Requiring the Impossible: Nursing Home Staffing Mandates During a Nationwide Labor Shortage Don’t Work

Advocacy; Workforce

​The Biden Administration plans to establish a federal staffing mandate for nursing homes this year. However, 45 states and the District of Columbia already have staffing requirements that exceed the current federal requirements, and more than two-thirds of states have staffing ratios or minimum hours for each resident per day on the books.
Due to a nationwide labor shortage, many nursing homes are struggling to find workers to comply with their state’s current requirements. The results are that nursing homes are having to downsize or limit new admissions; seniors must wait longer or widen their search for care; hospitals become overwhelmed with patients who are unable to be discharged; and current nursing home staff are stretched thin. 
Across the nation, state staffing mandates for nursing homes are signaling that a federal mandate without sufficient resources and waivers will be impossible to implement and will only exacerbate the current crisis:
  • New York is “providing a cautionary tale​” as 75 percent of the state’s 614 nursing homes cannot meet the state’s requirement that each facility provide 3.5 hours of care per resident per day. From 2019 to 2022, the number of empty nursing home beds in the state increased to 6,700. Stephen Hanse, president and CEO for the New York State Health Facilities Association (NYSHFA), said the mandate ultimately impacts access to care. “Mandated staffing minimums and referral bottlenecks, unfortunately, go hand-in-hand in the state of New York. They have the bed capacity, but they don’t have the staff.” 
  • In Illinois, the state passed an omnibus health care bill that delays fines tied to the state’s minimum staffing requirement for two-and-half more years. The state mandates minimum staffing ratios of 3.8 hours per resident per day, among other requirements. Matt Hartman, executive director of the Illinois Health Care Association, commented: “We still believe that centers must be held accountable to staff (sic) their resident’s needs... However, when our centers are facing the worst crisis they have ever seen in regards to staffing, now is not the time to pull critically needed funding away from where it is needed most.” 
  • Each day in Pennsylvania, about 2,000 patients are on waiting lists to enter a nursing home due to staffing shortages. This is prior to an increase in the state’s minimum level of direct care per day requirement, which will occur later this year. “It is clear our access to care crisis will not go away until our workforce crisis is first addressed,” said Zach Shamberg, the president of the Pennsylvania Health Care Association. 
  • The only place that has adopted a 4.1 hours of care per day staffing requirement is Washington, D.C., but the district demonstrates how these requirements are a “daily struggle” and can contribute to staff burnout. Tina Sandri, CEO of Forest Hills of DC, told NPR that she struggles to find certified nursing assistants, and that four out of five who initially express interest in a job don’t come in for interviews. So, in order to meet D.C.’s staffing requirements, staff are working “to the bones.” Sandri says, “They're tired. They're burned out. They're physically exhausted, and even committed people in this industry will turn around and say, 'I don't know how much longer I can do this.’” 
Not only are unfunded staffing mandates during a nationwide labor shortage unrealistic, but they fail to address the root cause of the industry’s recruitment and retention challenges. In a recent op-ed, Mark Parkinson, the president and CEO of the American Health Care Association and National Center for Assisted Living (AHCA/NCAL), argued for meaningful investments in long term care and workforce programs: 
“We need to fully fund Medicaid so nursing home providers can compete for workers and enhance their services and infrastructure. We need programs that will incentivize the next generation of health care workers to choose a career in long term care, such as tuition reimbursement and loan forgiveness.”
Moreover, staffing mandates are not the best approach to improve resident care. During the Obama Administration, the Centers for Medicare and Medicaid Services (CMS) came to the same conclusion. The agency was “concerned that a mandated ratio could result in unintended consequences” and stifle innovation.
A federal staffing mandate during a nationwide labor shortage fails to solve the crisis, help caregivers receive better wages, or improve resident care. It will only result in more nursing homes having to turn away residents, increasing the number of seniors on waiting lists and backlogs in hospitals. Federal policymakers must step up and provide the necessary resources to help nursing homes compete for and retain caregivers. Through a comprehensive, supportive approach, we can strengthen the long term care workforce and protect access to care for millions of seniors.