Press Release  AG Campbell Co-leads Letter Urging Federal Government To Implement Stronger Minimum Staffing Standards In Nursing Homes

BOSTON — Massachusetts Attorney General Andrea Joy Campbell, California Attorney General Rob Bonta, and New York Attorney General Letitia James are co-leading a coalition of 15 state attorneys general to encourage the U.S. Department of Health and Human Services and the Centers for Medicare and Medicaid Services’ (CMS) to promulgate a rule requiring stronger minimum staffing requirements for long-term care facilities. 

The letter, submitted on Monday by the coalition, responds to a proposal by CMS to adopt a rule requiring nursing facilities to have minimum staffing levels for certified nursing assistants (CNAs) and registered nurses (RNs), as well as requiring nursing facilities to have at least one RN working onsite 24 hours per day. The coalition applauds the administration for seeking to improve quality of care in long-term care facilities through mandated staffing levels and supports the 24-hour-per-day RN requirement, but also encourages the administration to adopt higher minimum staffing requirements than currently proposed.  

“One of my top priorities as Attorney General is to improve the quality of care delivered to our vulnerable elder communities,” said AG Campbell. “I am proud to join my colleagues from across the country in encouraging CMS to strengthen minimum staffing requirements to ensure that staff are adequately supported and residents in our long-term care facilities are safe.” 

State attorneys general are charged with protecting the safety and well-being of residents of nursing facilities. Their Medicaid Fraud Control Units, as well as consumer protection sections in some offices, have authority to investigate and prosecute those responsible for committing abuse or neglect of residents and misappropriation of residents’ funds in these facilities. 

In their letter, the coalition responds to CMS’s proposal to require 2.45 hours per resident day (HPRD) of care from CNAs and 0.55 HPRD from RNs. The AGs instead recommend that CMS adopt a minimum staffing standard ratio of 4.1 HPRD (with 2.8 HPRD for CNAs, 0.75 HPRD for RNs, and 0.55 HPRD for LPNs). This standard is consistent with the results of CMS’s 2001 staffing study, which found that 4.1 HPRD was the staffing threshold below which quality of care for long-term care patients was compromised.    

The letter further points out that the proposed minimum staffing rule does not include any minimum staffing requirements for licensed practical nurses (LPNs). Without such a requirement, the AGs argue that CMS’s proposed rule could incentivize many nursing facilities to operate only with RNs and CNAs to reach those federally mandated levels, which would, in turn, result in the assignment of even more duties to already overburdened RN staff. 

The coalition also urges CMS to limit the availability of exemptions from the minimum staffing thresholds. While the letter acknowledges the existence of workforce shortages throughout the country in long-term care facilities, the coalition urges CMS to narrow exemptions based on workforce shortages to true emergencies, which would avoid incentivizing for-profit facility owners to operate homes without appropriate staffing in order to siphon Medicare and Medicaid funds from the homes for their personal profit. 

The Massachusetts AG’s Office has brought several enforcement actions against long-term care facilities for failing to meet the needs of residents and recently entered into a settlement agreement with a chain of nursing facilities to resolve a series of allegations that the company lacked sufficient numbers of adequately trained staff to meet the needs of nursing home residents experiencing substance use disorder.  As part of that resolution, the nursing homes agreed to update their policies, procedures, and trainings and to undergo independent compliance monitoring to ensure that they will have appropriate levels of trained staff to meet the needs of residents with histories of substance use disorder. 

As part of her elder protection efforts, AG Campbell recently announced the creation of an Elder Justice Unit, led by Assistant Attorney General Mary Freeley. The Unit will work with staff from the Attorney General’s Criminal, Public Protection and Advocacy, and Health Care and Fair Competition Bureaus and convene existing resources to protect and promote the safety and well-being of elders through enforcement actions, legislative advocacy, and community engagement and education. 

Joining AG Campbell, AG Bonta, and AG James in the letter supporting the CMS proposed rule are the attorneys general of Arizona, Delaware, Illinois, Maryland, Michigan, Minnesota, Nevada, New Mexico, Oregon, Pennsylvania, Rhode Island, and Vermont.  

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