Only 29% of Nursing Homes Can Meet 4-Hour Daily Care Mandate

An analysis released this month from public policy group KFF indicates that less than a third of the nursing homes in the US would come close to meeting the proposed federal guidelines for minimum staffing requirements.

According to the study, only 29% of skilled nursing facilities would meet the mandate for 4.1 hours per day of direct care nursing time per patient (known in the industry as HPRD), and less than half (45%) said they could meet a standard of 3.5 hours per day.

KFF reported that most nursing homes said they have adequate staff to accommodate a standard of 2.5 hours per day of HPRD, while 85% said they could handle a mandate of three hours per day of direct care.

The report also found a “wide variation” in care levels across the country if facilities are required to meet staff levels exceeding 3.0 HPRD. The study was based on staffing data reported in June by 14, 575 nursing homes that are occupied by an estimated 1.2M residents, according to a report in Skilled Nursing News.

In November, the Biden Administration announced it will propose a new daily minimum standard based on a 2001 proposal from the Centers for Medicare & Medicaid Services, which called for 4.1 total hours of care, split between 2.8 hours from CNAs, 0.75 hours from RNs and 0.55 hours from nurse practitioners.

The current federal care standard, established in the 1987 Nursing Home Reform Act and updated by the Obama administration in 2016, requires the equivalent of just 0.3 HPRD for a 100-bed facility. According to KFF, 19% of skilled nursing facilities failed to have sufficient staff to meet this standard between July 2021 and July 2022.

“The proposed rule is likely to strengthen the HPRD minimum requirement and could potentially include additional nurse staffing requirements,” KFF researchers said, in the analysis.

“If the proposed rule includes requirements related to the types of nurses facilities must employ (and the hours they must work) or adjusts the number of required nurses based on patient health and frailty, fewer nursing facilities would meet a given requirement than are shown [in the study],” the report said.

Consulting giant McKinsey released a study last month warning that the shortfall of nurses in the US is on a trajectory that could top 450,000—double the gap at the end of 2022. Job openings in health care surged above 2M in April, on a pace to top last year’s record.

Despite record demand, which is pushing up wages for nurses, undergraduate enrollments at nursing schools declined for the first time in more than 20 years in 2022, according to the American Association of Colleges of Nursing.

The nursing profession is imploding as the nursing shortage forces existing professionals to work longer hours and deal with more patients—leading to burnout and making the job unattractive to new recruits. According to McKinsey’s survey, “not having a manageable workload” is the main reason cited by nurses who are planning to quit.

This is bad news for nursing home operators who have seen their margins shrink from rising labor costs despite occupancy levels that are approaching pre-pandemic levels. Nursing home occupancy, which plunged to a national average of 67% in January 2021, is tracking above 80% this year.

The American Health Care Association (AHCA) has estimated that the 4.1-hour-per-day care standard would add $11.3B annually to cost of operating the nation’s 15,500 nursing homes—and require an additional 191,000 nurses and nurse aides.