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On April 22, 2024, the Centers for Medicare and Medicaid Services (CMS) released a highly-anticipated final rule that creates new requirements for nurse staffing levels in nursing facilities, settings that provide medical and personal care services for 1.2 million Americans, and for which the adequacy of staffing has been a longstanding issue. CMS received nearly 50,000 comments on the proposed rule, ranging from comments that strongly supported the proposed standards to those that opposed them. Among those comments, the nursing home industry suggested the rule was too onerous, given staffing shortages and costs, and could lead to nursing facility closures, while resident and family advocates suggested the proposed standards were too weak to address quality concerns.
In the final rule, CMS adopted staffing standards that are mostly similar to the staffing requirements in the proposed rule. Requirements will take effect in different phases. When fully implemented for all facilities, nursing facilities will be required to meet minimum nurse staffing levels of 3.48 hours per resident day (HPRD), including 0.55 registered nurse (RN) and 2.45 nurse aide HPRD. Additionally, they will be required to have an RN on duty 24 hours a day, 7 days a week (24/7). By May 2027, prior to full implementation, the final rule requires nursing facilities to have an RN on duty 24/7 and at least 3.48 HPRD of total nurse staffing hours irrespective of staff type, without the more specific RN and nurse aide requirements that take effect when the rule is fully implemented. Timelines for meeting the interim and final requirements will differ for urban (10,400 facilities, or 73% of facilities) and rural facilities (4,000 facilities, or 27% of facilities). The interim requirements must be met by May 2026 for urban facilities and May 2027 for rural facilities. The final requirements must be met by May 2027 for urban facilities and May 2028 for rural facilities (though HHS press materials stated May 2029).
This analysis uses the most recent publicly-available data to examine the percentage of nursing facilities that currently meet the minimum staffing requirements in the final rule, which phases in beginning in May 2026 for some facilities. Specifically, this analysis calculates the share of facilities that currently meet the overall requirement of 3.48 HPRD (regardless of staff type) and the share that meet the fully implemented, more specific staffing standards (HRPDs of 3.48 overall, 0.55 for RNs, and 2.45 for nurse aides). This analysis uses Nursing Home Compare data from March 2024, which includes 14,403 nursing facilities (97% of all facilities, serving 1.18 million or 98% of all residents), and reflects staffing levels from July to September 2023. Due to data limitations, this analysis does not look at the 24/7 RN requirement. See Methods for more information.
KFF estimates that 19% of nursing facilities would meet the minimum HPRD staffing standards under full implementation of the final rule with their current staffing levels (Figure 1). Nearly 60% of facilities would meet the interim requirement of an overall requirement of 3.48 HPRD, but fewer facilities would meet the RN and nurse aide provisions that are required when the rule is fully implemented (49% and 30% respectively; data not shown).
The final rule also includes new reporting and assessment requirements and the process by which facilities may qualify for an exemption from the minimum staffing provisions. The final rule also indicates that CMS will release additional details later this year on how the $75 million investment in a nursing home staffing campaign will be structured. As noted in the proposed rule, CMS aims to balance the goal of establishing stronger staffing requirements against the practicalities of implementation and costs.
The analysis does not evaluate facilities’ ability to comply with other requirements in the final rule, including the requirement to always have a registered nurse on duty 24/7 or the ability to meet the new reporting and assessment requirements due to data limitations (see Methods). The analysis also does not estimate which facilities would qualify for an exemption or how staffing levels will change between now and when the staffing standards take effect.
A forthcoming analysis will look at the share of facilities that currently meet the new standards across a variety of dimensions, including ownership, state, and urban or rural location.
Methods
This analysis uses Nursing Home Compare as of March 2024 and reflects staffing levels from July to September 2023. Nursing Home Compare is a publicly available dataset that provides a snapshot of information on quality of care and key characteristics for approximately 14,900 Medicare and/or Medicaid-certified nursing facilities. This analysis drops about 3% of nursing facilities, including the facilities in Guam and Puerto Rico and nursing facilities for which there was not staffing data available for the fourth quarter of 2023, for a total analytic sample of 14,403 facilities. The number of facilities identified in this analysis as meeting/not meeting requirements may differ from CMS’ estimates due to different years and quarters of data used for estimates.
The Office of Management and Budget’s (OMB) delineation of metropolitan and micropolitan statistical areas were used to designate rural and urban areas. Urban and rural facilities have different timelines to come into compliance with the rule, which this analysis does not take into account. This analysis reflects compliance rates if the HPRD requirements were in effect now for all facilities.
Due to the limitations of publicly available data, this analysis does not look at facilities that meet the requirement to have an RN on staff 24 hours a day, seven days a week (24/7). Nursing home staffing data is calculated from the Payroll Based Journal (PBJ), which includes data on the total number of RN hours worked per day at a facility, but no data on the timing of shifts. This limits our understanding of whether shifts were worked simultaneously by multiple employees (possibly not fulfilling the 24-hour requirement) or whether those hours were spread out over a 24-hour period (fulfilling the 24-hour requirement).
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