Which States Will Struggle Most to Meet New Nursing Home Staff Mandates?

The recent pandemic exposed dangerous shortcomings in nursing homes and other long-term care facilities (LTCFs). Specifically, the COVID deaths of more than 200,000 LTCF residents and workers served as a sobering call to action. In response, the Biden administration unveiled new federal guidelines in April 2024 to increase transparency and boost staffing requirements for the country’s 15,000 Medicare and Medicaid-certified facilities.

Some industry operators claim the requirements are too onerous and will force facility closures. Consumer advocates believe the mandate rolls out too slowly and needs to go further.

SeniorLiving.org has reviewed the rules and current nursing home staffing rates nationwide to provide a fair assessment of what to expect and a preview of regional compliance challenges.

Key Facts:

• The Biden administration recently updated federal staffing requirements for nursing homes, establishing specific targets for qualified caregiver coverage and mandating the full-time presence of registered nurses at all facilities.
• Only 18 percent, or around 2,700, of the nation’s nursing homes currently provide the recommended level of qualified staffing. To comply with the new policies, nearly 12,000 facilities would need to hire staff.
• Just 3 percent of facilities in Texas and Louisiana currently meet the new federal standards, which will be rolled out over the next 3-5 years. To satisfy the new rules, more than 1,000 nursing homes must increase staffing in Texas alone.
• Alaska, North Dakota, and Maine have the highest percentage of nursing homes already meeting the new federal standards. However, even in these states, one out of four facilities will still need to hire staff.

New Requirements for Medicare and Medicaid Long-Term Care Facilities

In his 2022 State of the Union address, President Joe Biden promised to set higher living standards for the 1.2M Americans residing in nursing homes. He tasked the Department of Health and Human Services with generating reforms to improve safety, staffing, accountability, and transparency for all Medicare/Medicaid-certified long-term care facilities.

After weighing industry concerns, family advocate requests, and fielding nearly 50,000 public comments (many detailing nursing home horror stories), the Administration unveiled new federal guidelines in April 2024. Here are the key provisions of the updated Requirements for Medicare and Medicaid Long Term Care Facilities:

1. Minimum Staffing Requirements: The new federal rule replaces vague workforce guidelines that trusted LTCF operators to employ “sufficient” staff to assure the safety and well-being of residents. Biden’s mandate establishes specific staffing requirements, calling on facilities to provide at least 3.48 nursing staff hours per resident day (calculated by dividing total work hours by the number of residents). This staff coverage must include the following:
   • 0.55 hours by registered nurses (RNs)
   • 2.45 hours by certified nurses’ aides (NAs)
   • 0.48 hours by any combination of certified nurse aides, registered nurses, and licensed practical or vocational nurses (LPN/LVNs).For example, a nursing home with 100 residents would need two or three RNs, ten or eleven nurse aides, and two additional nursing staff for each eight-hour shift, according to the White House. Nationally, this will represent a significant increase in mandatory staffing. Though 35 states already enforce LTCF staffing rules, only six (California, Florida, Illinois, Massachusetts, New York, and Rhode Island) demand as many hours as the new federal decree.
2. Onsite Registered Nurses: LTCFs must have an onsite RN 24/7, replacing the previous rule of eight consecutive hours daily. This change is linked to better health outcomes for nursing home residents.
3. Facility Assessments: LTCFs must conduct annual, evidence-based assessments of resident outcomes, staffing levels, and staff competencies to ensure compliance and adaptability to new challenges.

These new policies will not go into effect immediately, but in three phases over the next three to five years. This gradual transition is designed to minimize disruption and provide ample time to train and hire additional caregivers. The new rule also includes hardship exemptions for facilities legitimately unable to hire adequate staff.

Though these provisions may seem moderate and reasonable, they represent dramatic staffing increases for most LTCFs around the country—requirements the nursing home industry has labeled unconscionable and unattainable. According to the American Health Care Association, the new rules could cost $6.5 billion annually and require 100,000 more caregivers to join the workforce.

Nearly 12,000 Nursing Homes Nationwide Will Need to Hire Staff to Comply With Federal Mandates

A recent Kaiser Family Foundation study found that 82 percent of America’s LTCFs (nearly 12,000 facilities) must upgrade or expand staffing to satisfy the Biden administration's new guidelines. However, nursing home staffing levels vary widely across the country, with some states well ahead of and behind the new staffing regulations.

We’ve created an interactive map below showing how many nursing homes in each state meet the new staffing requirements and how many will need to hire additional staff.

Most of the positive outliers above, such as Alaska and North Dakota, host relatively small nursing home contingents. Of the five states with most LTCFs meeting the new staff requirements, only Oregon has more than 5,000 people in long-term facilities. This indicates that maintaining an adequate staff becomes increasingly difficult at scale.

In Texas, the state with the third-largest nursing home population, only three percent of LTCFs currently meet future staffing mandates. The Texas state code requires only 0.4 licensed-care hours per resident day in its nursing homes. Louisiana tied with Texas for the worst compliance rate in the country.

Though the weather in America's South may be attractive for retirement and spending one’s golden years, the five states with the highest percentages of understaffed LTCFs all lie below the Mason-Dixon line. Beyond shared regional geography and conservative politics favoring minimal government interference (all five states voted Republican in every presidential election this century), these five states also feature some of the nation's highest poverty rates and lowest levels of health insurance coverage. These states will require massive additional funding and training programs to achieve the dramatic healthcare staffing increases envisioned by the new rules.

However, the need for resources won’t be limited to any one region. States with larger populations tend to contain the most nursing homes requiring a staffing boost. According to the new guidelines, the ten states with the most work to do to staff their LTCFs are scattered throughout the country.

These numbers depict a senior care industry facing an uphill battle to meet looming federal standards. The Administration’s new rule is ambitious and well-intentioned but will require significant time, training, and money before achieving an improved reality.

Conclusion

While most agree that America’s senior care sector needs reform, the Biden administration’s new nursing home staffing requirements have drawn criticism from all sides.

Consumer advocates wanted more significant hourly requirements, quicker implementation, fewer exemptions, higher caregiver pay, and independent enforcement. Industry operators argue that the measures will cost $6.5 billion annually (compared to the government's $4.4 billion estimate), require hiring 100,000 additional care providers, and could displace one-quarter of nursing home residents due to closures.

This criticism could indicate a reasonable compromise or a lack of support that will undermine the implementation needed to keep nursing homes operational. Projections show that older Americans will outnumber children by the next decade, and the senior population will increase 47 percent by 2050. This will strain LTCF networks, where homes are already closing, and staff is hard to find.

Opinions vary on the new regulations: some believe they demand too much; others, too little. Only 18 percent of facilities currently meet the upcoming staffing requirements. SeniorLiving.org will continue to follow the story and monitor policy implementation, which will roll out in three phases over the next five years.

Our data

This analysis uses Nursing Home Compare data, which was released in April 2024. Nursing Home Compare is a publicly available dataset from the Centers for Medicare and Medicaid Services that provides information for Medicare or Medicaid-certified nursing facilities. This analysis does not include facilities in Guam and Puerto Rico and nursing facilities for which staffing data was not available. Our sample includes reporting for 14,595 facilities.

When full requirements are in place for all facilities in 2029, nursing facilities will be required to meet minimum nurse staffing levels of 3.48 hours per resident day (HPRD), including 0.55 hours for registered nurses (RN) and 2.45 for nurse aides. Additionally, they will be required to have an RN on duty 24 hours a day, 7 days a week (24/7).

The new federal requirements will rollout in different timelines for rural and urban facilities. There are also varying interim requirement timelines for each facility before the full mandate is in force. This analysis reflects compliance rates if the HPRD requirements were in full effect now for all facilities.

While we do have access to data on the total number of hours worked per resident by an RN, this data does not include shift information and therefore cannot be used to determine if the RN staff hours were worked concurrently or could be considered 24/7 RN staffing. For this reason, the 24/7 RN staffing requirement was not a factor in our analysis.

The “current nursing home resident” impact was calculated based on the reported average number of residents per day.

Data appendix