There are plenty of numbers to be found in the new minimum staffing rule, which will dictate how many workers should be clocking in at nursing homes around the country.
On every shift. In every unit. Every day. For possibly many years to come.
We’ve got the now-dreaded 3.48 hour total, broken into two main slices of 2.45 hours for nurse aides and 0.55 hours for registered nurses, with a remainder going to more of the same and/or other nurses.
We’ve got requirements kicking in at 90 days, 2 years, 3 years and 5 years.
We’ve got complex labor pool calculations that include a 20% workforce shortage threshold to qualify for a 1-year exemption, which the Centers for Medicare & Medicaid Services projects some 25% of providers might get.
But nursing home operators are still missing one key detail needed to complete the complicated mathematical equations that will dominate their planning and spending for the next few years.
Exactly who counts in the RN categories for both round-the-clock coverage and hourly commitments? The requisite six-digit occupation codes are conspicuously missing.
The Centers for Medicare & Medicaid Services did expand on the topic when it released the 329-page final rule on Monday. Tucked into that was some good news: Directors of nursing can count toward the RN requirement.
But by Wednesday, individual providers and at least one major provider group said they were left taking calculated guesses as to whether and how other nurse supervisors or those with administrative duties could be counted.
On the DON front, CMS has said the nurse must be available to deliver care if counted toward the minimum. Well, couldn’t the same be expected of an assistant DON or the MDS nurse?
We all know how able those “back office” nurses proved themselves during COVID, when they often stepped back into frontline roles during staffing shortages. Not that we want to encourage them to be sidetracked from their day jobs, but if the CMS intent is truly to have a nurse available to residents at all times, throwing that bone could be a key strategy to help boost compliance.
Multiple nurses and managers have told me over the last seven months that their buildings hardly, maybe never, require RN-level care at night. This is especially true in facilities with mostly long-term care patients who don’t require intensive treatments.
Allowing trained RNs who primarily perform other, non-patient-facing functions to be tapped on as-needed basis during some shifts seems to make more sense than paying millions of extra dollars to staff who might be under-tasked and leave the sector because they’re often doing tasks below their licensure.
CMS has clarified who qualifies as an aide; that can include both CNAs-in-training and medication technicians.
And though it comes with a tradeoff of more required clock time, at least providers can keep the doors open for licensed practical nurses. CMS said they meet the level of staff needed to fill required minutes not assigned to RNs or CNAs.
But without those missing RN job codes or some other short-term clarification from CMS, providers are going into their first important staffing rule deadline blind. The updated resident assessment to be used to set acuity-based staffing levels and determine needed roles must be completed by Aug. 10.
Providers could, of course, hope that CMS hasn’t published the official job code list because they’re still working to expand it. To that I’d say, just don’t count on it.
Kimberly Marselas is senior editor of McKnight’s Long-Term Care News.
Opinions expressed in McKnight’s Long-Term Care News columns are not necessarily those of McKnight’s.
