Proposed Federal Nursing Home Mandates Would Limit Access to Care

This article originally appeared as an Op-Ed by LeadingAge PA member, Beth McMaster, President & CEO of United Church of Christ Homes based in Camp Hill, PA.

Right now, Pennsylvania nursing homes are working around the clock to provide the best care for the loved ones of countless Pennsylvania families. It’s a labor of love we take personally because every resident deserves to live their lives with dignity, and their families deserve peace of mind. Unfortunately, administrators also are working 24/7 to find enough qualified workers to meet Pennsylvania’s new mandated staffing requirements. To be clear, the mandate is well-intentioned, but a worker shortage crisis has made meeting the mandate a full-time effort, which often falls short because even staffing agencies cannot find enough workers to fill all the positions the government says are required. 

Unfortunately, things could get worse. 

On top of state staffing mandates, new proposed federal mandates through the Centers for Medicare and Medicaid Services (CMS) will only make these challenges more difficult. The CMS proposal is currently accepting public input until Nov. 6. Instructions for submitting comments are here. 

Senior care facilities will certainly be making our case that more mandates don’t improve the health and safety of residents, and even if they did, the employee pool to meet these minimums simply doesn’t exist. We are already seeing the myriad of unintended consequences prescriptive staffing ratios are having in Pennsylvania, including reducing the number of beds available to those who need them, raising costs for residents who have the ability to pay for their own care, and the outright closure or sale of facilities. Worse, dedicated employees are facing severe burnout. These unfunded mandates only result in the exacerbation of the access-to-care crisis by further contributing to hospital backlogs and preventing older adults from being able to receive care in the most appropriate setting when they need it most. 

CMS estimates in their proposed rule that nearly 90,000 new RNs and nurse aides will be required nationwide to meet these proposed standards. Additionally, CMS has not included licensed practical nurses (LPNs) in the staffing calculations — unlike in Pennsylvania’s rule, they have erroneously determined that LPNs, who play a significant role in every nursing home’s care team, do not contribute to the quality of care for our residents. Nearly 79% of nursing homes will need to staff up, but where will these staff come from?  

A recent member survey from LeadingAge PA, which represents nonprofit and mission-driven nursing homes and other aging services providers in Pennsylvania, found nearly 60% of respondents have been unable to fill work shifts to meet the state mandates since July 1, despite working with staffing agencies. As a result, over 50% have been forced to reduce the number of beds available (up from 34% in a March 2023 survey) and overwork an already exhausted workforce. It’s become so bad that nearly 16% indicated they will have to consider selling or closing their facility if the federal mandate is implemented, and over 60% would have to further reduce their census. Oct 2023 Member Survey Results (leadingagepa.org) 

Of course, the federal mandate comes without new funding to pay for it. CMS estimates the cost would exceed $4.2 billion per year, but LeadingAge national estimates the cost is closer to $7 billion nationwide. In Pennsylvania alone, the additional cost would be $436 million annually. Pennsylvania nursing homes, despite serving one of the oldest populations in the nation, are chronically underfunded. According to an independent report commissioned by LeadingAge PA in 2022, in Pennsylvania’s nursing homes there was a shortfall of nearly $1.2 billion in Medicaid in 2019-2020. Facilities rely largely on Medicaid to cover the costs of residents who do not have the assets to pay for their care.  

While the $294 million Medicaid rate increase in state fiscal year 2022-23 (the first across-the-board increase in nearly a decade) was a good first step in addressing this shortfall, providers continue to face increased costs, and an estimated $900 million gap remains. Increased costs, the lingering impact from the pandemic and insufficient Medicaid funding have already begun to erode last year’s investment.  

Like many facilities across the commonwealth, United Church of Christ Homes in Camp Hill is trying to find a way to address state mandates, prepare for federal mandates and present a balanced budget, all without adequate funding. In some cases, if one person calls off work because of illness, the facility could be punished for being out of compliance. The only option is to overstaff as much as possible, which isn’t always an option. 

We certainly respect that the government wants to improve the lives of nursing home residents. So do we. It’s our never-ending mission. But the unintended consequences of government staffing mandates will lead to fewer facilities and fewer beds.  

Pennsylvania families who have a loved one who requires around-the-clock nursing care deserve better.