Biden-Era Nursing Home Staffing Standards Killed: What Happens to Care Quality Now?

The Biden administration’s attempt to mandate minimum staffing levels in nursing homes has been repealed, leaving many to wonder about the future of care quality in these facilities. This move has sparked a heated debate between industry groups, who argue the standards were unrealistic and financially unsustainable, and patient advocates, who fear a decline in care quality and resident safety. With an aging population and increasing demand for long-term care, the stakes are high. What impact will this have on the well-being of our vulnerable elderly population, and what can be done to ensure they receive the quality care they deserve?

The Core of the Issue: Staffing Levels and Care Quality

For years, studies have consistently shown a strong link between nursing home staffing levels and the quality of care residents receive. Insufficient staffing can lead to a cascade of negative consequences, including:

Increased risk of neglect and abuse: Overworked and underpaid staff may not have the time or resources to adequately attend to residents’ needs, leading to missed meals, dehydration, poor hygiene, and unattended medical issues. Understaffing can also create an environment where abuse is more likely to occur due to lack of supervision and increased staff frustration.
Higher rates of falls and injuries: Without enough staff to assist with mobility and supervision, residents are more likely to fall and suffer injuries.
Development of bedsores: Bedridden or immobile residents need regular repositioning to prevent pressure ulcers, a task that may be neglected due to staffing shortages.
Medication errors: Rushing between patients, nurses may misread instructions or give the wrong dose, causing dangerous side effects or worsening conditions.
Increased mortality rates: Studies have shown that higher staffing levels, particularly of registered nurses (RNs), are associated with lower mortality rates in nursing homes.

These issues not only compromise the health and safety of residents but can also lead to legal repercussions for nursing homes found negligent in their care.

The Contentious Staffing Mandate: A Summary

In 2024, the Biden administration finalized a rule mandating minimum staffing levels for nursing homes receiving Medicare and Medicaid funding. This rule required:

A total nurse staffing standard of 3.48 hours per resident day (HPRD).
A minimum of 0.55 HPRD of direct registered nurse (RN) care.
A minimum of 2.45 HPRD of direct nurse aide care.
A registered nurse on-site 24 hours a day, seven days a week.

The Centers for Medicare & Medicaid Services (CMS) argued that these standards were necessary to address quality concerns highlighted during the COVID-19 pandemic, where inadequate staffing was linked to higher rates of falls, illnesses, and lower patient health outcomes. The administration cited research indicating that increased staffing levels were associated with better patient health.

Why the Mandate Was Killed

Despite the Biden administration’s intentions, the staffing mandate faced fierce opposition from industry groups and some lawmakers. Their primary arguments included:

Financial burden: The American Health Care Association (AHCA) estimated that the mandate would cost the industry billions of dollars annually, potentially leading to facility closures, especially in rural areas. CMS projected that roughly three-quarters of nursing homes would need to increase staffing, at an estimated collective cost of $4 billion. Industry analyses placed the figure even higher, at $6.8 billion, warning that many facilities might reduce resident headcounts rather than absorb the added expense.
Workforce shortages: Nursing homes already face significant staffing shortages, making it difficult to meet the mandated levels.
One-size-fits-all approach: Critics argued that the mandate didn’t account for the unique needs and circumstances of individual facilities, particularly those in rural and tribal communities. HHS repealed the rule, saying it would disproportionately burden rural and Tribal communities. HHS Secretary Robert F. Kennedy Jr. stated that “Safe, high-quality care is essential, but rigid, one-size-fits-all mandates fail patients”.
Legal challenges: The American Health Care Association (“AHCA”) and Texas Attorney General Ken Paxton led lawsuits challenging the staffing mandate, which were consolidated in federal court. The Court ultimately ruled that HHS had exceeded its statutory authority.

Ultimately, a federal judge struck down significant portions of the rule, arguing that the Department of Health and Human Services (HHS) exceeded its statutory authority. This decision, combined with the passage of the One Big Beautiful Bill Act (which included a 10-year moratorium on implementing the minimum staffing requirements), led to the mandate’s repeal.

The Current Landscape: What Happens Now?

With the federal mandate gone, the future of nursing home staffing standards is uncertain. Several potential scenarios could unfold:

Return to pre-mandate standards: Nursing homes would be required to have “sufficient nursing staff” with the “appropriate competencies and skills” to provide care to residents, a standard that many patient advocates found too vague and difficult to enforce.
State-level action: Individual states could implement their own minimum staffing requirements, potentially creating a patchwork of regulations across the country.
Industry self-regulation: Nursing home operators could voluntarily adopt higher staffing levels to attract residents and improve their reputation.
Focus on alternative solutions: Policymakers could explore alternative strategies to improve care quality, such as increased funding for training and recruitment, improved oversight and enforcement, and innovative care models.

The Impact on Care Quality: A Cause for Concern?

The repeal of the staffing mandate raises concerns about the potential impact on care quality in nursing homes. Without clear and enforceable standards, there is a risk that some facilities may prioritize profits over patient care, leading to reduced staffing levels and a decline in quality.

Americans already view nursing homes poorly. Recent surveys indicate that nursing homes receive an average grade of D+, with 36% of adults rating them as ‘D’ (poor) and 6% giving them an ‘F’ (fail). Over 42% of U.S. adults think nursing homes are ineffective in preventing harm, highlighting worries about neglect and infections. The average number of hours of nursing care residents receive dropped by 8% from 2015 to 2024, further contributing to care quality concerns. The share of facilities with serious deficiencies increased from 17% to 28% in recent years.

Protecting Residents: What Can Be Done?

Despite the setback at the federal level, there are steps that can be taken to protect nursing home residents and ensure they receive quality care:

Advocate for state-level action: Encourage state lawmakers to implement and enforce meaningful staffing standards.
Demand transparency: Support efforts to increase transparency in nursing home ownership, finances, and staffing levels.
Report concerns: If you suspect neglect or abuse, report it to the appropriate authorities, such as the state’s long-term care ombudsman or adult protective services.
Seek legal counsel: If a loved one has been injured or harmed due to nursing home negligence, consult with an experienced attorney to explore legal options. A nursing home abuse lawyer plays a crucial role in advocating for abuse victims. They provide invaluable assistance by investigating claims, gathering evidence, and representing the victim in legal proceedings.
Monitor care: Regularly visit loved ones in nursing homes to monitor their care and identify any potential problems.
Support quality facilities: Choose nursing homes with a proven track record of providing high-quality care and adequate staffing.

The Path Forward: A Call for Innovation and Accountability

The debate over nursing home staffing standards highlights the complex challenges of providing quality long-term care in an aging society. While the federal mandate may be gone, the need to protect vulnerable residents remains. It is crucial for policymakers, industry leaders, and patient advocates to work together to find innovative solutions that ensure accountability, promote transparency, and prioritize the well-being of those who rely on nursing homes for their care. This includes exploring alternative staffing models, investing in workforce development, and strengthening oversight and enforcement mechanisms. Only through a concerted effort can we ensure that all nursing home residents receive the quality care and respect they deserve.