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AG Nessel Joins Letter Urging Federal Government to Implement Stronger Minimum Staffing Standards in Nursing Homes

LANSING – Michigan Attorney General Dana Nessel has joined a coalition of 15 state attorneys general to encourage the U.S. Department of Health and Human Services and the Centers for Medicare and Medicaid Services (CMS) to promulgate a rule requiring stronger minimum staffing requirements for long-term care facilities. 

The letter, submitted on Monday by the coalition, responds to a proposal by CMS to adopt a rule requiring nursing facilities to have minimum staffing levels for certified nursing assistants (CNAs) and registered nurses (RNs), as well as requiring nursing facilities to have at least one RN working onsite 24 hours per day. The coalition applauds the administration for seeking to improve quality of care in long-term care facilities through mandated staffing levels and supports the 24-hour-per-day RN requirement, but also encourages the administration to adopt higher minimum staffing requirements than currently proposed. 

“The connection between quality of care in nursing homes and staffing is clear. I support the concept of a robust federal minimum staffing rule to help ensure our most vulnerable citizens receive the care they deserve,” said Nessel. “The proposed rule advances some good ideas—but it needs to go further in a few important respects. The comments my colleagues and I submitted to CMS detail necessary improvements to the rule that are supported by research and our collective experience.” 

State attorneys general are charged with protecting the safety and well-being of residents of nursing facilities. State Medicaid Fraud Control Units – like the AG’s Health Care Fraud Division – have authority to investigate and prosecute those responsible for committing abuse or neglect of residents and misappropriation of residents’ funds in these facilities. 

In their letter, the coalition responds to CMS’s proposal to require 2.45 hours per resident day (HPRD) of care from CNAs and 0.55 HPRD from RNs. The AGs instead recommend that CMS adopt a minimum staffing standard ratio of 4.1 HPRD (with 2.8 HPRD for CNAs, 0.75 HPRD for RNs, and 0.55 HPRD for LPNs). This standard is consistent with the results of CMS’s 2001 staffing study, which found that 4.1 HPRD was the staffing threshold below which quality of care for long-term care patients was compromised. 

The letter further points out that the proposed minimum staffing rule does not include any minimum staffing requirements for licensed practical nurses (LPNs). Without such a requirement, the AGs argue that CMS’s proposed rule could incentivize many nursing facilities to operate only with RNs and CNAs to reach those federally mandated levels, which would, in turn, result in the assignment of even more duties to already overburdened RN staff. 

The coalition also urges CMS to limit the availability of exemptions from the minimum staffing thresholds. While the letter acknowledges the existence of workforce shortages throughout the country in long-term care facilities, the coalition urges CMS to narrow exemptions based on workforce shortages to true emergencies, which would avoid incentivizing for-profit facility owners to operate homes without appropriate staffing in order to siphon Medicare and Medicaid funds from the homes for their personal profit. 

Joining AG Nessel in the letter supporting the CMS proposed rule are the attorneys general of Arizona, California, Delaware, Illinois, Maryland, Massachusetts, Minnesota, Nevada, New Mexico, New York, Oregon, Pennsylvania, Rhode Island, and Vermont.


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