CMS recently proposed new minimum staffing mandates for Skilled Nursing Facilities (SNFs). These minimum staffing mandates require more nurse staffing time than required by any current state mandate. Washington DC is the exception. However, it does not mandate hour distribution by nurse staffing level.

The proposed new mandate includes minimum staffing requirements of:

• 0.55 RN direct care hours per resident day (HPRD)
• 2.45 nurse aide HPRD
• An RN on site 24 hours a day

Importantly, the mandate also does not list a minimum staffing requirement for LPNs, who currently make up a large percentage of the SNF nursing workforce and on average, account for 0.89 HPRD of SNF staffing. The mandate also does not include a total nursing staff requirement.

While LPNs have more nursing education than nurse aides (and accordingly, are paid higher salaries), the proposed mandate suggests that the 2.45 nurse aide HPRD can “if necessary” be completed by LPNs. However, LPNs are not a substitute for RN hours.

Over 100 members of congress, as well as the American Health Care Association and National Center for Assisted Living, have critiqued the proposed mandate. Many argue that it is out of touch with the already struggling nursing workforce and the reality that staffing shortages and financial challenges have already led to an alarming number of SNF closures and bed reductions. Many fear that a majority of SNFs won’t be able to meet these requirements, causing more closures and additional strain on the healthcare ecosystem.

We analyzed the most recently available nursing home care and provider data from CMS to understand the current ability of SNFs to meet the proposed requirements.

The good news: the majority of SNFs currently have at least 3.0 HPRD of nurse staffing.  Where it gets dicey, however, is the breakdown of nurses by level.

If we assume that LPN HPRD can count toward the nurse aide requirement, a majority of SNFs do not have an issue with the nurse aide HPRD portion of the mandate. However, only 49.69% of SNFs currently meet the RN HPRD portion of the mandate. Overall, only 42.8% of SNFs would be able to meet both HPRD portions of the proposed mandate.

The picture is murkier if LPNs are not counted as nurse aides. Our analysis showed that 26.7% of SNFs can meet the nurse aide HPRD requirement with nurse aide HPRD alone, reducing the percentage of SNFs able to meet both HPRD portions of the mandate to 17.7%.

Data is not available to determine which SNFs would meet the 24-hour RN requirement.

We also wanted to understand the geographic implications involved in meeting these requirements. To do that, we examined the percentage of SNFs in each county that met the proposed HPRD requirements.

Based on our analysis, we determined that 20% of counties are currently able to meet both HPRD portions of the mandate in all of their SNFs, and 35% of counties do not currently have any SNFs meeting both HPRD portions of the mandate.

When we looked at the average RN and nurse aide staffing hours spread between SNFs across counties, we found that 50.57% of counties do not have enough nurse staffing hours to meet both portions of the HPRD requirements. This underscores the difficulty that SNFs will have meeting these requirements and indicates that not enough nursing staff exist in these counties. Furthermore, the solution is not as easy as moving nursing staff around within the county. 

The staffing shortages that SNFs face also have implications for hospitals. Hospitals in counties where no SNFs currently meet the proposed requirements have an average length of stay (ALOS) that is 0.14 days longer than counties where all of the SNFs met the proposed requirements. If SNFs are forced to close because they don’t meet the proposed requirements, hospitals in those counties will face even longer ALOS. Based on an analysis previously done by Advisory Board, we know that hospitals in counties where SNFs have closed have an ALOS that is 0.66 days longer.

Meeting the proposed requirements will be challenging, but not impossible, for a majority of SNFs.  Meeting the RN portions of the mandate will be the most challenging, as competition for a shrinking RN workforce continues to escalate.

Since most SNFs already have 3.0 HRPD, the mandate will likely lead to more nursing staff turnover and higher costs for SNFs as they attempt to hire more RNs. SNFs will have to combat the higher costs of RN labor in creative ways, which may include reducing the number of other nursing professionals on staff. SNFs may also choose to reduce their LPN staff in favor of nurse aides, who typically are paid at lower rates.

To attract and retain RN staff, SNFs should continue to improve their employee value propositions. Showing RNs the unique benefits and experience of working at a SNF will help SNFs compete with other sites of care. If possible, SNFs should offer benefits and flexibility that may not be possible working elsewhere.

Hospitals will need to prepare for the possibility of delays in SNF placement for patients ready for discharge. If SNFs are forced to close or reduce capacity because of difficulty meeting the staffing requirements, hospitals will need to explore home health placement options to reduce the impact of these delays. When SNF placement is available, hospitals should collaborate with SNFs to ease the discharge process and prevent further delays.