June 10, 2022 Washington, DC — In comments filed to the Centers for Medicare & Medicaid Services’ (CMS) on its 2023 Skilled Nursing Facility proposed payment rule, a top aging services organization warns CMS of the potential dire impact of a payment reduction and implementation of staffing requirements on older adults and families. Ultimately, access to the care and services needed to age well will be reduced or become unavailable. 

“Funding goes hand in hand with quality care. Today, nursing homes continue to struggle financially as the cost of medical supplies and staff to provide the care have increased,” said Katie Smith Sloan, president and CEO of LeadingAge, the association of nonprofit providers of aging services, including nursing homes. “Nursing homes are closing all across the country, and their challenges will be further exacerbated by implementation of the parity adjustment. CMS cannot defend a plan to pay less for care that costs more.”

Describing the impact of potential staffing mandates on nursing homes already buckling from sustained pressure of staffing shortages, Sloan said: “One administrator in Kansas recently told me he’s got a waiting list of residents, but not enough staff to admit. He’s contracted with four staffing agencies, but not one can provide a licensed registered nurse. His story is not unique. Across the country, providers are being forced to pare back admissions. Some of our members say the situation is increasingly unsustainable.” 

Excerpts from LeadingAge’s response to CMS’ request for information on mandatory minimum staffing levels: 

• Both the nursing home reform agenda released by the Biden Administration in February 2022 and National Academies of Sciences, Engineering, and Medicine’s (NASEM) National Imperative to Improve Nursing Home Quality study will require an extensive, cross-departmental campaign to address recruitment, training, and retention of workers in the long-term care workforce. Ignoring these imperatives and simply imposing a staffing standard without addressing the workforce crisis is illogical and unjustly punishes nursing homes that are unable to meet standards due to factors beyond their control. 
• Enforcing a staffing standard while simultaneously siphoning off resources is a self defeating exercise. One commonly discussed solution to improve workforce recruitment and retention is to pay competitive wages. LeadingAge reminds CMS that staff wages and benefits cannot be increased when the system is underfunded and reimbursements to providers are being cut. 
• Only after investing in staffing improvements, both functionally and financially, should CMS consider how to measure a staffing standard
• A fresh study, initiated to examine exactly what is intended to be measured and regulated, should form the basis for considering a staffing standard.
• As recommended in the NASEM report, the unique characteristics of a nursing home should be considered in determining whether staffing is adequate. Factors such as census, resident acuity, and case mix, as well as any particular needs identified in the facility assessment, factor into the unique level and type of staff that would be required to meet the needs of the residents. Noting that these factors could change on a daily basis, it would be advisable to establish benchmarks rather than absolute values in staffing requirements. 
• The medical directors, administrators, and directors of nursing are most familiar with the individual resident needs and plans of care, and with the skills and competencies of their staff. These individuals are the experts on staffing their communities and they must have the flexibility to make choices about the staffing that will best ensure safety and quality of care.
• CMS must also consider factors such as geographic location and workforce availability, including availability of workforce specific to the position. Rural or frontier locations may have difficulty filling roles based on limited numbers of qualified candidates

Comments from LeadingAge nursing home members on the impact of the proposed rule: 

• “Today, frail older adults have limited options for care and support; most providers have already reduced services because of uncompensated care. The unfunded mandate to increase the cost of additional staffing will result in providers turning away more people in need. We have seen families in crisis looking for a place for a loved one with limited to no options.” —Laura Roy, Executive Director, Passavant Community, Lutheran Senior Life, Zelienople, PA
•  “Any further cuts bring us to a question of whether skilled nursing care will truly be sustainable in many communities. South Dakota has had four nursing homes announce this year that they are closing, and it’s highly likely there will be more doing the same. In a rural state with great distances between communities and aging sector resources, that has a huge, sometimes devastating impact on individuals in need of services and their families.” —Deb Paauw, Executive Director of Quality and Data Integration, Avera, Sioux Falls, SD
• “Nothing has gone down [in price]: personal protective equipment, food, other supplies…. Wages are way up. [The Biden Administration] needs to understand that the hourly wage of staff is through the roof… It is killing us. It’s all about being able to care for our community. Without being able to hire staff, we can’t do that.” —Joel Smith, Health Services Administrator, BayView Life Plan Community Seattle, Seattle, WA
• “Staffing requirements will be too high to meet since CMS expects higher staffing levels [during a severe workforce shortage] and with much lower reimbursement, which creates an unfunded mandate.” —Brian Robbins, Vice President & COO, Buckner Retirement Services, Dallas, TX 

We represent more than 5,000 nonprofit aging services providers and other mission-minded organizations that touch millions of lives every day. Alongside our members and 38 state partners, we use applied research, advocacy, education, and community-building to make America a better place to grow old. Our membership, which now includes the providers of the Visiting Nurse Associations of America, encompasses the continuum of services for people as they age, including those with disabilities. We bring together the most inventive minds in the field to lead and innovate solutions that support older adults wherever they call home. For more information visit leadingage.org.