In September 2023, the Centers for Medicare & Medicaid Services issued a proposal for the first-ever federal staffing mandate for U.S. nursing homes. The rule would require facilities to provide a minimum of 3.0 hours of direct care per patient day — 0.55 hours by a registered nurse and 2.45 hours by a nurse aide.

Non-rural nursing homes would have three years to comply with the mandate, while those in rural areas would be given five years to do so. A requirement for 24/7 RN coverage — three times the current standard — would also be initiated two years after the rule takes effect for urban facilities, with rural facilities granted an additional year.

U.S. Secretary of Health and Human Services Xavier Becerra said, “Establishing minimum staffing standards for nursing homes will improve resident safety and promote high-quality care so residents and their families can have peace of mind.”

According to CMS, as of today, 75% of nursing homes would need to add staff to reach these minimum compliance levels. Given the workforce crisis within the industry, the proposal contains an option for hardship waivers. While it is not offering any direct funding for hiring nurses, CMS stated that it would provide $75 million to support financial incentives for workers, such as scholarships and tuition reimbursement.

Other features of the proposal include changes to the facility assessment process, stipulating that nursing homes must employ evidence-based methods in care planning, conduct evaluations of each resident’s specific needs, and develop a staffing strategy to boost recruitment and retention.

In addition, new institutional payment reporting regulations would require states to report to CMS on the percentage of nursing home Medicaid payments spent on compensation for direct care workers and support staff.

In the works for nearly two years, the proposed CMS mandate represents an unprecedented step — one that consumer advocates have called for and that struggling facility operators have argued against.

The long-term care sector has still not recovered from the pandemic-era loss of 210,000 workers between February 2020 and December 2022. The American Health Care Association and the American Hospital Association have warned that, at the current pace of job growth, nursing homes will not return to pre-COVID staffing levels until 2027.

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