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This rule establishes minimum staffing standards for long-term care facilities, as part of the Biden-Harris Administration’s Nursing Home Reform initiative to ensure safe and quality care in long term care facilities. In addition, this rule requires States to report the percent of Medicaid payments for certain Medicaid-covered institutional services that are spent on compensation for direct care workers and support staff.Consistent with the Administration’s commitment to maximize transparency and public engagement, and to allow communities greater opportunities to provide input in the regulatory process, HHS sought the expertise of colleagues in the Office of Management and Budget, the General Services Administration, and the Consumer Financial Protection Bureau to inform an alternative approach to public comments for the proposed nursing home minimum staffing rule. The Department ultimately established and disseminated in public materials a direct web link to allow a more accessible comment submission path to the public, lowering the barriers to participation for the nursing home residents, families, and facility staff who will be directly impacted by this regulation.

Overall Description of Deadline: Per the CMS notice published December 30, 2004 (69 FR 78442), except for certain Medicare payment regulations and certain other statutorily-mandated regulations, we schedule all Medicare final regulations for publication within the 3-year standardized time limit in the current Unified Agenda. We do not intend to delay publishing a Medicare final regulation for 3 years if we are able to publish it sooner.

Statement of Need:

Ensuring that beneficiaries receive safe, reliable, and quality nursing home care is a critical function of the Medicare and Medicaid programs and a top priority of CMS. The COVID-19 Public Health Emergency (PHE) tragically caused unprecedented illness and death among nursing home residents and workers. The PHE also exacerbated staffing challenges experienced in many facilities and further highlighted disparities in care and outcomes. Despite existing requirements that facilities provide sufficient levels of staffing in LTC facilities, chronic understaffing remains a significant concern.  This rule establishes minimum staffing standards for long-term care facilities, as part of the Biden-Harris Administration's Nursing Home Reform initiative to ensure safe and quality care in long-term care facilities. In addition, this rule requires States to report the percent of Medicaid payments for certain Medicaid-covered institutional services that are spent on compensation for direct care workers and support staff.

Summary of the Legal Basis:

Sections 1819 and 1919 of the Act authorize the Secretary to issue requirements for participation in Medicare and Medicaid, including such regulations as may be necessary to protect the health and safety of residents (sections 1819(d)(4)(B) and 1919(d)(4)(B) of the Act).

Alternatives:

In developing the policies contained in this rule, we considered numerous alternatives.  The proposed rule solicited comments on alternative policy options that should be considered for establishing minimum nurse staffing standards that would maintain acceptable quality and safety within LTC facilities.

Anticipated Costs and Benefits:

The proposed rule included an estimated cost of $40.6 billion over 10 years for the 24/7 RN and the 0.55 RN and 2.45 NA hours per resident day (HPRD) requirements and $147 million for the Medicaid institutional payment transparency reporting requirement. Quantified benefits include an estimated Medicare savings of $2.5 billion over 10 years due to fewer hospitalizations and emergency department visits, as well as increased resident discharges to home or the community.

Risks:

This action establishes minimum staffing standards that nursing homes must meet in order to ensure that residents receive safe and quality care in LTC facilities. The minimum staffing standards also provide staff in LTC facilities with the support they need to safely care for residents and reduce staff turnover and burnout, which can lead to improved safety and quality for residents and staff.  In addition, the rule promotes public transparency related to the percent of Medicaid payments for certain institutional services that are spent on compensation to direct care workers and support staff.  While there may be additional costs to implement these requirements, the proposals strike an appropriate balance between cost and benefit and are necessary at this time to protect resident health and safety and ensure their needs are met.