Minimum-Staffing Rule For Nursing Homes Finalized, Likely Complicating Post-Acute Care Labor Dynamics

The White House on Monday announced that the nursing home minimum-staffing rule has been finalized.

Effectively, the rule requires all nursing homes that receive Medicare and Medicaid funding to maintain a certain staffing threshold at all times. The U.S. Centers for Medicare & Medicaid Services (CMS) first proposed the minimum-staffing requirement last fall.

“Medicare and Medicaid pay billions of dollars per year to ensure that 1.2 million Americans that receive care in nursing homes are cared for, yet too many nursing homes chronically understaff their facilities, leading to sub-standard or unsafe care,” a White House fact sheet from Monday stated.


While the minimum-staffing rule does not apply to home health agencies, it is something that all home-based care providers should be aware of, as its finalization will likely complicate labor dynamics in the post-acute care sector. In-home care providers and nursing homes often go head-to-head on hiring for clinical roles in their markets, and nursing homes may now be forced to act more aggressively in recruiting and retaining staff.

Home Health Care News last year confirmed that CMS had no immediate plans to put forward a similar staffing-related proposal for home-based care providers.

The minimum-staffing rule is primarily meant to improve the care of nursing home residents, but the Biden administration also hopes it will offset worker burnout.


“This rule will not only benefit residents and their families, it will also ensure that workers aren’t stretched too thin by having inadequate staff on site, which is currently a common reason for worker burnout and turnover,” the fact sheet continued.

Specifically, the rule mandates a minimum of 3.48 hours per resident per day of total staffing for nursing homes, with specific allocations for registered nurses (RN) and nurse aides. For every resident per day, the staffing requirements include 0.55 hours from registered nurses and 2.45 hours from nurse aides.

This translates to facilities with 100 residents needing a minimum of two to three RNs, plus 10 to 11 nurse aides per shift, along with two additional nurse staff members, who could be registered nurses, licensed professional nurses or nurse aides.

“Many facilities would need to staff at a higher level based on their residents’ needs,” the White House stated in its fact sheet. “It will also require facilities to have a registered nurse onsite 24 hours a day, seven days a week, to provide skilled nursing care, which will further improve nursing home safety.”

The nursing home staffing rule stems from a comprehensive package of intended nursing home reforms that the White House first released in 2022.

The rule will be introduced in phases, with longer timeframes for rural communities, according to the Biden administration. “Limited, temporary exemptions” will be available for certain aspects of the rule, but they’ll only be for “nursing homes in workforce shortage areas that demonstrate a good faith effort to hire.”

In the White House fact sheet highlighting that the nursing home minimum-staffing rule had been finalized, the Biden administration also announced that CMS will be moving forward with what has become known as the Medicaid 80-20 rule.

Under the “Ensuring Access to Medicaid Services” final rule, at least 80% of Medicaid payments for home care services must go toward workers’ wages.

Several industry groups that represent senior care providers have already criticized both of Monday’s developments.

“Two major issues – the lack of qualified candidates and the cost of recruiting and training staff – mean that implementation of the nursing home final rule will likely limit older adults and families’ access to care and services,” LeadingAge President and CEO Katie Smith Sloan said in a statement. “On the Medicaid Access rule, the lack of infrastructure for collecting and reporting out accurate information, of financing to support added resource needs, and of data to ensure that the dollars are being distributed as intended, will decrease access to care. What’s more, given these shortcomings, there is no guarantee that this rule will increase worker compensation.”

Additional reporting by Shelby Grebbin.

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