ANA Applauds CMS for Establishing Long-Term Care (LTC) Facility Staffing Standards


Achieving safe staffing levels for nurses across care settings remains a top priority for ANA. That is why we are pleased about a recent regulatory win—the Centers for Medicare & Medicaid Services (CMS) issued a final rule aimed at bolstering nurse staffing at long-term care (LTC) facilities.

This landmark regulation sets minimum staffing standards for nurses in LTC facilities across the country. CMS was directed to engage in this rulemaking by a February 2022 Executive Order issued by President Biden, as part of a larger focus on addressing challenges faced by nursing homes. The Administration signaled that this issue remains a top priority with Vice President Harris announcing the release of the final rule with an accompanying White House fact sheet.

ANA submitted November 2023 comment letters on the proposed rule that was released in September 2023—one on behalf of the association and the other along with over 25 state and organizational affiliates. The letters urged the agency to finalize its proposals with suggested refinements. ANA is pleased to see CMS finalize this landmark regulation, which sets nurse minimum staffing standards in LTC facilities across the country. The standards set specific ratios for registered nurses (RNs) and nurse aides (NAs) that are part of a total staffing standard. ANA is disappointed that CMS did not specifically call out licensed practical nurses/licensed vocational nurses (LPNs/LVNs) in the standard in recognition of their critical contribution to the patient care team but appreciates that the agency did note that these nurses can be used to meet total staffing standard requirement.

ANA is especially pleased that CMS also finalized its proposed requirement for all LTC facilities to have an RN onsite 24 hours a day, seven days a week (24/7). ANA has long advocated for this requirement and is encouraged that the agency also recognizes the importance of having an RN onsite 24/7. ANA comments on the proposed rule also encouraged CMS to ensure nurses are included in facility assessments and that any exemptions are granted based on rigorous assessments—which the agency incorporated in the final rule. Last, CMS also noted that they have $75 million to invest in LTC workforce development. The agency is still determining how best to roll out this initiative and ANA is watching for any opportunities to weigh in on any approaches to make sure they truly support and provide incentives for our nurses.

While ANA is encouraged that CMS finalized this important regulation—signaling the importance of safe staffing in LTC facilities across the country—we know our work on these standards is not done. Groups opposed to the rule have publicly shared that they will continue to fight to delay or halt implementation all together, potentially through the court system. We know that before the agency issued the final rule, efforts in Congress to tie CMS’ hands from issuing this rulemaking was making progress. We are discouraged by these efforts as ANA understands how important safe standards are for nurses and the patients that they serve.

ANA continues to analyze the provisions of the rule and educate its members on its importance—while taking time to recognize the significant win that this final rule represents for safe staffing efforts. We will continue to seek opportunities to protect this rule and promote similar efforts. Together with our members, we will continue to make real strides in addressing safe staffing for nurses and the patients they serve. 

ANA Issues Updated Climate Change Position


According to the World Health Organization, climate change is the biggest health threat facing humanity. This assertion opens ANA’s latest position statement–Nurses’ Role in Addressing Global Climate Change, Climate Justice, and Health­–which was released today. This new position statement builds on previous work at ANA around the nurses’ role in addressing this global health issue. Recognizing that climate change is a critical public health issue, the position statement calls for nurses to take action while providing additional guidance for nurses in all specialties and settings.

Foremost, ANA calls on nurses to integrate the science of climate and health in nursing education, research, and practice. Nurses also must work with other stakeholders and policymakers to identify and implement approaches to addressing climate-related health impacts. The vital role of the nurse in the nation’s health care delivery system makes our nurses critical contributors as climate change mitigation and adaptation efforts are identified and implemented.

ANA outlines several recommendations for how nurses can affect change in professional settings and in state- and federal-level legislative and regulatory advocacy. Recommendations for nurses in the professional setting include educating patients, modeling and promoting strategies responding to the impacts of climate change, and prioritizing nursing workforce capacity for disaster/climate change preparedness. State- and federal-level legislative and regulatory advocacy recommendations include advocating for underserved patients, calling for just and equitable climate responses in public health, and promoting coalitions and other partnerships.

ANA also provides guidance for all nursing organizations to build on member education, and collaborate with partners and stakeholders to strengthen the influence nurses have on climate change legislation and policy. Further, the position statement details the importance of supporting research led or supported by our nurses to further identify innovative and real approaches on climate change and climate justice.

Such efforts will be futile if we fail to participate in policy making and fail to engage in climate justice. Which is why it is imperative for nurses to use their voice to lead action aimed at mitigating the impacts of climate change and to protect vulnerable individuals, families, and communities responding to changing climate conditions. As the most trusted profession, nurses are in a unique position to also serve as a source of hope—acting ethically on behalf of their patients.

ANA does not have all the answers to climate change and its outsized impacts on healthcare delivery. As a first step, it is critical that we all recognize that the health concerns related to climate change exacerbate every issue our nursing organizations actively work to resolve. The threat of climate change will not be addressed in a silo—an all-hands approach is called for to make real and lasting progress on this issue. The guidance and recommendations in ANA’s newest position statement are a call to action, and a call for nursing leaders to get involved.

Additional ANA Resources:

ANA House of Delegates Resolution (Historic policy, 2012) — Nurses’ Role in Recognizing Educating, Advocating for Healthy Energy Choices

ANA House of Delegates Resolution (Historic policy, 2008) – Global Climate Change

ANA Makes Nurses’ Voices Heard on Equity and Efficiency


Recently, the Centers for Medicare & Medicaid Services (CMS) issued a Request for Information (RFI) entitled Make Your Voice Heard: Promoting Efficiency and Equity Within CMS Programs. Through this RFI, CMS solicited feedback from stakeholders on the impact of the COVID-19 public health emergency (PHE) on the healthcare delivery system, with specific questions related to access, health equity, and workforce challenges. ANA took advantage of the opportunity to provide feedback to the agency on the nurses’ perspectives. We focused on how the COVID-19 pandemic has impacted the nation’s health care system and pointed to important areas of consideration as we all look to the future.

Representing and supporting over 4.3 million registered nurses, ANA understands the importance of elevating the nurse’s voice regarding the challenges in health care because nurses are integral to patient care. In sharing firsthand experiences from members and association priorities, ANA’s comments addressed access to health care, the nurse’s experience in providing care, advancing health equity, and assessing the impact of waivers issued in response to the PHE. A few key ANA recommendations to CMS are:

  • Make permanent the waivers that allow better access to telehealth and that allow Advanced Practice Registered Nurses (APRNs) to practice at the top of their license by removing unnecessary barriers; and
  • Acknowledge and support the role of the nurse in addressing health inequity and other long-standing nursing concerns about patient care.

Accessing Healthcare and the Public Health Emergency Waivers:

CMS asked to understand what challenges health care workers face that impact their wellbeing and present challenges to meet patient needs. In response, ANA shared member stories of patients who experienced barriers to care due to restrictive rules on APRN practice, such as not being able to access needed mental health care or obtain prescriptions for necessary medications.

We know that when APRNs are allowed to practice at the top of their license, more patients overcome barriers to receiving safe and cost-effective care. ANA recommended that current waivers still in place from the PHE, set now to expire in January 2023, be made permanent through CMS action, so that APRNs can continue to practice at the top of their license. These recommendations also support ANA’s legislative advocacy as we encourage lawmakers to support H.R. 8812, the Improving Care and Access to Nurses (ICAN) Act which would allow for changes in Medicare and Medicaid for APRNs to provide necessary care within their scope to better reach and support the needs of more patients.

APRNs at the #ICAN Act Press Event in September, 2022

Allowing APRNs to continue to serve their communities as they have been able to through the PHE waivers offers more timely and accessible care options in underserved areas and specialties where care can be delayed. Additionally, the PHE waivers for telehealth flexibilities have allowed APRNs to better reach patients where they are needed. ANA recommended to CMS that telehealth allowances be continued and made permanent to increase accessibility to care for more patients.

Understanding Provider Experiences:

CMS also sought feedback to better understand the challenges that impact health care workers’ wellbeing and the challenges in their meeting patient needs. ANA responded by highlighting issues that were exacerbated by COVID-19. Limited resources, critical staffing shortages, and increasing levels of burnout during the ongoing pandemic are several key issues that still need to be addressed. ANA called on CMS to take concrete steps to protect nurses and their patients using all available authority and resources to address these concerns.

In sharing provider experiences, ANA made sure to promote nurse and patient wellbeing and safety issues in its comments. These experiences include:

  • encountering the stigma of needing mental health care, affecting patients and providers;
  • lack of meal breaks during shifts;
  • unenforced safe staffing standards;
  • inadequate nurse involvement in leadership decisions where nursing is impacted; and
  • needing to promote nursing education to keep up with the growing need for more nurses.

In addition, ANA recommended that CMS support nurses and providers by promoting retention efforts of healthcare workers through payment and reimbursement system changes which would allow for appropriate compensation of nurses that more accurately reflect the value of nursing to the healthcare system. ANA also suggested that CMS look further into ensuring documentation requirements are appropriate, to allow nurses to spend more time with patients, and less time charting extraneous details which are nonessential to daily care tasks.

Advancing Health Equity and COVID-19 PHEs:

Continuing their work on advancing health equity, CMS asked how to better help eliminate health disparities. The agency also inquired about COVID-19 PHE waivers, asking what was helpful and what needs to be improved upon from these waivers. ANA responded by continuing to emphasize the important role that nurses perform in their daily tasks and the accessibility that APRNs practicing at the top of their license provides to many patients in underserved areas.

An APRN advocating for the #ICAN Act in September, 2022

Nurses have firsthand experience witnessing health disparities and barriers to care that impact their patients’ health and wellbeing. The culturally competent care nurses provide allows them to identify and offer invaluable insight on the individualized needs of patients and more widely, on advancing health equity in their communities. Because of this, ANA encourages nurse involvement in researching, designing, and implementing measures to address health disparities and advance health equity. ANA stresses the importance of recognizing the role of the nurse in any proposed measure to advance health equity.

Allowing APRNs to practice at the top of their license, as well as the emergence of widely used telehealth appointments increases the accessibility of healthcare resources and making these emergency waivers permanent is one way CMS can immediately act to advance health equity before the waivers expire and we are forced to take a step backwards in access to high quality nursing care.

ANA continues to advocate on behalf of its members and the nursing profession with the federal agencies.

This blog was guest-authored by Samantha Karp. She is completing her Master of Science in Nursing with a focus in Nursing Leadership in Healthcare at Gonzaga University and has spent her practicum semester working with the ANA Policy and Government Affairs team, learning how nurses can be active advocates in policy.