Comments on Staffing Rule Pour in to CMS

Nov 6, 2023 | Minimum Staffing, CMS' PBJ Policies

News Digest: Overwhelming Response to CMS’ Proposed Rule on Minimum Staffing

The 60 day comment period for the Proposed Minimum Staffing Rule ended November 6, 2023.  AHCA and Leading Age associations led efforts to generate industry response.  Comments flooded in and extended into a public relations effort. With CMS obligated to read and digest every comment, the timing for a Proposed Rule to be converted to a Final Rule remains up in the air.


CMS leader mum on staffing mandate, delivers ‘back to basics’ message

If nursing home leaders were hoping to learn new insights about the proposed federal staffing rule from a top government official Tuesday, they came up all but empty. But they also came away informed on an array of other hot regulatory topics, many of them reflecting a back-to-basics theme in the wake of the COVID-19 pandemic.

The director of the nursing homes division at the Centers for Medicare & Medicaid Services made it clear at the start of his policy update session at the LeadingAge annual meeting here that he would not be discussing the controversial staffing rule. At last count, it was approaching 50,000 comments from providers, consumer advocates, union members and others. But the topic received just a few indirect references from CMS’ Evan Shulman.


Berklan, James M. “CMS Leader Mum on Staffing Mandate, Delivers ‘Back to Basics’ Message.” McKnight’s Long-Term Care News, 8 Nov. 2023,


One last chance to let CMS know how you feel

Ask not for whom the Centers for Medicare & Medicaid Services staffing proposal tolls, long-term care provider. It tolls for thee.

And today is your last chance to let federal regulators know what you think about an unfunded staffing proposal that could cost nursing homes billions of dollars to implement.

This most burdensome regulatory proposal in decades has sparked intense industry blowback. In fact, more than 26,000 comments had already been submitted before the final weekend started.

As McKnight’s earlier reported, the Ensign Group has rallied approximately 1,500 submissions from its partners and affiliates. Similarly, Cascadia Healthcare has contributed over 400 comments, and Diversicare has provided more than 500 unique comments. Their proactive involvement underscores the rule’s significance for the industry.


O’Connor, John. “One Last Chance to Let CMS Know How You Feel.” McKnight’s Long-Term Care News, 4 Nov. 2023,


CMS Flooded With Staggering 40K-Plus Comments on Nursing Home Staffing Mandate

More than two months after the Centers for Medicare & Medicaid Services (CMS) announced its minimum staffing proposal for the skilled nursing industry, commentary from stakeholders came to a close Monday with a staggering 40,000-plus comments received.

Reviewing the hefty load of comments on the proposal may take as long as a year, according to industry leaders. And encouraged by the size of the comments, advocacy groups are already eyeing the next phase of countering the stipulations contained in the staffing mandate and planning to work with Congress, LeadingAge CEO Katie Smith Sloan said in a meeting with editors from Skilled Nursing News.

“There’s been some organic interest in Congress and putting pressure on CMS. I think we’re going to continue to try to mobilize that and see if we can expand that pressure,” said Smith Sloan, referring to numerous letters sent to CMS by members of Congress in the last month.


Stulick, Amy. “CMS Flooded With Staggering 40K-Plus Comments on Nursing Home Staffing Mandate.” Skilled Nursing News, 7 Nov. 2023,


Comments offer nuances that might salvage CMS staffing rule in operators’ eyes

With just four days left to submit comments on a proposed first-ever federal nursing home staffing rule, providers who haven’t already offered the Centers for Medicare & Medicaid Services their concerns and suggestions are fine-tuning their messaging today.

Total comments posted to a site associated with the Federal Register surpassed 24,000 by Thursday night. While those comments represent a wide range of stakeholders, skilled nursing advocates are already well represented among the masses.

Emboldened by serious operational and financial stakes, many operators and owners have taken a broader view of the comment process and asked mid-level managers, individual administrators and other staff to weigh in on the rule, which was officially proposed Sept. 6.

Among those embracing such an approach, executives told McKnight’s Long-Term Care News this week, were the Ensign Group, with an estimated 1,500 submissions from its partners and affiliates; Idaho-based Cascadia Healthcare, with more than 400 as of Monday; and Tennessee-based Diversicare, with more than 500 unique comments.


Marselas, Kimberly. “Comments Offer Nuances That Might Salvage CMS Staffing Rule in Operators’ Eyes.” McKnight’s Long-Term Care News, 3 Nov. 2023,


It’s time to dig in and let CMS do the digging out

It’s the nature of this job to cozy up to public documents and mine their contents for previously undiscovered details, provider concerns and critical perspectives.

But nursing home operators, you’ve outdone yourselves this time. You’ve generated so many new public documents that it’s hard to even know where to start to dig.

Less than two months after the Centers for Medicare & Medicaid Services began accepting comments on its proposed rule on nursing home minimum staffing standards (which the agency formally refers to as the “Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting”), the Federal Register notched some 22,740 as processed as of Wednesday.

Now, those aren’t just from providers and owners who find the proposed rule and its stipulations regarding RN and CNA coverage too onerous. While the American Health Care Association launched a campaign to garner 10,000 provider comments opposing the rule, unions and consumer advocates also have mounted their own intense efforts to lobby the regulatory agency for tougher standards.


Marselas, Kimberly. “Comments Offer Nuances That Might Salvage CMS Staffing Rule in Operators’ Eyes.” McKnight’s Long-Term Care News, 3 Nov. 2023,


SBA COMMENTS: Medicare and Medicaid Programs; Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting (

On September 6, 2023, the Centers for Medicare and Medicaid Services (CMS) published a proposed rule entitled, “Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting.” This letter constitutes the Office of Advocacy’s (Advocacy) public comments on the proposed rule.

Advocacy shares CMS’ desire to advance policies aimed at improving the quality of care for the nation’s seniors and acknowledges the difficulties CMS faces in balancing the policy goal of establishing stronger staffing requirements against the practicalities of implementation and costs.
However, Advocacy is concerned that this rule may have unintended consequences that negatively impact long-term care facilities and other related providers, the vast majority of which are small businesses. These impacts are particularly troublesome at a time when there is a real shortage of qualified nurses and other nursing home caregivers in the United States, especially in rural areas.

CMS certified in the Regulatory Flexibility Act (RFA) section of the rule that this proposal will not have a significant impact on a substantial number of small entities.



Former CMS chief Verma: Regulators ‘over their skis’ with staffing mandate

Federal regulators are in over their heads with the proposed first-ever nursing home staffing mandate, the former head of the Centers for Medicare & Medicaid Services said Wednesday.

She added, however, that there appears to be a strong window of opportunity for influencing how the final rule will be shaped and offered advice to providers hoping to make it more favorable.

Seema Verma also forecast that if a final rule is not issued by the end of the year, it could very well be put off until after the 2024 presidential election. With comments on the proposed staffing rule already topping 22,000 with five days to go until the cutoff, veteran observers said the chances of a final rule coming in the next two months seem highly unlikely.


Berklan, James M. “Former CMS Chief Verma: Regulators ‘Over Their Skis’ With Staffing Mandate.” McKnight’s Long-Term Care News, 2 Nov. 2023,


‘Room for Adjustment’: Former CMS Chief on Countering Staffing Mandate, Public Image of Nursing Homes

Seema Verma, the former administrator of the Centers for Medicare & Medicaid Services (CMS), isn’t happy with the talk on Capitol Hill around nursing homes, saying that it shows a lack of knowledge on the lawmakers’ part, making it incumbent upon sector leaders to engage with lawmakers directly, even inviting them into facilities.

Currently senior vice president and general manager at Oracle Corporation (NYSE: ORCL), Verma said that her previous role of overseeing health plans covering a staggering 140 million lives, managing a formidable budget of $1.3 billion, and offering guidance to around 6,000 employees provided her with invaluable insights into the intricacies of health care policy.


Grebbin, Shelby. “‘Room for Adjustment’: Former CMS Chief on Countering Staffing Mandate, Public Image of Nursing Homes.” Skilled Nursing News, 2 Nov. 2023,


AHA: Nursing Home Staffing Mandate Would Not Align with Modern Clinical Practice, Stifle Innovation

The Centers for Medicare & Medicaid Services (CMS) should not implement the proposed nursing home staffing mandate for numerous reasons, including that “numerical staffing staffing thresholds are not consistent with the modern clinical practice.”

That’s according to the American Hospital Association (AHA), which commented on the proposed mandate on behalf of its nearly 5,000 member hospitals, 2,425 post-acute care members, and other constituencies.

“A simple mandate of a base number of RN and NA hours per resident day emphasizes staff roles and responsibilities of yesterday rather than what current and emerging practices may show is most effective and safe for the patient and best aligned with the capabilities of the care team,” wrote AHA Executive Vice President Stacey Hughes, author of the organization’s comment letter.


Mullaney, Tim. “AHA: Nursing Home Staffing Mandate Would Not Align With Modern Clinical Practice, Stifle Innovation.” Skilled Nursing News, 27 Oct. 2023,


AHA Comments on Long-term Care Facility Minimum Staffing Proposed Rule

Dear Administrator Brooks-LaSure,

On behalf of our nearly 5,000 member hospitals and health systems who work with long term care facilities to serve hundreds of thousands of patients each year, our professional membership groups and affiliates including the American Organization for Nursing Leadership, and our 2,425 post-acute care members, the American Hospital Association (AHA) appreciates the opportunity to provide comment on the proposed rule regarding minimum staffing standards for long-term care (LTC) facilities.

The AHA and its members are committed to safe staffing to ensure high quality, safe, equitable and patient-centered care in all health care settings, including LTC facilities. However, CMS’ proposal to implement mandatory nurse staffing levels is an overly simplistic approach to a complex issue that, if implemented, would have serious negative unintended consequences for not only nursing home patients and facilities, but the entire health care continuum.


AHA Comments on Long-term Care Facility Minimum Staffing Proposed Rule | AHA.” American Hospital Association, 26 Oct. 2023,


Will there be light at the end of the staffing mandate tunnel?

It’s been just over a month since the federal staffing minimum landed in our inboxes, its details continuing to send ripples through the long-term care sector as readers dig deeper to interpret potential impacts.

At the American Health Care Association’s annual convention and expo in Denver this week, there was a mix of resolute defiance in the face of potentially crushing requirements and continued consternation that any federal regulator would have the chutzpah to attempt them in the current environment.

And then there was one tiny glimmer of hope, followed by another.

Those were signs that providers and lobbyists who worked to get ahead of the rule in its pre-proposal phase may be seeing the fruits of their labor.


Marselas, Kimberly. “Will There Be Light at the End of the Staffing Mandate Tunnel?” McKnight’s Long-Term Care News, 5 Oct. 2023,


Ensign CEO Expects a Long Comment Period for Potential Minimum Staffing Mandate as Company Focuses on Deals, Retention

Nursing home operators can expect a long comment period once the federal minimum staffing mandate comes out, potentially drawing out into the following year before anything is finalized.

Barry Port, CEO of the Ensign Group (Nasdaq: ENSG), said during the company’s second quarter conference call on Friday, that this is the tiniest bit of clarity the industry has at the moment on a potential minimum staffing mandate – and even that could change. San Juan Capistrano, Calif.-based Ensign has in the meantime been visiting D.C. at policymakers’ requests, providing comments and feedback on the coming rule.

“We don’t think [the potential staffing mandate] will be out for another month or so,” Port said. “We’re not reacting much to what we don’t know. What we have been focused on is making sure that we continue to be the best employer we can be.”


Stulick, Amy. “Ensign CEO Expects a Long Comment Period for Potential Minimum Staffing Mandate as Company Focuses on Deals, Retention.” Skilled Nursing News, 28 July 2023,


OMB Still Analyzing Nursing Home Staffing Mandate, with Flurry of Stakeholder Meetings

As the staffing minimum mandate inches closer to an official release, associations with ties to the nursing home industry continue to meet this week with the Office of Management and Budget (OMB) – the government agency currently reviewing the proposal.

The Centers for Medicare & Medicaid Services (CMS) transferred the proposal to OMB for review on May 30, federal records show. Association leaders say they are encouraged to see so many stakeholders engaging with OMB as the proposed staffing rule is being reviewed.

Most recently, the National Rural Health Association met with the federal agency on Monday, according to the OMB registry. Meanwhile, the American Hospital Association (AHA) met with the agency Tuesday afternoon.


Stulick, Amy. “OMB Still Analyzing Nursing Home Staffing Mandate, With Flurry of Stakeholder Meetings.” Skilled Nursing News, 11 July 2023,

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