On May 10, 2024, the Centers for Medicare & Medicaid Services (CMS) published the Minimum Staffing Standards for Long-Term Care (LTC) Facilities and Medicaid Institutional Payment Transparency Reporting final rule, which aims to reduce potential risks to residents in LTC facilities by assuring appropriate nurse staffing levels. The final rule will become effective on June 21, 2024.

The final rule sets a nurse staffing standard of 3.48 hours per resident day (HPRD). The 3.48 HPRD requirement includes a minimum of 0.55 HPRD of direct registered nurse (RN) care and 2.45 HPRD of direct nurse aide care. The additional 0.48 HPRD required to comply with the standard can be fulfilled using any combination of nursing staff including RNs, licensed practical nurses (LPN), licensed vocational nurses (LVN) or nurse aids. The rule further requires LTC facilities to have an RN onsite 24 hours a day, seven days a week to provide skilled nursing care.

In addition to these minimum staffing standards, CMS also announced that it is finalizing additional requirements for the facility-wide assessments that LTCs are already required to conduct annually to determine what resources are necessary to care for their residents. These assessments must use evidence-based methods when care planning for each of the facility’s residents, including consideration of a resident’s behavioral health needs, and any significant changes in facility census or facility leadership. The assessment must include input from the LTC leadership, management, and direct care staff. LTC facilities must also seek out and consider input from residents, their representatives and family members. The use of these enhanced assessments may result in a need for staffing above the minimums set forth in the rule.

The implementation of the rule will be staggered over a three-year period for all non-rural LTC facilities.

• Phase 1 will require facilities to meet the facility assessment requirements within 90 days.
• Phase 2 will require facilities to meet the 3.48 HPRD total nurse staffing requirement and the 24/7 RN requirement within two years.
• Finally, Phase 3 will require facilities to meet the 0.55 RN and 2.45 nurse aid HPRD requirements within three years.

CMS acknowledges that meeting these requirements will be more difficult for LTC facilities in rural areas, and accordingly it is providing such facilities with an additional one year to implement Phase 1 and two additional years to implement Phase 2.

When CMS initially proposed this rule, it was accompanied by an initiative to invest more than $75 million in a nursing home staffing campaign which would include incentives for workers to pursue careers in the field. However, such financial incentives were not included in the final rule.  Rather, CMS indicated it was still conducting research on the issue and anticipated financial incentives to begin in 2025.

The final rule will undoubtedly increase costs for LTC facilities. Indeed, comments to the proposed rule suggest that such staffing requirements may not be feasible, due not only to the cost involved, but also to the significant nursing shortages for all healthcare providers. Accordingly, LTC facilities should keep a close eye on any financial incentives that may be provided to alleviate this burden.