In 2022, the Biden Administration published a brief, Protecting Seniors by Improving Safety and Quality of Care in the Nation's Nursing Homes. Last month, the Administration took the step of proposing a minimum nurse staffing ratio of 3.0 nursing hours per resident day (NHPRD), with at least .55 of those hours being given by an RN and the remaining 2.45 by a certified nursing assistant. There were no LPNs built into the recommendation, although nursing homes rely on LPNs to do the work that is within their scope of practice, while RNs can focus on what they are licensed to do. This proposal has a 60-day comment period and then will probably take about 12-18 months before it is actually implemented.
This proposal has been met with mixed reactions. It creates what I have called in the past "the 3 legged stool" conundrum. The 3 legs are quality and safe care, supply of RNs, and salary constraints. No one believes that people in nursing homes should have substandard care, but to provide the NHPRD to care for this vulnerable, complex population of older adults, we need a greater supply of nurses going into and staying in Long-term Care (LTC), and the LTC industry must receive reimbursement that allows for competitive pay scales.
Research has shown that increased RN hours in nursing homes increases the quality and safety of care. However, research also shows recruitment of nurses to long-term care is difficult, and turnover is often as high as 50% per year. Further complicating retention is that the salary scale in LTC is often as much as 20% less than in acute care hospitals.
The Nursing Home Staffing Study conducted in 2023 found that between 3.8 NHPRD and 4.6 NHPRD would be adequate to keep rates of omission of activities of daily living (ADL) and clinical care below 10%. Importantly, these ratios do include LPNs, who are a very important part of the LTC workforce.
Yes, we do need to have an adequate mix of RNs, LPNs, and certified nursing assistants to provide safe and quality care to this increasingly complex nursing home population. However, we need creative solutions to increase the supply of nurses wanting to practice in LTC with excellent nurse leadership in nursing homes to enhance retention and a payment system that incentivizes and compensates nurses who do this extraordinary work.