Rethinking Nursing Home Staffing: Unpacking the Impact of Proposed CMS Rules

Staffing is the most important input to providing high quality nursing home care. However,  many U.S. nursing homes struggle to staff at levels that promote resident safety and well-being.

In September of 2023, the Centers for Medicare and Medicaid Services proposed a new rule regarding minimum staffing standards for US nursing homes.  The New England Journal of Medicine spoke with HCP’s professor of Health Care Policy, David Grabowski, PhD, about his recent perspective piece on the new ruling.

Grabowski noted that three main types of staff care for residents of nursing homes: registered nurses (RNs), licensed practical nurses (LPNs), and certified nurse aides (CNAs). Clinical needs and medications are covered by RNs and LPNs, while CNAs provide the bulk of the assistance with activities of daily living.  

Although current requirements call for an RN or LPN to be onsite at all times, there are no specific guidelines on particular hourly staffing levels. Nursing homes are broadly required to staff at a level that promotes the safety and well-being of the residents.

The new proposed ruling requires a total of 3 hours of staff time per resident per day, with roughly 30 minutes of RN time, and the remaining 2.5 hours to be staffed by CNAs. There is no specific requirement about LPN time. Moreover, the rule now requires an RN to be onsite at all times.

Although the new proposed rule is a step in the right direction in terms of establishing better staffing guidelines, Dr. Grabowski raised a number of potential issues during his interview. One concern is that the guidelines will lead to the demise of the LPN role in nursing homes. Because the rules only specify hourly RN and CNA requirements,  there is a worry that nursing homes will staff to the RN level and then fill the remaining time with CNAs, cutting out LPNs, who are valuable members of the nursing home labor force.

A second concern is the delayed implementation period proposed for the new mandate. Such a slow ramp-up may be unnecessary in many cases, especially when there is evidence of the immediate need for change.

Grabowski also raised the concern that the proposed rule exempts certain nursing homes from the staffing requirements because they face hiring difficulties. This exemption might allow some nursing homes to forego the new policy altogether. Grabowski suggested that these exemptions provide “…a signal that we have more than a staffing problem, if we have to exclude a lot of nursing homes from this rule we have a payment problem, not just a staffing problem, but a broader policy failure here.”

And finally, there is the question of whether the minimum staffing level under the proposed rule goes far enough. The proposed rule discussed the possibility of introducing a minimum level of 3.5 total hours on top of the existing RN and CNA requirements. Grabowski expressed support for this approach.

There is recognition that policy change might be a slow and challenging process due to stakeholder criticism and the complexity of the task at hand, but in the aftermath of the pandemic and its toll on nursing homes, it is crucial to continue the path of nursing home and staffing reform. As Grabowski stated, ”low staffing is this symptom rather than the cause of a lot of nursing home problems. I would love to see much more comprehensive reform in this sector… this staffing reform is the biggest change in decades, but I hope it’s the start of a lot of changes and not just a one off. “