The CMS nursing home minimum staffing requirements began with the Biden administration in February 2022. The agency at the time had a broad plan to crack down on unsafe nursing homes. This significant rule was the first of its kind and marked the first time the federal government mandated specific staffing levels for nursing home.
The rule would have increased the total hourly requirements for direct patient care and required every nursing home in the nation to have an RN on staff 24 hours per day. Current rules set by Congress require an RN to be on duty eight hours a day in every nursing home. In addition to dictating 24-hour registered nurse coverage at every skilled nursing facility, operators also would have to provide 3.48 hours a day of direct patient care. Below is an example of the staffing standards.
The proposed CMS requirement was a result of the COVID-19 pandemic and a reported 200,000 resident and staff deaths and the lack of infection prevention and control programs in 82% of inspected nursing homes from 2013 to 2017. During that time, CMS officials felt that establishing staffing levels would ensure that residents would receive safe and quality care and enable workers to have the support needed to conduct their jobs.
As a result, nursing home groups, including American Health Care Association (AHCA), celebrated the decision to contend with the rule as the organization felt the rule was unrealistic due to workforce shortages and the cost to facilities of 6.8 billion annually to comply.
On April, 2025, a federal judge threw out a national nursing home staffing mandate. Judge Matthew J Kascmaryk of the U.S. District Court of Northern Texas vacated two provisions of a major 2024 CMS nursing staffing regulations requiring nursing homes to have an RN on site 24 hours a day, seven days per week setting minimum staffing standards based on a skilled nursing facilities’ number of residents.
In the order, the court ruled that the two nurse staffing provisions would be vacated not just for the immediate parties but also on a nationwide basis. In the order, the court held that CMS exceeded its statutory authority with the 24/7 requirements. Because Congress set a clear numerical baseline of eight hours per day for RN coverage, the court ruled that CMS was not free to amend the statute and replace eight hours a day with 24 hours a day.
The Court confirmed that CMS does not have the authority to issue staffing requirements, only Congress does. Because of this finding, the AHCA and Center for Assisted Living issued a statement, “In light of evolving care practices and our nation’s changing demographics, federal policymakers should not be dictating staffing hours but encouraging innovation and high-quality outcomes. The staffing mandate is a 20th Century solution that should be blocked by Congress once and for all.”
Over the next few weeks, providers will be analyzing the aftermath of the ruling. RN requirements could still stand if the federal government appeals the Kacsmaryk’s ruling and could impact similar cases moving through the U.S. District Court for Northern Iowa.
The decision may be appealed by the federal government, and it does indicate a significant setback to administrators’ push for tighter federal control over nursing home staffing standards. The Supreme Court decision could weaken federal agencies authority to regulate industries, including the recently finalized federal minimum staffing rule for nursing homes.
Because of the existing Republican majority in both chambers of Congress and the Democrat’s disagreement with the rule, there can be a feasible path of Congress blocking the rule entirely. The ruling leaves no federal staffing standards in place, reverting to pre-2024 rules (e.g., only eight hours of RN coverage daily). Some advocates have concerns as this could cause understaffing and burnout.
Debates continue between Democratic and Republican lawmakers. Republican lawmakers and industry groups are urging innovation over mandates (telehealth and artificial intelligence solutions) while Democrats and nursing unions are pushing for legislative action. States such as California and New York have their own staffing laws, which remain unaffected. Advocacy groups may shift focus to state-level reforms.
Amid uncertainty about the status of the ongoing debates on staffing mandates, nursing facilities can follow practical guidelines that can keep facilities’ staffing levels and policies in line with state and federal regulations.
Nursing home staffing has been an ongoing challenge and debate for years. Nursing home staffing is a complex interplay of factors related to quality of care, regulatory compliance, workforce shortages and financial constraints.
An ongoing dialogue will hopefully create a balance of competing interests and produce a remedy to ensure the well-being of staff and residents that work and reside in the nursing home industry.
WTW hopes you found the general information provided here informative and helpful. The information contained herein is not intended to constitute legal or other professional advice and should not be relied upon in lieu of consultation with your own legal advisors. In the event you would like more information regarding your insurance coverage, please do not hesitate to reach out to us. In North America, WTW offers insurance products through licensed entities, including Willis Towers Watson Northeast, Inc. (in the United States) and Willis Canada Inc. (in Canada).
