Biden Admin Proposes Long-Awaited Staffing Requirements for Nursing Homes

The Biden administration released the first-ever nursing home staffing requirements today after first promising them in advance of the 2022 State of the Union address. If finalized, the standards will be the most significant change to nursing home regulations since they were first created in the 1970s.

Health policy experts are mixed on what the new standards will mean for residents and workers — the majority of whom are women. While some are calling the new policy a good first step, others say it doesn’t go far enough to address inadequate staffing that endangers both residents and staff.

The proposed standard will require a minimum of 0.55 hours of care from a registered nurse per resident per day and 2.45 hours of care from a nurse aide per resident per day. A required minimum for licensed practical nurses, who make up a vital part of nursing home care, is absent.

The rule is currently a proposed regulation — advocates and stakeholders will have 60 days to provide comments before the final rule is established. Then there is a three-year proposed phase-in for non-rural facilities and a five-year proposed phase-in for rural facilities.

There is a well-established link between a higher number of staff per resident and better outcomes for patients.

“The more staffing that we have available in nursing homes, the more opportunities that we have to respond to the needs of residents. If you have sufficient staff, you’re going to have staff to answer the call bells, to walk residents to the bathroom, to change them when they need to be changed, to position them,” said Jasmine Travers, an assistant professor of nursing at New York University.

“If you don’t have sufficient staffing to be able to do those basic care needs, the residents will suffer. They will stay in bed longer than they’re supposed to. They won’t be turned as often as they should be, which can create pressure ulcers. They may not be able to use the bathroom, which can increase chances for urinary tract infections. They might try getting out of bed themselves and fall,” Travers said.

Charlene Harrington, a professor emerita of nursing at the University of California-San Francisco, described the Biden administration’s standard as “completely inadequate.”

“It’s not sufficient. We — professional nurses, geriatric nurses and geriatricians — have sent all kinds of letters and summaries of all the research to [the Centers for Medicare and Medicaid Services] and basically that was all just ignored,” Harrington said.

Harrington and other experts cited a previous report from 2001 indicating that 4.1 total nursing hours per resident would be necessary to result in significant improvement for nursing home resident outcomes. However, even that number may be low.

“Our resident population has changed significantly since 2001. They’re much more complex. We have a lot more residents living with dementia, for example. That means they require a lot more staffing hours,” Travers said.

But David Grabowski, a professor of health care policy at Harvard Medical School, is optimistic about the impact the move will have, even if the staffing numbers are lower than what he and other experts have recommended.

“If you look at this relative to what a lot of experts and advocates would have liked, this seems low. But I think if you look at this relative to the distribution of how facilities actually staff, this is going to be really important. I think I should say this very clearly: This is a big deal. This has been something that has been called for going back to the 1980s. And it’s been really hard to implement,” Grabowski told The 19th.

According to the Centers for Medicare and Medicaid Services, 75 percent of U.S. nursing homes will need to hire more staff in order to meet their new proposed standard.

“Could it have gone further? Yes. Is it perfect? Of course not. But I do think it’s a good start,” Grabowski said.

Nursing home workers and the larger industry also disagree on the impact of the proposed rule.

Labor groups like AFL-CIO praised the move, calling it a “critical first step towards strengthening our long-term care system” in a written statement. While nursing home industry group LeadingAge decried it, stating, “it’s meaningless to mandate staffing levels that cannot be met” in their press release.

Health policy experts did uniformly praise one new requirement: At least one registered nurse must be available on site at all times. Currently, nursing homes are only required to have a registered nurse for eight hours per day.

“If you have an issue at 9 p.m., if you’re short of breath or fever and there isn’t an RN, that’s a real gap,” Grabowski said.

Harrington also praised the move, despite being largely disappointed with the administration’s proposal.

“Having an RN 24 hours a day? That’s very good,” she said, “but the standards themselves are just completely not plausible to have a three-year phase-in — it’s ridiculous. If you’re going to have such low standards, it shouldn’t take that long to meet them.”

In addition to the health risks for nursing home residents, insufficient staffing creates distress for nursing home workers. Louise Santee, 62, has been a certified nursing assistant at Phoebe Allentown, a Pennsylvania nursing home, for 27 years. She is also a member of SEIU. She is responsible for residents’ personal care, such as bathing them, taking them to the bathroom, feeding them and more.

“When residents have to go to the bathroom, they have to go to the bathroom. But if I can’t get to them or other staff can’t get to them, that’s a problem. We do whatever we can to take care of our residents. It’s up to us to take care of them in the best way we can do it. And if we don’t have the staff, we just can’t do it,” she told The 19th.