Healthcare staffing in long-term care (LTC) facilities has long been unsatisfactory and challenging.
To address this persistent issue, the Centers for Medicare and Medicaid Services (CMS) set national standards for minimum nurse staffing levels. The mandate aims to significantly reduce the risk of unsafe and low-quality care for nursing home residents.
Learn what the CMS minimum staffing rule entails and what the implications are for healthcare facilities and nursing professionals.
What is the CMS staffing mandate?
On April 22, 2024, the CMS issued the final rule on Minimum Staffing Standards for Long-Term Care (LTC) Facilities and Medicaid Institutional Payment Transparency Reporting. The CMS then published final rules for nurse staffing standards for nursing facilities on May 10, 2024.
The minimum staffing requirements for nursing homes did not come as a surprise. In fact, the Biden administration announced the plan for the proposed rule on February 28, 2022.
A review of data collected since 2016 indicated chronic understaffing of registered nurses (RNs), licensed practical/vocational nurses (LPNs/LVNs), and certified nurse aides/certified nursing assistants (CNAs) in LTC facilities. These findings raised concerns regarding healthcare quality and patient safety.
The rules aim to hold nursing homes responsible for providing high-quality, safe care for the approximately 1.2 million residents receiving care in Medicare- and Medicaid-certified long-term care facilities across the country.
Staffing requirements
The final rules establish three separate and independent nurse staffing requirements:
- A facility assessment process
- At least 3.48 hours per resident day (HPRD) of total nursing care (.55 HPRD by an RN, 2.45 HPRD by a CNA, and .48 by an RN, a CNA, or an LPN/LVN)
- RNs in every nursing facility 24 hours a day, seven days per week (including Directors of Nursing (DONs) if they are available to provide direct resident care)
The first requirement for nursing facilities is not actually new. The 2016 modifications to the Requirements of Participation for nursing facilities created the facility assessment process instead of requiring specific staffing ratios.
However, the 2024 staffing rule moves the facility assessment requirement to its own regulatory provision (§483.71). This move emphasizes the importance of the process and complements the minimum numerical staffing standards (89 Fed. Reg., 40906).
The revised facility assessment process requirements became effective for all facilities on August 8, 2024. However, the numerical staffing requirements will not take effect for two to five years.
Implementation timeline
The time frame depends on whether the facilities are in rural or non-rural areas. Furthermore, some facilities may qualify for exemptions based on workforce unavailability and other factors.
The following is the implementation time frame for the new staffing rules in non-rural and rural facilities:
- Phase 1: Rural and non-rural facilities must meet the facility assessment requirements within 90 days of the final rule publication.
- Phase 2: Non-rural facilities must meet the 3.48 HPRD total nurse staffing requirement and the 24/7 RN requirement within two years of the final rule publication. Rural facilities have three years to meet these requirements.
- Phase 3: Non-rural facilities must meet the 0.55 RN and 2.45 NA HPRD requirements within three years of the final rule publication. Rural facilities have five years to comply with this rule.
The CMS will closely monitor and assess the provisions of this final rule over the next several years to determine whether any updates or changes are necessary.
CMS staffing guidelines: an overview
The CMS minimum staffing requirements affect long-term care facilities like nursing homes. However, the CMS staffing requirements are not applicable to hospitals. The federal nursing home staffing mandate requirements are significantly below the nurse-to-patient staffing ratios required in acute care settings.
The nursing home minimum staffing rule only requires 3.48 HPRD of total nursing care and merely .55 HPRD by a registered nurse. Staffing needs in hospitals are quite different.
For example, in a California hospital’s neonatal intensive care unit (NICU), RNs must provide 24/7 care for patients. Furthermore, they may only care for one patient at a time. This translates to 24 hours per patient day (HPPD) in this setting.
Impact and implications of the CMS minimum staffing rule
The federal nursing home staffing mandate has started a ripple effect that will significantly impact health care facilities and nursing professionals for years to come.
How the CMS staffing mandate affects healthcare facilities
Facilities with staffing ratios below those stipulated in the CMS nursing home staffing mandate will have to focus efforts on nurse recruitment over the following years. Other predicted impacts include the following:
- The nationwide scramble for additional care staff will lead to higher competition for nursing talent.
- Increasing staffing levels will also lead to increased staffing costs.
- The need for additional staff and ongoing facility assessments will require an increased focus on monitoring and care planning.
How the CMS staffing guidelines affect nursing professionals
The CMS staffing guidelines are mainly beneficial for nurses. The minimum staffing requirements for nursing homes are likely to impact nursing clinicians as follows:
- There will be more job opportunities for nursing professionals, particularly in long-term care settings.
- Nurses specializing in long-term care and related areas, such as wound care, hospice, and palliative care, will be in high demand.
- However, maintaining the mandated nursing home staffing ratios in the context of a nursing shortage may also lead to overworking internal staff.
Best practices for healthcare facilities
Faced with the CMS minimum staffing provisions, healthcare facilities must explore new solutions to staffing challenges and be proactive in their efforts.
The following are suggestions to align practices with the new CMS staffing mandate:
1. Prioritize nurse retention
Many facilities will have to recruit new staff over the following years. However, recruitment efforts will only be effective if facilities can retain both new and existing staff. To this end, facilities must implement strategies to prevent nurse burnout. Financial incentives can help but are not enough on their own to retain nurses.
2. Optimize facility scheduling practices
Administrators and schedulers should carefully asses current scheduling practices, such as overtime and on-call practices, and the impact these may have on nurse turnover and burnout rates. Flexible staffing options can help facilities adapt to inevitable fluctuations in patient census without overworking internal staff.
3. Diversify your recruiting strategy
In addition to traditional recruitment strategies involving sifting through seemingly endless resumes and scheduling numerous interviews, facilities should consider other staffing solutions.
For example, facilities can rely on PRN nursing apps to address immediate staffing needs. Furthermore, contracting PRN/per diem nurses on-demand via an online marketplace is an excellent way to see potential employees in action and determine whether they would be good fits and assets for the facility in the long term.
4. Create a contingency plan for emergencies
In healthcare, a contingency plan is a must. Numerous situations can lead to significant increases in patient census and/or drops in staffing levels: natural disasters, pandemics, strikes, etc. Again, in these situations, facilities must be able to access flexible options for emergency staffing.
What role can staffing platforms play?
PRN staffing platforms, such as Nursa, are valuable resources to help facilities comply with the CMS staffing mandate and maintain patient care quality.
Facilities can rely on independent contractor nurses to cover short-term needs and maintain safe staffing levels. Furthermore, a PRN clinician who is a good match with a facility can become a permanent employee, providing long-term staffing solutions.
One example of a facility that addressed staffing challenges with PRN clinicians is Brookfield Health. This facility was experiencing staffing shortages and last-minute call outs. The facility started using Nursa to cover weekend shifts, holidays, and last-minute needs. With the help of PRN nursing, this skilled nursing and rehabilitation provider was able to adapt to fluctuating needs and reduce unfulfilled shifts.
Staffing, Nursa, and the healthcare industry: learn more
Healthcare regulations like the CMS staffing mandate aim to improve patient conditions. Healthcare facilities share this goal. However, staffing mandates pose a significant challenge for facilities, particularly in the context of the ongoing nurse staffing shortage.
Contracting PRN clinicians to cover fluctuating needs is an efficient and cost-effective strategy facilities can use to comply with minimum staffing requirements.
Discover how other facility leaders have addressed staffing challenges in this recent research survey.
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