New CMS Rule Sets Stringent Staffing Standards for Long-Term Care Facilities

In a landmark move, on April 22, 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. This action underscores the CMS determination to enhance the safety and quality of care in the nation’s nursing homes, which serve nearly 1.2 million residents under the Medicare and Medicaid programs.

The decision followed extensive public engagement, with CMS considering over 46,000 comments from stakeholders. The resulting standards introduce mandatory minimum nurse staffing levels aimed at reducing risks associated with inadequate care. Under the new rule, LTC facilities must ensure a daily average of 3.48 hours of direct nursing care per resident. This includes a minimum of 0.55 hours from registered nurses (RNs) and 2.45 hours from nurse aides, with flexibility in how the remaining 0.48 hours are fulfilled by individuals falling under different nursing staff categories.

A significant aspect of the rule is the requirement for an RN to be on-site 24 hours a day, seven days a week, to address the increasingly complex medical needs of residents. This requirement aims to prevent safety incidents, especially during off-peak times such as nights and weekends.

Additionally, the rule mandates enhanced facility assessments to ensure that LTC homes are making informed staffing decisions based on resident needs. Facilities must now utilize evidence-based methods in care planning, particularly for residents with behavioral health needs, and adjust staffing according to significant changes in resident populations.

Recognizing the associated workforce challenges, particularly in rural areas, CMS has introduced a staggered implementation timeline and potential exemptions for facilities facing significant staffing shortages. Facilities can qualify for exemptions based on geographic staffing unavailability, financial commitment to staffing, and documented efforts to recruit and retain staff.

The implementation of the staffing requirements will occur in phases over three years for non-rural facilities and up to five years for rural facilities, allowing them time to adapt.

To further enhance transparency and accountability, the rule also includes provisions for Medicaid Institutional Payment Transparency. States are now required to report the percentage of Medicaid payments used for compensation of direct care workers and support staff. This move complements other CMS initiatives, including a $75 million campaign launched in September 2023 to increase nursing staff in LTC facilities by offering financial incentives like tuition reimbursement and promoting career pathways within the nursing field.

CMS’s comprehensive approach, from setting rigorous staffing minimums to fostering workforce development and transparency in Medicaid payments, may aim to secure high-quality, safe care for all LTC facility residents, but on the slim profit margins of the nursing home industry, can nursing homes stay in business? Such facilities are already seeing the impact of the rise of Medicare Advantage cutting rates and reducing approved stays.