Key Issues

In May 2024, the Centers for Medicare & Medicaid Services (CMS) published a final rule that set new staffing requirements for skilled nursing facilities. The rule requires a total of 3.48 hours of care per resident each day, with specific allocations for registered nurses (RNs) and nurse aides, and mandates that an RN be present 24/7. Nursing homes started implementing the new staffing rules in June 2024. Full compliance with operational regulations was required by August 2024. The staffing requirements must be fully met by May 2026 for non-rural facilities and by May 2027 for rural facilities.

The one-size-fits-all staffing mandate has raised significant concerns because fewer than one-quarter of facilities in over half of states currently meet all three required staffing minimums. This gap means many nursing homes need temporary exemptions to comply with the new rules. Moreover, the mandate marginalizes the role of licensed practical nurses (LPNs), especially in rural areas that rely heavily on them. Adding to the complexity, a recently leaked study commissioned by the CMS revealed that no single staffing level guarantees better care. This study, which questioned the effectiveness of a strict staffing mandate, highlighted the potential financial strain that increased staffing levels could cost up to $11.7 billion annually. 

In July 2024, the Supreme Court’s removal of the Chevron doctrine made it easier to challenge federal agencies like the CMS on their regulations. This decision could impact the CMS’s new staffing requirements, including requiring an RN to be on-site 24/7. Rather than enforcing a rigid staffing rule, a more flexible approach should focus on improving workforce recruitment and retention, increasing funding, and tailoring solutions to the unique needs of each facility and community. The ongoing shortage of nursing home beds and recent closures, which have displaced thousands of residents, underline the urgent need for practical and adaptable solutions.

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The United States faces a critical nursing shortage, further strained by a visa freeze for foreign nurses implemented in June 2024 for the remainder of the fiscal year. The State Department’s July Visa Bulletin reveals that only those who applied before December 1, 2021, are eligible for visa interviews. With an annual cap of around 40,000 EB-3 visas — unchanged since 1990 — the system cannot keep up with the increasing demand. Foreign nurses, who represent about 15% of the U.S. nursing workforce and 28% of all direct care workers, are vital to staffing nursing homes. Around 10,000 international nurses are awaiting visa processing, facing wait times that have now stretched to approximately two and a half years. The new federal staffing mandate, which requires nursing homes to hire an additional 102,000 nurses and nurse aides over the next five years, intensifies this challenge. The inability to meet these staffing requirements could force skilled nursing facilities to limit admissions, downsize, or close, potentially displacing nearly 300,000 residents. The research underscores that immigrant caregivers enhance nursing home quality, highlighting the urgent need for the bipartisan Healthcare Workforce Resilience Act (S. 3211/H.R. 6205) to recapture unused visas and address this escalating staffing crisis.

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States need more instructors and available testing sites to meet the number of applicants ready to take the Certified Nursing Aide (CNA) certification exam. The TNA waiver ended with the conclusion of the COVID-19 public health emergency (PHE) in May 2023. This waiver was crucial during the pandemic for addressing staffing shortages by allowing temporary nurse aides to work without immediate certification. Since the PHE ended, the CMS has yet to extend the waiver nationwide. Although some states received short-term extensions, a broader waiver is needed to address ongoing workforce shortages. Reintroducing a federal TNA waiver is essential, as it would support continued staffing levels and facilitate the professional development of this critical careforce, who have been vital for maintaining consistent care for nursing home residents. Congress must revisit and act upon the Building America’s Health Care Workforce Act (H.R. 468) to support and strengthen the long-term care workforce. This bill proposes extending the certification deadline for TNAs from four to 24 months to address training and testing backlogs. It also allows TNAs to apply their on-the-job experience toward the 75-hour federal training requirement for certification as nursing assistants.

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In 2024, significant strides have been made to tackle the urgent issue of price gouging by temporary staffing agencies in nursing homes. States like Connecticut, Louisiana, Oregon, and Tennessee have enacted legislation to regulate and cap the fees these agencies can charge. These new laws address the rising costs that nursing homes face when relying on temporary staffing, often leading to inflated charges and unfair pricing practices. It is crucial to support and advance these regulatory measures to protect the financial stability of nursing homes and enable them to deliver high-quality care without incurring excessive costs. By promoting equitable and transparent practices in the staffing industry, we can ensure that healthcare providers and the residents they serve benefit from fair pricing and more stable financial conditions.

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Medicaid coverage for assisted living varies widely across the United States, with 46 states and the District of Columbia offering some form of financial assistance. While Medicaid traditionally does not cover room and board, it may fund activities of daily living (ADL), medication management, and sometimes transportation or light housekeeping. Home and Community-Based Services (HCBS) waivers can further assist with costs for personal care and supportive services in assisted living settings. As more states recognize that assisted living is often less expensive than skilled nursing facility care, expanding Medicaid coverage to offer more consistent and comprehensive support is crucial. Such an expansion would ensure that all seniors have access to the dignified and effective care they need, regardless of their location or financial situation.

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In 2023, Congress extended telehealth flexibilities through December 31, 2024, preserving many pandemic-era provisions that support continued telehealth coverage and use. Telehealth has been especially valuable for senior care communities, reducing the need for travel, minimizing infection risks, and facilitating more frequent consultations with specialists. Recent legislative progress includes the bipartisan Preserving Telehealth, Hospital, and Ambulance Access Act, passed by the U.S. House Ways & Means Committee in May 2024, which extends these flexibilities through December 31, 2026. Additionally, The Telehealth Modernization Act of 2024, advanced by the Energy and Commerce Committee, seeks to permanently eliminate geographic restrictions for federally qualified health centers and rural health clinics and extend audio-only telehealth coverage. Our focus is on ensuring that these legislative measures become law to maintain and enhance telehealth access. Continued advocacy is crucial to ensuring that telehealth remains a vital tool for improving healthcare access, reducing in-person visits, and increasing specialist consultations for seniors.

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The global pandemic has accelerated technology adoption in senior care communities, leading to notable improvements in resident quality of life and staff productivity. By streamlining workflows and reducing redundant tasks, technology enables these communities to operate more efficiently and effectively, even with limited resources. Innovative technology and connected devices enhance energy efficiency and reduce operational costs. These savings can be redirected toward increasing staff wages, helping to address high turnover rates, and attracting new talent — critical challenges in the sector.

Successful technology integration requires vital internet infrastructure and robust security measures. Federal financial assistance is critical to ensure effective adoption and overcome existing workforce challenges. We advocate for the CMS to adjust Medicare reimbursement rates to incentivize investments in technology that improve clinical outcomes and ease the burden on direct care staff. Aligning financial incentives with technological advancements will support the development of senior care communities and enhance overall care quality.

Securing adequate funding for nursing homes is increasingly critical as we face a complex financial landscape. The recent 4.2% increase in Medicare reimbursement rates falls short of covering the rising costs driven by inflation, higher labor expenses, and federal staffing requirements. Similarly, Medicaid, which is the primary funding source for many long-term care facilities, often reimburses at rates lower than the actual costs, with 2024 rates still insufficient. To address these issues, we are advocating for a substantial increase in Medicare rates, higher and more equitable Medicaid reimbursement rates, and reforming outdated rate-setting methodologies. This includes revising forecasting methods and correcting calculation errors to better reflect current economic conditions. Additionally, we are pushing for specific provisions in reimbursement policies to support the rising labor costs and staffing requirements imposed by the new federal mandate. Our goal is to ensure that both Medicare and Medicaid payments are fairly distributed, particularly to skilled nursing facilities with high Medicaid populations, so they can cover their costs, meet staffing needs, and invest in workforce development while providing quality care.

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As states tighten regulations requiring nursing homes and assisted living facilities to install reliable emergency power systems, it is essential to provide these communities with adequate time and funding to meet the new requirements. The costs for installing emergency generators can vary significantly, from around $20,000 for smaller, newer facilities to over $720,000 for larger, older ones. Without dedicated state or federal funding, the financial burden can be overwhelming. To ensure that these long-term care communities can comply with the new rules while continuing to provide safe and uninterrupted care, it is crucial to offer financial support and a reasonable timeline for implementation. This approach will help facilities manage the costs and avoid compromising resident safety during the transition.

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