Details on the rule

The rule, which was first proposed in September, will require nursing homes to provide a minimum of 3.48 hours of nursing care per resident day, which will include 0.55 hours of care from an RN per resident day as well as at least 2.45 hours of care from a nurse aide per resident day.

The rule also requires nursing homes to have an RN on site 24 hours a day, seven days a week. Currently, CMS requires at least eight consecutive hours of RN presence each day as well as a licensed nurse of any level on duty 24 hours a day.

Facilities will be allowed to use any combination of staff — including RNs, licensed practical nurses, licensed vocational nurses, or nurse aids — to account for additional time.

Under the new rule, a facility with 100 residents would need two to three RNs and 10 or 11 nurse aids, as well as two additional nursing staff per shift to meet the new standards set by the rule, the Biden administration said.

According to a fact sheet from CMS, most of the roughly 15,000 nursing homes in the United States will likely need to hire staff to meet the new standards.

Reaction

When unveiling the final rule, Harris said the standards "will mean more staff" for residents, "which means fewer ER visits potentially, more independence. For families, it's going to mean peace of mind in terms of your loved one being taken care of."

"This is about dignity, and it's about dignity that we as a society owe to those in particular who care for the least of these," Harris added.

HHS Secretary Xavier Becerra said the new rule is about setting a standard for quality of care.

"We believe, that with more and more Americans going to nursing homes, it's time to make sure that quality is the standard that everyone strives for," he said.

Becerra added that the Biden administration listened to feedback from the nursing home industry following the proposed rule. The final rule will be phased in with longer time frames for nursing homes located in rural communities, and there will be temporary hardship exemptions for places where it's difficult to find staff.

Rep. Lloyd Doggett (D-Texas), who led more than 100 House members in a comment letter on the rule last year, said the Biden administration "has made modest improvements to new minimum nurse staffing standards. While much more is needed to ensure sufficient care and resident safety, I am pleased that this represents some hope of better care for vulnerable nursing residents with complex medical needs."

However, others argued the new mandates will pose a significant burden to nursing homes and could ultimately lead to closures.

Stacey Hughes, EVP of the American Hospital Association, said the final rule "could lead nursing homes to reduce capacity or close outright, including those that are otherwise high performers on quality and safety metrics." She added that the rule "could exacerbate the already serious shortages of nurses and skilled health care workers across the care continuum."

Mark Parkinson, president and CEO of the American Health Care Association, said in a statement that the rule's finalization was "unconscionable" given the nationwide workforce shortages.

"At the end of the day, the agency is overstepping with a one-size-fits-all enforcement approach that is deeply flawed," he said. "This fight is not over. Momentum against the mandates continues to build among both Democrats and Republicans, and we hope to work with lawmakers on more meaningful solutions that would help boost the long term care workforce."

John Bowblis, an economics professor and research fellow with the Scripps Gerontology Center at Miami University, noted that if Medicaid payments from states to nursing homes don't increase, then facilities will close.

"There aren't enough workers and there are shortages everywhere," he said. "When you have a 3% to 4% unemployment rate, where are you going to get people to work in nursing homes?"

Nate Schema, president and CEO of Evangelical Good Samaritan Society, which operates 132 skilled nursing facilities across seven states, said his company has more than 1,500 job openings. He noted that the mandate will require the nonprofit to focus more on filling clinical positions rather than other positions that are also important to residents.

"Now, instead of trying to meet the needs of patients from a psychosocial standpoint, by hiring additional activities staff or hiring additional spiritual ministry staff, I have to hire very specific categories to meet the rules of this regulation," Schema said. "It completely blows up how our staffing model works today." (AHA News, 4/22; Licon/Superville, Associated Press, 4/22; Weixel, The Hill, 4/22; Rau, KFF Health News, 4/22; Eastabrook, Modern Healthcare, 4/23)

CMS is on the verge of proposing new mandatory staffing levels at SNFs, a move that could improve care quality but may cost the industry billions of dollars. Learn about three ways the mandate could unfold — and how to prepare for what comes next.