CMS releases final rule requiring minimum staffing standards for nursing homes

April 30, 2024

The Centers for Medicare and Medicaid Services (CMS) released a final rule April 22 related to staffing requirements in nursing homes that receive Medicaid or Medicare funds. The new requirements exceed Washington’s state-level requirements for nursing home staffing. The rule requires a registered nurse (RN) to be on-site and available to provide direct patient care 24 hours per day and seven days per week. It also requires every resident to receive a minimum of 3.48 hours of care per resident day (HPRD), with 0.55 HPRD provided by an RN and 2.45 HPRD provided by a nurse aide. The remaining 0.48 HPRD can be provided by any combination of nursing staff, including licensed practical nurses/licensed vocational nurses (LPNs/LVNs).

Washington State requires that nursing homes provide 3.4 HPRD but does not distinguish between licensure levels for the provision of care. The state also only requires a nursing home to have an RN on-site if the facility is considered a large, nonessential community provider with more than 60 beds. With the final regulation from CMS, all nursing homes receiving Medicaid or Medicare funds will have to have an RN on-site 24/7 regardless of their size. Both the federal and state requirements have an exemption process if facilities have made a good-faith effort to hire, but the process differs between the two.

Implementation of the rule will be phased in, with an extended timeframe for rural communities. For non-rural area nursing homes, the 24/7 on-site RN and the 3.48 total HPRD requirement must be met within two years. Within three years, non-rural facilities must meet the 0.55 RN and 2.45 nurse aide HPRD requirement. Facilities in rural areas will have three years to meet the 24/7 on-site RN and 3.48 total HPRD requirement, and five years to meet the 0.55 RN and 2.45 nurse aide HPRD requirement. CMS opted to use the Office of Management and Budget (OMB) definition of rural for this purpose. This is a change from the proposed rule, in which CMS proposed to use the U.S. Census Bureau definition.

Other requirements in the final rule include changes to facility assessment requirements and state Medicaid reporting on what percentage of payments for Medicaid-covered services are spent on direct care and support staff compensation.

WSHA submitted a comment letter to CMS on the proposed rule and worked closely with our long-term care partners to submit a joint letter. WSHA’s comments primarily focused on CMS’s one-size-fits-all approach to staffing, failure to include LPNs/LVNs in staffing requirements and using the U.S. Census Bureau’s definition of rural.

A fact sheet from CMS is available here. If you have any questions about the finalized regulation, please contact WSHA Policy Director Remy Kerr at (Remy Kerr)


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