November 4, 2023
The Honorable Chiquita Brooks-LaSure
Centers for Medicare and Medicaid Services
Department of Health and Human Services
Via Electronic Submission at http://www.regulations.gov
Re: File Code CMS-3442-P – Medicare and Medicaid Programs: Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting
Dear Administrator Brooks-LaSure:
On behalf of the National Association of State Veterans Homes (NASVH), and our members, thank you for the opportunity to provide comment on the Centers for Medicare and Medicaid Services’ (CMS) proposed rule concerning the Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting, particularly as it relates to the availability of long-term care for our aging Veterans.
State Veterans Homes date back to 1864. Following the Civil War, a large number of indigent and disabled Veterans were no longer able to earn their own livelihood and needed care. While the federal government operated national homes for disabled union volunteer soldiers, the total number of Veterans needing access to care was overwhelming resulting in underserved Veterans. In recognition of this need, and the debt that a grateful nation owed its defenders, a number of states independently established State Veterans Homes (SVHs) to help care for those who had borne the battle.
NASVH is an all-volunteer organization with a history dating back to 1952, and we are dedicated to promoting and enhancing the quality of care and life for the Veterans and families in our SVHs through education, networking, and advocacy. Our executive leadership is comprised of licensed nursing home administrators, as well as senior executive leaders who have oversight of their SVHs, and as a whole we have hundreds of years of experience operating and managing skilled nursing home programs. NASVH members represent all 50 states and the commonwealth of Puerto Rico, with our members being the largest long-term care nursing home provider to our Nation’s Veterans.
Today, there are 165 SVHs across the Nation, to include 158 skilled nursing care programs, with close to 25,000 beds collectively providing up to 9 million days of care per year to our Veterans, and 74 percent of these 158 homes are CMS certified. Additionally, our membership is expected to continue to expand with the anticipation that there will be 24 new SVHs seeking CMS and/or VA recognition between now and 2024.
With the writing of this comment, NASVH wishes to express our grave concerns over this proposed rule. While NASVH couldn’t agree more with CMS that it is a top priority to ensure nursing home residents receive safe, reliable, and the utmost quality nursing home care possible, it is careless to implement a minimum staffing requirement without first addressing the feasibility and taking into consideration the health care workforce distribution and staffing shortage issues experienced in our urban and rural communities.
It is no secret, as a nation, we are facing historic workforce challenges and our SVHs continue to struggle to find nursing staff following the “Great Resignation.” Unfortunately, unless more focus is placed and meaningful measures are taken to address our nation’s nursing staffing crisis, it is only expected to get worse over the next decade. The RN workforce is expected to grow from 3.1 million in 2022 to 3.3 million in 2032, which is a 6 percent growth and faster than the average for all occupations, according to recent data from the Bureau of Labor Statistics.1 Additionally, according to an October 2023 brief, published by the Health Resources and Services Administration (HRSA) under the Department of Health and Human Services, the overall national demand for workers in long-term services and support settings (not including nurses) is projected to grow by 42 percent between 2021 and 2036, from 1.88 million full-time equivalent professionals to 2.67 million. Also, the demand for nursing assistants is projected to grow by 44 percent.2
In addition, as a whole, our nation’s population is aging at an increasingly large rate, with the Baby Boomer generation entering the age for needing health services. As further identified by HRAS, in 2030, all Baby Boomers will be age 65 or older, accounting for 1 out of every 5 Americans.3 In 2029, the last of the Baby Boomer generation will reach retirement age, resulting in a 73 percent increase in Americans 65 years of age and older, 41 million in 2011 compared to 71 million in 2019, according to an article from the National Center for Biotechnology Information, National Library of Medicine.4
Furthermore, according to the U.S. Department of Veterans Affairs’ (VA) FY2024 Budget Submission, there are an estimated 8.4 million living Veterans aged 65 or older, including approximately 2.6 million who are 80 or older, of which about 1.3 million are 85 or older.5 VA demographic data trends further project that there will be a 73 percent increase in enrollees ages 85 or older between 2023-2035.
As previously indicated, our SVHs are currently already very challenged in hiring and retaining staff because of workforce shortages and the significant competition from local hospitals, higher-paying transitionary agency positions (e.g., traveling nurses), and others. These staffing shortages are also impacting Veteran access to care since SVHs are having to turn away new admits due to lower staffing levels. We are also already concerned about the above described inadequate nursing staff projections, particularly as it relates to the care and services needed by our aging Veteran population within the next ten years. The simple truth is – the health care workforce supply does not meet the demand for services, and the current proposed staffing mandate will only exacerbate this problem more since we are all drawing from the same labor pool. This will also result in additional worrisome unintended consequences to include our SVHs being forced to continue to restrict the number of Veterans they can serve, and it is possible we could see some SVHs close altogether, with both scenarios causing Veterans to be at risk for displacement.
As initially stated, our states have worked extremely hard for the past 160 years in maintaining and enhancing the quality of care and services we can provide in our SVHs to help care for those who had borne the battle. Prior to this, the total number of Veterans needing access to care was overwhelming resulting in underserved Veterans. As a Nation, it is unacceptable to put our Veterans at risk and we cannot allow this to happen again.
Based on the above, NASVH urges CMS to strongly reassess and rescind this proposed staffing mandate, and we advocate that a proper feasibility study be conducted to include reevaluating the staffing model before any punitive mandates are reconsidered and enforced.
As is the opinion of numerous other health care organizations and leaders, CMS also failed to acknowledge the value of licensed practical nurses (LPNs) working within our homes, and this position should be recognized as a licensed nurse rather than given zero credit for the high-quality care LPNs provide to our Veterans and the critical role they play as licensed nurses. There is also not a one-size-fits-all answer to staffing ratios or the industry problems we face. Staffing decisions need to be based on each unique Veteran/resident and their individualized Veteran-centric or person-centered care plan.
In addition, we are advocating for supplementary programs that provide additional funding and/or resources to help our SVHs recruit and retain sufficient staffing and allow more Veterans to be served by our homes. Every SVH has had to significantly increase expenditures (to include increasing non-direct care staffing) related to the various needs and changing CMS requirements associated to the pandemic. Even now with effective vaccines, treatments, and testing available to mitigate many of the dangers from COVID-19, SVHs still face significant challenges in bringing their occupancy rates back up to normal levels, primarily due to national staffing shortages impacting all health care facilities. It is, therefore, unreasonable, and unrealistic to expect nursing homes to bear the burden of these significant costs.
Lastly, NASVH strongly urges CMS to genuinely work with long-term care stakeholders and Congress on finding reasonable alternative solutions. It is imperative that any future actions implemented do not further exacerbate the serious challenges and concerns already facing our SVHs and the community nursing facilities across the county.
Again, we appreciate this opportunity to provide comment, and thank you for your consideration on this especially important mater.
If you should have any questions, please do not hesitate to contact me.
Caring for America’s Heroes.
Tracy M. Schaner,