The Biden administration finalized nursing home staffing rules Monday that will require thousands of them to hire more nurses and aides while giving them years to do so.

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The new rules from the Centers for Medicare & Medicaid Services are the most substantial changes to federal oversight of the nations roughly 15,000 nursing homes in more than three decades. But they are less stringent than what patient advocates said was needed to provide high-quality care.

Spurred by disproportionate deaths from covid-19 in long-term care facilities, the rules aim to address perennially sparse staffing that can be a root cause of missed diagnoses, severe bedsores, and frequent falls.

For residents, this will mean more staff, which means fewer ER visits potentially, more independence, Vice President Kamala Harris said while meeting with nursing home workers in La Crosse, Wisconsin. For families, its going to mean peace of mind in terms of your loved one being taken care of.

When the regulations are fully enacted, 4 in 5 homes will need to augment their payrolls, CMS estimated. But the new standards are likely to require slight if any improvements for many of the 1.2 million residents in facilities that are already quite close to or meet the minimum levels.

Historically, this is a big deal, and were glad we have now established a floor, Blanca Castro, Californias long-term care ombudsman, said in an interview. From here we can go upward, recognizing there will be a lot of complaints about where we are going to get more people to fill these positions. Email Sign-Up

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The rules primarily address staffing levels for three types of nursing home workers. Registered nurses, or RNs, are the most skilled and responsible for guiding overall care and setting treatment plans. Licensed practical nurses, sometimes called licensed vocational nurses, work under the direction of RNs and perform routine medical care such as taking vital signs. Certified nursing assistants are supposed to be the most plentiful and help residents with daily activities like going to the bathroom, getting dressed, and eating.

While the industry has increased wages by 27% since February 2020, homes say they are still struggling to compete against better-paying work for nurses at hospitals and at retail shops and restaurants for aides. On average, nursing home RNs earn $40 an hour, licensed practical nurses make $31 an hour, and nursing assistants are paid $19 an hour, according to the most recent data from the Bureau of Labor Statistics.

CMS estimated the rules will ultimately cost $6 billion annually, but the plan omits any more payments from Medicare or Medicaid, the public insurers that cover most residents stays meaning additional wages would have to come out of owners pockets or existing facility budgets.

The American Health Care Association, which represents the nursing home industry, called the regulation an unreasonable standard that creates an impossible task for providers amid a persistent worker shortage nationwide.

This unfunded mandate doesnt magically solve the nursing crisis, the associations CEO, Mark Parkinson, said in a statement. Parkinson said the industry will keep pressing Congress to overturn the regulation.

Richard Mollot, executive director of the Long Term Care Community Coalition, a New York City-based advocacy nonprofit, said it is hard to call this a win for nursing home residents and families given that the minimum levels were below what studies have found to be ideal.

The plan was welcomed by labor unions that represent nurses and whom President Joe Biden is counting on for support in his reelection campaign. Service Employees International Union President Mary Kay Henry called it a long-overdue sea change. This political bond was underscored by the administrations decision to have Harris announce the rule with SEIU members in Wisconsin, a swing state.

The new rules supplant the vague federal mandate that has been in place since the 1980s requiring nursing homes to have sufficient staffing to meet residents needs. In practice, inspectors rarely categorized inadequate staffing as a serious infraction resulting in possible penalties, federal records show.

Starting in two years, most homes must provide an average of at least 3.48 hours of daily care per resident. About 6 in 10 nursing homes are already operating at that level, a KFF analysis found.

The rules give homes breathing room before they must comply with more specific requirements. Within three years, most nursing homes will need to provide daily RN care of at least 0.55 hours per resident and 2.45 hours from aides.

CMS also mandated that within two years an RN must be on duty at all times in case of a patient crisis on weekends or overnight. Currently, CMS requires at least eight consecutive hours of RN presence each day and a licensed nurse of any level on duty around the clock. An inspector general report found that nearly a thousand nursing homes didnt meet those basic requirements.

Nursing homes in rural areas will have longer to staff up. Within three years, they must meet the overall staffing numbers and the round-the-clock RN requirement. CMS rule said rural homes have five years to achieve the RN and nurse aide thresholds.

Under the new rules, the average nursing home, which has around 100 residents, would need to have at least two RNs working each day, and at least 10 or 11 nurse aides, the administration said. Homes could meet the overall requirements through two more workers, who could be RNs, vocational nurses, or aides.

Homes can get a hardship exemption from the minimums if they are in regions with low populations of nurses or aides and demonstrate good-faith efforts to recruit.

Democrats praised the rules, though some said the administration did not go nearly far enough. Rep. Lloyd Doggett (D-Texas), the ranking member of the House Ways and Means Health Subcommittee, said the changes were modest improvements but that much more is needed to ensure sufficient care and resident safety. A Republican senator from Nebraska, Deb Fischer, said the rule would devastate nursing homes across the country and worsen the staffing shortages we are already facing.

Advocates for nursing home residents have been pressing CMS for years to adopt a higher standard than what it ultimately settled on. A CMS-commissioned study in 2001 found that the quality of care improved with increases of staff up to a level of 4.1 hours per resident per day nearly a fifth higher than what CMS will require. The consultants CMS hired in preparing its new rules did not incorporate the earlier findings in their evaluation of options.

CMS said the levels it endorsed were more financially feasible for homes, but that assertion didnt quiet the ongoing battle about how many people are willing to work in homes at current wages and how financially strained homes owners actually are.

If states do not increase Medicaid payments to nursing homes, facilities are going to close, said John Bowblis, an economics professor and research fellow with the Scripps Gerontology Center at Miami University. “There arent enough workers and there are shortages everywhere. When you have a 3% to 4% unemployment rate, where are you going to get people to work in nursing homes?”

Researchers, however, have been skeptical that all nursing homes are as broke as the industry claims or as their books show. A study published in March by the National Bureau of Economic Research estimated that 63% of profits were secretly siphoned to owners through inflated rents and other fees paid to other companies owned by the nursing homes investors.

Charlene Harrington, a professor emeritus at the nursing school of the University of California-San Francisco, said: In their unchecked quest for profits, the nursing home industry has created its own problems by not paying adeuate wages and benefits and setting heavy nursing workloads that cause neglect and harm to residents and create an unsatisfactory and stressful work environment.

[Update: This article was updated at 3:30 p.m. ET on April 24, 2024, with a statement issued by the Centers for Medicare & Medicaid Services to clarify when the minimum staffing thresholds for RNs and aides working at rural nursing homes will take effect. CMS said those minimum levels will begin in five years, in May 2029, not in four years as originally stated in the text of the regulation.]

Jordan Rau: jrau@kff.org, @jordanrau Related Topics Aging Health Industry Rural Health Biden Administration CMS Nursing Homes Contact Us Submit a Story Tip

More than 60 years ago, policymakers in Colorado embraced the idea that early intervention could prevent child abuse and save lives. The states requirement that certain professionals tell officials when they suspect a child has been abused or neglected was among the first mandatory reporting laws in the nation.

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Since then, mandatory reporting laws have expanded nationally to include more types of maltreatment including neglect, which now accounts for most reports and have increased the number of professions required to report. In some states, all adults are required to report what they suspect may be abuse or neglect.

But now there are efforts in Colorado and other states to roll back these laws, saying the result has been too many unfounded reports, and that they disproportionately harm families that are poor, Black, or Indigenous, or have members with disabilities.

Theres a long, depressing history based on the approach that our primary response to a struggling family is reporting, said Mical Raz, a physician and historian at the University of Rochester in New York. Theres now a wealth of evidence that demonstrates that more reporting is not associated with better outcomes for children.

Stephanie Villafuerte, Colorados child protection ombudsman, oversees a task force to reexamine the states mandatory reporting laws. She said the group is seeking to balance a need to report legitimate cases of abuse and neglect with a desire to weed out inappropriate reports.

This is designed to help individuals who are disproportionately impacted, Villafuerte said. Im hoping its the combination of these efforts that could make a difference. Email Sign-Up

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Some critics worry that changes to the law could result in missed cases of abuse. Medical and child care workers on the task force have expressed concern about legal liability. While its rare for people to be criminally charged for failure to report, they can also face civil liability or professional repercussions, including threats to their licenses.

Being reported to child protective services is becoming increasingly common. More than 1 in 3 children in the United States will be the subject of a child abuse and neglect investigation by the time they turn 18, according to the most frequently cited estimate, a 2017 study funded by the Department of Health and Human Services Childrens Bureau.

Black and Native American families, poor families, and parents or children with disabilities experience even more oversight. Research has found that, among these groups, parents are more likely to lose parental rights and children are more likely to wind up in foster care.

In an overwhelming majority of investigations, no abuse or neglect is substantiated. Nonetheless, researchers who study how these investigations affect families describe them as terrifying and isolating.

In Colorado, the number of child abuse and neglect reports has increased 42% in the past decade and reached a record 117,762 last year, according to state data. Roughly 100,000 other calls to the hotline werent counted as reports because they were requests for information or were about matters like child support or adult protection, said officials from the Colorado Department of Human Services.

The increase in reports can be traced to a policy of encouraging a broad array of professionals including school and medical staff, therapists, coaches, clergy members, firefighters, veterinarians, dentists, and social workers to call a hotline whenever they have a concern.

These calls dont reflect a surge in mistreatment. More than two-thirds of the reports received by agencies in Colorado dont meet the threshold for investigation. Of the children whose cases are assessed, 21% are found to have experienced abuse or neglect. The actual number of substantiated cases has not risen over the past decade. More from the Mountain States

While studies do not demonstrate that mandatory reporting laws keep children safe, the Colorado task force reported in January, there is evidence of harm. Mandatory reporting disproportionately impacts families of color initiating contact between child protection services and families who routinely do not present concerns of abuse or neglect, the task force said.

The task force said it is analyzing whether better screening might mitigate the disproportionate impact of mandatory reporting on under-resourced communities, communities of color and persons with disabilities.

The task force pointed out that the only way to report concerns about a child is with a formal report to a hotline. Yet many of those calls are not to report abuse at all but rather attempts to connect children and families with resources like food or housing assistance.

Hotline callers may mean to help, but the families who are the subjects of mistaken reports of abuse and neglect rarely see it that way.

That includes Meighen Lovelace, a rural Colorado resident who asked KFF Health News not to disclose their hometown for fear of attracting unwanted attention from local officials. For Lovelaces daughter, who is neurodivergent and has physical disabilities, the reports started when she entered preschool at age 4 in 2015. The teachers and medical providers making the reports frequently suggested that the county human services agency could assist Lovelaces family. But the investigations that followed were invasive and traumatic.

Our biggest looming fear is, Are you going to take our children away? said Lovelace, who is an advocate for the Colorado Cross-Disability Coalition, an organization that lobbies for the civil rights of people with disabilities. Were afraid to ask for help. Its keeping us from entering services because of the fear of child welfare.

State and county human services officials said they could not comment on specific cases.

The Colorado task force plans to suggest clarifying the definitions of abuse and neglect under the states mandatory reporting statute. Mandatory reporters should not make a report solely due to a family/childs race, class or gender, nor because of inadequate housing, furnishings, income or clothing. Also, there should not be a report based solely on the disability status of the minor, parent or guardian, according to the groups draft recommendation.

The task force plans to recommend additional training for mandatory reporters, help for professionals who are deciding whether to make a call, and an alternative phone number, or warmline, for cases in which callers believe a family needs material assistance, rather than surveillance.

Critics say such changes could leave more children vulnerable to unreported abuse.

Im concerned about adding systems such as the warmline, that kids who are in real danger are going to slip through the cracks and not be helped, said Hollynd Hoskins, an attorney who represents victims of child abuse. Hoskins has sued professionals who fail to report their suspicions.

The Colorado task force includes health and education officials, prosecutors, victim advocates, county child welfare representatives and attorneys, as well as five people who have experience in the child welfare system. It intends to finalize its recommendations by early next year in the hope that state legislators will consider policy changes in 2025. Implementation of any new laws could take several years.

Colorado is one of several states including New York and California that have recently considered changes to restrain, rather than expand, reporting of abuse. In New York City, teachers are being trained to think twice before making a report, while New York state introduced a warmline to help connect families with resources like housing and child care. In California, a state task force aimed at shifting mandated reporting to community supporting is planning recommendations similar to Colorados.

Among those advocating for cange are people with experience in the child welfare system. They include Maleeka Jihad, who leads the Denver-based MJCF Coalition, which advocates for the abolition of mandatory reporting along with the rest of the child welfare system, citing its damage to Black, Native American, and Latino communities.

Mandatory reporting is another form of keeping us policed and surveillanced by whiteness, said Jihad, who as a child was taken from the care of a loving parent and placed temporarily into the foster system. Reform isnt enough, she said. We know what we need, and its usually funding and resources.

Some of these resources like affordable housing and child care dont exist at a level sufficient for all the Colorado families that need them, Jihad said.

Other services are out there, but its a matter of finding them. Lovelace said the reports ebbed after the family got the help it needed, in the form of a Medicaid waiver that paid for specialized care for their daughters disabilities. Their daughter is now in seventh grade and doing well.

None of the caseworkers who visited the family ever mentioned the waiver, Lovelace said. I really think they didnt know about it. Related Topics Mental Health Race and Health Rural Health States California Children's Health Colorado Disabilities Disparities Indigenous Health New York Contact Us Submit a Story Tip

A top investor in Glosslab says he is no longer associated with the embattled nail salon even as it continues to shutter stores across the Big Apple, The Post has learned.

The New York-based company which is imploding following a bout of wild overexpansion backed by celebrity investors including Olivia Culpo, ex-Tinder CEO Sean Rad and The Chainsmokers is now operating just two salons in Manhattan, down from six earlier this month, according to its website.

One crucial investor who was burned is Joshua Coba, co-founder of European Wax Center a nearly $1 billion publicly held company with 1,000 locations. Coba secured the franchise rights for Glosslab in south Florida where there are five salons.

Coba who was supposed to oversee the companys franchise development nationwide, according to press releases also lent the company $5 million, but Glosslab has recently defaulted on the loan, sources told The Post.

Im no longer associated with them as a franchisee or in any respect, Coba told The Post. I own and operate the Florida locations and the Closter, NJ store.

Coba added that he plans to hold onto those businesses, but he also said he doesnt have a specific plan at this time regarding [his investment]. I dont have much to say at this time. Im still working through that.

Glosslab did not respond for comment about Coba.

Cobas Glosslab salon in Closter, NJ is actively hiring, according to posts on Indeed.com.

In Manhattan, two locations in the trendy Flatiron and Tribeca neighborhoods remain open. Thats down from a half dozen salons earlier this month, including locations at 860 Seventh Ave. and at 1206 Third Ave.

The company allegedly stiffed its landlords at a number of locations, as The Post previously reported.

Chief Executive Rachel Glass, a former hedge fund executive who founded the membership-based chain in 2018, told The Post last month the company is currently moving to a franchise model and working with landlords to that effect. 

One of the companys challenges, say multiple former employees, was hiring experienced and licensed nail technicians as it scrambled to staff the rapidly expanding chain. Some customers posted negative reviews on social media, complaining about botched manicures.  

When I was hired they never asked to see my license, said Katherine Tenesaca, who worked as a nail technician at Glosslabs Seventh Avenue salon until April 11 and said she has a license.

I never saw anyones license hung up on the walls where it should be. And our manager did ask us after the New York Post article whether we have our license. But were never asked to show an actual photo. They took our word for it.

Employing unlicensed nail techs can lead to the New York’s Department of State, which regulates the industry, “to issue a $500 per violation and/or suspend/revoke the license,” according to the regulation. “The penalties may vary,” a spokeswoman for the agency told The Post.

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The Post has a pending public record request regarding potential fines assessed against Glosslab.

The company vigorously denied allegations that it hired unlicensed nail technicians.

“All Glosslab nail technicians, including Katherine Tenesaca, were asked for their licenses and these were kept at the locations, Katherine Snyder told The Post.

The company “has never failed an inspection or had to pay a fine by the state of New York for doing otherwise.”

The company vigorously denied allegations that it hired unlicensed nail technicians.

Another Glosslab spokesperson, Stu Loeser, told The Post that state inspectors visited all six New York locations on March 29, “at which time they checked that all technicians on premises have licenses on display in the locations.

The fact that Glosslab locations have never been shut down for unlicensed technicians or any other regulatory reason proves that at this unannounced visit and all previous State Board visits all technicians were licensed. These facts about State oversight and visits alone disprove the former nail techs allegation, Loeser said.

Recently, some Glosslab members who pay $140 per month for unlimited manicures and pedicures said they have showed up to appointments at salons that closed suddenly or described their difficulty canceling their accounts.

I have been trying to cancel mine for over two weeks and they are ignoring my emails, calls, and Instagram DMs, Emma, a customer for the past 18 months, told The Post. I was charged $141.08 on April 15 despite emailing to cancel my subscription on April 2.”

During the preceding weeks and months, signs of trouble had been multiplying, according to Tenesaca.

We stopped getting supplies like gloves and files, she said. I had to buy my own gloves one time and eventually there were no more masks and the towel laundry service stopped recently. 

The college student, who worked part-time at the Glosslab on Seventh Avenue for the past year, said she and her colleagues received an email after 9 p.m. on April 11 telling them not to come to work the next day.

Weve made the extremely difficult decision to close select locations in our NY market, according to the email obtained by The Post. As a result, we will be parting ways with the GLOSSLAB employees of these locations. We are so grateful for all of your contributions to GLOSSLAB, and we would love to be a resource and a reference to you for future employment opportunities.