Proposed federal staffing mandate raises alarm
Nursing home industry says rule unrealistic
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About 83% of North Dakota nursing homes currently don't meet a proposed federal staffing mandate that a study shows would displace as many as 421 residents if fully implemented, according to the North Dakota Long Term Care Association.
The Biden administration's proposed rule would require specific nursing home staff to spend a minimum number of hours with each resident and require facilities to have a registered nurse (RN) on site around the clock. The Centers for Medicare and Medicaid Services currently is taking comments on the mandate prior to deciding whether to finalize it.
Minot nursing home administrators are among others in the state and national long-term care industry who are voicing concern over the proposed rule.
"Having worked in a lot of different nursing homes in my life and run multiple facilities, I can tell you that rural facilities are not going to be able to meet this," said Wade Peterson, administrator for Trinity Homes in Minot. "We're going to see more facilities close."
Labor shortages already have led to nursing homes limiting resident admissions, closing units and wings or closing permanently, including a recent closure in Mohall, according to the N.D. Long Term Care Association (NDLTCA). The Good Samaritan Society in Mohall announced it will close its doors Nov. 25 due to difficulty in obtaining staff, combined with the rising cost of delivering care.
Chris Haseleu, administrator at Minot Health and Rehab, said the proposed federal mandate is not realistic, given existing staffing shortages.
"We are already working with situations where we have to bring in traveling staff to fill positions at times, so then to say that you are going to impose more impact on RNs that have to be in your building, that can become cumbersome," he said.
"A rule of this nature will, unfortunately, crush rural nursing homes," said Shelly Peterson, NDLTCA president, Bismarck, in a statement accompanying the release of an analysis of the proposed rule. "We are dealing with a significant staffing crisis. Putting a rule like this in place does not create more caregivers. It will close nursing homes that will not be able to meet this impossible standard."
Among findings of the CliftonLarsenAllen LLP analysis:
- 83% North Dakota nursing homes are not meeting at least one of the three proposed staffing requirements.
- Achieving the mandate's staffing levels would cost North Dakota facilities $4 million a year.
- Facilities with a bed size of 31-45 are most negatively impacted by the proposed regulation. Facilities of this size are most common in rural North Dakota.
- Six nursing homes have closed in the last three years, which is unusual for North Dakota. All but one had been in rural communities.
- If nursing homes are unable to increase their workforce to meet these new requirements, more than 421 nursing home residents could be impacted by census reductions.
The mandate would not preclude Minot Health and Rehab from operating but there could be impact on its census, Haseleu said.
"We can make it happen but it's going to take some adjustments," he said. Even then, there's concern about being able to maintain the staffing consistently, seven days a week, because all it would take is a winter storm or other disruption to create noncompliance, he said. Under the rule, an RN must be available every day to stay in compliance.
Wade Peterson said there is discussion that the new rules might not allow for a director of nursing to count as the RN on duty as part of the 24/7 RN staffing. In a recent quarterly report showing staffing at nursing homes in the state, Trinity Homes was the only facility that would have met the mandate for hours of care and RN coverage, even if the nursing director was excluded, he said.
"That doesn't mean we'll meet it next quarter," Peterson said. "I don't have a problem with having some sort of staffing level, but the way they're implementing it, it's going to be impossible to meet. Even for facilities like mine that meet it today."
He added the rule doesn't address LPNs in the care spectrum, assigning them no value. The discussion is that LPNs might be treated the same as certified nursing assistants (CNAs) in the rule, which fails to account for their higher level of training, he said.
Haseleu said the federal mandate should prompt discussion about nursing training in North Dakota because although LPNs are necessary in the continuum of care, their value isn't being recognized.
There also are questions about whether nursing homes can take on the costs associated with the staffing rule because there would be no additional federal reimbursement. According to CliftonLarsenAllen, 60% of nursing homes nationally are operating in the red now.
The proposed rules would take effect in stages. Most nursing homes would have three years to meet most of the new standards, and those in rural areas, including Minot, would have five years. To meet the requirement for a registered nurse on site 24/7, rural facilities would have three years and other facilities two years. Exemptions to minimum staffing could be made available if hardship is shown.
The proposal also would invest more than $75 million into a national nursing career pathways campaign to recruit, train and transition workers into nursing home careers.
The NDLTCA prefers the comprehensive workforce proposals laid out in the American Health Care Association's Care for Our Seniors Act. The act supports 24-hour RN coverage but also includes increased Medicaid funds for workforce wages and recruitment.