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Nursing Home Staffing Standards are Finally Becoming a Reality

September 19, 2023


On September 1, just a few days before Labor Day, the Centers for Medicare & Medicaid Services (CMS) released a long-awaited proposed rule on minimum staffing levels in nursing homes nationwide. The proposed minimum staffing level and other provisions discussed below represent the most significant nursing home regulatory reform for decades, and PHI celebrates this major step forward. We are also gratified to see our arguments and evidence on the critical links among job quality, workforce recruitment, retention, and care quality reflected throughout the proposed rule. At the same time, we call for CMS to provide key amendments to the rule and elevate the factors critical to its implementation.

In this article, we outline our thoughts on this rule, including what we appreciate, how it could be improved, and why its implementation will benefit from a concerted effort in the field to ensure workers and nursing homes are prepared to meet this mandate.


For decades, PHI has advocated for minimum staffing standards in nursing homes that would foster reasonable workloads and promote safety while ensuring the delivery of quality care to nursing home residents. While the standards in the proposed regulations from CMS fall below the staffing level many researchers and other experts have proposed—as described later in this article—they nevertheless send a strong message that nursing homes must be adequately staffed to protect both staff and residents from harm, countering a profound vulnerability that the COVID-19 pandemic exposed and tragically amplified.

A key proposal in the CMS rule is that nursing homes must ensure that a registered nurse (RN) is on-site 24 hours a day, seven days a week. Today’s population of nursing home residents, as with other long-term care beneficiaries, are living with higher acuity levels than in previous years, as evidenced by high rates of dementia, cardiovascular disease, and diabetes, among other conditions, which are also among the leading causes of death in this country. These individuals deserve sufficient support, which requires this consistent RN oversight as well as the skilled, essential direct care offered by certified nursing assistants (CNAs) and licensed practical/vocational nurses (LPNs), described further below.

The rule also appropriately proposes measures to enhance transparency in nursing homes (and institutional intermediate care facilities for individuals with intellectual disabilities, or ICF/IIDs)—specifically requiring that states report their Medicaid per diem rates and the percentage of Medicaid payments spent on compensation for frontline staff. For nursing assistants and other direct care workers, evidence shows that inadequate compensation forces many of them to leave this field, destabilizing the sector and leading to poor quality care for residents. This requirement helps increase clarity around compensation in nursing homes, which is critically needed to inform and evaluate improved wages and benefits for these essential staff.

Taken together, these measures align with recent federal initiatives that indicate a growing momentum for nursing home reform. Among these developments are: President Biden’s February 2022 initiative on nursing homes, which announced a set of reforms for this sector, including its intent to establish a minimum staffing ratio; the 2022 report on nursing home quality from the National Academies of Sciences, Engineering, and Medicine, which pronounced that the nursing home sector “has suffered for many decades from underinvestment in ensuring the quality of care in nursing homes and a lack of accountability in how resources are allocated” and proposed a robust range of solutions, including minimum staffing; and a recent rule from CMS that seeks to improving access to Medicaid services, including HCBS, for millions of people, with an explicit emphasis on increasing transparency and addressing compensation for the direct care workforce.


More than two decades ago, a study commissioned by CMS found that 4.1 hours of care per resident day (HPRD) was necessary to support quality care, including 0.75 RN hours, 0.55 LPN/LVN hours, and 2.8 CNA hours. In contrast, the proposed rule only puts forward two lower-level occupation-specific standards—0.55 RN hours and 2.45 CNA hours, with no requirements for LPNs/LVNs. CMS also invites consideration of a total of 3.48 minimum HPRD (including but exceeding the RN- and CNA-specific requirements). Given the ever-increasing acuity of residents and the evidence that nursing assistants support, on average, 13 residents per shift (or more, in many cases), PHI strongly supports the minimum proposed RN and CNA HPRD plus the total “direct care” HPRD, allowing nursing homes flexibility in determining how they staff the additional 0.48 hours to ensure sufficient resident care.

We also strongly recommend that this rule define compensation as annual wages and benefits, given the need to ensure that workers receive both a livable, competitive wage and essential benefits such as health coverage, sick days, paid family and medical leave, childcare support, and more. In this context, we recommend collecting annual wage data and reporting it distinctly from other aspects of compensation. To promote equity, we also propose that all compensation data be disaggregated by race/ethnicity, gender, and age to track for disparities commonly experienced by people of color, women, and older adults—populations disproportionately represented in the direct care workforce.

We also appreciate the rule’s focus on strengthening the assessment process to ensure staffing levels reflect residents’ needs, goals, and preferences—beyond the minimum staffing mandate. In this spirit, we call on CMS to ensure that assessment requirements are made more explicit and enforceable, including, as two examples, the requirement that facilities with higher acuity levels increase their RN, LPN/LVN, and CNA staffing levels accordingly and the requirement that CNAs and/or their representatives are meaningfully involved in the assessment process.

As the rule is implemented nationwide, we also encourage CMS and the nursing home sector to ensure the definition of “direct care worker” refers specifically to nursing assistants, the largest segment of the frontline workforce in nursing homes—consistent with the way that CMS and other federal agencies like the Administration on Community Living use this term. Defining RNs and LPNs as “direct care workers,” as the proposed rule currently does, risks confusion and obscures the unique contributions and challenges of each role. For example, poverty-level wages and a disproportionate reliance on low-income women of color and immigrants create unique barriers for the CNA workforce compared to other nursing home staff—and these realities must be addressed.


CMS has proposed staggered implementation for the minimum staffing requirements, ranging from 60 days after the final rule’s publication to as much as five years later, depending on the particular requirement and urban versus rural location. As the rule is finalized and the implementation period begins, a concerted, collaborative effort must be made to address existing workforce challenges and help ensure that nursing homes are prepared to comply— including under-resourced nursing homes that may need targeted assistance and support.

We look forward to commenting in detail on the proposed rule and working with CMS to ensure that the needs and perspectives of CNAs, in particular, are centered in this effort and that transparency and accountability are maximized.

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