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While (mostly) not directly affecting PTs or PTAs who work in long-term care facilities, a new proposed rule from the U.S. Centers for Medicare & Medicaid Services could have a big impact on their employers: In its first-ever attempt to establish nursing home staffing minimums, CMS offers a rule that it estimates will require 75% of those facilities to increase staffing levels. That provision is one of three major proposed changes that CMS says are intended to "hold nursing homes accountable for providing safe and high-quality care."

The proposed rule comes on the heels of a leak that drew media attention. On Aug. 29, CMS accidentally posted a 2022 nurse staffing study completed by Abt Associates that examined potential minimum staffing requirements, along with barriers and unintended consequences of implementation. LTC facility groups, which largely oppose staffing mandates, used the study's findings to support their arguments.

Nevertheless, CMS moved ahead. The proposed rule, which covers staffing standards and facility assessment requirements, would tie registered nurse and nurse aide staffing numbers to a facility's Medicare and Medicaid patient population by way of the ability to provide at least three hours of staff attention per resident, per day — a provision CMS dubs the facility's HPRD, or "hours per resident per day," requirement. The three-hour requirement is broken out as 0.55 HPRD for RN staff, and 2.45 HPRD for nurse aide staff. Depending on patient acuity levels and results of enhanced assessments — also a part of the proposed rule — LTC facilities could be required to increase that HPRD rate. Facilities would have three years to adopt the requirements after the rule is adopted, with some hardship exemptions possible.

CMS also proposed beefed-up facility assessment requirements that gather more data on resident and staff needs. According to CMS, part of the aim of the change is to make it clear to facilities that staffing standards are minimum requirements, and that the patient population and needs of any particular facility may require higher staffing levels.

The third major component of the proposed rule would require LTC facilities to ensure that an RN is on site 24 hours a day, seven days a week. Rural facilities would have three years to implement that provision; all other facilities would need to meet the requirement within two years. All facilities would be required to comply with the new assessments within 60 days after publication of the final rule.

In addition to enforcement of the rule, CMS would also publish individual facility results on its Care Compare website. Another proposed data point that would be shared with the public: individual facility reports on the percent of Medicaid payments spent on direct care workers, which include PTs.

APTA will comment on the rule before the Nov. 6 deadline.

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