The Centers for Medicare & Medicaid Services on Monday revealed more details about how it will use nursing home site visits, data and other tools to formulate a minimum staffing standard, one that is meant to “build on” rather than replace previous studies.

That may mean bad news for operators who had hoped the agency would take a broader view of staffing by including non-nursing positions in its calculations or by creating shift coverage rules instead of hourly minimums.

Agency researchers said Monday that in addition to comments already collected about the potential new rule, they will use four main components in their ongoing work. The elements include a literature review of previous studies; a cost analysis; and site visits. There also will be a quantitative analysis to identify staffing levels associated with improved quality of care and resident safety, as well as trends in nursing home staffing from 2018-2021. 

The study is expected to culminate in a proposed new rule by early spring 2023.

“Onsite interviews, surveys, and direct observations of nursing home staff will provide qualitative, contextual information to inform the establishment of minimum staffing requirements,” CMS Senior Nurse Researcher Pauline Karikari-Martin, PhD, and policy analyst Cameron Ingram wrote in a blog Monday. “Research questions will address not only what level of staffing is needed, but also the impact on quality of care, any barriers to implementation, and any potential unintended consequences of imposing minimum staffing requirements.”

One long-term organization said Monday afternoon it expects the site visits could be eye-opening for CMS in terms of illustrating the staffing challenges providers are facing.

“We are confident that while conducting this study, CMS will come across many providers who are doing everything they can to recruit and retain staff, but lack the proper government resources and support,” said Holly Harmon, senior vice president of quality, regulatory and clinical services at the American Health Care Association/National Center for Assisted Living.

Taking a deeper look

An agency contractor will conduct interviews and collect data at some 75 site visits (up from the 65 announced previously). In their blog, Ingram and Karikari-Martin said the first round of visits would include 50 stops. An additional 25 will “help validate the initial findings as part of CMS’s iterative policy process.”

The nursing homes are in 15 states and represent a cross-section of size, ownership type, geographic location, Medicaid population, and Five-Star Quality Rating System staffing and overall ratings.

Harmon said the visits should underscore how badly the sector needs a funding mechanism to bolster any eventual proposal that requires more workers.

“AHCA will continue to urge the administration that an unfunded staffing mandate is unrealistic and will only further limit access to care for vulnerable seniors,” she added. “We need a comprehensive, collaborative approach to tackling this labor crisis in long-term care, and we also need to acknowledge the variety of staff members in addition to our amazing nurses who greatly contribute to the care residents receive.”

That last point speaks to the blog’s reference to establishing “a minimum staffing level, which would include RN, LPNs/LVNs, and CNAs.”

Many providers have asked the agency to include other frontline, clinical caregivers in their calculations, noting that the time respiratory therapists, physical therapists, dietitians and others spend in patient-facing care improves the quality of care delivered.

But the standard bearer of previous staffing minimum research includes only nurse hours, and CMS also noted Monday that, “Importantly, this study … seeks to build on, not replace, previous studies.”

No extra money needed?

The most-often cited nursing minimum was proposed in a 2001 study that recommended a 4.1-hour per resident, per day standard. Charlene Harrington, RN, PhD, professor emeritus at the University of California-San Francisco School of Nursing, previously told McKnight’s that the nursing minimum should likely exceed that now, given the increased complexity of today’s nursing home residents.

Harrington on Monday said she did not know enough yet about the CMS study — which is being conducted on what the agency called an “accelerated timeline” — to say whether it would be thorough enough.

Terry Fulmer, PhD, RN, president of The John A. Hartford Foundation, told McKnight’s Monday that she fully supports the CMS “examination of and potential establishment of minimum staffing requirements because nothing prior has seemed to create the necessary impetus to improve staffing and safety in nursing homes.” The foundation was the primary sponsor of the National Academies report calling for major nursing homes reform.

Ingram previously outlined some of the 3,000-plus comments provided to CMS after it proposed the establishment of a staffing minimum this spring.

Monday’s blog reiterated many of her previous points about conflicting viewpoints among nursing home operators and patient advocates. Many providers have said that they welcome staffing rules, as long as the federal government supports the measures with additional funding. One recent study has put the annual cost of a mandate at $10 billion more annually, and estimated nursing homes would need to hire another 187,000 workers — in addition to the 238,000 they lost to the pandemic.

Ingram and Karikari-Martin on Monday, however, said that advocacy groups had “observed that, in their view, staffing has always been a challenge and emphasized that while additional efforts are needed to bolster the workforce, it should not deter CMS from setting minimum staffing levels in nursing homes.

“Additionally, some commenters noted that evidence shows that most facilities have adequate resources to increase their staffing levels without additional Medicaid resources,” the authors wrote.

But the variability of state Medicaid labor reimbursement is a major challenge. It’s one CMS itself tried to address Monday in a bulletin to states. In that memo, CMS urged states to tie increases in Medicaid funding to staffing improvements and other accountability measures.

A cost-benefit analysis is required for any rulemaking, Ingram and Karikari-Martin noted, and  CMS will evaluate “any associated incremental costs that facilities would likely face …  associated with meeting the new staffing requirement, such as increases in staffing levels or changes to the mix of staff.”