing by American Health Care Association/National Center for Assisted Living (AHCA/NCAL) at the week’s start, and saw key figures from AHCA and LeadingAge, as well as operators, detailing the potential adverse effects of the staffing mandate on the sector.

Mark Parkinson, president and CEO of AHCA, opened the session by expressing the sector’s collective desire to improve staffing, but he also underlined the impracticality of the proposed rule.

“Everyone here wants more staffing in facilities. Members of our associations know it’s beneficial for residents. However, the staffing mandate does not solve the problem and, in many respects, makes it worse,” Parkinson stated. 

He emphasized that 94% of nursing homes currently fall short of meeting all four staffing requirements, with the 24/7 registered nurse (RN) mandate proving particularly challenging.

Parkinson detailed the hurdles facilities face, particularly in maintaining RN coverage during the night shift. Many facilities, especially those in rural areas, rely on licensed practical nurses (LPNs) and on-call RNs due to difficulties in hiring night-shift RNs.

“The 24/7 RN requirement is simply very hard to meet,” he said.

The final staffing rule mandates a total nurse staffing standard of 3.48 HPRD, including at least 0.55 HPRD of RN care and 2.45 HPRD of direct nurse aide care. The additional 0.48 HPRD can be met by any combination of nurse staff, including registered nurses (RNs), LPNs, or nurse aides. Furthermore, the rule requires an RN to be onsite 24 hours a day, seven days a week, to ensure the availability of skilled nursing care. 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.

Health inequities made worse

Additionally, Parkinson highlighted the financial strain the mandate would impose.

According to the Centers for Medicare & Medicaid Services (CMS), compliance could cost an average facility $300,000 annually. However, Parkinson argued that AHCA’s deeper analysis suggested a cost closer to $400,000.

“Whether it’s $300,000 or $400,000, it’s an unfunded mandate that the vast majority of buildings across the country simply don’t have the funds to meet,” he said, noting that an estimated 102,000 additional RNs and CNAs would be needed nationwide.

The impact on facilities with a high number of Medicaid residents also loomed large in Parkinson’s remarks. Such facilities, which already struggle due to inadequate state reimbursement rates, would be less able to meet the new staffing requirements. 

“This policy just exacerbates health inequities,” Parkinson warned, indicating that poorer residents in Medicaid facilities would face reduced access to care.

Disconnect between labor supply and demand

Katie Smith Sloan, president and CEO of LeadingAge, echoed Parkinson’s sentiments, stressing the vital connection between staffing and funding. Representing nonprofit, mission-driven providers of aging services, Sloan outlined the historical commitment of these providers to quality care. However, she noted, “Our current infrastructure of long-term care cannot sustain staffing mandates until they are supported by adequate funding and available staff.”

Sloan underscored the daunting workforce challenges, pointing out that over 100,000 new hires would be required just in the first year of the mandates.

“Where will those 100,000-plus qualified, caring individuals come from?” she asked, emphasizing the shortage of nurses graduating from schools and the broader national labor crisis.

“Between 2021 and 2031, nearly 9.3 million total direct care jobs will need to be filled,” Sloan stated, highlighting the disconnect between workforce supply and demand.

Moreover, the cost to fufill the demands of extra direct care workers could exceed $7 billion in the first year, based on fourth-quarter 2023 data, she projected. This cost includes wages and training necessary to build essential competencies among the workforce.

Sloan called for aligning reimbursement rates with the actual cost of providing quality care to ensure sustainability.

Both Parkinson and Sloan emphasized the broader systemic effects of the mandates. Sloan pointed to stories of patients unable to be discharged from hospitals due to the unavailability of nursing home or home health services, describing the strain this places on the entire healthcare system.

“Limited admissions and bed shortages strain the entire system,” she noted, warning that the ripple effects could extend to acute care, home health, and hospice services.

The nursing home leaders urged a halt to the mandates, calling instead for a range of policy actions to address long-term workforce needs. This would involve aligning reimbursement with the cost of care, including paying staff a living wage, creating incentives to attract and retain staff in the sector, immigration reform to accommodate foreign born workers, and education and training programs.

“We need real policy solutions and investments, not mandates. We are drawing on every available tool—legislative, legal, and regulatory–to stop this rule’s implementation and to address the fundamental issue of building the long-term care workforce,” Sloan said.

Sloan’s remarks come after LeadingAge, whose members span the care continuum, joined AHCA’s lawsuit filed late last week to dismiss the mandate altogether.

“Just as we are seeing people unable to access nursing home beds, we are seeing the same happen to those seeking hospice and home health services,” Sloan said. “We need to stop the mandate and address long-term care workforce needs.”