Biden’s Nursing Home Reform Plan Proposes Minimum Staffing Requirements

On February 28, the Biden administration released an announcement detailing its plan for nursing home reform. The statement was entitled “Protecting Seniors and People with Disabilities by Improving Safety and Quality of Care in the Nation’s Nursing Homes.” The reform plan demonstrates that President Biden is serious about addressing nursing home issues, and in a rare move the president even mentioned nursing homes in his State of the Union address on March 1.


The February 28 announcement describing Biden’s nursing home reform plan said the plan is designed to “improve the safety and quality of nursing home care, hold nursing homes accountable for the care they provide, and make the quality of care and facility ownership more transparent so that potential residents and their loved ones can make informed decisions about care.”


In order to achieve this objective, the announcement said the reforms will ensure that 1) every nursing home has a sufficient number of trained staff; 2) poorly performing nursing homes are held accountable and make improvements, otherwise they will be “cut off from taxpayer dollars”; and 3) more information about nursing homes is made available to the public so that people can make more informed decisions about which nursing home to choose.


Perhaps the most controversial proposal in Biden’s nursing home reform plan is the inclusion of a proposed minimum staffing requirement. In setting forth the reasons for the minimum staffing requirement, the February 28 announcement said that nursing home staffing levels are directly correlated with the quality of their care and cited a study which found that increasing registered nurse staffing by 20 minutes per resident day was associated with 22% fewer COVID-19 cases and 26% fewer COVID-19 deaths.


The nursing home reform plan thus ordered the Centers for Medicare and Medicaid Services (CMS) to conduct a research study to determine the level and type of staffing needed in order to “ensure safe and quality care” and directed CMS to issue proposed staffing rules within one year.


Biden’s nursing home reform announcement also said that establishing minimum staffing levels would ensure that “all nursing home residents are provided safe, quality care, and that workers have the support they need to provide high-quality care.” Finally, the announcement said that nursing homes would be “held accountable” if they fail to meet this standard.


This last part about holding nursing homes accountable is what really irks the nursing home community because it raises the possibility of monetary fines or other penalties being imposed on nursing homes that fail to satisfy the standard even though we are in the midst of a severe skilled nurse shortage.


In addition, nursing home industry leaders and advocates have said that requiring nursing homes to increase the number of skilled nurses at their facilities without a corresponding increase in government funding would make the economic viability of operating a nursing home with sufficient staff simply impossible.


While Biden’s reform plan does propose measures to increase the number of skilled nurses by expanding and decreasing costs of nurse training and recruitment programs, these efforts won’t bear fruit for a number of years, so it’s simply unrealistic to expect nursing homes to increase their staff levels overnight and unfair to impose penalties on nursing homes who fail to meet Biden’s proposed minimum staffing requirement.


The current staff shortage at nursing and residential care facilities is the most severe it’s been in 15 years, and according to a statement released by the American Health Care Association on February 9, if lawmakers don’t take action to quickly address the shortage of skilled nurses “our nation’s most vulnerable seniors risk reduced access to care as facilities are forced to limit admissions or even close down altogether.”


At a congressional hearing on February 10, labor policy analyst Rachel Greszler from the Heritage Foundation, a right-leaning Washington think-tank, said that “lives are literally at stake because of the healthcare workforce shortage, and many regulations are needlessly making this worse.”


In fact, the dire shortage of skilled nurses has even prompted some states to reduce staffing requirements rather than increase them.


The legislature of Florida—the state with the second-highest number of seniors overall and as a percentage of the population—passed a bill this week which changes staffing standards at nursing homes. The bill, which was passed with hefty majorities in both houses of Florida’s legislature and is awaiting Gov. Ron DeSantis’ signature, comes amid a growing national debate over minimum staffing requirements.


Opponents of the Florida bill, including the state’s long-term care ombudsman, the AARP, and a union representing nursing-home workers, have argued that it will lead to less care for nursing home residents and thus potentially cause harm.


But the bill’s sponsor in the Florida senate, Ben Albritton (R-Wauchula), was quoted by Health News Florida as saying that “If I really, really believed that this was going to injure a resident, my name would not be on this bill.”


Florida’s legislature originally established staffing standards in 2001 along with other nursing home reforms, but these standards were controversial and the new bill was passed after lobbying from the nursing home industry, which insisted that the changes were necessary to tackle staffing shortages.


The bill will reduce the required minimum daily number of certified nursing assistant direct care hours per resident to 2 hours from the current requirement of 2.5 daily hours of direct care per resident.


In addition, the bill will allow time spent by other nursing home staff—such as physical and occupational therapists—to be included in Florida’s weekly average requirement of 3.6 daily hours per patient of direct care by certified nursing assistants and licensed nurses.


Florida’s efforts to reduce staffing requirements at the state level underscores the challenges which the Biden administration will confront as it pushes for higher staffing requirements.


Indeed, in a letter sent on March 8 to the Biden administration written by Mark Parkinson, the president and CEO of the American Health Care Association/National Center for Assisted Living, Parkinson criticized President Biden’s proposed minimum staffing requirements on grounds that they would be impossible to satisfy and result in “nearly every nursing home being out of compliance.”

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