The New Federal Minimum Staffing Standards
As of April 2024, CMS established new federal minimum staffing standards for all Medicare and Medicaid certified nursing homes. These rules aim to improve care quality and safety through key requirements:
- A total of 3.48 hours of nursing care per resident per day (HPRD).
- At least 0.55 HPRD provided by a Registered Nurse (RN).
- At least 2.45 HPRD provided by a Nurse Aide (NA).
- An RN must be physically on-site 24/7.
These are minimum requirements, and facilities should use a comprehensive facility assessment to determine if higher staffing levels are needed based on resident needs.
Phased Implementation and Timelines
The CMS rule includes a phased implementation plan to help the industry adjust, with different timelines for rural and non-rural facilities.
Non-Rural Facilities:
- Phase 1 (Within 90 days of rule publication): Strengthened facility assessment requirements must be met.
- Phase 2 (Within two years): The 3.48 HPRD total nurse staffing requirement and the 24/7 RN requirement must be met.
- Phase 3 (Within three years): The 0.55 RN and 2.45 NA HPRD requirements must be met.
Rural Facilities:
- Phase 1 (Within 90 days of rule publication): Strengthened facility assessment requirements must be met.
- Phase 2 (Within three years): The 3.48 HPRD total nurse staffing requirement and the 24/7 RN requirement must be met.
- Phase 3 (Within five years): The 0.55 RN and 2.45 NA HPRD requirements must be met.
State vs. Federal Requirements
The CMS rule sets a federal baseline, but states often have their own, sometimes more stringent, staffing regulations. Nursing homes must comply with both sets of rules, adhering to the higher standard when they differ.
Comparison of Staffing Regulations
| Feature | CMS Federal Mandate (Final Phase) | Example: Hypothetical State Mandate | Implication for Facilities |
|---|---|---|---|
| Total HPRD | 3.48 HPRD | 4.0 HPRD | Must meet the higher state standard of 4.0 HPRD. |
| RN HPRD | 0.55 HPRD | 0.55 HPRD | Must meet the same standard as the federal rule. |
| NA HPRD | 2.45 HPRD | 2.75 HPRD | Must meet the higher state standard of 2.75 HPRD. |
| 24/7 RN Onsite | Yes | Yes | Must meet the standard set by both regulations. |
Understanding Hours Per Resident Day (HPRD)
HPRD measures the average direct nursing care a resident receives daily. It's calculated by dividing total direct care staff hours by the number of residents and is a key indicator of staffing adequacy.
