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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.

This story also ran on NPR. It can be republished for free.

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

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Farage has ‘grabbed the mic’ to dominate media agenda, says Harman

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Farage has 'grabbed the mic' to dominate media agenda, says Harman

Nigel Farage has successfully exploited the Commons recess to “grab the mic” and “dominate” the agenda, Harriet Harman has said.

Speaking on Sky News’ Electoral Dysfunction podcast, the Labour peer said that the Reform UK leader has been able to “get his voice heard” while government was not in “full swing”.

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Mr Farage used a speech this week to set himself, rather than Kemi Badenoch’s Tories, up as the main opposition to Sir Keir Starmer at the next election.

The prime minister responded on Thursday with a speech attacking the Clacton MP.

Baroness Harman said: “It’s slightly different between opposition and government because in government, the ministers have to be there the whole time.

“They’ve got to be putting legislation through and they kind of hold the mic.

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“They can dominate the news media with the announcements they’re making and with the bills they’re introducing, and it’s quite hard for the opposition to get a hearing whilst the government is in full swing.

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“What we used to do when we were in opposition before 1997 is that as soon as there was a bank holiday and the House was not sitting, as soon as the half-term or the summer recess, we would be on an absolute war footing and dominate the airwaves because that was our opportunity.

“And I think that’s a bit of what Farage has done this week,” Harman added.

“Basically, Farage can dominate the media agenda.”

She went on: “He’s kind of stepped forward, and he’s using this moment of the House not sitting in order to actually get his voice heard.

“It’s sensible for the opposition to take the opportunity of when the House is not sitting to kind of grab the mic and that is what Nigel Farage has done.”

But Baroness Harman said it “doesn’t seem to be what Kemi Badenoch’s doing”.

She explained that the embattled leader “doesn’t seem to be grabbing the mic like Nigel Farage has” during recess, and added that “there’s greater opportunity for the opposition”.

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UK to build weapons factories and buy thousands of missiles in £6bn push to rearm

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UK to build weapons factories and buy thousands of missiles in £1.5bn push to rearm

The UK will buy up to 7,000 long-range missiles, rockets and drones and build at least six weapons factories in a £6bn push to rearm at a time of growing threats.

The plan, announced by the government over the weekend, will form part of Sir Keir Starmer’s long-awaited Strategic Defence Review, which will be published on Monday.

However, it lacks key details, including when the first arms plant will be built, when the first missile will be made, or even what kind of missiles, drones and rockets will be purchased.

The government is yet to appoint a new senior leader to take on the job of “national armaments director”, who will oversee the whole effort.

Andy Start, the incumbent head of Defence Equipment and Support – the branch of defence charged with buying kit – is still doing the beefed-up role of national armaments director as a sluggish process to recruit someone externally rumbles on.

Keir Starmer and  Volodymyr Zelenskyy speak to the press as they attend a presentation of Ukrainian military drones.
Pic: Reuters
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Sir Keir Starmer and Volodymyr Zelenskyy at a presentation of Ukrainian military drones. Pic: Reuters

Revealing some of its content ahead of time, the Ministry of Defence said the defence review will recommend an “always on” production capacity for munitions, drawing on lessons learned from Ukraine, which has demonstrated the vital importance of large production lines.

It will also call for an increase in stockpiles of munitions – something that is vitally needed for the army, Royal Navy and Royal Air Force to be able to keep fighting beyond a few days.

Some £1.5bn will be invested in the new factories, the government said. It said this additional funding will lift total expenditure on munitions to £6bn this parliament.

Sky News will launch a new podcast series on 10 June based around a wargame that simulates an attack by Russia against the UK to test Britain’s defences

“The hard-fought lessons from [Vladimir] Putin’s illegal invasion of Ukraine show a military is only as strong as the industry that stands behind them,” John Healey, the defence secretary, said in a statement released on Saturday night.

“We are strengthening the UK’s industrial base to better deter our adversaries and make the UK secure at home and strong abroad.”

Army Commandos load a 105MM Howitzer in Norway.
Pic: Ministry of Defence Crown Copyright/PA
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Army Commandos load a 105mm Howitzer in Norway. Pic: Ministry of Defence/PA

The UK used to have a far more resilient defence industry during the Cold War, with the capacity to manufacture missiles and other weapons and ammunition at speed and at scale.

However, much of that depth, which costs money to sustain, was lost following the collapse of the Soviet Union in 1991, when successive governments switched funding priorities away from defence and into areas such as health, welfare and economic growth.

Even after Russia’s full-scale invasion of Ukraine in 2022 and a huge increase in demand from Kyiv for munitions from its allies, production lines at UK factories were slow to expand.

A reaper drone in the Middle East as part of Operation Shader. Pic: Ministry of Defence
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A reaper drone in the Middle East. Pic: Ministry of Defence

Sky News visited a plant run by the defence company Thales in Belfast last year that makes N-LAW anti-tank missiles used in Ukraine. Its staff at the time only worked weekday shifts between 7am and 4pm.

Under this new initiative, the government said the UK will build at least six new “munitions and energetics” factories.

Energetic materials include explosives, propellants and pyrotechnics, which are required in the manufacturing of weapons.

There were no details, however, on whether these will be national factories or built in partnership with defence companies, or a timeline for this to happen.

There was also no information on where they would be located or what kind of weapons they would make.

King Charles  visiting HMS Prince of Wales as the Royal Navy finalises preparations for a major global deployment to the Indo-Pacific this spring.
Pic: PO Phot Rory Arnold/Ministry of Defence/PA
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King Charles visits HMS Prince of Wales. Pic: PO Phot Rory Arnold/Ministry of Defence/PA

In addition, it was announced that the UK will buy “up to 7,000 UK-built long-range weapons for the UK Armed Forces”, though again without specifying what.

It is understood these weapons will include a mix of missiles, rockets and drones.

Sources within the defence industry criticised the lack of detail, which is so often the case with announcements by the Ministry of Defence.

The sources said small and medium-sized companies in particular are struggling to survive as they await clarity from the Ministry of Defence over a range of different contracts.

One source described a sense of “paralysis”.

The prime minister launched the defence review last July, almost a year ago. But there had been a sense of drift within the Ministry of Defence beforehand, in the run-up to last year’s general election.

The source said: “While the government’s intentions are laudable, the lack of detail in this announcement is indicative of how we treat defence in this country.

“Headline figures, unmatched by clear intent and delivery timelines which ultimately leave industry no closer to knowing what, or when, the MOD want their bombs and bullets.

“After nearly 18 months of decision and spending paralysis, what we need now is a clear demand signal from the Ministry of Defence that allows industry to start scaling production, not grand gestures with nothing to back it up.”

As well as rearming the nation, the government said the investment in new factories and weapons would create around 1,800 jobs across the UK.

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Prison officers should be armed with lethal weapons to crack down on Islamist terrorists, Tories say

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Prison officers should be armed with lethal weapons to crack down on Islamist terrorists, Tories say

Prison officers should be armed with lethal weapons to crack down on Islamist terrorists in jail, the shadow justice secretary has said.

Highly trained teams should also be equipped with tasers, stun grenades and baton rounds to tackle dangerous criminals in high-security jails, Robert Jenrick said.

The plan is taken from a series of recommendations by counter-extremism expert and former prison governor Ian Acheson.

It comes after a prison officer at high-security prison Long Lartin in Worcestershire was stabbed on Friday morning with a weapon Sky News understands was brought in from outside the prison.

It also follows several attacks on prison officers in jails.

In April this year, the Manchester Arena bomb plotter, Hashem Abedi, allegedly assaulted prison staff by throwing hot oil on them and then launching a stabbing attack, injuring three officers.

At Belmarsh prison, Southport killer Axel Rudakubana has been accused of throwing boiling water over an officer through the hatch in his cell door earlier this month.

A prison wall. Pic: PA
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File pic: PA

Mr Jenrick said: “Islamist gangs and violent prisoners in our jails are out of control.

It’s a national security emergency, but the government is dithering. If they don’t act soon, there is a very real risk that a prison officer is kidnapped or murdered in the line of duty, or that a terrorist attack is directed from inside prison.”

He said he commissioned Mr Acheson to conduct a rapid review into measures the government could adopt.

The measures include removing all radical Islamist imams working in prisons, immediately rolling out high-collar stab vests to frontline officers, and mandating the quarterly release of data on religious conversions in prison and faith-based incidents.

It also recommended legislating to overturn the De Silva ruling to strip back judicial interference in operational decisions by governors to isolate extremists.

Mr Jenrick added: “We have to stop pussy-footing around Islamist extremists and violent offenders in jails.

“That means arming specialist prison officer teams with tasers and stun grenades, as well as giving them access to lethal weapons in exceptional circumstances.

“If prison governors can’t easily keep terrorist influencers and radicalising inmates apart from the mainstream prisoners they target, then we don’t control our prisons – they do. We must take back control and restore order by giving officers the powers and protection they need.”

Mr Acheson said: “Too often what goes wrong behind the walls of our high security jails passes unnoticed, as does the bravery of the men and women in uniform who deal every day with terrorists and other highly dangerous offenders.

“Robert Jenrick is right – the threat to officer safety is now intolerable and must be met decisively by the government.

“The balance inside too many of our prisons has shifted away from control by the state to mere containment and the price is soaring levels of staff assaults and wrecked rehabilitation. Broken officers can’t help fix broken people – or protect the public from violent extremism.”

A Ministry of Justice source said: “The government considers the introduction of lethal weapons into prisons would put prison officers at greater risk.”

They added: “The last government added just 500 cells to our prison estate, and left our jails in total crisis. In 14 years, they closed 1,600 cells in the high-security estate, staff assaults soared, and experienced officers left in droves. Now the arsonists are pretending to be firefighters.

“This government is cleaning up the mess the last government left behind. We are building new prisons, with 2,400 new cells opened since we took office. And we take a zero-tolerance approach to violence and extremism inside.”

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