Long-term Care Facilities Minimum Staffing

The Centers for Medicare and Medicaid Services (CMS) published a final rule creating new requirements for staffing levels in CMS-certified long-term care facilities on May 10, 2024, in the Federal Register, effective June 21, 2024. The final rule makes the following changes:

• Minimum staffing hours. Facilities must provide a minimum of 3.48 hours per resident day of direct nursing care, of which at least 0.55 hours per resident day must be by registered nurses (RNs) and 2.45 hours per resident day must be made by nurse aides (NAs). The remaining 0.48 hours per resident day may be provided by any combination of nurse staff, including RNs, NAs, Licensed Vocational Nurses (LVNs), and Licensed Practical Nurses (LPNs);
• RN on-site requirement. Facilities must have at least one RN on-site 24 hours a day, 7 days a week (24/7) and available to provide direct resident care. The on-site RN may be the Director of Nursing (DON). However, the DON must be available to provide direct resident care; and
• Facility assessment requirements. Certain changes to the facility assessment include the following:
  • Require evidence-based methods when planning care for residents, including those residents with behavioral health needs;
  • Assess specific needs of each resident and adjust care based on the assessed needs in the resident population;
  • Consider input from nursing home leadership, management, direct care staff, residents, and family members; and
  • Develop a staffing plan to maximize recruitment and retention of staff.

Hardship Exemptions

Facilities may qualify for a temporary hardship exemption if the facility meets all of the following requirements based on its geographic area:

• Exemption from 3.48 hours per resident day requirement. The facility must demonstrate that the combined licensed nurse—which includes RNs, LVNs, and LPNs—and nurse-aide-to-population ratio is a minimum of 20 percent below the national average;
• Exemption from 0.55 RN hours per resident day requirement, and exemption of 8 hours per day from the RN on-site 24/7 requirement. The facility must demonstrate the RN-to-population ratio is a minimum of 20 percent below the national average; and
• Exemption from 2.45 nurse aide hours per resident day requirement. The facility must demonstrate the NA-to-population ratio is a minimum of 20 percent below the national average.

Facilities receiving an exemption must post notice in the facility, notify residents, and notify the State’s Long-term Care Ombudsman.

Implementation

The final rule has a different timeline based upon facility geographic classification as follows:

Non-rural facilities:

• By August 8, 2024, facilities must have complied with the facility assessment requirements;
• By May 11, 2026, facilities must comply with the requirement to have an RN on-site 24/7 and with the 3.48 hours per resident day total nurse staffing requirement; and
• By May 10, 2027, facilities must comply with the minimum staffing requirement of 0.55 and 2.45 hours per resident day for RNs and NAs.

Rural facilities: Note: “Rural facilities” are defined as facilities that are not part of a metropolitan statistical area, which is defined by the federal Office of Management and Budget as having at least one urbanized area with a minimum population of 50,000.

• By August 8, 2024, facilities must have complied with the facility assessment requirements;
• By May 10, 2027, facilities must comply with the requirement to have an RN on-site 24/7 and with the 3.48 hours per resident day total nurse staffing requirement; and
• By May 10, 2029, facilities must comply with the minimum staffing requirement of 0.55 and 2.45 hours per resident day for RNs and NAs.