Feds to require more staff in nursing homes. Most in St. Louis area don’t meet the bar. (2024)

ST. LOUIS — The Biden administration announced Monday that it has finalized a rule that sets minimum staffing levels for nursing homes that receive Medicare and Medicaid dollars, a controversial move that resident advocates have long called for and that industry groups have fiercely opposed.

The rule will be introduced in phases to give nursing homes time to hire, with longer time frames for rural areas, where recruitment is often more difficult. But if it took effect today, about half of the nursing homes in the St. Louis region — and two-thirds in the state — would fail a key requirement.

Advocates have called for a federal, minimum staffing standard for nursing homes for decades, arguing that in chronically short-staffed facilities, residents wait hours for staff to answer call lights, bathing schedules are spaced out and problems go unnoticed. Working conditions for existing staff also worsen, which leads to higher turnover.

“This was a huge step forward for resident safety,” said Marjorie Moore, executive director of VOYCE, the Marlborough-based nonprofit that serves as the region’s long-term care ombudsman program.

Industry groups have fought such proposals, arguing they place impossible requirements on facilities that are already struggling to hire.

“It’s just unrealistic,” said Nikki Strong, executive director of the Missouri Health Care Association, the state trade association for nursing homes. “We can’t find nurses. Hospitals can’t find nurses.”

Strong called instead for more efforts around education and workforce development to bring more people into the profession.

Under the new rules, nursing homes will be required to provide 3.48 hours of nursing staff time per resident per day. One analysis of federal data found that 320 of 486 Missouri nursing homes fall short. The rule relies on calculations of the number of staff working in the building on a given week, compared with the number of residents.

Missouri nursing homes average 3.2 hours of nursing care per resident per day, the lowest in the nation, and Illinois averages 3.24, according to the data analysis by the Long Term Care Community Coalition, a New York-based nonprofit that advocates on behalf of residents.

‘Pushed for this for decades’

The most significant requirements in the rule won’t take effect for years.

The first deadline is an assessment that nursing homes must complete in the coming months to determine whether a facility’s staffing level should be higher than the new minimum. As part of the process, the homes must take account of their residents’ needs, gather input from facility leadership and develop a staffing plan.

Within two years, facilities must meet the 3.48-hours-per-day threshold and have a registered nurse on site around the clock. Rural facilities have three years to meet that part of the rule. More criteria take effect after three years, or five years for rural facilities.

It’s the first federal requirement of its kind, and much stronger than the current Missouri regulation that requires one registered nurse on duty during the day shift and an RN or licensed practical nurse on duty during evening and night shifts. Enforcement will be handled mainly through inspections, which in Missouri and many other parts of the country are conducted by state agencies.

Richard Mollot, executive director of the Long Term Care Community Coalition, raised concern about leaving oversight up to state inspectors, who are often short-staffed. But he applauded the requirement for 24-hour RN staffing.

“Study after study has shown that the RN staffing levels are really the most important indicators of quality and safety,” Mollot said. “We and other advocates have pushed for this for decades.”

Mollot said he worried that the 3.48-hours-per-day requirement is a relatively low bar and will give nursing homes the impression that it is an acceptable amount of care. Some facilities that now exceed the requirement may decrease staffing levels after the rule is imposed, he said, and lawsuits filed against facilities for abuse or neglect may be weakened if nursing homes can claim to have adequate staffing.

“You run the risk of a race to the bottom,” Mollot said.

Temporary exemptions will be available for nursing homes in places federally designated as workforce shortages areas and that demonstrate good-faith efforts to hire. Residents and families will be notified when a facility uses such an exemption.

Trade group: New rule is ‘unconscionable’

Advocates have argued that chronic understaffing in nursing homes erodes the quality of care for residents. And workers at St. Louis-area facilities have said that as more seniors try to “age in place,” nursing homes in the region have accepted more younger residents with mental health conditions. Staffing levels and training, they said, don’t always keep up with the difficulty of the population.

Industry groups, meanwhile, say Medicaid simply doesn’t pay enough to cover higher staffing levels.

Missouri has a much lower Medicaid reimbursem*nt rate than many other states, said Strong, of the state trade association. A “one-size-fits-all” minimum staffing requirement for all U.S. nursing homes isn’t the way to go, she said.

“From our perspective, our facilities are either going to downsize or close,” Strong said. “There are so few facilities that meet this mandate.”

Strong said her staff examined how many nursing homes in Missouri would meet the requirements based on an earlier, proposed version of the rule (there were several changes between that version and the final text). They found only six.

Mark Parkinson, CEO of the American Health Care Association, the federal trade group that lobbies on behalf of nursing homes, on Monday called the new rule “unconscionable.” Parkinson said in a statement that it sets an impossible task before facilities that are already struggling with labor shortages and an aging U.S. population.

Lenny Jones, state director for SEIU Healthcare Missouri, which represents nursing home staff in the area, called the rule a “huge win” for workers, who often shoulder guilt and blame for delays in care at short-staffed facilities. He pushed back on the industry argument about reimbursem*nt rates.

“You hear the same arguments when the minimum wage goes up,” Jones said. “That just, on the whole, is not true. ... They’ll have to figure out how to get it done.”

A special committee created by the St. Louis Board of Aldermen to examine the city’s long-term care industry has backed the creation of a staffing requirement.

In March, the committee called for the board to pass a resolution in support of the federal rule. The committee also called on state legislators to raise the Medicaid per diem rate to match that of Medicare — and to allocate a portion to hiring and retention.