CMS 2022 Guidelines Are Still in Flux: What Nursing Home Leaders Need to Know Today

nursing home staffing requirements by state for 2022

The Centers for Medicare & Medicaid (CMS) recently launched changes to its Nursing Home Five-Star Quality Rating System, giving many post-acute leaders reason to pay even closer attention to CMS guidelines for 2022—especially since this appears to be just the beginning of some significant changes from the agency. 

The announcement opens the door to multiple questions around nursing home staffing requirements by state for 2022. The short answer is that it’s still up to each state—but there are a lot of interesting recent happenings coming down from CMS, which we’re going to cover for you here. 

The enhanced rating system has launched

The Five-Star Quality Rating System was created to help healthcare consumers, families, and caregivers make more informed comparisons and ask better questions about the topics in nursing home care they care most about. The latest enhancements leverage data on weekend staffing rates (for nurses and turnover among nurses and administrators), integrating this information to increase transparency. This initiative stems from the Biden-Harris Administration’s efforts to improve nursing home quality and the care residents receive. 

CMS Administrator Chiquita Brooks-LaSure emphasizes the fact that staffing levels and turnover, which now includes temporary staff, can have substantial impact on the health outcomes and quality of care that people living in nursing homes receive. The emphasis on turnover comes from CMS research, which finds that higher turnover is associated with a lower quality of care. For example, nurses who have worked longer at a facility are more familiar with residents and administrators who have longer tenures are able to create stable leadership and more consistent protocols and policies. 

CMS launched an RFI and minimum staffing study for nursing homes

It’s important to keep in mind that these changes aren’t happening in a vacuum. In late August 2022, CMS announced new minimum staffing requirements to ensure each facility is maintaining staff who are properly trained and are able to provide the quality of care their residents need. To accomplish this, CMS launched a multi-faceted effort to determine minimum levels and types of staffing needed to maintain safety and care quality. This initiative has included a Request for Information (RFI) and a new study. 

The RFI happened in early 2022 and was part of the Fiscal Year 2023 Skilled Nursing Facility Prospective Payment System Proposed Rule. The promised rule making on minimum staffing requirements will be issued in Spring of 2023. 

Results of the RFI

Public comments on the RFI closed on June 10, 2022, with CMS receiving over 3,000 comments from parties ranging from long-term care ombudsman, providers, resident advocates, nursing home staff and administrators, caretakers, and labor unions. 

Nursing home resident advocates and industry associations provided views that diverged from one another, with advocacy groups and families of residents generally exhibiting strong favor of establishing minimum staffing requirements, and other groups expressing concerns. Family and caretakers largely voiced concerns about residents not receiving adequate care because of chronic understaffing. Some commenters suggested a move away from a minimum staffing requirement and instead implementing an acuity staffing model per shift. Other commenters recommended a staff to patient ratio as an alternative. Advocacy groups also stated that acuity should stand as a primary determinant in the establishment of minimum staffing standards. 

What will the study look like? 

The study will involve both quantitative and qualitative elements that will inform the staffing proposal. This will include interviews, observation data, surveys, Minimum Data Set (MDS) and Medicare Payroll-based Journal (PBJ) data. It will also include a literature review, site visits, (across 15 states) and cost analyses. 

How nursing home leaders should move forward

Here is a posture you can take as CMS continues their efforts. 

Refine your temp staffing strategy for the nursing home staff requirements by state in 2022-2023

While turnover is being tracked, keep in mind that there is pressure on CMS to focus on patient outcomes as a defining metric. This means that nursing home administrators have an opportunity to balance their use of PRN staffing against CMS requirements and patient outcomes. As the agency has stated, “in addition to analyses of the relationship between staffing and safe and quality care, CMS will also conduct descriptive analyses of staffing levels, examining trends in nursing home staffing from 2018-2021 and identifying specific factors that are related to staffing levels.”

Also, know that there is ample room between permanent staff and per-diem options. Look for ways to incorporate block booking, contract, and float pool approaches to staffing that will help you achieve the positive patient outcomes and consistency for your residents that CMS is interested in.

To learn more about the options you have in building out a temp staffing strategy that aligns with CMS’ shifting approach to staffing minimums and care quality, start here


Megan is a business writer with over 15 years’ experience in healthcare enterprise technology. She holds an MBA and B.S. in Healthcare Administration. She now keeps an ongoing eye on the latest developments and successes in healthcare admin technology and the people who use it to build a better world for providers, patients, and their care communities.


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