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CMS Staffing Standards Spark Debate Over Role of Licensed Practical Nurses

Md. Parvez
licensed-practical-nurses

The recently finalized minimum staffing standards by the Centers for Medicare & Medicaid Services (CMS) have ignited a significant debate among nursing home leaders regarding the inclusion and role of licensed practical nurses (LPNs). Announced on April 22, 2024, these new comprehensive minimum nurse staffing requirements aim to enhance the quality of care in skilled nursing facilities. However, the rule's limited recognition of LPNs has raised concerns about its feasibility and impact on resident care.


Understanding the New CMS Staffing Rule


The new CMS rule mandates a total nurse staffing standard of 3.48 hours per resident day (HPRD). This includes at least 0.55 HPRD of registered nurse (RN) care and 2.45 HPRD of direct nurse aide care. The additional 0.48 HPRD can be fulfilled by any combination of nurse staff, including RNs, LPNs, or nurse aides. Furthermore, the rule requires an RN to be onsite 24 hours a day, seven days a week, ensuring the availability of skilled nursing care at all times.


Jodi Eyigor's Insights


Jodi Eyigor, Director of Nursing Home Quality Policy at LeadingAge, appreciates the flexibility in the final rule to include LPN hours in meeting the 3.48 total nurse staffing requirement. However, LeadingAge advocated adjusting the 0.55 RN HPRD to 0.55 "licensed nurse" HPRD.


"LPNs are an integral part of long-term care, providing hands-on, clinical care in collaboration with RNs and nurse aides," Eyigor said. "Long-term care employs more LPNs than any other sector, and LPNs are employed at higher rates than RNs in nursing homes. This rule marginalizes the contributions of LPNs in the long-term care workforce by focusing exclusively on RNs and nurse aides with no opportunity to substitute LPNs."


Leah Klusch's Perspective


Leah Klusch, Executive Director of The Alliance Training Center, expressed concerns about the rule's oversight of LPNs, emphasizing their crucial role in skilled nursing facilities.


"The issue of not recognizing the value of licensed practical nurses in our staffing process is a big mistake," Klusch said. "The numbers just don't add up to me," she continued, highlighting the challenges facilities will face in meeting the staffing requirements amid a current shortage of available nurses and caregivers.


David Grabowski's Critique


David Grabowski, a professor of healthcare policy at Harvard Medical School, acknowledged the significance of the new staffing rule but criticized its oversight regarding LPNs.


"This new rule will establish a staffing floor to prevent dangerously low staffing levels," he said, noting the positive impact on resident care. However, he expressed concern that the rule's focus on RNs and certified nursing assistants (CNAs) might lead to a decreased use of LPNs, potentially affecting care quality.


Impact on Rural and Local Facilities


In states like Nebraska, where the LPN workforce is particularly robust, the new CMS staffing requirements pose significant challenges. Jalene Carpenter, CEO of the Nebraska Healthcare Association, highlighted these concerns.


"LPNs are the backbone of many of our facilities," Carpenter said. While LPNs are counted in overall staffing hours, they are not included in specific categories for RNs and CNAs, complicating efforts to meet the new requirements. The mandate for a 24/7 RN presence is particularly concerning, as it could be catastrophic for many facilities.


"I've heard organizations are already looking at trying to only hire RNs moving forward," she said. "That's going to be difficult as well."


AHCA's Stand on the Issue


The American Health Care Association (AHCA) has also been vocal about the essential role of LPNs in the long-term care workforce. Holly Harmon, AHCA's Senior vice president of Quality, Regulatory, and Clinical Services, underscored this critical role.


"LPNs are a critical part of the nursing home workforce, making up 13% of the total workforce," Harmon told Skilled Nursing News. She criticized the rule for not allowing LPNs to be counted with their fellow RNs, undermining recruitment and retention efforts.


"The federal government discounting the value and role of LPNs undermines critical recruitment and retention efforts by nursing homes working diligently to build their nursing workforce," she said.


Looking Ahead: The Path Forward for Licensed Practical Nurses


CMS has provided a staggered implementation timeframe and potential exemptions for facilities facing significant workforce challenges, particularly in rural areas. The agency will closely monitor the implementation to determine if any adjustments are necessary. Despite the rule's intentions to improve care quality, nursing home operators still need to be more concerned about the practicality of meeting these standards amid a workforce shortage.


As the industry grapples with these new regulations, the debate over the role of LPNs continues. Nursing homes can work towards sustainable solutions that prioritize resident care and facility viability by leveraging local resources, advocating for flexible regulations, and investing in training programs.

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