CMS’ Staffing Mandate Proposal For Nursing Homes Could ‘Spell Trouble’ For Home Health Care

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The Centers for Medicare & Medicaid Services’ (CMS) nursing home staffing proposal has been a dark cloud over the industry. Some believe it could spell trouble for home health care as well.

In September, CMS released a proposal that would require nursing homes to implement a minimum staffing standard, if finalized. The proposal introduces a variety of provisions, but the one that has received the most spotlight is the requirement that nursing home facilities have enough staff to provide residents with at least 0.55 hours of registered nurse (RN) care, and 2.45 hours of nurse aide care, on a daily basis.

Additionally, the proposal calls for nursing homes to have an on-site RN available for residents, 24 hours per day and 7 days per week.


If the proposal is finalized, these requirements will be phased in over the next few years.

In general, nursing home industry stakeholders have pushed back against CMS’ proposal.

“We share the administration’s goal of ensuring access to quality nursing home care,” LeadingAge wrote in a press statement in September. “This proposed rule works against that shared goal. One-size-fits-all staffing ratios don’t guarantee quality, as the administration’s own Abt research findings made clear. That aside, it’s meaningless to mandate staffing levels that cannot be met. There are simply no people to hire – especially nurses. The proposed rule requires that nursing homes hire additional staff. But where are they coming from?”


LeadingAge noted that the proposal would mean that nursing homes will need to hire an estimated 13,000 RNs during the first 2-5 years in order to keep pace with the requirements from CMS.

That said, nursing home stakeholders and industry advocates aren’t the only ones with concerns.

Those on the home health care side are concerned that in this era of staffing shortages, particularly nursing, these requirements could draw nurses away from their sector.

“It’s an acute shortage in home health care for a number of reasons, including the stress coming from the payment rate cuts under the Medicare home health benefit,” William A. Dombi, president of the National Association for Home Care & Hospice (NAHC), told Home Health Care News. “Increasing the demand in other sectors would add to that stress. That’s not to offer the opinion that the staffing ratio is a wrong thing to do. Instead I’m saying, if the nursing homes are going to be using more nurses, that means less available to deliver care in the home.”

Oftentimes, home health providers are recruiting from the same talent pool as the rest of the health care sector at large.

Aside from the staffing challenges this could create for home health providers, industry stakeholders are also wondering if home health will see similar mandates from CMS in the future.

One state is already considering a staffing ratio relative to home health care services as part of its licensing requirements, according to Dombi.

Still, Dombi doesn’t believe that a staffing mandate is a move that CMS should pursue for home health providers.

“We certainly don’t believe that CMS would be making the right move in requiring agencies to offer home health aide services, but instead should continue to focus on a long standing condition of participation, which is that patients are accepted only if the home health agency determines they can safely and effectively meet the patient needs,” he said.

Dombi also pointed out that the ability to control patient volume through that condition of participation makes the need for a staffing mandate less likely.

“I don’t think a staffing ratio is a good fit, given the way home health operates, compared to the way nursing homes are required to operate,” he said.

While home health providers are waiting to see if staffing mandates will be finalized for nursing homes, there are some ways they can prepare for the potential fallout.

“[Providers] should be thinking strategically around performing a workforce analysis in their local communities,” Felicia Sadler, vice president of quality at the analytics, assessments and education firm Relias, told HHCN. “They should be identifying where the resources are, and partnering with nursing schools locally to begin enhancing and building that workforce. If this rule does come forward, there’s a transition time that’s allowed for them to meet the requirements. Thinking about all of this now, and planning forward, is critically important.”

Dombi stressed the importance of retention as a response to future headwinds stemming from the mandate being finalized.

“You don’t want to lose your staffing resources,” he said. “We know that home health agencies, and hospices, are paying attention to that, but sometimes you have to redouble your efforts when there’s a greater threat. Retention has many facets to it. Compensation is one of them, but so is emphasizing flexibility and the respect factor for the workforce that they do have.”

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