Biden Administration Delivers on the President’s State of the Union Promise with Proposed Federal Minimum Staffing Requirements, Tougher Enforcement Initiatives, and Efforts to Expand Nursing Workforce

The nursing home industry receives nearly $100 billion annually from American taxpayers, yet too many nursing homes chronically understaff their facilities—resulting in poor, substandard care that endangers residents. When nursing homes stretch workers too thin, residents may be forced to go without basic necessities like hot meals and regular baths, or even forced to lie in wet and soiled diapers for hours.

Residents also suffer avoidable injuries like falls and bedsores. Workers become burnt out from the daily struggle to deliver the quality care they know their residents deserve. During the pandemic, over 200,000 nursing home residents and workers died—around one-fifth of all COVID-19 deaths in the United States.

President Biden is committed to building a long-term care system where all seniors can age with dignity, where people with disabilities can receive high-quality services and supports in the setting of their choice, and where there is a pipeline of direct care workers into good-paying jobs with the free and fair choice to join a union. In his State of the Union address, President Biden pledged that his Administration would “protect seniors’ lives and life savings by cracking down on nursing homes that commit fraud, endanger patient safety, or prescribe drugs they don’t need.”

In April, President Biden signed an Executive Order on Increasing Access to High-Quality Care and Supporting Caregivers, a first of its kind, government-wide commitment to support caregivers, direct care workers, and families caring for children, people with disabilities, and aging loved ones. The Executive Order carries forward Department of Health and Human Services (HHS) actions to enhance access to home and community-based services, raise wages for and retain direct care workers, help residents smoothly transition back home from nursing homes, and advance a government-wide strategy to lift up family caregivers. It also builds on the President’s 2024 budget request for a $150 billion transformative investment in home care.

Today, the Biden-Harris Administration is following through on the President’s commitment to nursing home residents and their families. HHS is announcing important new steps to crack down on nursing homes that endanger resident safety:

The Centers for Medicare & Medicaid Services (CMS) is proposing a rule to set a federal floor for staffing levels, so that nursing home owners could not slash staffing to unsafe levels. If finalized, the proposal would require every facility to have a Registered Nurse on site 24/7, to have a certain minimum number of registered nurses and nurse aides to help provide routine care, and to staff according to resident needs based on a robust assessment of the facility’s residents. To ensure affected nursing homes have ample time to hire necessary staff, CMS is proposing that the minimum staffing requirements go into effect in phases.
To improve nursing home safety in the short-term, CMS is also announcing new efforts to improve enforcement of existing staffing standards, which currently require nursing homes to provide “sufficient” staffing and eight hours per day of Registered Nurse care. These actions will help address substandard care and strengthen accountability even before the new minimum staffing requirements come into effect.
The HHS Office of the Inspector General (HHS-OIG) is also undertaking important oversight of nursing home performance, examining nursing home spending of taxpayer funds, inappropriate prescribing of antipsychotic medications, and emergency preparedness planning by facilities.

In addition, HHS is announcing new steps to help expand the nursing workforce:

CMS, in partnership with the Health Resources and Services Administration (HRSA), is announcing a national nursing career pathways campaign. The campaign will help recruit, train, retain, and transition workers into nursing home careers as nursing staff. This plan will invest over $75 million in scholarships and tuition reimbursement.

Today’s announcement builds on steps taken by the Administration over the past few years to support nursing home residents and workers. These efforts also align with the Administration’s continued support for care at home, including significant investments in home and community-based services.

Setting a Minimum Federal Floor for Safe Levels of Nursing Home Staffing

Staffing levels at nursing homes are closely linked to quality of care. For instance, a study of one state’s nursing facilities showed that even a 20-minute increase in staffing per resident day from a Registered Nurse was associated with 22% fewer cases of COVID-19 and 26% fewer COVID-related deaths in nursing homes. Other studies similarly find that higher staffing is associated with better quality of patient care and patient health outcomes. Chronic understaffing disproportionately affects facilities serving a higher share of residents from certain racial and ethnic groups. In recent years, there has been a disturbing trend towards private equity firms and other large corporate owners purchasing nursing homes and slashing levels of staff as a way to maximize profits.

Research suggests the result is more illness and more deaths in those homes. For example, a working paper examining 18,000 nursing home facilities between 2000 and 2017 found that private equity ownership increased excess mortality for residents by 10%, increased prescription of antipsychotic drugs for residents by 50%, decreased hours of frontline nursing staffing by 3%, and increased taxpayer spending per resident by 11%. The study implies an additional 20,150 lives lost as a result of private equity ownership.

Based on a multi-faceted approach aimed at determining the minimum level and type of staffing needed to ensure long-term care facilities have a workforce sufficient for resident safety and well-being, CMSis proposing a rule to set a federal floor for staffing levels. Under the proposed rule, if finalized:

Nursing facilities must have a Registered Nurse on site around-the-clock. The academic literature has repeatedly found that having a trained professional on site 24/7 is important for improving nursing home safety. Under the proposal, 22% of nursing homes would have to hire Registered Nurses to meet this requirement.
In addition to having at least one Registered Nurse full-time, nursing homes must provide at least .55 hours (33 minutes) per resident day of care from a Registered Nurse, exceeding standards in nearly all states. Staffing hours per resident per day are the total number of hours worked by each type of staff divided by the total number of residents. This means that a facility with 100 residents would be required to provide a total of 55 Registered Nurse hours over the course of a day. If broken out into 8-hour shifts, this would mean having two Registered Nurses on staff for each 8-hour shift, and a third Registered Nurse for one shift during the day. Under the proposal, 36% of nursing homes would have to hire Registered Nurses to meet the hours per resident day standard after accounting for Registered Nurses hired for the 24/7 requirement.
Nurse aides are especially critical to safe, quality care. These workers help residents with basic tasks of daily living, like eating, bathing, and going to the bathroom. Under the proposal, nursing homes must provide 2.45 hours (2 hours and 27 minutes) per resident day of care from nurse aides, exceeding standards in all states. This means a nursing home would need roughly ten nurse aides per each 8-hour shift in a facility with 100 residents. Under the proposal, 68% of nursing homes would have to hire nurse aides to meet this requirement.

When accounting for average hours currently worked by other types of workers that are not covered by these standards, this translates to expected nurse staffing of about 3.9 hours per resident per day.

The proposal also makes clear that the numerical staffing levels are a floor—not a ceiling—for safe staffing. Under the proposal, nursing homes would have to undertake a robust assessment of their particular facility, including consulting with workers and their representatives, to determine whether higher levels of staffing and what staff competencies are needed to meet the needs of their particular resident population. Nursing homes caring for residents with more acute needs may well have to hire more workers than the minimum standards in order to provide a safe environment. In addition, state laws with higher staffing requirements would not be preempted.

The federal minimum staffing standards proposed by CMS are robust yet achievable. For example, non-profit nursing homes are about three times as likely as for-profit homes to already provide staffing at or above the proposed levels. We recognize that nursing homes in rural areas may face greater challenges and require greater time to hire additional workforce. To ensure that affected nursing homes have ample time to identify and hire the necessary workers, the proposed rule would give most nursing homes three years to meet the new standard for nurses and nurse aides, and nursing homes located in rural areas would have five years to meet the new standards. To meet the requirement for a Registered Nurse on site 24/7, rural facilities would have three years and all other facilities would have two years.

The proposal includes possible hardship exemptions from the minimum staffing requirements. The need for an exemption must be proven with documentation that demonstrates meaningful efforts to hire workers at prevailing wages, as well as demonstrated financial investments in staffing.

The proposal also increases transparency about how taxpayer dollars are being spent. If finalized as proposed, state Medicaid agencies would need to publicly report the percent of payments for Medicaid-covered services that are spent on compensation for direct care workers and support staff in nursing facilities and intermediate care facilities for individuals with intellectual disabilities.

Increasing Nursing Home Accountability

As the Administration works to implement the new proposed minimum federal floor for staffing, it is also committed to improving nursing home safety in the immediate-term. That’s why today HHS is announcing new efforts to improve enforcement of existing standards. HHS is taking action to:

Increase Audits of Nursing Homes’ Staffing: CMS is expanding audits of the direct care staffing data that nursing homes must report to make sure that federal and state inspectors, as well as residents and their families, have accurate information, including through Nursing Home Care Compare, CMS’ informational website that families and prospective residents use to learn about facilities.
Ensure Taxpayer Dollars Go Toward Safe, High-Quality Care: HHS-OIG is performing new oversight work to follow the money on how nursing homes spend the taxpayer funds they receive. This will include analysis of how nursing homes may profit at the expense of taxpayers and residents by using services, suppliers, or facilities controlled by parties they own or are otherwise connected to, rather than from vendors who might charge a more competitive price. These “related-party transactions,” have not only obscured how taxpayer funds are being used by nursing homes, but also obscure whether profits and payouts to shareholders are prioritized above investments in resident safety and fair wages for workers.

Improve Nursing Home Inspections: CMS will undertake new analyses of state inspection findings to ensure cited deficiencies receive the appropriate consequence, particularly in incidences involving resident harm. These analyses will ensure citations are applied more consistently and reflect the seriousness of the deficiency, permitting appropriate follow-through and enforcement.
Crack Down on Inappropriate Antipsychotic Prescribing Practices and Risks: Grave concerns persist that nursing homes are overprescribing dangerous antipsychotic drugs to residents. To support efforts to reduce the misuse of these powerful medications, HHS-OIG is examining risks at nursing homes that have concerning prescribing practices. This builds on recent actions by CMS to increase oversight of inappropriate use of antipsychotic medication.
Enhance Resident Safety During Emergencies: Nursing home residents are often among the most vulnerable to public health emergencies, and recent emergencies have exposed weaknesses in nursing home emergency planning and harm to residents who suffered from inadequate care. The HHS-OIG is undertaking a new effort to improve resident safety during emergencies, including launching a national study of nursing home preparedness and key challenges, and identifying practices to strengthen protections for residents.

The Administration is committed to using its existing authorities to enhance the safety, quality, and accountability of nursing facilities. But Congress also needs to act. For over eight years, funding for survey and certification programs to conduct health and safety inspections hasn’t changed, even as the volume of complaints about nursing homes has risen. That’s why the President’s 2024 budget called onCongress to adequately fund nursing home inspections.

Growing the Nursing Workforce and Supporting Job Quality

CMS, in partnership with HRSA, is launching a new nursing home staffing campaign to help workers pursue careers in nursing homes. To bolster recruitment, training, and retention among nursing home workers, CMS will invest over $75 million in scholarships and tuition reimbursement for nursing workers through the Civil Money Penalty Reinvestment Program. CMS will also work to streamline entry to and raise awareness of rewarding career opportunities in nursing homes.

These new investments are on top of the hundreds of millions of dollars the Administration has made available to invest in training and recruiting nurses and other caregivers. For example:

The Department of Labor’s Nursing Expansion Grant program made nearly $80 million in grants available to address barriers to training in the nursing workforce and expand our national pipeline of qualified nursing professionals. These funds have been allocated to programs across the country to train healthcare professionals and paraprofessionals, including direct care workers, to advance in their careers and to increase the number of clinical and vocational nursing instructors and educators.
HRSA has also provided grant funding to increase the number of nursing preceptors—those who supervise nursing students in clinical rotations—to help support nursing schools in expanding admissions to train more students and providing those students with clinical exposure.
The American Rescue Plan also supported HRSA’s Nurse Corps scholarship and loan repayment program with $200 million in funding.

Tying together these critical investments, HHS is strengthening the health workforce through its Health Workforce Initiative by connecting skilled health care providers to communities in need through grants, loan repayment, and scholarship programs and helping to build the pipeline of health workers in the most underserved communities.

Building on Other Nursing Home Reform Progress

Today’s announcement builds on steps taken by the Administration to support nursing home residents and workers in furtherance of the President’s Action Plan. These include:

Shedding light on ownership and management. CMS issued a proposed rule requiring nursing homes to disclose additional information about their owners and management, and sets the stage for the disclosure of whether these entities are private equity investors or real estate investment trusts. For the first time, CMS also released data on mergers, acquisitions, ownership changes, and consolidations of Medicare-enrolled hospitals and nursing homes, and data identifying common ownership across facilities.

Incentivizing quality performance through Medicare and Medicaid funding. CMS issued a final rule updating Medicare payment policies and rates for FY 2024, including an over $1 billion payment increase under the Skilled Nursing Facility (SNF) Prospective Payment System and updates to the Skilled Nursing Facility (“SNF”) Quality Reporting Program and the SNF Value-Based Purchasing Program to encourage high-quality care. CMS has also issued a bulletin encouraging states to use their Medicaid authorities to drive better health outcomes for residents and improve staff pay, training, and retention.
Strengthening oversight of the worst-performing nursing homes. CMS implemented escalating penalties and raised the safety standards for homes in the Special Focus Facility program, which provides oversight for the worst-performing nursing homes. It also enhanced technical assistance to help such facilities improve.
Addressing misdiagnosis and overprescribing. CMS is giving the public more access to information on misdiagnosis of schizophrenia, which can lead to overprescribing of dangerous antipsychotics. CMS is conducting audits of schizophrenia coding by nursing homes and adjusting Care Compare quality ratings based on audit findings involving inaccurate schizophrenia diagnoses.
Preventing abuse and Medicare fraud. CMS issued a final rule requiring nursing home owners to be fingerprinted for federal background checks.
Cracking down on illegal debt collection. CMS and the Consumer Financial Protection Bureau are reinforcing regulations banning facilities from illegally holding families responsible for their loved ones’ nursing home debt.
Improving pandemic preparedness. CMS updated guidance to require an infection control specialist be on site at least part-time in nursing homes to improve response to pandemics—not just an off-site consultant as the prior Administration allowed.
Improving families’ ability to comparison shop. Caregivers and prospective residents can better choose between facilities based on improvements to the Nursing Home Five-Star Quality Rating System and Care Compare, including new data on turnover, weekend staffing, and charges of violations, as well as owners, affiliated entities, and chains.
Increasing vaccination access. HHS is working to increase COVID-19 vaccination rates for long-term care residents. CMS finalized the adoption of quality measures intended to encourage nursing homes to ensure all residents and workers are up-to-date on their COVID-19 vaccinations. Additionally, CMS recently finalized requirements for nursing homes and other long-term care facilities to offer COVID-19 vaccines to residents and workers and provide education on their benefits.

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