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
Subscribe to KFF Health News' free Weekly Edition. Your Email Address Sign Up
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
A senior official in former president Joe Biden’s administration has told Sky News that he has no doubt that Israel has committed war crimes in Gaza.
Speaking to the Trump 100 podcast, Matthew Miller, who, as a state department spokesman, was the voice and face of the US government’s foreign policy under Mr Biden, revealed disagreements, tensions and challenges within the former administration.
In the wide-ranging conversation, he said:
• It was “without a doubt true that Israel has committed war crimes”; • That Israeli soldiers were not being “held accountable”; • That there were “disagreements all along the way” about how to handle policy; • And that he “would have wanted to have a better candidate” than Mr Biden for the 2024 election.
Mr Miller served as the state department spokesman from 2023 until the end of Mr Biden’s presidential term. From the podium, his job was to explain and defend foreign policy decisions – from Ukraine to Gaza.
“Look, one of the things about being a spokesperson is you’re not a spokesperson for yourself. You are a spokesperson for the president, the administration, and you espouse the positions of the administration. And when you’re not in the administration, you can just give your own opinions.”
Now out of office, he offered a candid reflection of a hugely challenging period in foreign policy and US politics.
Please use Chrome browser for a more accessible video player
1:37
Miller: Israel ‘committed war crimes’
Gaza disagreements
Asked about Gaza, he revealed there were “small and big” disagreements within the Biden administration over the US-Israeli relationship.
“There were disagreements all along the way about how to handle policy. Some of those were big disagreements, some of those were little disagreements,” he said.
Pushed on rumours that then-secretary of state Antony Blinken had frustrations with Mr Biden over both Gaza and Ukraine policy, Mr Miller hinted at the tensions.
Spreaker
This content is provided by Spreaker, which may be using cookies and other technologies.
To show you this content, we need your permission to use cookies.
You can use the buttons below to amend your preferences to enable Spreaker cookies or to allow those cookies just once.
You can change your settings at any time via the Privacy Options.
Unfortunately we have been unable to verify if you have consented to Spreaker cookies.
To view this content you can use the button below to allow Spreaker cookies for this session only.
“I’ll probably wait and let the secretary speak for himself… but I will say, speaking generally, look, it is true about every senior official in government that they don’t win every policy fight that they enter into. And what you do is you make your best case to the president.
“The administration did debate, at times, whether and when to cut off weapons to Israel. You saw us in the spring of 2024 stop the shipment of 2,000-pound bombs to Israel because we did not believe they would use those in a way that was appropriate in Gaza.”
Through the spring and summer of 2024, the Biden administration was caught between its bedrock policy of the unconditional defence of its ally Israel and the reality of what that ally was doing in Gaza, with American weapons.
Mr Mill said: “There were debates about whether to suspend other arms deliveries, and you saw at times us hold back certain arms while we negotiated the use of those arms…
“But we found ourselves in this really tough position, especially in that time period when it really came to a head… We were at a place where – I’m thinking of the way I can appropriately say this – the decisions and the thinking of Hamas leadership were not always secret to the United States and to our partners.”
Image: Matthew Miller during a news briefing at the state department in 2023. Pic: AP
He continued: “And it was clear to us in that period that there was a time when our public discussion of withholding weapons from Israel, as well as the protests on college campuses in the United States, and the movement of some European countries to recognise the state of Palestine – appropriate discussions, appropriate decisions – protests are appropriate – but all of those things together were leading the leadership of Hamas to conclude that they didn’t need to agree to a ceasefire, they just needed to hold out for a little bit longer, and they could get what they always wanted.”
“Now, the thing that I look back on, that I will always ask questions of myself about, and I think this is true for others in government, is in that intervening period between the end of May and the middle of January [2025], when thousands of Palestinians were killed, innocent civilians who didn’t want this war, had nothing to do with it, was there more that we could, could have done to pressure the Israeli government to agree to that ceasefire? I think at times there probably was,” Mr Miller said.
Asked for his view on the accusation of genocide in Gaza, he said: “I don’t think it’s a genocide, but I think it is without a doubt true that Israel has committed war crimes.”
Challenged on why he didn’t make these points while in government, he said: “When you’re at the podium, you’re not expressing your personal opinion. You’re expressing the conclusions of the United States government. The United States government had not concluded that they committed war crimes, still have not concluded [that].”
Image: Anthony Blinken, left, with then US President Joe Biden. Pic: AP
He went on to offer a qualification to his accusation.
“There are two ways to think about the commission of war crimes,” he said.
“One is if the state has pursued a policy of deliberately committing war crimes or is acting recklessly in a way that aids and abets war crimes. Is the state committing war crimes?
“That, I think, is an open question. I think what is almost certainly not an open question is that there have been individual incidents that have been war crimes where Israeli soldiers, members of the Israeli military, have committed war crimes.”
The Israeli government continues to strongly deny all claims that it has committed war crimes in Gaza.
On Joe Biden’s election hopes
Mr Miller also offered a candid reflection on the suitability of Mr Biden as a candidate in the 2024 US election. While Mr Biden initially ran to extend his stay in the White House, he stepped aside, with Kamala Harris taking his place as the Democratic candidate.
“Had I not been inside the government, had I been outside the government acting kind of in a political role, of course, I would have wanted to have a better candidate,” he said.
“It’s that collective action problem where no one wants to be the first to speak out and stand up alone. You stand up by yourself and get your head chopped off, stand up together, you can take action.
“But there was never really a consensus position in the party, and there was no one that was willing to stand up and rally the party to say this isn’t going to work.
“I don’t think there is anyone on the White House staff, including the most senior White House staffers, who could have gone to Joe Biden in the spring of 2023 or at any time after that and told him: ‘Mr President, you are not able to do the duties of this job. And you will not win re-election.’ He would have rejected that outright.”
Please use Chrome browser for a more accessible video player
1:00
Biden’s presidency in 60 seconds
The Trump presidency
On the Donald Trump presidency so far, he offered a nuanced view.
He described Mr Trump’s Middle East envoy Steve Witkoff as “an extremely capable individual” but expressed his worry that he was being manipulated by Russian President Vladimir Putin.
“I know the people in the Biden administration who worked with him during the first negotiations for Gaza ceasefire thought that he was capable.
“I think at times he doesn’t know what he doesn’t know. And you see that especially in the negotiations to end the war in Ukraine, where you see him go into a meeting with Vladimir Putin and come out spouting Russian propaganda… I think he would benefit from a little diplomatic savvy and some experienced diplomats around him.”
Image: Trump’s Middle East envoy Steve Witkoff, left, with Vladimir Putin. Pic: Sputnik/AP
He continued: “But I do think it’s extremely important that when people sit down with an envoy of the United States they know that that envoy speaks for the President of the United States and it is very clear that Witkoff has that and that’s an extremely valuable asset to bring to the table.”
On the months and years ahead under Mr Trump, Mr Miller said: “The thing that worries me most is that Donald Trump may squander the position that the United States has built around the world over successive administrations of both parties over a course of decades.
“I don’t think most Americans understand the benefits that they get to their daily lives by the United States being the indispensable nation in the world.
“The open question is: will the damage that he’s doing be recoverable or not?”
Mount Etna in Sicily has erupted, sending a huge plume of ash into the sky.
Social media footage showed tourists running down the slopes as the highest active volcano in Europe erupted.
Italy‘s National Institute of Geophysics and Volcanology said it expected the erupting ash cloud to disperse in a west-southwest direction.
Image: Pic: Reuters
The monitoring institute said the “amplitude values of volcanic tremors are currently high” and were “showing a tendency to increase”.
Image: Pic: Reuters
It added the eruptive activity has “continued with strombolian explosions of increasing intensity that, at the moment, are to be considered to be very intense and almost continuous”.
“In the last few hours there’s been reports of [a] little thin ash in Piano Vetore,” the institute said.
Follow The World
Listen to The World with Richard Engel and Yalda Hakim every Wednesday
The Volcanic Ash Advisory Centre Toulouse has issued a “code red” aviation warning, advising planes that a significant volume of ash in the atmosphere is likely.
Image: Pic: Reuters
Mount Etna is one of the world’s most active volcanoes. It was added to the list of UNESCO World Heritage Sites in 2013.
The suspect in the Colorado attack told investigators he planned it for a year and said he wanted to “kill all Zionist people”, it is claimed.
Mohamed Soliman is accused of throwing Molotov cocktails and using a makeshift flamethrower on a group of people at a rally in support of Israeli hostages – with the FBI describing the incident as a targeted “act of terrorism”.
The 45-year-old, from El Paso County, Colorado, yelled “Free Palestine” during the attack, it is alleged.
Soliman has been charged with the federal crime of causing bodily injury because of actual or perceived race, colour, religion, or national origin. Authorities said they would announce further charges later on Monday.
Four women and four men, aged between 52 and 88, were injured and taken to hospitals. One victim is in a critical condition and others were seriously hurt, authorities said.
Image: Suspect Mohamed Soliman. Pic: Boulder Police Department
In a federal criminal complaint, investigators said Soliman confessed to the attack and told them that he had planned it for a year.
The alleged attacker said he researched on YouTube how to make Molotov cocktails – an improvised bomb made from a bottle filled with petrol and stuffed with a piece of cloth to use as a fuse, it was claimed.
He allegedly made them before driving to Boulder, Colorado, to carry out the attack on the weekly demonstration, where people were calling for release of Israeli hostages held in Gaza.
Soliman told investigators he “wanted to kill all Zionist people and wished they were all dead”, and “he would do it (conduct an attack) again”, according to the criminal complaint.
The suspect said he had been planning the attack for a year, and was waiting until after his daughter graduated to carry it out, it was alleged.
Unlit Molotov cocktails found near scene
According to the federal complaint, officers found a black plastic container with a yellow top near where Soliman was arrested, containing “at least 14 unlit Molotov cocktails”.
Investigators said the projectiles were comprised of “glass wine carafe bottles or Ball jars,” and that near the container “was a backpack weed sprayer, potentially containing a flammable substance”.
It was later determined the liquid in both the bottles and weed sprayer was the flammable liquid xylene, the complaint said.
Mark Michalek, a special agent in charge of the FBI’s Denver field office, described the sprayer as a “makeshift flamethrower”.
Image: The suspect was seen clutching two glass bottles
Trump condemns ‘horrific’ attack
Law enforcement officials told Sky News’ US partner network NBC News that Soliman is an Egyptian national who seemingly acted alone. They said he has no previous significant contact with law enforcement.
Tricia McLaughlin, assistant secretary at the Department of Homeland Security, said Soliman was in the US “illegally”.
She posted on X: “He entered the country in August 2022 on a B2 visa that expired on February 2023. He filed for asylum in September 2022.”
US President Donald Trump said the “horrific” attack in Boulder “will not be tolerated in the United States of America”.
Police chief Steve Redfearn said the attack happened at around 1.26pm local time on Sunday and initial reports were that “people were being set on fire”.
“When we arrived we encountered multiple victims that were injured, with injuries consistent with burns,” Mr Redfearn said.
The attack happened as a “group of pro-Israel people” were peacefully demonstrating, police said.
The walk is held regularly by a volunteer group called Run For Their Lives, which aims to raise awareness of the hostages who remain in Gaza.
Image: A bomb disposal robot at the scene. Pic: AP
Israeli Prime Minister Benjamin Netanyahu said he was praying for the full recovery of the people wounded in the “vicious terror attack” in Colorado.
“This attack was aimed against peaceful people who wished to express their solidarity with the hostages held by Hamas, simply because they were Jews,” he said.
Follow the World
Listen to The World with Richard Engel and Yalda Hakim every Wednesday
US Senate minority leader Chuck Schumer, a prominent Jewish Democrat, said the attack was “horrifying” and “this cannot continue”, adding: “We must stand up to antisemitism.”