CMS Minimum Staffing Rule-Requirements

As noted in last month’s Survey & Regulatory Update addressing the facility assessment requirements for minimum staffing, on April 22, 2024, the Centers for Medicare and Medicaid Services (CMS) released the anticipated final rule, Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting. While the final rule was published in the Federal Register on May 8, 2024, the effective date for this final rule is June 21, 2024. It is important to be aware that several components of the rule have specific implementation dates beyond this effective date.

For nursing homes, CMS finalized specific total nurse staffing, nurse aide, and RN HPRD, as well as the 24/7 RN requirements. Each and every facility must meet or exceed a minimum of 3.48 HPRD for total nurse staffing including but not limited to:

• A minimum of 0.55 hours per resident day for registered nurses. The Director of Nursing (DON), as well as RNs with administrative duties, likely count toward the 0.55 HPRD for registered nurses as long as they are available to provide resident care when needed.
• A minimum of 2.45 hours per resident day for nurse aides (NAs). The final rule does not change the definition of NAs, which per the State Operation Manual states, “Nurse aides include certified nurses (NACs), aides in training and medication aides/technicians, which all require training.”

The facility must have RN onsite 24 hours per day, seven days a week, that is available to provide direct resident care. The DON can meet the RN requirement as long as they are available to provide care.

Facilities cannot staff only to the numerical HPRD standards stated above. Facilities must continue to ensure sufficient staff with the appropriate competencies and skills sets to ensure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments, acuity and diagnoses of the facility’s resident population in accordance with the facility assessment.

CMS has outlined the following implementation timeframes regarding the requirement for the HPRD, and 24/7 RN requirements, and 0.55 RN and 2.45 NA requirements in rural areas and non-rural areas:

• Facilities in rural areas (as defined by the Office of Management and Budget (OMB)):
  • Facility Assessment: 90 days after the publication date of the final rule (August 8, 2024)
  • 3.48 total HPRD and 24/7 RN: 3 years after the publication of the final rule (May 10, 2027)
  • 0.55 RN HPRD and 2.45 NA HPRD: 5 years after the publication of the final rule (May 10, 2029)

• Facilities in non-rural areas (as defined by OMB):
  • Facility Assessment: 90 days after the publication date of the final rule (August 8, 2024)
  • 3.48 total HPRD and 24/7 RN: 2 years after the publication of the final rule (May 10, 2026)
  • 0.55 RN HPRD and 2.45 NA HPRD: 3 years after the publication of the final rule (May 10, 2027)

The July 2024 WHCA Survey & Regulatory Update will address the Waiver Processes Available for Facilities Related to the Minimum Staffing Requirements. If you have questions, please call Elena Madrid at (800) 562-6170, extension 105, or email.