The Biden administration’s plan to set minimum staffing levels for nursing homes prompted comments from more than 46,500 people and organizations — including residents of homes and nurses with harrowing stories about conditions inside.

  • One resident purchased a bullhorn with a siren to get nurses’ and aides’ attention because he was often left sitting in his own stool, one commenter recounted.
  • Nurses at one facility declared a “med holiday,” according to a dietitian, and threw away all the drugs for a shift because they didn’t have time to pass them out.
  • A day shift nurse found a resident choking on vomit and having seizures after a night when there had been only one nurse and one aide on duty — for 100 residents.

Hundreds of comments like these cemented the resolve of officials at the Centers for Medicare and Medicaid Services last month to stick to plans to set minimum numbers of registered nurses and nurse aides for homes, despite the industry’s insistence it’s infeasible. CMS added a third mandate for minimum total staffing.

The agency also toughened requirements for the self-assessments each home must perform to determine whether they have enough skilled workers to properly care for their residents. The assessment can mean a home with residents who are especially ill or in need of extensive assistance should exceed minimum staffing mandates.

President Biden’s crackdown on nursing home staffing is among the most significant health-care regulatory moves he’s pursuing in what could be his last year in the White House. That it comes in an election year, when the president is counting on improving his support among older voters and their families, only raises the stakes — though nursing homes have until 2026 to come into compliance. Labor unions representing nurses and aides have strongly backed the plan.

Still, CMS rebuffed calls from resident advocates to require all nursing homes to meet the new requirements.

The industry as well as rank-and-file nurses raised concerns about finding enough staff to meet the new federal requirement. A licensed practical nurse from rural Minnesota wrote: “We currently offer sign on bonuses, referral bonuses, higher wages than we have ever had, and still no applications are received.”

CMS is allowing nursing homes exemptions from the staffing minimums if they are in areas with workforce shortages. CMS also will allow homes to request an exemption from one of the toughest mandates in the regulation: having a registered nurse on-site around-the-clock. If they’re in an area with a shortage of RNs, they can request to have one on-site for just 16 hours a day. (That’s still double the existing requirement.) CMS estimates that a quarter of the nation’s 15,000 nursing homes will end up obtaining exemptions from part or all of the staffing rules

The final regulation hasn’t entirely pleased anyone. Most advocates for patients still think the staffing minimums are too low and will allow some homes to continue to provide substandard care. And the nursing home industry says it can’t find or afford the extra staff — and its lobbyists are working Congress, and probably the White House should Biden lose, to overturn the rules.

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