On September 1st, 2023, CMS proposed the
Minimum Staffing Standards for Long-Term Care (LTC) Facilities and Medicaid Institutional Payment Transparency Reporting rule. This rule was proposed in response to recent trends of poor employment rates at LTC facilities, coupled with the devasting effects of the COVID-19 Pandemic. With nearly 25% of COVID-19 deaths in the US coming from LTC facilities, and the current 1.2 million Americans being treated in a LTC facility - combating this is at the forefront of CMS's priorities. The implications of this ruling are far-reaching, affecting not only the facilities themselves but also the residents, staff, and the healthcare industry as a whole.
Along with the ruling, CMS is investing roughly $75 million for financial incentives, such as nursing scholarships and tuition reimbursement, paired with the Health Resources and Services Administration's (HRSA's) award of $100 million to train and grow the nursing workforce, and LTC facility owners are expected to follow suit.
Key Components of the Ruling:
- 1. Establishing Minimum Nurse Staffing Standards
To address staffing concerns, especially among low-performing facilities, CMS aims to establish a baseline of care for all residents of long-term care facilities. The proposed, minimum staffing requirements are 0.55 Registered Nurses (RN) hours per resident day and 2.45 Nurse's Aide (NA) hours per resident day. CMS is expecting facilities to staff beyond these minimums in order to properly address needs of their residents' based on acuity levels. - 2. Improving the On-Site RN Requirement
This portion of the proposal aims to reduce risks of avoidable resident safety events when there is not an RN on-site, particularly evenings, overnight, weekends, and holidays. CMS is proposing that all facilities have an RN on site 24 hours a day, seven days a week to provide direct patient care. While not every resident of long-term care facilities require constant, specialized treatment, many do, and CMS aims to limit these residents exposure to improper care.
Based on the US average hourly rate of $40.09, for a registered Nurse, this would be an additional $350,000 of annual expense for providers. This amount also gives no consideration into the cost of sourcing, on-boarding, retaining and scheduling a pool of RNs capable of meeting this criterion. CMS has not given much detail on how state Medicaid nor federal Medicare will adjust reimbursement rates to properly reflect this additional cost. - 3. Strengthening the Facility Assessment Requirement
Long term care facilities are required to conduct, document, and review annually and, as necessary, a facility-wide assessment to determine what resources are necessary to properly care for residents both day-to-day and during emergencies. CMS aims to ensure that facilities are using the assessment as intended by making several of the following updates to the reporting requirement:
- Clarifying that facilities must use evidence-based methods when care planning for their residents, including consideration for those residents with behavioral health needs.
- Requiring that facilities use the facility assessment to assess the specific needs of each resident in the facility and to adjust as necessary based on any significant changes in the resident population;
- Requiring that facilities include the input of facility staff, including, but not limited to, nursing home leadership, management, direct care staff (i.e., nurse staff), representatives of direct care staff, and staff who provide other services; and,
- Requiring facilities to develop a staffing plan to maximize recruitment and retention of staff consistent with what was described in the President's April Executive Order on Increasing Access to High-Quality Care and Supporting Caregivers.
CMS is aware that given the current demand for healthcare workers, there are shortages in the market for qualified individuals. Because of this, CMS has also implemented a hardship exemption from the requirements and a staggered implementation.
The proposed hardship exemption will grant facilities a waiver from the staffing requirements if they are able to meet the following criteria:
- Workforce unavailability based on their location, as evidenced by either a medium or low provider-to-population ratio for the nursing workforce.
- Good faith efforts to hire and retain staff through the development and implementation of a recruitment and retention plan.
- A financial commitment to staffing by documenting the total annual amount spent on direct care staff.
CMS's staggered implementation of the proposed ruling currently splits the timeline between urban and rural facilities. For urban facilities, the implantation would occur over a three-year period (3 phases):
- Phase 1 would require facilities located in urban areas to comply with the facility assessment requirements 60 days after the publication date of the final rule.
- Phase 2 would require facilities located in urban areas to comply with the requirement for an RN onsite 24 hours and seven days/week two years after the publication date of the final rule.
- Phase 3 would require facilities located in urban areas to comply with the minimum staffing requirements of 0.55 and 2.45 hours per resident day for RNs and NAs, respectively, three years after the publication date of the final rule.
For Rural Facilities:
- Phase 1 would require facilities to comply with the facility assessment requirements 60 days after the publication date of the final rule
- Phase 2 would require facilities to comply with the requirement for an RN onsite 24 hours and seven days/week three years after the publication date of the final rule.
- Phase 3 would require facilities to comply with the minimum staffing requirement of 0.55 and 2.45 hours per resident day for RNs and NAs, respectively, five years after the publication date of the final rule.
All of this is still "proposed" and is not currently being enforced by CMS, they have not given a definite date as to when the final ruling will be settled and what will all be included. CMS has opened the discussion to providers and is willing to take suggestions on any changes to the proposal.
It is hard to gauge the true impact this could cause without first considering CMS's plans to adjust reimbursement rates in response to the proposed minimum staffing requirements, on which there has been little discourse.
