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What CMS' Minimum Staffing Standards Proposed Rule Means for SNFs

Analysis  |  By Jasmyne Ray  
   September 07, 2023

The proposed staffing minimum exceeds the existing standards in most states.

The Centers for Medicare & Medicaid Services' newly released proposed rule for minimum staffing standards for the nation's nursing homes could further exacerbate the long-term sector's workforce struggles.

Meant to be the Biden Administration's ongoing solution for nursing home quality, the Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Report has raised concerns among the post-acute sector as a "one-size-fits-all" approach that would not guarantee quality care and could negatively affect operations.

Under the proposed rule, it requires nursing homes to implement specific nurse staffing levels to provide care for residents:

  • Facilities would be required to provide a minimum of 0.55 hours of care from a registered nurse (RN) each day
  • Another 2.45 hours of care from a nurse aide, per resident per day (PPD)

CMS has noted that these standards are higher than existing standards in almost every state, and it will mean that 75% of nursing homes will have to strengthen their current staffing. It has been estimated by critics of this proposal that the costs for raising staff levels will be in the billions.

For skilled nursing facility administrators who are already experiencing workforce shortages and recruitment and retention challenges, this standard could cause undue burden for the nation's nursing homes. Administrators will have to find ways to squeeze money from already tight operational budgets to hire nurses or find alternative means of funding. Finding and hiring nurses post-pandemic is also a difficulty as many nurses retired or left the nursing profession altogether. Not having enough staff could also mean nursing homes would have to shut down their operations.

CMS attempts to resolve these issues in a few ways. To support staffing, CMS also announced a nationwide campaign that is designed to create better career access for those interested in pursuing a nursing position in long-term care. CMS, working alongside the Health and Human Services Workforce Initiative and Department of Labor, will invest $75 million in financial incentives, including scholarships and tuition reimbursement.

Also, recognizing that the staffing minimum may be more difficult for facilities in rural and underserved community, CMS said it would take these difficulties into consideration through "staggered implementation and exceptions processes."

Paying post-acute nurses and nurse aides a competitive wage is also an issue. Direct care workers in nursing homes are vastly underpaid for the type of work they do.

CMS responded to this pain point by proposing in the rule that states will be required to collect, report on, and publish their compensation as a percentage of Medicaid payments for those who working in skilled nursing or intermediate care facilities.

Publishing the compensation of direct care workers is one step toward addressing their pay inequity, but it will require actual policy change or action from Medicaid to see results.

With the criticism that the proposed rule is “unfounded, unfunded, and unrealistic,” the nation’s long-term care administrators will be closely following how CMS listens and responds to their concerns about staffing minimums and if it truly is the answer to bettering the quality of nursing homes.

Editor's note: This article was updated on September 13, 2023.

Jasmyne Ray is the revenue cycle editor at HealthLeaders. 


Skilled nursing facilities will be required to provide a minimum of 0.55 hours of care from an RN each day.

The standards are posed to increase the financial strain on many facilities as they continue to struggle with hiring and retaining workers.

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