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Build Back Better Act Provisions Could Strengthen Nursing Home Staffing and Oversight

Nursing homes lead with “nursing” in their nomenclature because they depend on registered nurses (RNs) and nursing care teams to deliver safe care to their residents. Unless they have an adequate nursing staff, including licensed practical nurses (LPNs), and certified nursing assistants (CNAs) led by a registered professional nurse around the clock, that is not possible.

The evidence is clear on this crucial point and demonstrates that it is important to have minimum nursing staff requirements in place to prevent harm. Research has consistently found that increasing the presence of RNs in nursing homes is a key driver of care quality and resident safety. We have seen the impact of understaffing on residents and families throughout the COVID-19 pandemic. Nursing homes with lower RN staff time per resident were more likely to have resident infections and deaths.

A pathway to ensuring a stronger RN presence and establishing evidence-based minimum staffing requirements in federal law is included in the Build Back Better Act that recently passed in the U.S. House of Representatives and is under consideration by the U.S. Senate. The bill includes several sections that could drive improvement in nursing home staffing and ultimately resident care and safety. It is important to note that other sections of the bill provide funding for direct care workforce development, including monies to hire, train, and support new workers. These dollars could bolster the direct care workforce specifically in nursing homes.

Importantly, Medicare and Medicaid reimburse nursing homes for the care they provide, and the Centers for Medicare & Medicaid Services holds regulatory authority over nursing homes that receive these public dollars. In recent years, nursing homes annually received more than $50 billion from Medicaid and more than $25 billion from Medicare. In addition to reimbursements, nursing homes have received billions in emergency funding during the COVID-19 pandemic to help pay for staff and other costs.   

24/7 Registered Nurse Presence

The Build Back Better Act would require nursing homes to have at least one RN on site 24 hours per day, seven days per week. Currently, nursing homes need only to have an RN at the facility for 8 hours each day. RNs are essential to quality nursing home care because they bring important skills and competencies not expected from LPNs or CNAs, including oversight of care and resident assessment.

Under the House-passed bill, this provision would take effect in October 2024, providing nursing homes significant time to increase their RN staffing levels and follow the law.  

Nursing Home Staff to Resident Ratios

The bill directs the U.S. Department of Health and Human Services (HHS) to study and report to Congress on whether and what level of minimum nursing staff-to-resident ratios in nursing homes would be required to meet resident care needs. Based on the study recommendations, HHS could establish regulations setting those ratios that facilities would need to follow and staff accordingly.

While nursing homes are currently required to report hours of care provided per resident per day by nursing level, there is no specific federal, legal minimum amount of time per resident required or minimum nursing staff to resident ratio. The only current requirement of nursing homes here is to report data.

Some states have implemented minimum staffing ratios. In Connecticut, for example, nursing homes must staff CNAs at a minimum level of one aide per 10 residents between 7:00 AM and 9:00 PM and one per 20 residents at other times. Establishing minimum ratios at the federal level is important to ensuring that facilities across the nation actually staff their services adequately.

HHS would have up to four years to publish the report and potential regulations on minimum staffing ratios, giving nursing facilities sufficient time to prepare and adjust staffing as needed. While the bill requires that HHS study potential staff-to-resident ratios, it does not require that the department find that ratios are needed or set any specific ratio for HHS to impose on facilities. In addition, Build Back Better allows facilities in rural areas with a dearth of nursing homes to receive a waiver from any potential minimum ratios.

Historically, nursing homes that serve predominantly Black and/or Hispanic residents have reported lower levels of staffing and staff time per resident, per day than other facilities. The Build Back Better Act could help close this disparity through its nursing home staffing provisions by potentially holding all facilities to the same, concrete minimum staffing standards.

Improved Data Collection and Oversight

Underpinning the success of all nursing home oversight is good data reporting and strong enforcement. Current law requires nursing homes to report data regularly on staffing, quality, and other attributes. Facilities also submit cost reports that quantify their expenses and often influence their reimbursement rates.

The Build Back Better Act would improve on current requirements by providing HHS the tools it needs to ensure the data nursing homes report are accurate. Specifically, the bill would provide funding for HHS to audit cost reports for more facilities and create a path for HHS to reduce payments to facilities that report inaccurate data. It would also fund a review of and potential revisions to nursing home survey and enforcement processes, which are necessary to help federal and state oversight agencies fully enforce the law and protect nursing home residents.

After the last almost two years with over 186,000 resident and staff deaths in nursing homes and other long-term care facilities, residents and their families deserve nothing less than quality care. Residents in nursing homes should receive this care with enough well-trained staff to provide safety, quality of care, and quality of life.

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