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 Advocacy Focuses on Safe Staffing, Looks to Opportunities in the New Year


Achieving safe staffing levels continues to be one of the biggest challenges facing nurses at the bedside. Workforce shortages, while not new, are being deeply felt across the country. The COVID-19 pandemic exacerbated existing shortages and has led to significant burnout among our nurses, driving even more nurses out of the profession. These shortages are unsustainable, making it even more vital that policymakers act now to identify and take action on new approaches to addressing safe staffing and other workforce challenges. 

At ANA, we recognize this issue is essential to our nurses and are working hard to make real change at the federal level by advocating for the Administration and Congress to recognize and address this crisis. Through our regulatory advocacy, ANA has reached out to Centers for Medicare & Medicaid Services’ (CMS’) Center for Clinical Standards & Quality as well as the White House Domestic Policy Council to call for more meaningful conditions of participation that provide additional requirements and enforcement mechanisms for staffing at acute care hospitals. 

More recently, ANA submitted comments on CMS’ proposal to institute the first-ever ratios for staffing in long-term care (LTC) facilities. As directed by an Executive Order issued by President Biden, CMS was tasked with studying staffing levels in these facilities and issuing regulations aimed at improving nurse staffing levels to enhance patient care quality. CMS issued a proposed rule in early September that would set minimum ratios for registered nurses (RNs) and nurse aides and require an RN onsite 24/7, among other implementation and enforcement requirements. When finalized, this proposed regulation will set a precedent for federal staffing requirements that could bolster our advocacy efforts related to safe nurse staffing in other settings as well. 

This proposed regulation is so significant that, in addition to our comment letter, we also submitted a coalition letter to the agency that included 25 state nursing and organizational affiliate associations. Both letters echo previous calls for the Administration—CMS and other federal agencies—to work closely with the nursing community and other stakeholders to take real action to address workforce needs and challenges.  

As part of our legislative advocacy, ANA recently endorsed the Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act (H.R. 2530/S.1113), introduced by Senator Sherrod Brown (D-OH) in the U.S. Senate and Representative Jan Schakowsky (D-IL-9) in the U.S. House of Representatives. This bill would establish minimum nurse-to-patient staffing ratios in hospitals to help ensure patients have access to nurses who can provide them with the time and attention necessary to deliver high quality patient care. ANA sees the adoption of safe staffing levels as part of a multi-pronged approach to addressing the work environment challenges resulting in burnout and workforce attrition among nurses. 

As we look to 2024, ANA will continue the drumbeat with federal policymakers about the critical need to take real action to address safe staffing for our nation’s nurses. We will keep pushing federal agencies to use their existing authority to ensure safe staffing levels in the health care facilities under their purview, while watching closely for CMS to issue the final rule on LTC facilities. ANA will also seek opportunities to call on Congress to implement safe staffing standards, while identifying and pushing back against any policies that could further exacerbate the nurse staff workforce crisis. Together with our members, we will continue to make real strides in addressing safe staffing for nurses and the patients they serve. 

Introducing the Safe Staffing for Nurse and Patient Safety Act


Advocating for and passing legislation that helps nurses and patients is a fundamental part of our Year of Advocacy. Nurses advocate every day for their patients, their communities and the profession, but it is also important that nurses lend their expertise to elected officials as they draft and pass legislation relevant to the nursing profession.

Earlier this month our bipartisan champions in the House of Representatives and Senate introduced a bill that will improve care and help keep nurses and patients safe. Champions including Reps. David Joyce (R-OH-14), Suzan DelBene (D-WA-10), Suzanne Bonamici (D-OR-1), and Tulsi Gabbard (D-HI-2) as well as Senator Jeff Merkley (D-OR), came together to introduce the Safe Staffing for Nurse and Patient Safety Act of 2018 (S. 2446, H.R. 5052).

The bill requires hospitals to establish a committee, composed of at least 55 percent direct care nurses, to create nurse staffing plans that are specific to each unit. As nurses across the country know, patients risk longer hospital stays, increased infections, and avoidable injuries when units are understaffed. Understaffing also leads to lower nurse retention, higher rates of injury and burnout.

“RN staffing makes a critical difference for patients and the quality of their care,” said Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN, president of the American Nurses Association. “Appropriate nurse staffing keeps patients safe and protects them from preventable complications, even lowering the risk of death. Nursing care is like medication—we would never withhold a medication when we know its lifesaving effects. The Safe Staffing for Nurse and Patient Safety Act empowers direct care nurses to determine the unique and variable needs of their patients to ensure the safety and quality outcomes of care.”

Our Congressional champions also understand why this legislation is so important.

“As a husband of a nurse, I have experienced first-hand the many challenges and responsibilities nurses face on a day to day basis,” said Joyce. “Ensuring patient safety and care has always been a priority but has faced many challenges when nurses are over worked and hospitals are under staffed. As Co-Chair of the House Nursing Caucus, I am proud to introduce legislation that addresses the issue and protects our patients and nurses.”

“As the husband of a nurse, I know firsthand the many challenges nurses face and how critical their care is to patients,” said Merkley. “Safe staffing enhances the quality of patient care, reduces medical errors, and increases nurse retention.”

But introducing this bill is just the first step. We need your help getting more cosponsors for this legislation – let your Senators and Representatives know why safe staffing is so critical. Click here to send them an email asking them to support this bill and be sure to include a personal note on why nurse-driven ratios are so important.