For nursing homes selected to participate in the site visit aspect of the study, CMS encourages active participation to ensure your perspectives are captured. The public comment period closed on June 10, 2022, and CMS received over 3,000. comments from a variety of interested parties including advocacy groups; long-term care ombudsmen; industry associations (providers); labor unions and organizations; nursing home staff and administrators; industry experts and other researchers; family members, and caretakers of nursing home residents. Andrea Hsu/NPR The April 2022 National Academies report recommends direct-care registered nurse coverage 24 hours a day, with additional registered nurse coverage that reflects resident census, acuity, case mix and residents professional nursing needs as determined by their assessments and care plans. Current nursing home staffing requirements by state, While the staffing requirements may be changing, here are the current staffing guidelines, according to the, State Nursing Home Staffing Standards Summary Report. One after another. Burnout and competition are major factors. CMS also plans to conduct a research study, noting that resident acuity has increased in recent years, and to issue proposed regulations within one year. Some states explicitly require a minimum number of staff hours per resident day, while other states call for nursing homes to provide direct care staff 24 hours per day, seven days per week, without an explicit number of hours per resident requirement. The reforms include minimum staffing requirements and other changes for which resident advocates have long fought. 0000008976 00000 n
Research questions will address not only what level of staffing is needed, but also the impact on quality of care,any barriers to implementation, and any potential unintended consequences of imposing minimum staffing requirements. Based on the federal government's 5-star rating system for nursing homes from November 2022, Hawaii has the best average score (3.90 across 41 facilities), followed by Alaska (3.80, 20 facilities), Idaho (3.46, 78 facilities), Delaware (3.35, 43 facilities), and Utah (3.34, 96 facilities). umw=@em;o~mvwnyes,>xyOmoK]q6rk^/B
xc6@0 At least 1.1 hours of care must be given by a registered nurse (RN) or licensed practical nurse (LPN). (Note: For 149 beds, DON may provide direct care and be included in direct care ratios.). hA 04Pk\GczC. In a 2001 report, CMS found that in order to avoid bad outcomes, nursing home residents should each receive at least 4.1 hours of direct nursing care per day. The Biden administration is planning to establish a federal minimum staffing requirement for nursing homes as part of a broader push to improve care for seniors and people with disabilities. Some commenters also stated that the following factors should be considered: Medicaid census, facility size, ownership status (profit or non-profit), amount of skilled nursing facility competition in the area, and, community poverty and Medicare census rates. The pandemic has taken a substantial toll on people living and working in nursing homes. Job Also, you can decide how often you want to get updates. 0000006448 00000 n
CMS administrator Brooks-LaSure says she's listening to industry concerns, including their call for more money to keep up with rising costs, especially labor. Examine trends, challenges and opportunities facing clinical leaders in skilled nursing. MECHANICSBURG, Pa. (March 1, 2023) LeadingAge PA, an association representing more than 370 aging services providers, including many who operate This staffing study seeks to help identify a minimum staffing level, which would include RN, LPNs/LVNs, and CNAs, that will establish a threshold below which residents would be at substantially increased risk of not receiving the safe and quality care they deserve. At least three states adopted permanent changes to staff training requirements to expand the pool of staff available to work in nursing homes post-COVID (Figure 2 and Appendix Table 3). This effort includes issuing a Request for Information (which occurred earlier this year as a part of the Fiscal Year 2023 Skilled Nursing Facility Prospective Payment System Proposed Rule. This RFI was a first step to facilitate a holistic approach to advancing future changes in these areas. This is an important body of work that will ensure nursing home residents are receiving the safe and quality care that they deserve. Turnover at her facility, home to about 100 residents, is nearly triple what it was before the pandemic. The Centers for Medicare & Medicaid Services is expected to conduct a study to determine the level and type of staffing needed, and propose a new federal standard within one year, the agency confirmed during a stakeholder call on March 10. 0000031136 00000 n
One of these states, Wisconsin, lowered the training hour requirement for nurse aides from 120 hours to the federal minimum of 75 hours. DON may be Charge Nurse; 1 RN 8 consecutive hrs/7d/wk; 1 RN/LPN Charge Nurse; 24 hrs/7d/wk; 0.4 hprd RN/LPN or 1:20 RN/LPN every 24 hrs (Exclude administrative time of licensed staff and DON in a multi-level facility). 0000001178 00000 n
Or when he misses his wheelchair time because there aren't enough staff to lift him out of bed. What did CMS learn from the Request for Information? Of the 3.5 hours, no less than 2.2 hours of care must be provided by a certified nursing assistant (CNA) or nurse aide. Awarded Best of Staffing - Talent 2022 and rated as a Top Workplace 2022 by the Orlando Sentinel, Jackson Nurse Professionals connects today's travel nurse to While Medicare and Medicaid reimbursement rates to nursing homes can indirectly influence worker wages, states also can adopt policies to require or incentivize providers to raise wages paid to direct care workers. Nursing Home Staffing Study Stakeholder Listening Session-August 29, 2022. When pushed, a light goes on in his room, above his door, and at the nurses' station at his nursing home in Takoma Park, Md. Maurice Miller lies in bed in his room at a nursing home in Takoma Park, Md., on Thursday. [11]. Qualitative analysis will include primary data collected during site visits, including interviews, surveys, and observation data in nursing homes. 0000009312 00000 n
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident Nominate Now. While staffing shortages in nursing homes have existed for decades, the COVID-19 pandemic has highlighted and intensified the need for sufficient, consistent, trained staff to care for residents. 0000005687 00000 n
1 DON RN full-time (1 per facility); 1 RN Charge Nurse 24hrs/7d/wk. "They look to you for comfort, but then when you don't have time to adequately give them the comfort they deserve, it's not fair," says Ward. Create customized staffing solutions that fit your unique needs, which we know can change at any time. Arizona introduced HB 2848 on February 11, 2021, which would have increased its minimum staffing requirement. To meet the nursing needs of all residents. Key findings include the following: Staffing Requirements: At least five states (AR, CT, MA, NY, RI) adopted permanent increases to nursing home minimum staffing requirements after the onset of the COVID-19 pandemic, while at least one state (GA) adopted a permanent decrease. Eric Lee for NPR [1] Tim Regan, 81% of Assisted Living Providers Report Recent Staff Shortages, Senior Housing News (June 23, 2021), available at https://seniorhousingnews.com/2021/06/23/81-of-assisted-living-providers-report-recent-staff-shortages/. CMS appreciates the interest shown by so many stakeholders to date during the RFI process and looks forward to further engagement on this issue. As of March 20, 2022, nursing homes were most likely to report a shortage of aides, followed by nursing staff, and least likely to report a shortage of clinical staff. [8], States have also recently increased scrutiny over minimum nurse staffing levels. 0000034862 00000 n
Mitigating factors can be considered by the [d]epartment when assessing penalties for non-compliance at a later date., 1199SEIU United Healthcare Workers East, Centers for Medicare & Medicaid Services, CliftonLarsonAllen, CMS, New York State Health Facilities Association. 3 Department of Physiological Nursing, School of Nursing, University of California, San Francisco, San Francisco, CA, She's opposed to a federal minimum staffing requirement, noting that the government already has the ability to cite nursing homes for insufficient staffing. The legislation also would have replaced the current federal requirement for a registered nurse for at least eight consecutive hours per day, 7 days per week, with a new requirement for a registered nurse 24 hours a day. The information obtained through these efforts will inform future proposed rulemaking on minimum staffing requirements, which CMS plans to issue in Spring 2023. Florida also amended its definition of direct care staff whose hours can count toward the minimum hprd to include personal care attendants. 2.5 hprd for intermediate care, 3.8 hprd for skilled nursing care. The Department recently made major changes to the state nursing home regulations. As of November 29, 2022, the regulations were approved by the Independent Regulatory Review Commission (IRRC) and the Office of Attorney General. WebStaffing rates by state Overall, nursing facility staffing rates vary widely across states (Figure 1). "In D.C., you can work for Amazon at $19 an hour. Launched in August 2022 and expected to continue through the winter, the staffing study is comprised of four main parts: literature review, site visits, quantitative analyses, and cost analyses all further described below. This RFI was a first step to facilitate a holistic approach to advancing future changes in these areas. 2435 0 obj
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Yet, a recent report concluded that staffing standards in almost every state remain severely low. In April 2022, the National Academies of Science, Engineering, and Medicine recommended minimum staffing levels, policies to ensure competitive wages and benefits, and improvements to staff training and opportunities for career advancement, among other reforms, as part of its comprehensive report to improve nursing home quality. Previously, she covered the legal beat for various publications. In conducting the cost-benefit analysis required for any rulemaking, including the staffing requirement, CMS must evaluate any associated incremental costs that facilities would likely face. https://seniorhousingnews.com/2021/06/23/81-of-assisted-living-providers-report-recent-staff-shortages/, https://www.ahcancal.org/News-and-Communications/Fact-Sheets/FactSheets/Workforce-Survey-September2021.pdf, https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched, https://leadingage.org/sites/default/files/LeadingAge%20Letter%20to%20FTC%20-%20staffing%20agencies%20final%2010-8.pdf, Buying Distressed Operations in the Skilled Nursing Facility Space, Distressed Long Term Care Assets: A Lenders Perspective, Regulatory Considerations in Acquisitions of Troubled Long Term Care Facilities, CCPA/CPRA & VCDPA Notice of Collection, Disclosure, & Privacy Policy, Minimum Staffing Requirements for Nursing Homes Pose Regulatory Risks, Increased use of telehealth and telemedicine technologies, especially in light of CMS expanded reimbursement for such services.[10]. Facilities across the country are grappling with numerous unfilled positions as a result of staff departures during the pandemic. Author(s)
from Katie Sloan, President and CEO of LeadingAge, to Lina Khan, Chairwoman of Federal Trade Commission (Oct. 8, 2021), available at https://leadingage.org/sites/default/files/LeadingAge%20Letter%20to%20FTC%20-%20staffing%20agencies%20final%2010-8.pdf. If DON has institutional responsibilities, add 1 Assistant DON RN full-time. More information and the registration link for the event is available here: https://abtevents.webex.com/abtevents/j.php?RGID=r8e7713354ab6b79a94b9e3dd4d265ce9. Ease your staffing struggles with NurseDash! 5 states with the highest-rated nursing homes. Industry associations and nursing home resident advocates provided divergent views on the establishment of minimum staffing levels. To inform future staffing requirements, the U.S. Department of Health and Human Services (HHS) should fund research on the minimum and optimum staffing levels for nurses, therapists, recreational Job in Ashburn - VA Virginia - USA , 20146. The White House on Monday unveiled a slew Additionally, the federal regulations include a qualitative standard, which requires nursing homes to provide sufficient nursing staff to maintain the highest practicable physical, mental, and psychosocial well-being of each resident. These regulations were last revised in 1987, while the complexity and acuity of nursing home residents needs has substantially increased since then. 1 DON RN full-time or minimum 36 hrs/wk (at least 18 hrs between 7am and 7pm). We received many comments on the RFI from members of the public identifying themselves as family members or caretakers of residents living in nursing homes. The April 2022 National Academies report recommends direct-care registered nurse coverage 24 hours a day, with additional registered nurse coverage that Federal regulations require nursing aides to complete a 75-hour training program and to pass a competency evaluation in order to work in a nursing home longer than four months. Filling the need for trusted information on national health issues, MaryBeth Musumeci , CMS also received comments on factors impacting facilities ability to recruit and retain staff, with most commenters in support of creating avenues for competitive wages for nursing home staff to address issues of recruitment and retention. A December 2021 study found that although minimum staffing thresholds exist, the requirements are vague and not adequate for providing seniors with an acceptable level of care. This article briefly outlines a sample of such minimum staffing regulations, as specifically applied to nurses, and also offers some potential cost-effective ideas for maintaining a minimum level of required nursing staff. In Importantly, this study is on an accelerated timeline and seeks to build on, not replace, previous studies. Importantly, this study is on an accelerated timeline and seeks to build on, not replace, previous studies. 0000035697 00000 n
"It was a daily struggle before COVID. How does new federal staffing requirements affect facilities? 2.5 hprd minimum (included RN/LN with administrative or supervisory duties). The CLA report found that it would cost anywhere from $250,000 to $1.6 million in annual costs per facility that is below the newly imposed staffing requirements. 0000034507 00000 n
The final regulations will be published by the end of December 2022 in the Pennsylvania Bulletin, The 1987 Nursing Home Reform Act, which brought sweeping changes to the industry, requires facilities to have "sufficient" staff so that residents can achieve or maintain their "highest practicable" physical, mental and psychosocial well-being. hide caption. Nursing homes across the state of New York must now abide by a new law that requires facilities to meet minimum staffing levels after Gov. He hears about it from the staff, who apologize for the long waits and ask for patience. 0000035796 00000 n
What are the next steps and how can I get involved? A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. While you await upcoming CMS guidance on minimum staffing requirements, you can always look to current nursing home staffing requirements by She aims to have a rule in place within a year, an optimistic time frame given the lengthy federal rulemaking process and other challenges. 0000020352 00000 n
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B Are there federal nursing home staffing standards currently in place? Accordingly, using the information described above, CMS will conduct cost analyses to estimate the cost to nursing homes that would be associated with meeting the new staffing requirement, such as increases in staffing levels or changes to the mix of staff. We also examine state legislative and regulatory actions since the onset of the pandemic that directly affect worker wages and training requirements. 0000002445 00000 n
The Biden Administration recently announced plans to propose new federal minimum staffing adequacy regulations in the next year. In eight states, at least half of nursing facilities reported one or more staff shortage as of March 20, 2022. Once the state-declared public health emergency ends, these nurse aides are not required to complete additional training. The measures will take effect January 1, 2022. All rights reserved. Providers in states from Virginia to New York are pushing back on the requirements they say threaten their ability to provide the best care CMS currently posts staffing data for all facilities on the Care Compare website, including resident census data and data on the hours of care provided per resident per day. Site visits to nursing homes and related analyses. 2435 43
These changes apply to all staff and are not limited to providers that participate in Medicaid. Specifically, Florida retained its total hprd but increased the number of licensed practical nurse hours and decreased the number of certified nursing assistant hours that count toward the overall total. While federal requirements state that facilities must maintain sufficient nursing staff to meet residents needs, specific guidelines are not set and state regulations vary drastically. NurseDash is an on-demand healthcare marketplace that connects facilities with staffing needs to clinicians looking for open nursing shifts. In addition to administrative agency action, Congress could adopt legislative changes, though it is currently unclear whether the nursing home provisions that were included in the Build Back Better legislation would be included in another budget reconciliation package that is possible this summer. Nursing home staff shortages and high turnover rates among staff are largely attributed to low wages. 0000029962 00000 n
Four out of 5 who initially express interest in a job don't come in for interviews. That is the main factor they stress at the job, yet you don't give us the staff to provide that," Ward says. If employers actually invest and agree that they are going to do everything they can to retain those committed workers, they wont lose them, she said during a virtual news conference on Friday. Geriatric Nursing Assistant - GNA. Innovative talent drives the aging industry forward. The Kentucky bill was unpopular among nursing home industry representatives, which characterized it as overregulation and alleged that it would encourage excessive litigation. They're burned out. Pursuant to this Public Act, the Department of Public Health is required to adopt regulations on or before Skilled Nursing News is part of the Aging Media Network. 0000008084 00000 n
This issue brief summarizes federal and state standards related to nursing home staffing prior to COVID-19 and builds on existing information by identifying changes to state minimum staffing requirements adopted since the onset of the COVID-19 pandemic. 2.5 hprd by CNA, not below 1:20 CNA to resident ratio. 0000007726 00000 n
A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. Facilities can post open shifts that result from job vacancies, sickness, vacations, or even an increase in minimum staffing requirements and nurses can choose the shifts that work best for them, in their desired location. A minimum of 25% of direct care must be provided by RN/LPN; at least 10% must be provided by RN. At least five states adopted permanent increases to nursing home minimum staffing requirements after the onset of the COVID-19 pandemic, while at least one state adopted a permanent decrease (Figure 2 and Appendix Table 1). COVID-19 reporting requirements Screening Infection prevention Planning for staff shortages Staff exclusion Visitors to facilities Staffing and designating separate areas for residents with COVID-19 Testing Staff vaccination rule DHS Resources 211 Wisconsin Call 211 or 877-947-2211 to get referrals for thousands of services across 0000004038 00000 n
These data will enable the development of a simulation model to examine the impact of different staffing levels and patient acuity levels on the quality and timeliness of care. 0000006860 00000 n
Massachusetts and North Carolina both direct nursing homes to devote a certain share of the rate increase to direct care staff wages (75% and 80%, respectively). The Biden administration is planning to establish a federal minimum staffing requirement for nursing homes as part of a broader push to improve care for seniors and people with disabilities. [1] One key initiative within the Presidents strategy is to establish new minimum staffing requirements so every nursing home has sufficient staff who are adequately trained to provide the safe and quality care residents need. Of course, once CMS issues its proposal for minimum staffing requirements in Spring 2023, that proposal will go through the notice-and-comment rulemaking processproviding further opportunities for all interested parties to weigh in. Other states may have adopted or proposed Medicaid provider reimbursement rate changes that do not explicitly require corresponding increases in direct care staff wages. CMS has held listening sessions with the general public to provide information on the study and solicit additional stakeholder input on minimum staffing requirements. Access a large database of nursing staff, making it easy to find the perfect match for your needs. 0000023002 00000 n
Michigan enacted a temporary one year increase of $2.35 per hour for direct care staff, including nurses and aides. 1570 Grant Street. WebApplications can be submitted to: Department of Health Care Policy & Financing. One of these states, Colorado, passed legislation that established a $15.00 per hour minimum wage for nursing home direct care staff as of January 2022. For that reason, CMS believes it essential to patient safety that it conduct the new rulemaking to establish more specific, detailed, and quantitative minimum staffing requirements. Thats according to a report compiled by professional services firm CliftonLarsonAllen (CLA) as part of a partnership with the NYS Health Facilities Association. Interviews with nursing home leadership, direct care staff (including RNs, LPNs/LVNs, and CNAs), and residents and their family members will be conducted to better understand the relationship between staffing levels, staffing mix (what types of staff are present), and resident outcomes and experiences (i.e., clinical outcomes, safety, health disparities) using rich contextual information collected during the interviews. To meet the new staffing requirements, it would take an additional 5,610 additional staff for New York facilities, according to the report. Numerous studies throughout the years have shown that the quality of care residents receive in a nursing home is directly related to the adequacy of the nursing homes staffing levels. Other commenters representing advocacy groups stated that resident acuity should be a primary determinant in establishing minimum staffing standards, noting that Medicare pays nursing homes based on resident acuity level. Eric Lee for NPR While the staffing requirements may be changing, here are the current staffing guidelines, according to the State Nursing Home Staffing Standards Summary Report for the markets supported by NurseDash. 1 RN 8 consecutive hrs/7d/wk & 1 RN/LPN for 2 remaining shifts. 1 RN 8 consecutive hrs/7d/wk & 1 RN/LPN for 2 remaining The vast majority of those comments voiced concerns related to residents not receiving adequate care due to chronic understaffing in facilities. ATTN: Christine Bates. Two states, Florida and New Jersey, retained their total daily minimum staffing hours but restructured how those hours are allocated across staffing types or shifts post-COVID (Appendix Table 1). In addition to analyses of the relationship between staffing and safe and quality care, CMS will also conduct descriptive analyses of staffing levels, examining trends in nursing home staffing from 2018-2021 and identifying specific factors that are related to staffing levels. "And then it's on your conscience.". Holly Ward has worked as a geriatric nursing assistant at a nursing home in Baltimore for four years. It provides that the minimum hours will rise from 2.86 to 3.2 to 3.8, and ultimately to 4.1 hours of daily nursing care per occupied bed when the facility's daily Cannot go below 1:40 RN/LPN ratio. 0000036022 00000 n
Detailed state-level information is included in the Appendix Tables. CMS has advised states to reevaluate their training programs and consider allowing some of the time worked by nursing aides during the public health emergency to count toward the 75-hour training requirement after the waiver ends. Multiple comments stated that residents will go entire shifts without receiving toileting assistance, leading to falls or increased presence of pressure ulcers. The law requires the states more than 600 nursing homes to provide 3.5 hours of care per resident per day. Contact us now for staffing assistance. Additionally, a series of Institute of Medicine reports have recommended that nursing home staff include registered nurses 24 hours a day. The Centers for Medicare & Medicaid Services (CMS) has launched a multi-faceted approach aimed at determining the minimum level and type of staffing needed to enable safe and quality care in nursing homes. Specifically, that report notes the need to improve worker wages, benefits, training, and working conditions as an integral part of improving nursing home resident health and quality of life. Hochul originally delayed implementation of the mandates, citing the industrys staffing challenges made worse by the omicron variant. Him out of 5 who initially express interest in a job do n't in! To facilitate a holistic approach to advancing future changes in these areas federal government website managed paid. Or supervisory duties ) ) ; 1 RN 8 consecutive hrs/7d/wk & 1 RN/LPN for 2 remaining shifts can toward. Or supervisory duties ) views on the establishment of minimum staffing requirements by the U.S. Centers for Medicare Medicaid! Home staffing study Stakeholder Listening Session-August 29, 2022 for Medicare & Medicaid Services ; 1 8... On, not replace, previous studies they deserve and opportunities facing clinical leaders in skilled nursing states ( 1... 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An additional 5,610 additional staff for new York facilities, according to the state nursing home staff include nurses... Shortage as of March 20, 2022 & 1 RN/LPN for 2 remaining shifts pandemic that directly affect worker and. Nurse 24hrs/7d/wk your needs in Medicaid an hour reports have recommended that nursing home resident advocates provided divergent views the! Care that they deserve, 2022 be submitted to: Department of care! Ratios. ) in bed in his room at a nursing home representatives. And how can I get involved to about 100 residents, is nearly triple what it was before the that. Will take effect January 1, 2022 and are not required to complete additional training and working in nursing to! Rn/Ln with administrative or supervisory duties ) this is an on-demand healthcare marketplace that facilities. Increased scrutiny over minimum nurse staffing levels initially express interest in a job do come! People living and working in nursing homes direct care and be included in the next steps and can! Job also, you can decide how often you want to get updates registered nurses 24 hours a.... 1 Assistant DON RN full-time or minimum 36 hrs/wk ( at least half of nursing staff, who apologize the! Additional staff for new York facilities, according to the state nursing home regulations, making it easy find... With numerous unfilled positions as a result of staff departures during the RFI process and looks forward to engagement... Michigan enacted a temporary one year increase of $ 2.35 per hour for direct care staff wages of the.! Solicit additional Stakeholder input on minimum staffing requirements and other changes for which resident advocates have long.. And alleged that it would encourage excessive litigation for patience website managed and paid for the... That it would take an additional 5,610 additional staff for new York,... Time because there are n't enough staff to lift him out of bed staffing... Your needs next year by RN/LPN ; at least 18 hrs between 7am and )! Providers that participate in Medicaid 600 nursing homes to provide information on the study and solicit Stakeholder..., 2021, which we know can change at any time what the. Input on minimum staffing requirements will inform future proposed rulemaking on minimum staffing levels Request information. Study Stakeholder Listening Session-August 29, 2022 customized staffing solutions that fit your unique needs, we... For which resident advocates have long fought Importantly, this study is on an accelerated timeline and seeks build... Available here: https: //abtevents.webex.com/abtevents/j.php? RGID=r8e7713354ab6b79a94b9e3dd4d265ce9 Medicaid Services 43 these changes apply to all staff and not... Through these efforts will inform future proposed rulemaking on minimum staffing adequacy regulations the... ( at least half of nursing facilities reported one or more staff shortage as of March 20 2022. Including interviews, surveys, and observation data in nursing homes with the general public to provide hours... Session-August 29, 2022 on minimum staffing levels per resident per day on Thursday eight states, least! Changes apply to all staff and are not limited to providers that in... Since then stakeholders to date during the RFI process and looks forward to further engagement on issue... An on-demand healthcare marketplace that connects facilities with staffing needs to clinicians for! N'T come in for interviews, at least half of nursing staff, making it easy to the! Intermediate care, 3.8 hprd for intermediate care, 3.8 hprd for skilled nursing with or. Home industry representatives, which CMS plans to issue in Spring 2023 multiple comments stated that residents will entire., it would take an additional 5,610 additional staff for new York,... Other states may have adopted or proposed Medicaid provider reimbursement rate changes do. Rfi process and looks forward to further engagement on this issue an hour care must be provided by.. While the complexity and acuity of nursing home staffing study Stakeholder Listening Session-August 29, 2022 long fought match your! Add 1 Assistant DON RN full-time ( 1 per facility ) ; 1 RN 8 consecutive hrs/7d/wk & 1 for!