Is Your State Ready for the Proposed CMS Nursing Home Staffing Standards Rule?

More than 1.2 million older adults and people with disabilities live in over 15,500 Medicare- and Medicaid-certified nursing homes nationwide.1 As a substantial portion of our population continues to age, this number is expected to rise. It is critical we ensure that safe, high-quality care is available for our aging Americans. The Centers for Medicare & Medicaid Services (CMS) took on this charge in September, issuing the Minimum Staffing Standards for Long-Term Care (LTC) Facilities and Medicaid Institutional Payment Transparency Reporting proposed rule to address some of these issues.2

The proposed rule seeks to establish comprehensive staffing requirements for nursing homes—including, for the first time, national minimum nurse staffing standards to ensure that LTC facilities have a defined process to assess and address staff needed to provide ongoing care for its population.

Health policy consultants from ForHealth Consulting at UMass Chan Medical School have closely studied this new rule, and specifically what it could mean for state Medicaid agencies, staff working in nursing facilities, and the individuals who live there.

Secretary Xavier Becerra summarized the promising potential effect of the proposed reform:

When facilities are understaffed, residents suffer. They might be unable to use the bathroom…get out of bed, or have someone respond to their call for assistance. Comprehensive staffing reforms can improve working conditions, leading to higher wages and better retention for this dedicated workforce.

How States and Nursing Homes Can Prepare

CMS estimates approximately 75 percent of nursing homes would have to strengthen staffing in their facilities, while other estimates have been as high as 80 percent.2

Hiring and retaining sufficient staff for nursing homes will increase operating costs. CMS estimates that complying with the proposed rule will cost an extra $40 billion in the 10 years after the final rule takes effect. For context, in 2020, Medicaid spent nearly $53 billion dollars on skilled nursing facilities1—about twice the amount ($26 billion) that traditional Medicare spent —and residents and their family members paid $45 billion in out-of-pocket costs for care in nursing homes and other long-term care institutional settings. The impact on nursing homes will differ from state to state; for example, Massachusetts facilities would have to spend an additional $125 million annually while New York and Texas would have to spend as much as $409 million annually.3

In their analysis, the Kaiser Family Foundation found that “among all nursing facilities, fewer than one in five could currently meet the required number of hours for registered nurses and nurse aides, which means over 80 percent of facilities would need to hire nursing staff.”  In over half of states, less than a quarter of nursing facilities would meet the required hours per resident per day in the proposed rule.4

Another layer of concern for nursing homes and care facilities is how the pandemic affected healthcare workers in all settings, including those who provide care in skilled nursing and elder care facilities. As of June 2023, employment levels were still more than 11 percent below pre-pandemic levels for skilled nursing care facilities workers and three percent below pre-pandemic levels for workers in elder care facilities.1

ForHealth Consulting can provide state agencies with policy and analytic support to monitor nursing facility staffing and help predict the related workforce cost increase. This could include the creation of facility-specific reports or data visualizations to evaluate staffing levels and expense trends.

In addition, CMS is proposing new regulations that require state Medicaid agencies to report annually on compensation for direct care workers and support staff as a percentage of Medicaid payments (both base and supplemental) for nursing homes and intermediate care facilities for individuals with intellectual disabilities.2 Our experts can assist states and facilities with direct care wage reporting and tracking, rate development, and environmental scans.

This past July, CMS announced an additional $75 million investment through the Health Resources and Services Administration to provide scholarships and other financial incentives to support the nursing home workforce.2 The proposed rule, however, only addresses a few of the challenges of adequate staffing. For example, it does not address educational requirements. The National Institutes of Health have assessed the existing requirements for nursing home workers and found that “education and training requirements for a variety of nursing home staff are inadequate or nonexistent.” They recommend that “minimum education and competency requirements need to be enhanced or established for a variety of nursing home workers and made standard at the national level.”5

ForHealth Consulting’s training and workforce development team can work with states to develop and deliver training programs and continuing education for nursing homes to provide to staff at all levels, both virtually and in-person.

Additionally, the proposed rule does not address the additional staffing costs for nursing homes, which will impact states and other healthcare organizations. ForHealth Consulting can provide relevant decision-making data analysis to help states implement the new requirements of the federal rule. We have extensive expertise in analyzing CMS Staffing Data Submission Payroll Based Journal, Skilled Nursing Facility 2540-10 Cost Report Data, and state-specific staff and cost report data sources. Meeting all these potential new standards will be admittedly challenging for many of the organizations impacted. ForHealth Consulting is here to help states and thus their nursing home facilities address these complex new rules and ensure they comply, as well as support their provider network. We are committed to creating a better healthcare experience for everyone—making it equitable, effective, and accessible to all, and in particular, our older adults and those with disabilities. Let’s talk about how we can help you make healthcare better.

1 Burns, A., et al., What Share of Nursing Facilities Might Meet Proposed New Requirements for Nursing Staff Hours? September 18, 2023. Available at:


3 United States Census Bureau, Urban and Rural. Available at: