CMS Releases Final Nursing Home Staffing Rule

This week, the Centers for Medicare & Medicaid Services (CMS) issued the Minimum Staffing Standards for Long-Term Care (LTC) Facilities and Medicaid Institutional Payment Transparency Reporting final rule. 

CMS is finalizing a total nurse staffing standard of 3.48 hours per resident day (HPRD), which must include at least 0.55 HPRD of direct registered nurse (RN) care and 2.45 HPRD of direct nurse aide care. Facilities may use any combination of nurse staff (RN, licensed practical nurse [LPN] and licensed vocational nurse [LVN], or nurse aide) to account for the additional 0.48 HPRD needed to comply with the total nurse staffing standard.

CMS is also finalizing enhanced facility assessment requirements and a requirement to have an RN onsite 24 hours a day, seven days a week, to provide skilled nursing care. 

This final rule provides a staggered implementation timeframe of the minimum nurse staffing standards and 24/7 RN requirement based on geographic location as well as possible exemptions for qualifying facilities for some parts of these requirements based on workforce unavailability and other factors. The requirements of this final rule prioritize safety and health care quality while taking into consideration the unique workforce challenges some LTC facilities may be experiencing, especially those in rural areas. 

CMS will closely monitor and evaluate the provisions of this final rule, including but not limited to, the minimum staffing standards, the 24/7 RN requirement, the exemption process, and the definition of rural, as they are implemented over the next several years to determine whether any updates or changes are necessary in the future. 

Additionally, to increase transparency related to compensation for workers, CMS will also require states to collect and report on the percent of Medicaid payments that are spent on compensation for direct care workers, and support staff, delivering care in nursing facilities and intermediate care facilities, for individuals with intellectual disabilities.

To ensure that facilities are utilizing the facility assessment requirements as intended by making thoughtful, person-centered staffing plans, and decisions focused on meeting resident needs, including staffing at levels above the finalized minimums as indicated by resident acuity, CMS is finalizing the following:

• Facilities must use evidence-based methods when care planning for their residents, including consideration for those residents with behavioral health needs.
• Facilities must 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.
• Facilities must include the input of the nursing home leadership, including but not limited to, a member of the governing body and the medical director; management, including but not limited to, an administrator and the director of nursing; and direct care staff, including but not limited to, RNs, LPNs/LVNs, and NAs, and representatives of direct care staff as applicable. The LTC facility must also solicit and consider input received from residents, resident representatives, and family members.
• Facilities are required 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 High-Quality Care and Supporting Caregivers.

To give LTC facilities time to achieve compliance with the proposed minimum staffing requirements, CMS is implementing the minimum nurse staffing requirements to occur in three phases over a three-year period for all non-rural facilities. Specifically, we are finalizing the following for non-rural facilities:

• Phase 1 — Within 90 days of the final rule publication, facilities must meet the facility assessment requirements. 
• Phase 2 — Within two years of the final rule publication, facilities must meet the 3.48 HPRD total nurse staffing requirement and the 24/7 RN requirement. 
• Phase 3 — Within three years of the final rule publication, facilities must meet the 0.55 RN and 2.45 NA HPRD requirements.

CMS acknowledges the unique challenges that rural LTC facilities may 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 finalizing a later implementation date for rural facilities. Specifically, we are finalizing the following for facilities located in rural areas (as defined by the Office of Management and Budget):

• Phase 1 — Within 90 days of the final rule publication, facilities must meet the facility assessment requirements. 
• Phase 2 — Within three years of the final rule publication, facilities must meet the 3.48 HPRD total nurse staffing requirement and the 24/7 RN requirement. 
• Phase 3 — Within five years of the final rule publication, facilities must meet the 0.55 RN and 2.45 NA HPRD requirements. 

The final rule is available to review today in the Federal Register at: https://www.federalregister.gov/public-inspection/2024-08273/medicare-and-medicaid-programs-minimum-staffing-standards-for-long-term-care-facilities-and-medicaid

The Society is analyzing the final rule and submitted comments as well as issued a statement on the proposed rule. Both can be found here https://paltc.org/news-media/amda-urges-prioritization-adequate-staffing-response-new-rule and https://paltc.org/policies/position-staffing-standards-long-term-care.