The Biden administration set a first-ever minimum staffing rule for nursing homes Monday, making good on the president’s promise more than two years ago to seek improvements in care for the nation’s 1.2 million nursing home residents.

The final rule, proposed in September, requires a registered nurse to be on-site in every skilled nursing facility for 24 hours a day, seven days a week. It mandates enough staff to provide every resident with at least 3.48 hours of care each day. And it beefs up rules for assessing the care needs of every resident, which will boost staff numbers above the minimum to care for sicker residents.

For a facility with 100 residents, it translates to a minimum of two or three registered nurses and at least 10 or 11 nurse aides, as well as two additional staffers that could be nurses or aides, the administration said. Set to phase in over the next few years, the mandate will replace the current vague standard that gives operators wide latitude on how to staff their facilities.

The nation’s 15,000 nursing homes are regulated by the federal government, which pays for the majority of stays through Medicaid and Medicare federal insurance programs. Neglect and abuse have been a concern for decades, but the crisis of care reached a peak during the pandemic, when more than 160,000 nursing home residents died from covid-19.

While the administration has said the rule will improve care, industry lobbyists have said it’s unworkable, with staffing goals that will be impossible to achieve because of a shortage of workers.

The administration received 47,000 public comments on the rule since it was proposed last September. They included observations of people lying in their own filth for hours, not being fed appropriately and being left on the floor too long after falling, Secretary of Health and Human Services Xavier Becerra said in an interview Monday.

“These are the kinds of things that drive nightmares in the minds of family members,” he said. “If you’re claiming that you can’t find nurses, then explain to me how you’re running a nursing home.”

An industry study last year, in response to the proposal, said nearly all nursing homes would not meet the new standards and would be required to hire more people. Nursing homes would need to hire more than 100,000 more workers, 80,077 nurse aides and 22,077 registered nurses, the study said.

The pandemic exacerbated staffing shortages in nursing homes. Poor wages and grueling working conditions put large amounts of stress on a low-wage workforce, which is made up mostly of women, minorities and immigrants.

An independent study released last year by KFF, a nonprofit group specializing in health care, said around 80 percent of facilities would need to hire more staff to meet the new requirements.

While the government said the cost of the plan would be $4.4 billion per year by the third year of adoption, industry groups said the number was closer to $7 billion.

“It is unconscionable that the Administration is finalizing this rule given our nation’s changing demographics and growing caregiver shortage,” Mark Parkinson, president and CEO of the American Health Care Association, the top lobbying group for the nursing home industry, said Monday in response to the administration’s release of the final proposal. “Issuing a final rule that demands hundreds of thousands of additional caregivers when there’s a nationwide shortfall of nurses just creates an impossible task for providers.”

The industry has warned that rural facilities may be forced to close if they can’t meet the requirements.

In a 71-bed facility in Pipestone, Minn., the operator, a large nonprofit system called Good Samaritan Society, would have to hire five registered nurses and five certified nurse assistants, said Nate Schema, Good Samaritan’s president and CEO. That’s in a community of just 4,100 people.

“It’s unrealistic,” he said. “This unfunded mandate just doesn’t make sense, and its going to create additional access challenges for residents and families that we service.”

On Capitol Hill, Sen. Deb Fischer (R-Neb.) sponsored a bill that would prevent the administration from imposing the rule, but it did not advance after receiving insufficient support in the Democratic-controlled chamber.

The Democratic co-sponsor, Sen. Jon Tester (Mont.), warned that some rural nursing homes may close in his state. “I have serious concerns that this burdensome staffing requirement will be unworkable for rural nursing homes,” he said in a statement.

Nursing-home owners in urban areas will have two years to comply with the rules, while rural operators will have three years. Operators in rural areas without enough workers can qualify for hardship exemptions, the administration said.

The new requirement will replace a rule that merely required an operator to maintain a staff level that is “sufficient” to assure the safety and well-being of residents. Facilities will be required to have enough registered nurses to provide 0.55 hours of care and enough nurse aides to provide 2.45 hours of care. The additional 0.48 hours of care can be provided by a registered nurse, a licensed practical nurse or a care aide, under the rule.

The rule also increases guidelines for annual assessments of residents’ care needs, which will dictate to what degree operators must exceed the new hourly requirements

“They’re acknowledging this is a minimum. This is the floor, not the ceiling,” said Toby Edelman, senior policy attorney with the Center for Medicare Advocacy, which has fought for stronger quality and staffing requirements.

Advocates for the health and safety of nursing home residents say operators could attract workers if they pay more. Front-line workers in nursing homes are paid around $17 an hour, according to PHI, a nonprofit that tracks wage data for elder-care workers.

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