As seen in Providence Business News

Staffing has always been an ongoing challenge in the long-term care industry. However, since the pandemic in January 2020, staffing shortages have been exacerbated. Many factors have contributed to the staffing challenges, including:

• Compliance and regulatory requirements are constantly changing and updating to improve resident safety and outcomes;
• Staff are being held to higher standards and are being asked to do more with less resources;
• Residents in long-term care facilities have more complex and challenging medical, physical, behavioral, and psychological needs;
• Reimbursements from federal Medicare, state Medicaid, and third-party insurance companies have remained stagnant, hindering nursing homes from being able to compete with the rising rates of pay in the market; and
• Fear from the pandemic has prevented people from entering or returning to the long-term care industry.

These factors have led to mental and physical burnout resulting in staffing shortages in the long-term care industry. Employers such as retailers, grocery stores, and coffee shops have offered rates of pay similar to or higher than those of certified nurse aides (CNA). In addition, the reduced responsibilities of these employers compared to the responsibilities of resident care have lured CNAs away from nursing homes.

Throughout the pandemic, media coverage has highlighted instances of resident abuse and misappropriation of federal and state aid meant to compensate workforce. As a result, the federal and state governments have implemented more stringent staffing mandates. The goal of these staffing mandates is to improve the quality of care and safety for residents. Despite the historic labor shortages, federal and state governments have proceeded to implement these staffing mandates.

In May 2021, Rhode Island passed a law that included the highest standards for nursing home staffing in the country. It established a minimum standard of 3.58 hours per resident day (HPRD) of direct nursing care, with at least 2.44 HPRD provided by CNAs, effective January 1, 2022. The minimum standard increased to 3.81 HPRD of direct nursing care, with at least 2.6 HPRD provided by CNAs, effective January 1, 2023. As of current, there have been no changes to the minimum standard. Since its passage, the law has not been enforced and no fines to nursing homes have been levied. Governor McKee has continued to issue executive orders to suspend monetary penalties for nursing homes that fail to meet the State’s minimum staffing requirements due to the ongoing staffing shortages.

In April 2024, the Centers for Medicare and Medicaid Services (CMS) finalized the Minimum Staffing Standards for Long-Term Care (LTC) Facilities. The federal minimum standards require a registered nurse (RN) onsite 24 hours a day, seven days a week to provide skilled nursing care. In addition, the total nurse staffing standard is 3.48 HPRD which must include at least 0.55 HPRD of RN care and 2.45 HPRD of CNA care. The remaining 0.48 HPRD can be a combination of RN, licensed practical nurses (LPN), and CNA care. Implementation of these minimum staffing requirements will be phased in over three years beginning in May 2026.

Both the federal and state minimum staffing requirements aim to reduce the risk of unsafe environments and low quality of care for residents. Although constructed with good intentions, the federal and state staffing mandates present critical issues to many nursing homes. The lingering effects from the pandemic include attracting and retaining quality talent while reducing staff turnover. Rising labor costs are at the center of the staffing shortage. The costs of hiring staff, including advertising, recruiting, training, and educating, continue to escalate. The costs of offering more attractive benefits, including retirement plans and health insurance, have risen. Most importantly, rates of pay have increased significantly, including sign on bonuses, retention bonuses, and overtime incentives. Nursing homes will be faced with additional financial pressure to comply with the federal and state minimum staffing mandates. In a labor market that has reduced supply and rising costs, the federal and state minimum staffing mandates will come with a steep price.

In September 2023, CMS announced that it would invest $75M in a national nursing home staffing campaign. Rhode Island has passed legislation to increase Medicaid reimbursement rates by 14% effective October 2024. Although these initiatives do not come close to funding the staffing mandates, they are a step in the right direction.

Citrin Cooperman has a longstanding, dedicated Healthcare Industry Practice focused on providing specialized professional services and industry specific thought leadership to organizations across the entire healthcare ecosystem including providers, payors, and investors. If you have questions on how your healthcare organization can remain compliant with these upcoming regulations, please contact Lauren Florio at lflorio@citrincooperman.com.