CMS Staffing Mandate Modified to Include LPNs in Limited Way, Still Marginalizes ‘Backbone’ of Nursing Home Workforce

The newly finalized minimum staffing standards by the Centers for Medicare & Medicaid Services (CMS) have ignited a significant debate among nursing home leaders regarding the inclusion and role of licensed practical nurses (LPNs).

The mandate, announced on April 22, 2024, establishes new comprehensive minimum nurse staffing requirements, aiming to enhance the quality of care in nursing facilities. However, the rule’s limited recognition of LPNs has sparked concerns about its feasibility and impact on resident care.

The new CMS rule mandates a total nurse staffing standard of 3.48 HPRD, including at least 0.55 HPRD of RN care and 2.45 HPRD of direct nurse aide care. The additional 0.48 HPRD can be met by any combination of nurse staff, including registered nurses (RNs), LPNs, or nurse aides. Furthermore, the rule requires an RN to be onsite 24 hours a day, seven days a week, to ensure the availability of skilled nursing care.


Jodi Eyigor, director of Nursing Home Quality Policy at LeadingAge, told Skilled Nursing News that while the association appreciates CMS providing flexibility in the final rule to include LPN hours in meeting the 3.48 total nurse staffing, LeadingAge had advocated for the agency to adjust the 0.55 RN HPRD to 0.55 “licensed nurse” HPRD.

“LPNs are an integral part of long-term care, providing hands-on, clinical care in collaboration with RNs and nurse aides,” Eyigor said. “Long-term care employs more LPNs than any other sector and LPNs are employed at higher rates than RNs in nursing homes. This rule marginalizes the contributions of LPNs in the long-term care workforce by focusing exclusively on RNs and nurse aides with no opportunity for substitution of LPNs.”

CMS has provided a staggered implementation timeframe and potential exemptions for facilities facing significant workforce challenges, particularly in rural areas. The agency will closely monitor the implementation to determine if any adjustments are necessary, though rural facilities are concerned about the feasibility of the requirements.


Despite the rule’s intentions to improve care quality, nursing home operators are concerned about the practicality of meeting these standards amid a workforce shortage. As the industry grapples with these new regulations, the debate over the role of LPNs continues.

Industry leaders voice concerns

Leah Klusch, Executive Director of The Alliance Training Center, voiced her concerns about the rule’s neglect of LPNs, which she said play a crucial role in skilled nursing facilities.

“The issue of not recognizing the value of licensed practical nurses in our staffing process is a big mistake,” Klusch said. “The numbers just don’t add up to me,” she continued, adding that many facilities will have difficulty meeting the staffing requirements given the current shortage of available nurses and caregivers.

David Grabowski, a professor of healthcare policy at Harvard Medical School, acknowledged the significance of the new staffing rule but criticized its oversight regarding LPNs.

“This new rule will establish a staffing floor to prevent dangerously low staffing levels,” he said, noting the positive impact on resident care. However, he expressed concern that the rule’s focus on RNs and certified nursing assistants (CNAs) might lead to a decreased use of LPNs, which could negatively affect care quality.

Impact on rural and local facilities

In Nebraska, where the LPN workforce is particularly robust, Jalene Carpenter, CEO of the Nebraska Healthcare Association, said she foresees challenges for facilities.

“LPNs really are the backbone of a lot of our facilities,” she said.

She said that while LPNs are counted in the overall staffing hours, they are not included in specific categories for RNs and CNAs, making it difficult for providers to meet the new requirements. Carpenter added that the primary concern for providers is the mandate for a 24/7 RN presence, which could be catastrophic for many facilities.

“I’ve heard organizations are already looking at trying to only hire RNs moving forward,” she said. That’s going to be difficult as well.”

The American Health Care Association (AHCA) has also been vocal about the essential role of LPNs in the long-term care workforce.

“LPNs are a critical part of the nursing home workforce, making up 13% of the total workforce,” Holly Harmon, AHCA’s senior VP of Quality, Regulatory, and Clinical Services, told Skilled Nursing News.

Like RNs, LPNs are licensed nurses with the ability to provide high quality skilled care to seniors, Harmon said, adding that despite LPNs having long been part of the 24-hour licensed nursing services that nursing homes have provided, the final rule ignores their contributions as licensed nurses.

She criticized the rule for not allowing LPNs to be counted with their fellow RNs, undermining recruitment and retention efforts.

“The federal government discounting the value and role of LPNs undermines critical recruitment and retention efforts by nursing homes who are working diligently to build their nursing workforce,” she said.

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