CMS Minimum Staffing Standards Nursing Social Card

CMS Finalizes Rule Increasing Minimum Staffing Standards in Nursing Homes

New Minimum Staffing Standard

On April 22, 2024, The Centers for Medicaid and Medicare Services (CMS) released a final rule that implements new minimum nurse staffing requirements in nursing homes.

The final rule creates a standard of 3.48 nursing hours per patient per day. Specifically, the rule requires the following:

  • Registered nurses (RN) must provide 0.55 hours of direct care per patient per day.
  • Certified nurse aides must provide 0.45 hours of direct care per patient per day.
  • A combination of nurse staff (RN, licensed practical nurse (LPN) and licensed vocational nurse (LVN), or nurse aide) may be used to account for the remaining 0.48 hours of direct care per patient per day.

The final rule also requires an RN to be onsite 24 hours a day, seven days a week. The 24/7 RN onsite may be the Director of Nursing, but they must be available to provide direct resident care.

Additional Facility Assessment Requirements

While nursing homes are already required to conduct annual and as-needed facility-wide assessments to determine what resources are necessary to care for residents, the final rule imposes the following additional assessment requirements:

  • Use evidence-based methods when care planning for residents.
  • Use the facility assessment to assess the specific needs of each resident and adjust as necessary based on significant changes in resident population.
  • Include input from the following in conducting assessments:
    • A member of the governing body;
    • Medical director;
    • Administrator;
    • Director of nursing;
    • Direct care staff, including RNs, LPNs/LVNs, and nurse aides;
    • Residents, resident representatives, and family members.
  • Develop a staffing plan to maximize recruitment and retention of staff consistent with The Executive Order on Increasing Access to High-Quality Care and Supporting Caregivers.


The minimum nurse staffing requirements will be implemented in three phases over a three-year period for all non-rural nursing homes and a five-year period for all rural nursing homes.

Phase 1

Non-rural and rural nursing homes must meet the facility assessment requirements by August 8, 2024.

Phase 2

The 3.48 nursing hours per-patient per day and the 24/7 RN requirements must be met by May 10, 2026, for non-rural nursing homes, and by May 10, 2027, for rural nursing homes.

Phase 3

The 0.55 RN and 2.45 nurse aide hour requirements must be met by May 10, 2027, for non-rural nursing homes, and by May 10, 2029, for rural nursing homes.

Potential Implications

The final rule increased the time nurse staff must provide per patient per day from a proposed 3.0 hour standard to a 3.48 hour standard, ignoring provider concerns about their ability to comply with the mandate. The American Healthcare Association expressed opposition to final rule, calling the new requirements “out of touch and out of reach” due to the growing caregiver shortage.

Consequently, many nursing homes will need to hire additional staff to meet these new requirements. Although the final rule will be implemented in phases and allows for limited and temporary “hardship exemptions,” it largely fails to consider the nationwide RN shortage which will make compliance difficult if not impossible.

If you need assistance preparing for the upcoming additional assessment and minimum staffing standard requirements, please reach out to our Aging Services and Health Care teams.


This material is provided for informational purposes only. It is not intended to constitute legal advice nor does it create a client-lawyer relationship between Hall Booth Smith, P.C. and any recipient. Recipients should consult with counsel before taking any actions based on the information contained within this material. This material may be considered attorney advertising in some jurisdictions. Prior results do not guarantee a similar outcome.

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About the Author

Brittany H. Cone

Brittany H. Cone

Partner | Atlanta Office

T: 404.586.6620

Brittany H. Cone focuses her practice on a wide range of regulatory, administrative, and litigation matters in health care. Certified in Health Care Compliance by the Health Care Compliance Association, she works with providers on the full spectrum of issues they face including Medicare, Medicaid, regulatory compliance, administrative hearings, and appeals.

Jordan Johnson

Jordan Johnson

Partner | Atlanta Office

T: 404.586.6639

Jordan Johnson specializes in aging services and health care matters. His practice features a wide range of regulatory, administrative, and litigation matters, including the full spectrum of issues healthcare providers face such as reimbursement, regulatory compliance, and administrative hearings and appeals.

Caylie Cross

Caylie Cross

Attorney at Law | Atlanta Office

T: 404.954.6946

Caylie Cross works primarily on aging services and health care matters. She recently earned her Juris Doctor from Emory University School of Law. Caylie previously worked as a summer associate for the Atlanta office and has also interned at both the Atlanta Legal Aid Society and Rhode Island Center for Justice.

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