NIC Notes

Insights in Seniors Housing & Care

By: Bill Kauffman  |  May 14, 2024

Nursing Home Minimum Staffing Rule Finalized

Regulatory Environment  |  Skilled Nursing  |  Workforce  |  staffing

The White House recently announced the finalization of the nursing home minimum staffing rule. This will impact all skilled nursing properties that receive federal funding through Medicare and Medicaid. The proposed staffing rule has been the topic of many industry discussions since the White House released a comprehensive nursing home reform package in 2022. After the 2022 announcement, the Centers for Medicare & Medicaid Services (CMS) hired a consulting firm to study and determine the efficacy of implementing various staffing thresholds. CMS received nearly 50,000 comments on the proposed rule ranging from those that strongly supported the rule to those expressing opposition to the new standards. 

The final rule adopted standards that are largely similar to the proposed rule. The following is a summary of the standards, which will be rolled out across multiple phases. 

The timing for meeting the interim and final standards differs for urban and rural facilities. The interim requirements must be met by May 2026 for urban facilities and May 2027 for rural facilities, while the final requirements must be met by May 2027 for urban facilities and May 2028 for rural facilities. 

Highlights of the Rule 

  • Once fully implemented, nursing facilities will be required to meet minimum nurse staffing levels of 3.48 hours per resident day (HPRD), including 0.55 registered nurse (RN) and 2.45 nurse aide HPRD. 
  • CMS indicated that facilities may utilize a mix of nurse staff, including RNs, LPNs/LVNs, or nurse aides, to meet this standard. 
  • By May 2027, the final rule requires nursing facilities to have an RN on duty 24/7 and provide at least 3.48 HPRD of total nurse staffing hours irrespective of staff type. This initial deadline excludes the more specific RN and nurse aide requirements that will take effect once the rule is fully implemented. 
  • The final rule also includes new reporting and assessment requirements as well as a detailed process by which facilities may qualify for an exemption from the minimum staffing provisions. The final rule also indicates that CMS will release additional details later this year on how the $75 million investment in a nursing home staffing campaign will be structured. 

KFF performed an analysis and estimates that only 19% of nursing facilities would meet the minimum HPRD staffing standards under full implementation of the final rule with their current staffing levels and nearly 60% of facilities would meet the interim requirement of an overall requirement of 3.48 HPRD. 

Nursing homes may qualify for exemptions under certain conditions according to CMS. For example, if the property is located in an area where the supply of RN, NA, or total nurse staff is not sufficient to meet area needs as evidenced by the applicable provider-to-population ratio for nursing workforce. 

Note that the nursing home industry is expected to challenge the ruling. The industry is currently exploring various options including legal action. Additionally, several Senators and other officials have publicly expressed their concerns with the mandate and encouraged CMS and the current administration to reconsider. 

Readers can find detailed information on the CMS Fact Sheet here. 



About Bill Kauffman

Senior Principal Bill Kauffman works with the research team in providing research and analysis in various areas including sales transactions and skilled nursing. He has lead roles in creating new and enhanced products and implementation of new processes. Prior to joining NIC he worked at Shelter Development in investing/acquiring, financing, and asset management for over $1 billion in assets. He also had key roles in the value creation and strategic planning and analysis for over 65 entities. He received his Master of Science in Finance from Loyola University Maryland and holds the Chartered Financial Analyst Designation (CFA).

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