As operators continue to parse a proposed federal staffing mandate, one of the biggest concerns is for workers who get little attention in the proposed regulations: the licensed practical nurses whom many consider to be the sector’s nursing backbone.

In bypassing hourly requirements for LPNs, some fear the Centers for Medicare & Medicaid Services is undercutting the critical role that such shift nurses play in direct patient care.

“LPNs exist in our sector because there was a huge gap in the workforce of [registered] nurses that were willing to work in post-acute care. The LPN role has become probably 75 to 80% of the workforce in post-acute care. To eliminate them is huge. It’s huge,” said Sally Cantwell, PhD, RN, senior director of recruitment and retention at PACS, a management and consultant group that employs about 5,700 LPNs or LVNs in supporting close to 200 US nursing homes.

“Why would we eliminate a role that is majority-patient care focused? They love what they do. They’re absolutely day-to-day running our buildings,” she added. “Tell me why an LPN is inefficient. Tell us why you think an LPN is not qualified in this space when anyone you speak to in the post-acute care space will tell you that they’re their majority workforce.”

Some providers may be forced to reduce or eliminate LPNs if the final staffing rule forces them to hire greater numbers of more expensive RN staff to meet both round-the-clock coverage and per-patient day hourly requirements. In some facilities, LPNs will remain a linchpin because their hours are mandated by state rules.

But even so, the mandate clearly places the emphasis on other direct care staff, with one staffer telling stakeholders that studies showed RN and certified nurse aide care had a greater impact on patient outcomes. And with the cost of implementing other provisions already stressing providers, the question about how to maintain LPN coverage is a challenging one.

Baker Donelson shareholder Howard L. Sollins interprets that CMS expects nursing homes to continue staffing LPNs, given the proposed requirement “to maintain sufficient additional nursing personnel, including but not limited to LPN/LVNs, and other clinical and nonclinical staff, to ensure safe and quality care, based on the proposed facility assessment requirements.” Still, he has concerns.

“This rule is very detrimental to the ability of SNFs to comply, given that there is no additional funding for the ‘ramp-up’ of RN requirement, coupled with the agency’s assumption that LPN levels will not decrease,” Sollins told McKnight’s Long-Term Care News.

“CMS acknowledges this risk of a potential negative effect from the rule should LPN levels drop when it states: ‘If facilities covered under this proposed rule reduced other staff not covered by the rule, reduced nurse staff levels to the mandate minimum, or they obtained exemptions from the minimum staffing requirements, the requirement’s cost and benefits could decline significantly relative to what is presented above.’”

LPN needs against RN backdrop

Sacrificing LPNs is a choice Lynn Hood, CEO of Principle LTC, will not abide.

“We are committed to preserving the roles of LPNs within our communities,” Hood told McKnight’s over the weekend. “It is imperative that the government-mandated staffing levels include these valuable team members in per-patient day requirements.”

One possibility is that CMS would include LPNs in a higher 3.48 total nurse hour staffing rule alternative that it floated in its proposal. But in any case, the government has to be willing to pay for the additional workers, providers argue.

If they’re available, RNs’ pay can cost $10 to $15 more an hour compared to LPNs. In an even more competitive market, it remains to be seen how demand or agency reliance could drive nurse pay rates higher.

And there will be demand: The National Council of State Boards of Nursing predicts almost 900,000 RNs are expected to leave the healthcare workforce by 2027, and the Bureau of Labor Statistics estimates there will be about 193,100 openings for registered nurses annually through 2031.

“Hospitals, home health, walk-in clinics, doctors’ offices, nursing homes, schools and assisted livings will all be clamoring for a limited pool of professional nurses (both RN and LPNs) to care for our communities,” Hood said. “Finally, it is hard to fathom how this type of rule can be enforced without providing enough funding to pay for additional nurses when a government department has already predicted a serious supply and demand problem that will continue to drive up salaries and benefits.”

Some are upset that CMS could have elevated the role of the LPN, who can by license do almost all the work of an RN outside of admissions assessments and some limited, specific treatments. LPNs also can hold speciality certifications that make them well-suited to skilled nursing care. They also provide invaluable oversight when RNs are not available.

“To eliminate or ignore that middle level, that middle level management, that middle level leadership, in that progressive career path does a disservice to something that works,” said Steve La Forte, chief legal officer and executive vice president of corporate affairs at Cascadia Healthcare, which employs 429 LPNs across 46 facilities.

“That’s a frustrating part because this is an ecosystem that works,” he added.

RN education lacking

CMS has proposed just $75 million in educational funding to help build a stronger pipeline of RNs. It’s unclear whether any new programs will help cover the cost of transitioning some LPNs into RNs, or if that even falls under CMS goals.

If the agency does want nursing homes to promote their LPNs from within, the clock is already ticking. And the costs are sure to follow.

Additional RNs need to be in place two years after staffing mandate is finalized; with a three-year window in rural areas.

While a full-time nursing student might take just one additional year of school to become an RN after finishing his or her LPN, a working LPN would have to juggle a serious clinical course load and find a flexible program that supports working adults. Those options are few and far between, notes Cantwell.

“It is not overnight and it’s a huge financial investment to allow degree advancement and professional development in school,” she said. “And some states’ academic cost is crazy high versus others. It might be 10 grand to move up in some places. In others, it’s literally $90,000.”

Providers often do support career ladder advancement with tuition reimbursement programs, but those could pale when compared to demand. “It’s a wonderful retention offer, but if we have to convert the entire workforce, people can’t do that,” Cantwell added, especially without added reimbursement.

Under the current system, educational debt is one reason many RNs have gravitated toward higher-paying acute care jobs. To disrupt that pattern, providers need options that will provide loan forgiveness or otherwise incentive RNs to choose long-term care, experts said.

Since the staffing mandate was unveiled, lawmakers have introduced two bills that could help bolster the nursing pipeline. The bipartisan Train More Nurses Act, introduced Thursday, specifically aims to increase pathways for LPNs to become RNs.

And the Primary Care and Health Workforce Act aims to arm community colleges and universities with $1.2 billion in grants to boost the number of students enrolled in accredited, two-year registered nursing programs. 

Still, Hood predicts her facilities will need a more balanced approach to staffing.

“If LPNs are completely removed from the current mandate, we will rapidly have to close units and admission accessibility will go down as the registered nurses are simply not available to meet a 0.55 daily staffing PPD,” she said.

And while providers don’t necessarily want a higher nurse hour standard, they say some acknowledgement of the LPN role — and some funding to support — would be a critical feature of any finalized rule.

“The role and contribution of LPNs as licensed nurses as part of collaborating teams that include RNs should be recognized and encouraged,” Sollins added.