Omission of LPNs in Nursing Home Staffing Proposal Draws Outcry

Nursing home care could suffer and staffing shortfalls worsen if the Biden administration doesn’t allow licensed practical nurses to count toward a proposed staffing requirement for the facilities, professionals in the aging services sector say.

The administration’s plan to boost direct care staff at nursing homes calls for minimum staffing levels for registered nurses and nursing aides in facilities that accept Medicare and Medicaid beneficiaries. But the proposal sets no required staffing level for licensed practical nurses, who play a critical caregiving role at most facilities.

Some organizations and individuals say that omission could cause facilities trying to lower their costs to simply replace LPNs with less-expensive nursing aides; and then staff RNs only to the required minimum level. “I don’t see any reason that they would do anything else,” said Richard Mollot, executive director of the Long Term Care Community Coalition.

“Each facility would save $14 per hour,” since nursing aides cost roughly $21 per hour, compared with an estimated $35 per hour for an LPN, according to a comment letter from more than 60 aging services experts.

Under that scenario, the potential loss of LPNs—who have a higher training level than nursing aides—would lower the “skill mix” of the direct care staff and hurt the quality of care, Mollot said. It could also force RNs to assume more LPN duties, “potentially straining their already considerable workload,” said a comment letter on the proposal from the American Nurses Association, which represents registered nurses and advance practice nurses.

While states determine what tasks LPNs are licensed to perform, they typically administer medications and treatments that nursing aides are either not trained or not allowed to provide, according to the National Association of Social Workers. Additionally, LPNs apply bandages and dressings, monitor IVs, and take resident vital signs, like blood pressure, temperature, and heart rate.

Nursing aides, the primary caregivers in nursing homes, assist residents with daily living activities like dressing, eating, and toileting.

Registered nurses supervise LPNs and nursing aides. They also provide more complex direct care than LPNs, collaborate with doctors, rehab staff, social workers, and others about care goals and interventions, and implement regulatory requirements, according to the NASW.

The LPN issue is just one of several criticisms the nursing home staffing rule has received. Industry has called it costly and unworkable, while Sen. Deb Fischer (R-Neb.) has threatened legislation to stop implementation of the rule. Advocates for nursing home residents say the proposal doesn’t go far enough and isn’t tough enough to improve the quality of care.

Health Outcomes

In justifying its policy proposal, the Centers for Medicare & Medicaid Services argued that better health outcomes were only associated with increased staffing for RNs and nursing aides—not LPNs.

In fact, a CMS-commissioned study in 2022 showed no association “at any level” between LPN staffing and “safe and quality care.” And the agency cited concerns that LPNs could perform tasks “outside their scope of practice” without sufficient RN supervision. “This is concerning,” because LPNs “require an RN or a physician’s supervision to practice,” the CMS proposal said.

In a joint comment letter to CMS, the National Association of Licensed Practical Nurses joined the American Health Care Association, LeadingAge, and other groups in calling for the proposed rule to be rescinded. But if the rule is finalized, they want LPNs to count—just like RNs—toward any mandatory staffing requirement for nurses.

“These are integral and valued members of our nursing homes, and they should be treated as such,” the letter said. The National Association of Licensed Practical Nurses did not respond to several requests for comment.

Other groups urging LPNs to count toward a staffing requirement include the National Association of Social Workers, Medicaid Health Plans of America, National Nurses United, the American Association of Post-Acute Care Nursing, and Advion, which represents ancillary care providers in the long term and senior care markets.

Misgivings

Their misgivings are not new. In a 2016 nursing home final rule that implemented several industry reforms, the Obama administration questioned whether staffing requirements “could result in unintended consequences, such as staffing to the minimum, input substitution (hiring for one position by eliminating another), and task diversion (assigning non-standard tasks to a position).”

As millions of aging baby boomers with chronic conditions hit their senior years, the need for LPNs in residential care facilities is expected to grow. More than 54,000 annual job openings for LPNs are projected from 2022 to 2032, according to federal estimates.

Since some hospitals no longer use LPNs for acute care positions, long-term care facilities have become a growing employment source for LPNs, said Zina Gontscharow, a senior policy adviser for the American Nurses Association. Currently, licensed practical nurses, also known as licensed vocational nurses, or LVNs, make up 13%, or more than 186,000, of the nation’s 1.4 million-plus nursing home workforce.

“We are hearing more and more that the LPN is an increasingly important and integral part of the care team” in the long-term care facilities, Gontscharow said.

The proposed rule would require a minimum overall nurse staffing level of 3.0 “hours per resident per day,” or “3.0 HPRD.” That breaks down to a required 2.45 HPRD for nursing aides, and 0.55 HPRD for registered nurses. HPRD is the “total number of hours worked by each type of staff divided by the total number of residents,” according to the CMS.

The proposal would also require nursing homes to have a registered nurse on site at all times.

Precedent for Concern

Mollot said there’s precedent for the concern that nursing homes would cut LPNs if the final CMS rule contained no staffing requirement for the position.

He said nursing homes cut thousands of occupational and physical therapists in 2020 just before Medicare implemented a new payment system that based reimbursements more on a patient’s medical needs, rather than the amount of therapy hours provided.

The job cuts occurred “even though CMS maintained they still had to perform the same amount of services based on resident needs,” Mollot said.

The industry would counter that some job losses were a byproduct of the new payment system’s primary intent: to reduce incentives to provide unnecessary therapy services. It would also argue that resident health outcomes have not declined under the new system.

Other positions not included in the staffing requirement, like dietitians and social workers, could also be at risk in facilities that struggle financially to meet the proposed staffing requirements, according to Advion.

The American Association of Post-Acute Care Nursing, which represents nearly 19,000 nurses working in long-term care facilities, wants the CMS to conduct more research on the relationship between RN and LPN staffing ratios, how state laws influence the LPN scope of practice, and how much RN oversight LPNs need.