More than 1,000 Florida nursing home workers now have a new contract. It was recently ratified after months of often intense negotiations between bargaining team members with 1199SEIU United Healthcare Workers East, the largest union representing healthcare workers in Florida and nursing home owner and operator Aspire Health Group, one of the biggest companies in the industry.

“As a member of the bargaining team, I can say firsthand this was a hard fought campaign. It required strength, unity, and commitment to get over many hurdles to reach the finish line. I applaud my bargaining team members for staying united and committed to our mission to win a new contract,” said Christine Bricker, a certified nursing assistant (CNA) at Aspire at Spring Hill.

The new 3-year contract impacts both contracted and subcontracted workers with HCSG – Health Care Services Group. From cooks to caregivers, nursing home workers at eleven Aspire facilities will benefit from the new contract which includes a ratification bonus and wage increase. Most notably, it puts the lowest wage earners on a path to a $15 minimum wage. This is a step in the right direction says Mary Barnes, a longtime CNA at Aspire at West Palm Beach.

“For far too long, workers at my facility have been the lowest paid employees. That is why I was determined to make sure this would change in the new contract. I am grateful this was also a priority for our whole Bargaining Team. They stood with me during negotiations and made sure that our agreement included a path toward a $15 minimum wage,” said Barnes.

“As subcontracted employees, we work in Aspire facilities, but our employer is HCSG, Health Care Services Group, so we negotiated our own contract. But when it was time to fight for our rights, all employees stood side by side together. After all, our mantra is “one union, one fight”. That unity was essential to helping us achieve our goals,” said CNA and cook Darell Butler.

Butler is a longtime member leader with 1199SEIU. He has served on several bargaining teams over the more than 20 years he has worked in the industry. He says this contract campaign stands out as one of the longest and most difficult.

“We had pickets at all 11 Aspire nursing homes. Hundreds of workers and supporters braved the hot sun and rain outside of these facilities in Central and South Florida to make their

voices heard. It sent a powerful message to management that we were united and determined to earn the respect and fair wages we deserve,” explained Butler.

The pickets were covered by television and online news media. They highlighted a variety of issues including short staffing and low wages and how they impact the quality care nursing home residents need and deserve. Workers also voted to strike, but it was averted in the eleventh hour when a tentative agreement was reached.

“A strike is always the last option. But sometimes it must be considered if workers are disrespected, underpaid, and overworked,” said Margarette Nerette, Vice President at 1199SEIU. “I am glad we were able to find a resolution because these dedicated nursing home workers who provide compassionate care to our loved ones deserve to be respected, protected and paid a living wage and our facilities should be staffed at safe levels.”

MIAMI – Members of 1199SEIU United Healthcare Workers East, Florida’s largest union of healthcare workers, have launched an intensive contract campaign calling for improved wages, protections and safer staffing levels for patients and caregivers that would help solve the ongoing care crisis in nursing homes across the state.

Contracts between 1199SEIU long-term care (LTC) members and nursing home management are set to expire in almost 50 Florida facilities this year, directly impacting approximately 4,000 Certified Nursing Assistants (CNAs), dietary aides, housekeeping and other workers and 10,000 patients.

Many of these workers are paid less than $15 per hour, while the nursing home industry makes billions of dollars in profits each year, largely funded with taxpayer dollars.

“Part of the issue is an influx of out-of-state private equity firms buying up Florida nursing homes.  The prime directive of private equity is to make money, not provide care,” said Margarette Nerette, VP of Long-Term Care for 1199SEIU Florida. “We need facility owners to put patients before profit, and to be transparent and accountable for the billions of our tax dollars they receive each year.”

Contract negotiations already have begun between 1199SEIU members and 11 Florida facilities operated by Aspire Health Group, one of the largest rehabilitation and nursing home companies in the nation.  

Securing a living wage, necessary benefits and safer staffing levels are key priorities for long-term care workers who often are paid poverty-level rates.  In a particularly sad irony, some of these dedicated healthcare workers can’t afford health coverage for themselves. 

“We love our patients and are committed to provide the best quality care to them, but we have to protect ourselves and support our own families, too,” said Diane Wells, a CNA and 1199SEIU member in Central Florida.  “Caregivers are leaving this work because we can’t afford to pay Florida’s sky-high housing and so many other costs.”

 Reduced staffing standards passed by Florida’s legislature and signed by the governor in recent years also have added to work stress, burnout and high turnover in nursing homes because the hard job becomes even more difficult when caregivers must tend to more patients and tasks at once.

“Lower staffing and training requirements mean higher levels of risk for caregivers and patients,” said Mary Barnes, a CNA and 1199SEIU member in South Florida.  “We’re already at very concerning levels, and this will continue in a dangerous spiral unless facility owners across the state commit to safer staffing levels and working conditions that will attract and retain caregivers.”

Recently, the Biden Administration passed significant national staffing standards that will improve upon Florida care requirements over the next few years, but the current 1199SEIU bargaining campaign is demanding immediate and contractual obligations for safe staffing from nursing home wners. 

  “Nursing homes make up an essential part of the overall delivery of long-term care for Floridians,” said Nerette.  “Staffing and retention always has been an issue because it can be a complicated and back-breaking job for very little pay. Add the pandemic where workers were at ground zero of Covid risk, lowered safe-staffing rules in Florida and the state’s skyrocketing housing and insurance costs, and we have a perfect storm of pressure. To help relieve this crisis and to better protect patients and their caregivers across the state, we’re fighting for new contracts that respect us, protect us, pay and staff us.” 

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About 1199SEIU: 1199SEIU United Healthcare Workers East is the largest union of healthcare workers in the country representing more than 450,000 nurses and healthcare workers nationwide, including more than 35,000 in nursing homes, hospitals and other facilities throughout Florida.

“The members of 1199SEIU Florida approve and applaud the Biden Administration’s new proposed standards to better ensure quality care and to protect senior patients and their caregivers in nursing homes across the nation. 

 The new staffing requirements, the first ever on a national scale, are significant and positive steps to prioritize and improve the well-being of patients and caregivers. We appreciate that the administration requested the input of frontline staff, and we are proud of our members who shared their stories, experiences and expertise to push for these enhancements.  

 The new requirements will be especially meaningful and an improvement in Florida, where the governor, GOP legislature and nursing home industry — which takes in billions of our tax dollars — have been dangerously weakening regulations and worsening a critical staffing, retention and care crisis.  The national standards, most importantly, will result in Florida seniors receiving more direct care hours per day by trained staff, and will help reduce the industry’s profit-driven pattern of short-staffing that puts patients and caregivers at risk.  

 Our members will continue to fight for even better conditions and a faster implementation of the new national standards. While paid low wages in often back-breaking jobs, these workers are dedicated to provide the very best care to our parents, grandparents and other elderly loved ones in nursing homes across the state.  

 We look forward to working further with leaders like President Biden who has proven to truly put the needs of the people first, and hope we can convince or elect Florida officials who will do the same.  Patients, caregivers, their families and all Floridians deserve this.” 

 Margarette Nerette is Florida Vice President of Long-term Care for 1199SEIU United Healthcare Workers East, the largest union of healthcare workers in the state. 

Media contact: 
Ed Gilhuly 
305-807-6906/egilhuly@leftcom.com 

On September 1, 2023, the Centers for Medicare & Medicaid Services (CMS) issued the Minimum Staffing Standards for Long-Term Care (LTC) Facilities and Medicaid Institutional Payment Transparency Reporting proposed rule, which seeks to establish comprehensive nurse staffing requirements to hold nursing homes accountable for providing safe and high-quality care for the over 1.2 million residents receiving care in Medicare and Medicaid-certified LTC facilities each day.

Ensuring that beneficiaries receive safe, reliable, and quality nursing home care is a critical function of the Medicare and Medicaid programs and a top priority of CMS. The COVID-19 Public Health Emergency (PHE) tragically caused unprecedented illness and death among nursing home residents and workers. The PHE also exacerbated staffing challenges experienced in many facilities and further highlighted disparities in care and outcomes. Despite existing requirements that facilities provide sufficient levels of staffing in LTC facilities, chronic understaffing remains a significant concern.

The proposed rule consists of three core staffing proposals: 1) minimum nurse staffing standards of 0.55 hours per resident day (HPRD) for Registered Nurses (RNs) and 2.45 HPRD for Nurse Aides (NAs); 2) a requirement to have an RN onsite 24 hours a day, seven days a week; and 3) enhanced facility assessment requirements. The proposed rule also includes a staggered implementation approach and possible hardship exemptions for select facilities. This proposed rule results from a multi-faceted approach aimed at determining the minimum level and type of staffing needed to enable safe and quality care in LTC facilities. This effort included issuing a Request for Information (RFI) in the FY 2023 Skilled Nurse Facility Prospective Payment System Proposed Rule, hosting listening sessions and extensive engagement with various interested parties, conducting a 2022 Nursing Home Staffing Study, which builds on existing evidence and research studies using multiple data sources, and reviewing recent years of Payroll-Based Journal System staffing data. CMS also considered how the proposed minimum staffing requirements would align or interact with ongoing CMS initiatives and programs that impact the LTC community. Information gathered from each of these facets was used by CMS in the development of the proposed requirements that would ensure all nursing home residents are provided safe, quality care.

This proposed rule would also promote public transparency related to the percentage of Medicaid payments for services in nursing facilities and intermediate care facilities for individuals with intellectual disabilities that are spent on compensation to direct care workers and support staff. The Medicaid institutional payment transparency provision is intended to align with a similar transparency provision focused on specific Medicaid home and community-based services in the Ensuring Access to Medicaid Services proposed rule (CMS-2442-P), published in the May 3, 2023, issue of the Federal Register. 

Additionally, CMS announced a national campaign to support staffing in nursing homes. CMS will work with the Health Resources and Services Administration (HRSA) and other partners to make it easier for individuals to enter careers in nursing homes, investing over $75 million in financial incentives such as scholarships and tuition reimbursement. This staffing campaign builds on other actions through the HHS Health Workforce Initiative, including the recent announcement that HRSA awarded more than $100 million to train more nurses and grow the nursing workforce. 

 

Establishing Minimum Nurse Staffing Standards
Staffing in LTC facilities has remained a persistent concern, especially among low-performing facilities that are at most risk for providing unsafe care. CMS believes that national minimum nurse staffing standards in LTC facilities, the adoption of a 24/7 RN requirement, and enhanced facility assessment requirement (as discussed later in this fact sheet) are necessary at this time to protect resident health and safety and ensure their needs are met. 

Therefore, CMS proposes individual minimum nurse staffing standards for LTC facilities of 0.55 HPRD for RNs and 2.45 HPRD for NAs. However, these thresholds are minimums; while these proposed minimum standards, if finalized, would be applied across all LTC facilities, CMS also expects facilities to staff above these minimum baseline levels to address the specific needs of their unique resident population based on the facility assessment and resident acuity levels.

CMS is soliciting comments on alternative policy options that should be considered for establishing minimum nurse staffing standards. Based on the proposed policy presented in this rule, CMS is seeking feedback regarding whether alternative policy options would be better suited to meet and maintain acceptable quality and safety within LTC facilities, with consideration for external factors affecting staffing.

Specifically, CMS is seeking comment on an alternative total nurse staffing standard of 3.48 HPRD, among other alternatives, within which there would still be 0.55 RN HPRD and 2.45 NA HPRD minimums. Facilities would have to meet the individual standards for RNs and NAs, i.e., 0.55 and 2.45 HPRD, respectively, as well as the 3.48 HPRD, for total nurse staffing to be considered in compliance. Lastly, we seek comments on the benefits and tradeoffs of different standards, evidence, or methodologies states use to establish minimum staffing standards and other key considerations.

 

Improving the RN On-Site Requirement
LTC facilities provide care for residents with increasing medical complexity and acuity of health conditions who require substantial resources and care provided or supervised by an RN. While the minimum staffing standard proposal described above seeks to build on existing requirements by creating consistent and broadly applicable standards that significantly reduce the risk of unsafe and low-quality care across LTC facilities, the current minimum nurse standards do not reduce the risk of avoidable resident safety events when there is no RN on site, particularly during evenings, nights, weekends, and holidays. Therefore, CMS proposes that LTC facilities must have an RN onsite 24 hours a day, seven days a week, who is available to provide direct resident care.

This proposal aims to address these challenges and ensure that residents are receiving safe, quality care by an RN, at all times when needed. 

CMS is interested in comments regarding the feasibility of our proposed requirements for each LTC facility to have an RN on site 24 hours a day, seven days a week, including possible alternatives to this proposal.

 

Strengthening the Facility Assessment Requirement
To help improve the safety of residents, a comprehensive approach to establishing staffing standards is necessary to ensure that facilities are making thoughtful, informed staffing plans and decisions focused on meeting resident needs. As part of that approach, LTC facilities are already required to conduct, document, and review annually and, as necessary, a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. 

To ensure that facilities are utilizing the facility assessment as intended by making thoughtful, person-centered staffing plans and decisions focused on meeting resident needs, including staffing at levels above the proposed minimums as indicated by resident acuity, CMS is proposing several updates to the facility assessment as a means of strengthening these requirements, including:

• Clarifying that facilities must use evidence-based methods when care planning for their residents, including consideration for those residents with behavioral health needs; 
• Requiring that facilities use the facility assessment to assess the specific needs of each resident in the facility and to adjust as necessary based on any significant changes in the resident population; 
• Requiring that facilities include the input of facility staff, including, but not limited to, nursing home leadership, management, direct care staff (i.e., nurse staff), representatives of direct care staff, and staff who provide other services; and,
• Requiring facilities to develop a staffing plan to maximize recruitment and retention of staff consistent with what was described in the President’s April Executive Order on Increasing Access to Higher Quality Care and Supporting Caregivers. 

 

Permitting Regulatory Flexibility
CMS aims to hold nursing homes accountable for ensuring that residents receive safe and high-quality care. While we fully expect that LTC facilities will be able to meet our proposed minimum staffing standards, we recognize that in some instances, external circumstances may temporarily prevent a facility from achieving compliance despite the facility’s demonstrated best efforts. Moreover, some LTC facilities are still experiencing challenges in hiring and retaining certain nursing staff because of local workforce unavailability, which was exacerbated by the COVID-19 pandemic. Therefore, CMS proposes to allow for a hardship exemption in limited circumstances. LTC facilities may qualify for a temporary hardship exemption from the minimum nurse staffing HPRD standards only if they are able to meet specific criteria demonstrating the following:

• Workforce unavailability based on their location, as evidenced by either a medium (that is, 20 percent below the national average) or low (that is, 40 percent below national average) provider-to-population ratio for the nursing workforce, as calculated by CMS, by using the Bureau of Labor Statistics and Census Bureau data, or the facility is located at least 20 miles away from another LTC facility (as determined by CMS); and
• Good faith efforts to hire and retain staff through the development and implementation of a recruitment and retention plan; by documenting job postings, and job vacancies, including the number and duration of vacancies, job offers made, and competitive wage offerings, and
• A financial commitment to staffing by documenting the total annual amount spent on direct care staff.
• Prior to being considered, the LTC facility must be surveyed to assess the health and safety of the residents. Suppose an LTC facility is found noncompliant with the minimum staffing requirements while not meeting the exclusionary criteria (as outlined below). In that case, CMS will determine if the facility is in a workforce unavailability area. If CMS determines the facility is in a workforce unavailability area, the LTC facility’s documentation of a good faith effort to hire and retain staff and the LTC facility’s documentation of a financial commitment must be submitted to the State or CMS. CMS will then determine if the facility will be granted an exemption from enforcement. CMS will indicate if a facility has obtained an exemption on the Medicare.gov Care Compare website to ensure current and prospective residents and their families are aware that a facility has levels of staffing lower than the standard.

 

Facilities would not be eligible for an exemption if:

• They have failed to submit their data to the Payroll-Based Journal System;
• They have been identified as a special focus facility (SFF) or 
• They have been identified within the preceding 12 months as having widespread insufficient staffing with resultant resident actual harm or a pattern of insufficient staffing with resultant resident actual harm or have been cited at the immediate jeopardy level of severity with respect to insufficient staffing as determined by CMS.  

Given the complex health needs of residents living in LTC facilities and to protect resident health and safety, CMS believes that it is important for exempted facilities to continue to maintain compliance with existing requirements to provide services by a sufficient number of staff on a 24-hour basis to all residents in accordance with resident care plans. These requirements are responsive to longstanding concerns related to low staffing levels in facilities on weekends and evenings; further, ongoing RN presence is needed to provide care and monitor resident health. If a facility seeks relief from the 24/7 RN requirement, it would have to follow the applicable existing waiver process, as required by statute and set out in the current regulations.

 

Staggering Implementation
To give LTC facilities time to achieve compliance with the proposed minimum staffing requirements, CMS proposes that implementation of the final requirements will occur in three phases over a 3-year period for all non-rural facilities. Specifically, we propose for non-rural facilities:

• Phase 1 would require facilities located in urban areas to comply with the facility assessment requirements 60 days after the publication date of the final rule;
• Phase 2 would require facilities located in urban areas to comply with the requirement for an RN onsite 24 hours and seven days/week two years after the publication date of the final rule and
• Phase 3 would require facilities located in urban areas to comply with the minimum staffing requirements of 0.55 and 2.45 hours per resident day for RNs and NAs, respectively, three years after the publication date of the final rule.

CMS acknowledges the unique challenges that rural LTC facilities face, especially as it relates to staffing. We intend to promote safe, high-quality care for all residents regardless of location. We also recognize the need to strike an appropriate balance that considers the current challenges some LTC facilities are experiencing, particularly in rural areas. Therefore, we are proposing a later implementation date for rural facilities. Rural facilities will have three years to meet the proposed 24/7 RN requirement and five years to meet the proposed minimum staffing requirements (HPRD) as outlined below. Specifically, we propose for rural facilities:

• Phase 1 would require facilities to comply with the facility assessment requirements 60 days after the publication date of the final rule;
• Phase 2 would require facilities to comply with the requirement for an RN onsite 24 hours and seven days/week three years after the publication date of the final rule and
• Phase 3 would require facilities to comply with the minimum staffing requirement of 0.55 and 2.45 HPRD for RNs and NAs, respectively, five years after the publication date of the final rule.

 

Medicaid Institutional Payment Transparency
Millions of Americans, including children and adults of all ages, need long-term services and supports because of disabilities, chronic illness, and other factors. Today, most people who receive Medicaid-funded long-term services and supports are served in the community. However, about 1.5 million people receive Medicaid-funded long-term services and supports in nursing homes and intermediate care facilities for people with intellectual disabilities each year.

As the Biden-Harris Administration works to ensure that older adults, people with disabilities, and families have access to affordable, high-quality care, we recognize that workforce shortages and high rates of worker turnover in nursing facilities and intermediate care facilities for individuals with intellectual disabilities make it difficult for people with disabilities and older adults to have access to high-quality services.  

The proposed rule includes provisions that are intended to promote public transparency related to the percentage of Medicaid payments for services in nursing facilities and intermediate care facilities for individuals with intellectual disabilities that are spent on compensation to direct care workers and support staff.  The Medicaid institutional payment transparency reporting provisions, if adopted as proposed, would build on proposals in the Ensuring Access to Medicaid Services proposed rule in which CMS proposed to require, among other things, that states report to CMS and publicly on the percentage of Medicaid payments for certain home and community-based services that are spent on compensation for direct care workers.

 

Highlights from this proposed rule include:
New proposed institutional payment reporting requirements for states that would require states to report to CMS on the percentage of Medicaid payments for services in nursing facilities and intermediate care facilities for individuals with intellectual disabilities that are spent on compensation for direct care workers and support staff. These requirements would apply regardless of whether a state’s long-term services and supports delivery system is fee-for-service or managed care.

Promoting the public availability of Medicaid institutional payment information by proposing that both states and CMS make the institutional payment information reported by states to CMS available on public-facing websites. 

The goals of these proposed requirements are to promote accountability and inform efforts to address the link between sufficient payments being received by the institutional direct care and support staff workforce and access to and, ultimately, the quality of services received by Medicaid beneficiaries.

 

Comment Submission
There will be a 60-day comment period for the notice of proposed rulemaking, and comments must be submitted to the Federal Register no later than November 6, 2023.  For more information on how to submit comments or to review the entire rule, visit the Federal Register https://www.federalregister.gov/public-inspection/current.

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