September 21, 2023 Washington DC – Following the Center for Medicare and Medicaid Services (CMS)’s September 1, 2023 release of its highly anticipated proposed nursing home staffing rule—part of the administration’s efforts to enhance safety and quality in nursing homes — reaction is clear. If enacted as proposed, the rule will have a profound impact on older adults and families across America. 

“Ensuring quality care in nursing homes is a goal we share with the administration,” said Katie Smith Sloan, president and CEO of LeadingAge, whose mission-driven, nonprofit members serve older adults in nursing homes and a range of care settings and communities across the U.S. “But they’re not getting it right yet. Two major issues—the ongoing national aging services workforce crisis and the proposal’s astronomical implementation costs—make the proposal unrealistic. 

Speaking on behalf of thousands of members across the country, association leaders representing 33 states explain how the proposal raises very real challenges for the whole health care sector and actually jeopardizes access to care for older Americans. No state will be immune from the harm.”

ARIZONA Nearly 40 percent of Arizona’s population is 65 or older. That’s more than 2.5 million residents, thousands of whom are residents in nursing homes. Our nonprofit, mission-driven members serving older adults in nursing homes and assisted living communities are navigating significant staffing challenges while providing quality care. To do that, they frequently have to make hard choices: limit admissions or close wings, temporarily or permanently. Minimum staffing standards may sound like the solution to ensuring a consistent level of care throughout the country, but implementing them without addressing the underlying staffing crisis is meaningless. It’s putting a Band-Aid on a gushing wound; the most likely result will be to further limit care access. What’s needed is a comprehensive approach to attract, train, and retain healthcare workers in nursing homes and other aging services settings. Our population will not stop aging; the need for care will continue. Addressing workforce needs in Arizona and across the U.S. has got to be top priority. –Pam Koester, CEO Arizona LeadingAge

CALIFORNIA We are disheartened by CMS’s nursing home staffing proposal, the impact it will have on access to quality care for older adults, and the precedent it sets for blanket staffing mandates. By requiring 24/7 RN staffing, and excluding LPNs as part of the staffing matrix, the proposed rule would further exacerbate the healthcare workforce shortage, place undue financial burdens on care facilities, and potentially decrease access to care in California. This proposed rule is not realistic without sufficient financial and workforce supports. – Jeannee Parker Martin, president and CEO, LeadingAge California

COLORADO Colorado is experiencing a significant shortage of qualified workers who can provide high-quality services to our aging population. As the number of adults over 65 increases, our workforce pool is shrinking: by 2030, Colorado’s population age 65 and older will be 72% larger than it was in 2015, compared to the under 65 age group that will grow by only 20%. Due to turnover, between 2018 and 2028, Colorado will need 116,100 direct caregivers to meet the demand. There are simply not enough workers. – Laura Landwirth, CAE, president and CEO, LeadingAge Colorado

CONNECTICUT The proposed rule creates separate minimum staffing ratios for registered nurses and certified nurse aides. The breakout of separate minimum ratios is contrary to the philosophy and intent of the newly implemented nursing home acuity-rate system in Connecticut, which seeks to incentivize staffing patterns specifically to address higher acuity residents. The needs and underlying conditions of nursing home residents vary widely, as do the skills and capacities of health care professionals. CMS’s rule should recognize this and be more accommodating to staffing patterns designed to meet the varied needs of residents, rather than rely on prescriptive separate ratios as proposed, which will work against high-quality nursing home staffing models. – Mag Morelli, president, LeadingAge Connecticut

FLORIDA The reality is that over 40% of Florida’s nearly 700 nursing homes would not meet the minimum RN staffing hours per day as proposed. With the current shortfall of nurses and the outlook worsening in the future, this proposal is simply not realistic. The education system is not even able to meet the current demands. And the added demand that this rule would create would dramatically increase scarcity, with ripple effects throughout the entire healthcare system. – Steve Bahmer, president & CEO, LeadingAge Florida

GEORGIA  According to an article in the Gerontologist, caregivers’ reasons for nursing home placement included (a) the need for more skilled care (65%); (b) the caregivers’ health (49%); (c) the patients’ dementia-related behaviors (46%); and (d) the need for more assistance (23%). The mandated staffing requirements from CMS will likely decrease the availability of nursing home beds given the severe worker shortages. Adding impossible mandates will make accessing care more difficult for older Americans and their families as providers will have to limit admissions. – Ginny Helms, president, LeadingAge Georgia

ILLINOIS In Illinois, we anticipate communities will need to find and hire between 820 to 968 RNs and 7,500 to 8,039 CNAs at a time when communities are still desperately trying to recover from a 15% loss of workforce since 2020. Candidates are nowhere to be found. Further, this staffing mandate will cost between $383.2M to $416M, before any future wage inflation.  With no plan from the government to cover this massive increase in costs, the vast disparity in healthcare is going to become that much larger. – Angela Schnepf, MBA, CAE, president and CEO, LeadingAge Illinois

INDIANA The Indiana Medicaid Office is preparing to launch a massive rebalancing effort towards much more labor-intensive home and community-based services (HCBS) care. While troubling nationwide, a staffing mandate in Indiana could cripple both skilled care facilities and HCBS providers all at once. The proposed unfunded mandate presupposes that senior care providers caused a problem that they now have the tools to solve. Neither could be further from the truth. The administration must get real about the root causes of the staffing crisis we all face and how we might find a way forward together. An unfunded mandate divorced from reality is not a step in the right direction. – Eric Essley, president and CEO, LeadingAge Indiana

IOWA Iowa’s nursing homes have seen a 11.31% decrease in employment since the start of the pandemic, with the most significant drop (12.13%) during the first quarter of 2022, after the period studied in CMS’ Abt staffing report. Simply put, Iowa’s aging services providers are struggling now to find workers. Shortages have jeopardized access to care for older Iowans, backed up the healthcare system, and resulted in nursing home closures. A staffing mandate does not solve or even recognize this problem. It only exacerbates it. – Shannon Strickler, president and CEO, LeadingAge Iowa

KANSAS At least 47 nursing facilities have closed or reduced their offerings in Kansas since early 2020. By CMS’ own estimates, implementation of the 24/7 Registered Nurse requirement would dramatically increase the cost per resident day for small rural nursing homes that are serving the tens of thousands of older Kansans living in sparsely populated areas with few care options. The arbitrary and unfunded staffing minimums proposal will result in more rural nursing home closures and will rip away large swaths of older Kansans’ ability to access quality care. – Rachel Monger, president and CEO, LeadingAge Kansas

KENTUCKY Quality staffing in a nursing home has never been about counting bodies. Quality staffing is more appropriately determined by assessing staff experience levels, resident acuity, and the effectiveness of managerial supervision. – Timothy L. Veno, president, LeadingAge Kentucky

LOUISIANA AND MISSISSIPPI Currently, most of the nursing homes in Louisiana and Mississippi cannot meet the minimum RN staffing requirement. The RN shortage is a reality; and the RN schools cannot meet the demand.  CMS needs to be mindful of the RN shortage and take another look at their proposed rule  –Karen Contrenchis, NFA, President. LeadingAge Gulf States

MARYLAND We simply do not have enough individuals to meet this requirement today, or in the coming years. It is estimated that by 2035, our state will need an additional 13,800 RNs alone to meet the projected demand for care, and the pipeline is not big enough to meet this need. For example, a portion of potential nursing students are turned away each semester because the schools do not have enough clinical sites, faculty, or resources. Nationwide in 2020, 80,521 qualified nursing applicants were turned away for these reasons. Before we require increased staffing, we need to ensure that every individual who is eligible and interested in becoming an RN, LPN, or nursing assistant has the opportunity and support to do so. – Allison Roenigk Ciborowski, president and CEO, LeadingAge Maryland

MINNESOTA In a time when we face ongoing workforce shortages, tying the hands of providers to meet a potentially unattainable standard will not have the intended impact of increasing quality. The rule fails to embrace the unique care models we’ve implemented in Minnesota to safely and effectively allow staff like LPNs and medication aides to make meaningful contributions to care. And it fails to enact proactive solutions like funding for training programs, immigration reform, and increased reimbursement rates to cover the cost of care and increase wages. – Kari Thurlow, president and CEO, LeadingAge Minnesota

MISSOURI Missouri nursing home leaders are troubled by CMS’ proposed staffing mandates and believe there are both practical and philosophical reasons CMS should rethink it.  Providers in our state are downsizing – some closing – due to staffing shortages and below-cost care reimbursement.  Without higher reimbursement and substantial incentives for workforce development (LPNs are a vital part of this, and the proposal diminishes their role), the staffing mandates are unrealistic in Missouri.  Further, at its core, quality senior care is about compassionate, competent humans serving older humans in need of care.  While everyone recognizes more staff translates into more care, that does not automatically produce better care. Our members need incentives and support to reach care quality ceilings, not mandates to establish minimum floors.  –Bill Bates, CEO, LeadingAge Missouri

NEBRASKA Nebraska nursing homes come in every shape and size.  Each provides quality care while addressing the needs of their local community. There are entire counties in Nebraska that do not have a registered nurse living in them; recruiting additional staff to work in these communities is not possible. Minimum staffing requirements need to accurately reflect the needs of those being served in each community in order to keep our rural nursing homes. – Kierstin Reed, president and CEO, LeadingAge Nebraska 

NEW JERSEY & DELAWARE The federal government must not put nursing homes in a position where they are no longer able to pay staff and other expenses due to unfunded mandates. Just the opposite, in fact, is needed: nonprofit and mission-driven providers should be recognized for their unwavering commitment to serving seniors; their staff should be praised for their hard work and devotion to the residents. – James W. McCracken, president and CEO, LeadingAge New Jersey and Delaware

NEW YORK In New York state, which implemented a staffing mandate in 2022, members are trying desperately and can’t meet the mandate. We can’t compete in this marketplace. We’re not Taco Bell. If we don’t have staff, we can’t stop serving breakfast. We’re 24/7. The only thing you can do is shut down beds. – James W. Clyne, Jr., president and CEO, LeadingAge New York

OHIO In Ohio, we are seeing nonprofit and government-operated nursing facilities closing at a precipitous clip or aggressively reducing the amount of nursing home care they provide. Ohio alone has lost roughly 3,000 beds over the past two years. In most situations, there is no lack of demand, rather, a lack of workforce. The draft rule is simply out of touch with the reality of our sector. – Susan Wallace, president and CEO, LeadingAge Ohio

OKLAHOMA In an already heavily regulated environment that makes the typical day challenging, adding this minimum staffing requirement in the midst of the largest nursing shortage arguably in history, will be catastrophic in Oklahoma; business-ending for many providers who will be unable to accomplish this unreasonable expectation.  This will have a domino effect on Oklahoma residents living in these facilities, who will be forced to find alternative, lesser-quality housing. – Kristi Colclasure, CEO, LeadingAge Oklahoma.

OREGON Masked under the guise of “quality,” this disappointing mandate proves how deeply out of touch CMS is with the reality our sector is facing and the difficulties recruiting and retaining staff. The proposals will result in the closure of nursing homes that currently provide quality care, particularly in rural communities in Oregon. It’s simple: if CMS really cares about improving quality; then improve reimbursements and funding. – Kristin Milligan, CEO, LeadingAge Oregon

PENNSYLVANIA This proposed rule is unrealistic, overly prescriptive, and shortsighted. Mission-driven long-term care providers are contending with years of underfunding, dwindling resources, and the worst workforce crisis in memory. We cannot emphasize enough that the required workers simply do not exist. Rather than increasing quality, as CMS incorrectly presumes, these proposals will only result in decreasing available nursing beds and worsening the access-to-care crisis in Pennsylvania and across the nation. – Garry Pezzano, president and CEO, LeadingAge Pennsylvania

RHODE ISLAND A staffing ratio mandate is a blunt enforcement instrument that does not consider the numerous challenges facing providers, including Medicaid underfunding, lack of workforce, and the diversity of resident needs. Moreover, the imposition of severe financial penalties on homes that are unable to meet a staffing ratio is counterproductive: fines siphon off scarce resources that providers need as they seek to address their workforce and resident care needs. Our state’s experience illustrates the numerous challenges and unintended consequences of a staffing ratio mandate: the severity of fines, how compliance is measured and calculated, compliance costs, backlogs of people in hospitals waiting for skilled nursing care after admissions have been reduced due to a lack of staff and other access-related issues.  Moreover, even those homes that are currently able to comply with the staffing ratio are doing so at an unsustainable cost. We are working with state officials and other stakeholders to revisit some of the more onerous provisions of Rhode Island’s mandate, mitigate its effects, and pursue other less punitive approaches to meet our collective goal of ensuring adequate staffing and quality of care. At the same time, we’re also working on various initiatives to develop a pipeline of workers, which will quite simply take time. Whether state or federal, a staffing ratio mandate without an adequate workforce supply as well as financial resources poses an existential threat to the industry. – James Nyberg, president and CEO, LeadingAge Rhode Island

SOUTH CAROLINA CMS needs to recognize the negative implications this mandate will have on older adults, on families, and on providers. It is unrealistic to expect that nursing homes will be able to fill additional RN positions when there aren’t enough nurses to fill the current openings. The proposed rule could also lead existing staff to leave aging services. The pressure on nurse managers to maintain high quality ratings and full staff in a time when workers are scarce, boost staff morale, stay abreast of fast-changing regulations, and manage liability is a lot. This is not the answer. – Kassie South, CEO, LeadingAge South Carolina    

SOUTH DAKOTA In South Dakota, we have strong leadership and dedicated employees who go to work every day in our nursing homes, caring for our most vulnerable population. They have endured more than any other industry during and after the pandemic and continue to struggle with staffing, finances and an aging infrastructure. Nursing home admissions are limited today due to staffing; many wings and beds have been taken out of service because we just cannot find enough staff to apply for the open positions. The lack of availability creates a back-log in our hospitals and puts more pressure on families to find care for their loved-one in the home. In South Dakota, only 5.4% of RNs are employed in the nursing home industry and we have almost 1000 open RN positions in the state which cannot be filled. One member has had an RN position posted for over 300 days and cannot get a qualified applicant. This rule will be devastating to our rural communities and will threaten hospitals who rely on nursing home care in their community. – Tammy Hatting, MPA, COO, South Dakota, South Dakota Association of Healthcare Organizations 

TENNESSEE Of the 7 million people who live in Tennessee, nearly 1.7 million are age 60 and older; we’ll tip over 2 million by 2034 – less than 10 years from now. Nursing home providers struggle to remain fully staffed now; a mandate that provides punishment and not support, will worsen the situation. Admissions will cease and facilities will close. Then who will care for the greatest generation? This rule will not ensure better quality care, it will ensure more older adults not getting the care they need. We need to continually be asking the question, ‘who will care for our older Tennesseans?’ If we don’t figure out how to recruit and retain a workforce to care for this population, where will we be? –Gwyn E. Earl Executive Director, LeadingAge Tennessee

TEXAS Texas nursing homes are disheartened by the federal staffing mandate proposed by CMS, but not for the reasons some proponents suggest. There are over 1,100 nursing homes in our state serving urban and rural communities and day after day, nonprofit nursing homes demonstrate their commitment to providing the highest quality care to older Texans. CMS’ proposed rule is tone-deaf and unrealistic. Today, over 85% of Texas nursing homes would fail to meet the proposed standards. Right now, we need support, and our state and federal governments to partner with us on developing well-rounded solutions to the challenges we face, not arbitrary mandates and rhetoric that sow public doubt in the critical services thousands of older Texans and their families rely on. If we want to improve care now and into the future, it’s time to do the difficult work and stop pointing fingers. – George Linial, president and CEO, LeadingAge Texas    

VIRGINIA LeadingAge Virginia members have always prioritized quality care and healthy organizational cultures. But the workforce shortage is a reality we all must face. Providers need solutions, not mandates, to drive qualified people into this meaningful work. – Melissa Andrews 

president and CEO, LeadingAge Virginia 

WASHINGTON In Washington state, out of 192 facilities, 122 would not meet the 2.45 hours per nurse aide, with the state average at 2.21. The estimated cost for all facilities to comply with this mandate would be $20 million. The current state average for RN hours is 0.59, but 52 facilities would not meet the proposed 0.55 RN hour per resident day mandate, with an estimated cost of $5 million to fill these positions. Glaringly, the proposal is silent on the inclusion of LPN hours towards mandated staffing hours.  LPNs fill a vital nursing need in skilled nursing facilities allowing the RN to function at her/his highest scope of practice, are licensed to administer medications, and provide a higher level of skill and assessment support to CNAs.  Importantly, the proposal fails to address two fundamental needs: increased Medicaid funding and a pipeline of ready licensed and trained essential health care workers.  Without addressing these fundamental needs, mandating staffing levels as proposed will fail and the administration misleads the public while having done nothing to improve quality. – Deb Murphy, president and CEO, LeadingAge Washington

WISCONSIN Since the beginning of the COVID pandemic, Wisconsin has witnessed the closure of numerous nursing homes due to challenging economic conditions and a pronounced shortage of healthcare workers, particularly in rural regions. The proposed staffing ratio mandate will likely exacerbate these closures, resulting in reduced access to care, contrary to the intended goal of enhancing quality. – Jim Orheim, president and CEO, LeadingAge Wisconsin

WYOMING This staffing mandate has the potential of decimating access to care for those needing long-term care, especially in rural communities. Nursing homes have been adjusting their staffing levels for years, without a mandate, based on the acuity of the patients for whom they are caring. The national shortage of trained healthcare professionals is only going to get worse, especially in rural communities. The ultimate outcome of this administrative mandate will be the closures of much-needed nursing homes, limiting the access to care and forcing our aging population to seek care in hospitals or move out of their communities. – Eric Boley, president, LeadingAge Wyoming