CMS Issues First Enforcement Guidance on Staffing Mandate for Nursing Homes, Adds Few Details

The Centers for Medicare & Medicaid Services (CMS) issued its first enforcement guidance for the minimum staffing mandate, which will allow surveyors to assess nursing home compliance using facility assessments, although experts said little clarity was offered on key points of the provision.

The provision on facility assessments was issued in Tuesday’s Quality Safety & Oversight (QSO) memo, and will take effect by August 8, 2024. It will mark the first provision related to the staffing mandate to be implemented. The other stipulations of the final staffing rule are due to take effect over the next two to five years, depending on the rural versus urban designations of facilities.

Facility assessments lay out how facilities assess and allocate resources to meet resident needs and will require that facilities conduct a comprehensive evaluation to determine the resources necessary for competent resident care during routine operations and emergencies, including nights and weekends, CMS stated in the memo.


And, this assessment must be updated annually and whenever significant changes occur that would affect resident care.

CMS also issued revised guidance for state survey agencies and long-term care facilities, and added an emphasis on behavioral health.

“The facility assessment must address….the care required by the resident population using evidence-based, data-driven methods that consider the types of diseases, conditions, physical and behavioral health needs, cognitive disabilities, overall acuity, and other pertinent facts that are present within that population, consistent with and informed by individual resident assessments,” CMS memo stated.


The emphasis on data driven methods threatens to challenge small- to mid-sized operators.

Moreover, facilities must ensure active involvement from leadership, direct care staff, and input from residents and families during the assessment process, the memo emphasized. This inclusive approach is designed to capture diverse perspectives and ensure that all aspects of resident care are adequately addressed in staffing plans and resource allocations.

Guidance on key points still missing

“The newly issued guidance does not provide a lot of additional detail on some important key points, such as exactly what using ‘evidence-based, data-driven’ methods for staffing decisions means. Absent further clarifications, it will be up to facilities to make good faith efforts to apply these new rules,” said Brian Ellsworth, VP for Public Policy and Payment Transformation at Health Dimensions Group, which is in the process of developing it own guidance for facilities on these regulations.

And since these new regulations go into effect soon, it is imperative that existing facility assessments be reviewed and updated in short order, Ellsworth told Skilled Nursing News.

“CMS’ enforcement posture will likely unfold over time, but it is important for facilities to be prepared now to avoid any unpleasant surprises upon survey,” he said.

CMS’ updated guidance also underscores the importance of using the facility assessment to drive recruitment and retention strategies for direct care staff. This measure aims to maintain sufficient staffing levels with the requisite skills and competencies needed to deliver high-quality care consistently, the federal agency said.

Moreover, the enforcement guidance clarifies that while compliance is crucial, surveyors will also evaluate if staffing levels are adequate to meet residents’ actual needs. Facilities found in substantial compliance with the assessment requirements but failing to provide adequate care due to staffing shortages may be cited for noncompliance and required to implement corrective measures.

The regulatory updates reflect CMS’ commitment to enhancing transparency and accountability in long-term care facilities, the agency noted. By integrating evidence-based, data-driven assessments into staffing decisions and operational planning, CMS aims to improve overall care quality and resident outcomes across the spectrum of long-term.

Among some of the other requirements the facility assessment must address are the following:

  • Data on the facility’s resident population, including, but not limited to both the number of residents and the facility’s resident capacity
  • The staff competencies and skill sets that are necessary to provide the level and types of care needed for the resident population
  • The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population
  • Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services.
  • Presources, such as systems for electronically managing patient records and electronically sharing information with other organizations.