CMS Regulation to Establish Staffing Minimums: Why It Was Short-Lived

The pursuit of quality care in nursing homes is a long-standing concern, with adequate staffing levels often cited as a critical component. In 2024, the Centers for Medicare & Medicaid Services (CMS) finalized a rule aimed at establishing federal minimum staffing standards in long-term care facilities. However, this regulation, designed to enhance resident safety and care quality, faced significant pushback and was ultimately short-lived. This blog post will delve into the details of the CMS regulation, explore the reasons behind its swift reversal, and discuss the implications for nursing home residents and the long-term care industry.

The 2024 CMS Staffing Mandate: A Summary

The CMS regulation, finalized in April 2024, sought to address persistent concerns about understaffing in nursing homes. The key provisions of the rule included:

Minimum Nurse Staffing Standards: A requirement for facilities to provide a minimum of 3.48 hours per resident day (HPRD) of total direct nursing care. This total included at least 0.55 HPRD of direct registered nurse (RN) care and 2.45 HPRD of direct nurse aide care. Facilities could use any combination of RNs, licensed practical nurses (LPNs), and nurse aides to meet the additional 0.48 HPRD requirement.
24/7 RN On-Site Requirement: A mandate for nursing homes to have a registered nurse on-site 24 hours a day, seven days a week, to provide skilled nursing care.
Enhanced Facility Assessment Requirements: A call for more thorough assessments of facility needs to inform staffing plans and decisions.

These standards were set to be implemented in phases, with staggered timelines for rural and non-rural facilities, to allow nursing homes time to comply. CMS aimed to establish a national baseline for staffing that would reduce the risk of unsafe and low-quality care for residents.

Opposition and Legal Challenges

Despite the intentions behind the CMS regulation, it faced considerable opposition from the nursing home industry and some lawmakers. Several concerns were raised:

Workforce Shortages: A primary argument against the mandate was that it would exacerbate existing workforce shortages in the long-term care sector. Nursing homes, particularly those in rural and underserved communities, expressed concerns about their ability to find and hire the necessary staff to meet the new requirements.
Financial Burden: The cost of implementing the staffing standards was another major point of contention. The American Health Care Association and National Center for Assisted Living (AHCA/NCAL) estimated that the rule would require an additional 102,000 nurses and nurse aides, costing $6.5 billion each year.
Rigidity and Lack of Flexibility: Critics argued that the “one-size-fits-all” approach of the mandate failed to account for the diverse needs of residents and the unique circumstances of individual facilities. They contended that clinical judgment and flexibility were essential for determining appropriate staffing levels.

These concerns led to legal challenges against the CMS regulation. In one instance, a federal judge in Texas ruled that HHS had exceeded its statutory authority by requiring 24/7 RN staffing and setting per-resident minimum hours. The court argued that the existing statute only required “at least” eight hours of on-site nursing and that federal law mandated services “sufficient to meet the nursing needs” of residents, a more flexible standard.

The Repeal of the Staffing Mandate

The legal challenges, coupled with a legislative moratorium, ultimately led to the repeal of the CMS staffing mandate. In December 2025, the Department of Health and Human Services (HHS) issued an interim final rule that rescinded the key provisions of the 2024 regulation.

Several factors contributed to this decision:

Legislative Moratorium: The “One Big Beautiful Bill Act,” enacted in July 2025, imposed a 10-year implementation and enforcement moratorium on the minimum staffing requirements for long-term care facilities.
Court Decisions: Federal court rulings had already cast doubt on the legality of the mandate, with judges finding that CMS had overstepped its authority.
Concerns about Access to Care: HHS and CMS acknowledged concerns that the mandate could disproportionately burden facilities serving rural and tribal communities, potentially jeopardizing patients’ access to care.

By repealing the staffing mandate, CMS reverted to its prior policy, which required facilities to have an RN on staff for at least eight consecutive hours a day, seven days a week, and to designate an RN as the director of nursing. The facility assessment requirements adopted in the 2024 final rule, however, remain in place.

Implications and the Path Forward

The swift reversal of the CMS staffing mandate has significant implications for the long-term care industry and the residents it serves.

Relief for Nursing Homes: The repeal provides immediate relief for facilities that were facing the prospect of increased staffing costs and potential workforce challenges. It may help prevent facility closures, particularly in rural areas.
Concerns about Quality of Care: Advocates for nursing home residents have expressed strong concerns that the repeal will compromise resident safety and quality of care. They argue that minimum staffing standards are essential for ensuring that residents receive the attention and support they need.
Ongoing Debate: The debate over appropriate staffing levels in nursing homes is far from over. While the federal mandate has been rescinded, many states have their own staffing requirements, and the issue is likely to remain a focus of regulatory and legislative efforts.

Moving forward, it will be crucial to find sustainable and effective ways to improve the quality of care in nursing homes. This may involve:

Investing in Workforce Development: Addressing the long-term care workforce shortage through training programs, recruitment initiatives, and efforts to improve job quality and retention.
Promoting Innovative Staffing Models: Exploring alternative staffing models that leverage technology and interdisciplinary teams to enhance care delivery.
Strengthening Oversight and Enforcement: Ensuring that existing regulations are effectively enforced and that facilities are held accountable for providing quality care.
Engaging Stakeholders: Fostering collaboration among residents, families, providers, policymakers, and advocates to develop solutions that meet the diverse needs of the long-term care population.

The CMS regulation to establish staffing minimums may have been short-lived, but it has brought renewed attention to the critical issue of staffing levels in nursing homes. As the debate continues, it is essential to prioritize the safety, well-being, and dignity of the millions of Americans who rely on long-term care services.