[Federal Register Volume 90, Number 230 (Wednesday, December 3, 2025)]
[Rules and Regulations]
[Pages 55687-55698]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2025-21792]
=======================================================================
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Part 483
[CMS-3442-IFC]
RIN 0938-AV25
Medicare and Medicaid Programs; Repeal of Minimum Staffing
Standards for Long-Term Care Facilities
AGENCY: Centers for Medicare & Medicaid Services (CMS), Department of
Health and Human Services (HHS).
ACTION: Interim final rule with comment period.
-----------------------------------------------------------------------
SUMMARY: This interim final rule with comment period repeals provisions
of the final rule titled ``Medicare and Medicaid Programs; Minimum
Staffing Standards for Long-Term Care Facilities and Medicaid
Institutional Payment Transparency Reporting.'' This action is taken in
view of changes made by by public law, which precludes HHS from
implementing, administering, or enforcing certain provisions of the
final rule until September 30, 2034.
DATES: These regulations are effective on February 2, 2026.
Comment date: To be assured consideration, comments must be
received at one of the addresses provided below, by February 2, 2026.
ADDRESSES: In commenting, please refer to file code CMS-3442-IFC.
Comments, including mass comment submissions, must be submitted in
one of the following three ways (please choose only one of the ways
listed):
1. Electronically. You may submit electronic comments on this
regulation to http://www.regulations.gov. Follow the ``Submit a
comment'' instructions.
2. By regular mail. You may mail written comments to the following
address ONLY: Centers for Medicare & Medicaid Services, Department of
Health and Human Services, Attention: CMS-3442-IFC, P.O. Box 8016,
Baltimore, MD 21244-8016.
Please allow sufficient time for mailed comments to be received
before the close of the comment period.
3. By express or overnight mail. You may send written comments to
the following address ONLY: Centers for Medicare & Medicaid Services,
Department of Health and Human Services, Attention: CMS-3442-IFC, Mail
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
For information on viewing public comments, see the beginning of
the SUPPLEMENTARY INFORMATION section.
FOR FURTHER INFORMATION CONTACT: The Clinical Standard Group's Long
Term Care Team at [email protected].
SUPPLEMENTARY INFORMATION:
Inspection of Public Comments: All comments received before the
close of the comment period are available for viewing by the public,
including any personally identifiable or confidential business
information that is included in a comment. We post all comments
received before the close of the comment period on the following
website as soon as possible after they have been received: http://www.regulations.gov. Follow the search instructions on that website to
view public comments. CMS will not post on Regulations.gov public
comments that make threats to individuals or institutions or suggest
that the commenter will take actions to harm an individual. CMS
continues to encourage individuals not to submit duplicative comments.
We will post acceptable comments from multiple unique commenters even
if the content is identical or nearly identical to other comments.
I. Background
In the May 10, 2024 Federal Register (89 FR 40876), the Centers for
Medicare & Medicaid Services (CMS), published a final rule titled
``Medicare and Medicaid Programs; Minimum Staffing Standards for Long-
Term Care Facilities and Medicaid Institutional Payment Transparency
Reporting'' (hereinafter referred to as 2024 Minimum Staffing final
rule). This rule, among other items, established minimum staffing
standards for long-term care facilities participating in Medicare and
Medicaid programs. The standards were informed by data and literature
available in 2022 and 2023.
On July 4, 2025, Public Law 119-21 was signed into law. Section
71111 of Public Law 119-21 prohibits CMS from implementing,
administering, or enforcing the minimum staffing standards set forth in
Sec. 483.5, definitions related to staffing requirements, and Sec.
483.35, requirements for a registered nurse (RN) to be onsite 24 hours,
7 days per week and that each facility provides a minimum of 0.55 RN,
2.45 nurse aide (NA), and 3.48 total nurse staffing hours per resident
day (HPRD), for a specified time period. This legislative action
effectively suspends implementation of these provisions until September
30, 2034.
[[Page 55688]]
II. Basis for Repeal
A. Legislative Moratorium
Section 71111 of Public Law 119-21 precludes CMS from implementing,
administering, or enforcing the minimum staffing standards established
in the 2024 Minimum Staffing final rule (89 FR 40876) until after
September 30, 2034. This prohibition renders portions of Sec. Sec.
483.5 and 483.35 unenforceable and unimplementable during the period
before October 1, 2034. Congress has thus effectively suspended these
provisions for that period. We believe that this prohibition warrants
restoration of the previous version of the Code of Federal Regulations
(CFR). Without such revisions, the regulations would lack nurse
staffing standard that implements the minimum requirements for long-
term care facilities set forth in sections 1819(b)(4)(C)(i) and
1919(b)(4)(C)(i) of the Act.
B. Policy Considerations
HHS and CMS are committed to protecting the health and safety of
residents in long-term care facilities. Following the publication of
the final rule, interested parties continue to express their concerns
over the establishment of the quantitative minimum staffing standards,
requiring a RN to be onsite 24 hours, 7 days per week and that each
facility provides a minimum of 0.55 RN, 2.45 NA, and 3.48 total nurse
staffing HPRD.
LTC facilities, particularly those within rural and tribal
communities, raised significant concerns that these standards, even
with a comprehensive exemption process in place, could increase the
risk of facility closure, thus potentially decreasing access to
healthcare. Rural and tribal communities face a specific challenge of
geographic isolation, making it difficult to recruit nurses and for
patients to access care.\1\ LTC facilities continue to note hiring
challenges due to the existing labor supply and available resources
despite their best efforts to meet these requirements. The National
Indian Health Board stated that the 2024 final rule would be
catastrophic for keeping facilities open and meeting the trust and
treaty obligations in healthcare because of the difficulty of staffing
in Indian Country. Further, they noted that LTC facility closures like
this in tribal communities do not just remove jobs but break cultural
bonds and remove elders from their communities.
---------------------------------------------------------------------------
\1\ Taylor, Noelle, et al. ``Promising Practices to Address
Healthcare Needs Voiced by Local Native Americans.''
DigitalCommons@USU, 2025, digitalcommons.usu.edu/tcjournal/vol2/iss1/4/. Accessed September 18, 2025.
---------------------------------------------------------------------------
Likewise, multiple sources have described the current and projected
shortages, including the International Council of Nurses (ICN) report
calling for the worldwide shortage of nurses to be treated as a global
health emergency. The report, titled Recover to Rebuild: Investing in
the Nursing Workforce for Health System Effectiveness,\2\ details the
impact that the pandemic had on the world's nursing workforce, nurse
burnout, and access to care. The National Center for Workforce Analysis
(NCHWA) \3\ projects nationwide nursing shortages, including a shortage
of 295,800 nurses nationwide, with larger shortages of nurses in
nonmetropolitan areas including rural and tribal communities. In
addition, according to a Health Workforce Analysis published by the
Health Resources and Services Administration (HRSA), authorities
project just 63,720 people working as full-time RNs in 2030. Lastly,
the American Association of Colleges of Nursing predicts that RN
shortages will continue over the next decade and beyond, with a 13
percent deficit in the total number of RNs in nonmetropolitan areas
predicted to be needed in the United States by 2037, and a 5 percent
deficit of RNs predicted for metropolitan areas of the country.\4\
---------------------------------------------------------------------------
\2\ Buchan, James, and Howard Catton. RECOVER to REBUILD
INVESTING in the NURSING WORKFORCE for HEALTH SYSTEM EFFECTIVENESS
International Council of Nurses the Global Voice of Nursing. 2023.
\3\ McGhee, Moira. ``A Crisis by the Numbers: Nursing Shortages
in 2025 by State.'' Yahoo Finance, Vivian Health, February 24, 2025,
finance.yahoo.com/news/crisis-numbers-nursing-shortages-2025-163000209.html?guccounter=1&guce_referrer=aHR0cHM6Ly93d3cuZ29vZ2xlLmNvbS8&guce_referrer_sig=AQAAACgfnz8Zi44P6ei-zweMuE0reqyIi9N19l_UIZVnmeFi0iHKKbYKSrtXhK23rJ6yZQ9Ny2dDkmXAlJropGQI2grGod8aHqswrTZBa0eiYk6EEyW9usg5XEYExAWFSvEP24uxek-T5cxKAvfjFgVRWHFZDR98zsEBIafohInLbBiH. Accessed September 5, 2025.
\4\ American Association of Colleges of Nursing. ``Nursing
Shortages Fact Sheet.'' American Association of Colleges of Nursing,
2024, www.aacnnursing.org/news-data/fact-sheets/nursing-shortage.
---------------------------------------------------------------------------
Furthermore, two district courts have vacated at the summary
judgment stage the minimum staffing provisions related to HPRD and the
24/7 RN requirement as currently drafted and codified at 42 CFR
483.35(b)(1) and (c). First, in the summary judgement for American
Health Care Association v. Kennedy (Case Nos. 24-144 and 24-171, 777 F.
Supp.3d 691(N.D. Tex. 2025)) \5\ (appealed June 2, 2025 to the Fifth
Circuit), the court relied on the major questions doctrine in its
finding that HHS exceeded its statutory authority with the minimum
staffing policy changes. Second, in the summary judgement for Kansas v.
Kennedy (Case No. C24-110-LTS-KEM,_F. Supp. 3d_(N.D. Iowa, June 18,
2025) \6\ Interested parties should refer to the detailed order and
judgement for each case for additional information.
---------------------------------------------------------------------------
\5\ Available at https://caselaw.findlaw.com/court/us-dis-crt-n-d-tex-ama-div/117139174.html.
\6\ Available at https://caselaw.findlaw.com/court/us-dis-crt-n-d-iow-ced-rap-div/117400951.html.
---------------------------------------------------------------------------
HHS no longer believes that the current quantitative minimum
staffing standards affected by the moratorium and litigation are
appropriate, especially because the minimum staffing standards do not
follow from the best interpretation of the relevant statute. The
quantitative minimum staffing standards, as currently written, impose
one-size-fits-all minimum requirements on all facilities across the
country without accounting for differences in local labor supply,
overall acuity of the facility's resident population, or available
resources. Rural and tribal community facilities currently face
significant difficulties in recruiting and retaining staff; the current
quantitative minimum staffing standards could put many of these
facilities at an increased risk of closure, thus potentially decreasing
access to health care in these communities.
Given these policy considerations, HHS has modified its policy
views with respect to the quantitative minimum staffing standards.
C. Tribal Community Considerations
In view of the policy considerations stated previously, and upon
further consultation and review of certain comments, HHS and CMS
believe there is an opportunity to further engage with Tribal
communities. CMS received correspondence from tribal communities noting
that longstanding healthcare workforce shortages across Indian Country
make compliance with the LTC staffing rule impossible for many
facilities and that the rule would cause closures of many LTC
facilities due to limitations present in Health Provider Shortage Areas
(HPSA) in rural and remote areas. In addition, the Tribal Technical
Advisory Group (TTAG) is in favor of the 10-year moratorium, stating
that this ``supports the continued operation of rural Tribal LTC
facilities''. As noted previously, the minimum staffing standards, if
implemented, may impose disproportionate burdens on facilities serving
these communities, which face a distinct workforce and resource
constraints. Repealing the changes made to minimum staffing
[[Page 55689]]
standards by the rule provides an opportunity for CMS to reassess these
burdens and further engage in additional dialogue with Tribal
communities to better understand and address their concerns. We invite
and welcome additional consultation with Tribes on the impact of the
now-rescinded portions of the final rule and encourage Tribes to submit
comments during the comment period for this interim final rule with
comment period.
D. Agency Determination
Given the moratorium imposed by Public Law 119-21, the policy
considerations discussed previously, and a desire to further engage
tribal community concerns, we are repealing certain suspended
provisions of Sec. Sec. 483.5 and 483.35 and restoring the previous
language of Sec. 483.35, while soliciting further comment. This repeal
ensures that the regulations reflect current legal authority and HHS
policy, and allows for future rulemaking that incorporates new, up-to-
date evidence and interested party input.
III. Provisions of the Interim Final Rule With Comment Period
This interim final rule with comment period revises the following
sections of 42 CFR 483:
In Sec. 483.5, we are removing the definition of ``hours
per resident day'' since it is only used in relation to the minimum
staffing requirements in this section that this rule repeals;
therefore, the definition is no longer relevant.
In Sec. 483.35, we are making the following changes:
++ Removing the requirements for long term care facilities to have
an RN onsite 24 hours, 7 days per week and the minimum requirements for
0.55 RN, 2.45 NA, and 3.48 total nurse staffing HPRD requirements.
++ Reinstating the minimum statutory RN staffing requirement for
LTC facilities to use the services of an RN for at least 8 consecutive
hours a day, 7 days a week and to designate an RN to serve as the
director of nursing on a full-time basis except when waived.
With converting the nurse staffing requirements at Sec. 483.35
back to the requirements finalized in the 2016 ``Medicare and Medicaid
Programs; Reform of Requirements for Long Term Care Facilities'' final
rule (81 FR 68688), we are also including technical corrections to
several incorrect paragraph citations that were made as part of the
updates to Sec. 483.35 in the May 2024 Minimum Staffing final rule (89
FR 40996 through 40998). We are finalizing the corrected citations as
part of this interim final rule with comment period to assure accuracy
and clarity. Therefore, we are making the following revisions:
++ In the introductory paragraph, we are replacing the reference to
Sec. 483.70(e) with a reference to Sec. 483.71, where facility
assessment requirements are now located.
-- In paragraph (a)(2), we are changing the cross reference from
paragraph (c), Proficiency of nurse aides, to paragraph (e), Nursing
facilities: Waiver of requirement to provide licensed nurses on a 24-
hour basis. The requirement will now state that, except when waived
under paragraph (e), a facility must designate a licensed nurse to
serve as a charge nurse on each tour of duty.
-- In paragraph (f)(2), we are changing the cross reference from
paragraph (d)(1) to paragraph (f)(1), which allows for the Secretary of
the Department of Health and Human Services (Secretary) to waive the
requirement that a skilled nursing facility provide the services of an
RN for more than 40 hours a week, including a director of nursing
specified in paragraph (b) of this section, under certain
circumstances. This requirement will now state that a waiver of the RN
requirement under paragraph (f)(1) of this section is subject to annual
renewal by the Secretary.
-- In paragraph (g)(2)(i), we are changing the cross reference from
paragraph (e)(1) to paragraph (g)(1) the facility must post the nurse
staffing data on a daily basis. This requirement will now state that
the facility must post the nurse staffing data specified in paragraph
(g)(1) of this section on a daily basis at the beginning of each shift.
IV. Good Cause for Proceeding With an Interim Final Rule With Comment
Period
For the reasons described in this section, we have determined that
an interim final rule with comment period is the appropriate mechanism
to align regulations with current enforceable law. Although this
interim final rule with comment period is effective in 60 days,
comments are solicited from interested members of the public on all
aspects of the interim final rule with comment period. We will consider
these comments in deciding the next steps following this interim final
rule with comment period.
Under the Administrative Procedure Act (APA) (5 U.S.C. 553(b)(B))
and 42 U.S.C. 1395hh(b)(2), CMS may forgo notice-and-comment rulemaking
when it finds, for good cause, that such procedures are impracticable,
unnecessary, or contrary to the public interest. We find that there is
good cause based on the totality of the circumstances described later
in this section.
The current regulations at issue here have not yet been enforced,
and section 71111 of Public Law 119-21 precludes CMS from taking any
further actions to administer or enforce them until September 30, 2034.
Additionally, two Federal district courts have vacated portions of the
final rule and there is no current reliance on these provisions by
regulated entities or the public. The absence of a comment period
before repeal will not cause injury to any interested person.
Moreover, maintaining regulations that are unenforceable and
unimplementable for several years in the CFR is confusing and
impracticable. The presence of unenforceable and unimplementable
provisions during the moratorium could lead to misunderstandings
regarding applicable standards, potentially causing confusion among LTC
facilities, regulators, and the public. Repealing these specific
provisions immediately eliminates this risk and ensures regulatory
clarity. Moreover, it is impracticable to maintain these unenforceable
regulations because doing so would prolong the period in which there is
no specific implementing language for sections 1819(b)(4)(C)(i) and
1919(b)(4)(C)(i) of the Act to specify the level of staffing CMS views
as ``sufficient'' to meet nursing needs of residents and establish
consistent nationwide standards of mandatory minimum staffing levels in
regulated facilities. While many States have regulations in place for
minimum nursing services to LTC facility residents, those regulations
vary, and do not assure consistent minimum standards across the
country.
We also believe that including a comment period before repealing a
regulation that can only be enforced and implemented almost a decade in
the future is unnecessary. Further, the inclusion of a comment period
would delay the removal of unenforceable regulations and prolong
confusion and possible misapplication or misapprehension of standards,
which would be contrary to public health interests served by the
staffing standards, including setting a national and broadly applicable
baseline. We considered delaying the repeal until after a comment
period or delaying the effective date to 2034, but given the facts,
context, and litigation, we concluded that doing so would perpetuate
regulatory uncertainty and is not in the public interest.
[[Page 55690]]
While under these specific circumstances we find good cause for
issuing this interim final rule with comment period prior to a public
comment period, the agency is committed to considering public input. We
invite comments on this interim final rule with comment period and
future rulemaking. Comments received by the date specified in the DATES
section of this interim final rule with comment period will be
considered in determining whether further action is warranted.
V. Collection of Information Requirements
Under the Paperwork Reduction Act of 1995 (PRA), 44 U.S.C. 3501-
3520, we are required to provide notice in the Federal Register and
solicit public comment before a collection of information requirement
is submitted to the Office of Management and Budget (OMB) for review
and approval. To fairly evaluate whether an information collection
should be approved by OMB, 44 U.S.C. 3506(c)(2)(A) requires that we
solicit comment on the following issues:
The need for the information collection and its usefulness
in carrying out the proper functions of our agency.
The accuracy of our estimate of the information collection
burden.
The quality, utility, and clarity of the information to be
collected.
Recommendations to minimize the information collection
burden on the affected public, including automated collection
techniques.
This rule does not impose new information collection requirements.
Instead, it revises an information collection requirement established
in the 2024 Minimum Staffing final rule (89 FR 40876). In that rule, we
estimated that long-term care (LTC) facilities would spend 19 hours
annually reviewing and updating policies and procedures related to the
nurse staffing requirement at Sec. 483.35(a), which mandated 0.55
hours per resident day (HPRD) for registered nurses (RNs) and 2.45 HPRD
for nurse aides (NAs) (89 FR 40937).
To estimate the savings from removing this burden, we apply the
same methodology and data sources used in the 2024 rule. Readers can
refer to the 2024 final rule's collection of information section for
detailed discussion on the data sources and methodology used to
estimate costs.
In the 2024 final rule, the annual baseline cost of the requirement
at Sec. 483.35(a) was estimated at $24,440,832 (89 FR 40939).
In accordance with OMB guidance document (M-25-20), we are
adjusting this estimate to 2024 dollars using the Bureau of Economic
Analysis' GDP deflator (National Income and Product Accounts Table
1.1.9).7 8 We also apply a 2.31 percent annual increase in
real wage rates starting in 2025, consistent with the final rule. As
shown in Table 1, we estimate that removing this requirement will
result in total savings of $315,672,322 over 10 years, or annualized
savings of $31,567,232.
---------------------------------------------------------------------------
\7\ Office of Management and Budget. Guidance Implementing
Section 3 of Executive Order 14192, Titled ``Unleashing Prosperity
Through Deregulation''. https://www.whitehouse.gov/wp-content/uploads/2025/02/M-25-20-Guidance-Implementing-Section-3-of-Executive-Order-14192-Titled-Unleashing-Prosperity-Through-Deregulation.pdf (Accessed August 18, 2025).
\8\ Bureau of Economic Analysis. ``National Income and Product
Accounts.'' https://apps.bea.gov/iTable/?reqid=19&step=3&isuri=1&1921=survey&1903=13#eyJhcHBpZCI6MTksInN0ZXBzIjpbMSwyLDMsM10sImRhdGEiOltbIk5JUEFfVGFibGVfTGlzdCIsIjEzIl0sWyJDYXRlZ29yaWVzIiwiU3VydmV5Il0sWyJGaXJzdF9ZZWFyIiwiMjAyMSJdLFsiTGFzdF9ZZWFyIiwiMjAyNCJdLFsiU2NhbGUiLCIwIl0sWyJTZXJpZXMiLCJBIl1dfQ== (Accessed
August 18, 2025).
Table 1--Savings From Removal of 0.55 HPRD for RNs and 2.45 HPRD for NAs
Information Collection Requirements
------------------------------------------------------------------------
Year Calendar year Savings
------------------------------------------------------------------------
Year 1............................ 2025 $28,423,085
Year 2............................ 2026 29,079,658
Year 3............................ 2027 29,751,398
Year 4............................ 2028 30,438,656
Year 5............................ 2029 31,141,789
Year 6............................ 2030 31,861,164
Year 7............................ 2031 32,597,157
Year 8............................ 2032 33,350,151
Year 9............................ 2033 34,120,540
Year 10........................... 2034 34,908,724
-------------------------------------
10-Year Total Savings......... ................. 315,672,322
------------------------------------------------------------------------
VI. Regulatory Impact Analysis
A. Statement of Need
This interim final rule with comment period is necessary to align
the CFR with the statutory moratorium imposed by section 71111 of
Public Law 119-21, which prohibits CMS from implementing,
administering, or enforcing the minimum staffing standards currently in
place at Sec. Sec. 483.5 and 483.35 until September 30, 2034. In
addition, following the finalization of these staffing standards,
interested parties expressed significant concerns about the rule's
impact. In particular, LTC facilities within rural and tribal
communities indicated that the rule's requirements could increase the
risk of facility closure. As such, we are rescinding the requirements
that facilities have 24/7 RN coverage and that they provide a minimum
of 0.55 RN, 2.45 NA, and 3.48 total nurse HPRD.
B. Overall Impact
We have examined the impacts of this rule as required by Executive
Order 12866, ``Regulatory Planning and Review''; Executive Order 13132,
``Federalism''; Executive Order 13563, ``Improving Regulation and
Regulatory Review''; Executive Order 14192, ``Unleashing Prosperity
Through Deregulation''; the Regulatory Flexibility Act (RFA) (Pub. L.
96-354); section 1102(b) of the Act; and section 202 of the Unfunded
Mandates Reform Act of 1995 (Pub. L. 104-4).
Executive Orders 12866 and 13563 direct agencies to assess all
costs and benefits of available regulatory alternatives and, if
regulation is necessary, to select those regulatory approaches that
maximize net benefits (including potential economic, environmental,
public health and safety,
[[Page 55691]]
and other advantages; distributive impacts; and equity). Section 3(f)
of Executive Order 12866 defines a ``significant regulatory action'' as
any regulatory action that is likely to result in a rule that may: (1)
have an annual effect on the economy of $100 million or more or
adversely affect in a material way the economy, a sector of the
economy, productivity, competition, jobs, the environment, public
health or safety, or State, local, or tribal governments or
communities; (2) create a serious inconsistency or otherwise interfere
with an action taken or planned by another agency; (3) materially alter
the budgetary impact of entitlements, grants, user fees, or loan
programs or the rights and obligations of recipients thereof; or (4)
raise novel legal or policy issues arising out of legal mandates, or
the President's priorities.
A regulatory impact analysis (RIA) must be prepared for a
regulatory action that is significant under section 3(f)(1) of E.O.
12866. This interim final rule with comment period is significant as
per section 3(f)(1) as we estimate that it will result in savings of
$55,089,104,265 for long-term care facilities, patients and payors over
10 years, and costs of $3,255,827,043 for Medicare over 10 years
(analogous effects for other payers were and are unquantified). As
such, we have prepared a regulatory impact analysis that analyzes the
costs and benefits of this interim final rule with comment period.
C. Impacts From Removing LTC Minimum Staffing Requirements
1. Costs Savings From Removing Staffing Requirements
We are removing two existing requirements for nursing services for
LTC facilities at Sec. 483.35. We are removing the requirement that
facilities have RN coverage onsite 24 hours per day, 7 days a week (24/
7 RN) and that they provide a minimum of 0.55 RN, 2.45 NA, and 3.48
total nurse staffing HPRD. Although Public Law 119-21 does not allow
CMS to enforce the minimum staffing requirements until 2034, we follow
guidance provided in OMB Circular A-4 https://www.whitehouse.gov/wp-content/uploads/2025/08/CircularA-4.pdf that ``In some cases,
substantial portions of a rule may simply restate statutory
requirements that would be self-implementing, even in the absence of
the regulatory action. In these cases, you should use a pre-statute
baseline.'' As such, we continue to estimate the impact of removing
these requirements even during the years when the Public Law 119-21
moratorium is in effect.
To estimate the impact from removing each of these requirements, we
use the same methodology and data sources used to estimate the costs
for these requirements in the 2024 Minimum Staffing final rule (89 FR
40948). We refer readers to that rule's regulatory impact analysis for
a detailed discussion on the data sources and methodology for
estimating the savings for removing each requirement as outlined in
this section.\9\ Since these requirements were phased in over a 5-year
period starting in May 2024 and there were different timelines for
rural and non-rural facilities to meet the requirements, there is
yearly variation in the annual savings from removing each requirement.
We note that the 10-year savings from removing these requirements are
higher than the 10-year costs as outlined in the 2024 Minimum Staffing
final rule (89 FR 40973) since more than a year has passed since the
requirements were finalized and the phasing-in of the requirements led
costs to be lower during the first 5 years after the effective date
(than the eventual ongoing level). In addition, in line with the OMB
guidance document M-25-20, we are adjusting all estimates to 2024
dollars using the Bureau of Economic Analysis' GDP deflator (National
Income and Product Accounts Table 1.1.9).10 11
---------------------------------------------------------------------------
\9\ Caveats about the earlier analysis continue to apply now.
For instance, regulatory exemptions were and are generally not
captured in the quantitative estimates. As an additional example,
the quantitative approach continues to reflect an assumption that
LTC facilities would reallocate their existing staffing resources to
ensure compliance with the rule on a continual basis (for example,
if a long-term care facility has a staffing level that is compliant
with the 2024 rule over the course of a month or quarter, it may, in
the absence of this interim final repeal and related statutory and
judicial interventions, have needed to shift staff so that
compliance would be achieved each day); data limitations were
notable regarding the time LTC managers would spend on such
reallocation in the presence of the 2024 rule.
\10\ Office of Management and Budget. Guidance Implementing
Section 3 of Executive Order 14192, Titled ``Unleashing Prosperity
Through Deregulation''. https://www.whitehouse.gov/wp-content/uploads/2025/02/M-25-20-Guidance-Implementing-Section-3-of-Executive-Order-14192-Titled-Unleashing-Prosperity-Through-Deregulation.pdf (Accessed August 18, 2025).
\11\ Bureau of Economic Analysis. ``National Income and Product
Accounts.'' https://apps.bea.gov/iTable/?reqid=19&step=3&isuri=1&1921=survey&1903=13#eyJhcHBpZCI6MTksInN0ZXBzIjpbMSwyLDMsM10sImRhdGEiOltbIk5JUEFfVGFibGVfTGlzdCIsIjEzIl0sWyJDYXRlZ29yaWVzIiwiU3VydmV5Il0sWyJGaXJzdF9ZZWFyIiwiMjAyMSJdLFsiTGFzdF9ZZWFyIiwiMjAyNCJdLFsiU2NhbGUiLCIwIl0sWyJTZXJpZXMiLCJBIl1dfQ== (Accessed
August 18, 2025).
---------------------------------------------------------------------------
a. RN Onsite 24 Hours a Day, 7 Days a Week (24/7 RN) Requirement
Savings
To estimate the savings from removing the 24/7 RN requirement, we
first calculated each facility's savings from not needing to have an RN
onsite 24 hours a day, 7 days per week. We then aggregated the savings
across all facilities for a total savings of $349 million annually for
all facilities if these requirements had gone into effect in 2024.
The requirement that nursing homes provide 24/7 RN care included a
phased-in implementation that requires non-rural facilities to meet the
requirement by May 11, 2026, and rural facilities meeting the
requirement by May 10, 2027. We also assumed that facilities would
begin hiring RNs to meet this requirement in the year prior to the
implementation deadline. As such, we calculated savings separately for
rural and non-rural facilities. We estimate savings over 10 years
starting in 2025 when this interim final rule with comment period
removes the requirement. We include a 2.31 percent annual increase in
real wage rates starting in 2025, which is the same wage increase used
to estimate the requirement's cost in the 2024 Minimum Staffing final
rule (89 FR 40975). As Table 2 shows, we estimate that removing this
requirement results in average annual savings of approximately $431
million and $4,307,501,380 over 10 years.
Table 2--Annual and 10-Year Savings From Removing the 24/7 RN Requirement, by Rural/Non-Rural Location
----------------------------------------------------------------------------------------------------------------
24/7 RN requirement
Year Calendar year ------------------------------------ Total savings
Rural Urban
----------------------------------------------------------------------------------------------------------------
Year 1.................................. 2025 $0 $242,980,786 $242,980,786
Year 2.................................. 2026 162,877,843 248,593,642 411,471,485
Year 3.................................. 2027 166,640,321 254,336,155 420,976,476
[[Page 55692]]
Year 4.................................. 2028 170,489,712 260,211,321 430,701,033
Year 5.................................. 2029 174,428,024 266,222,202 440,650,227
Year 6.................................. 2030 178,457,312 272,371,935 450,829,247
Year 7.................................. 2031 182,579,676 278,663,727 461,243,402
Year 8.................................. 2032 186,797,266 285,100,859 471,898,125
Year 9.................................. 2033 191,112,283 291,686,689 482,798,972
Year 10................................. 2034 195,526,977 298,424,651 493,951,628
-----------------------------------------------------------------------
10-Year Total Savings............... ................ 1,608,909,413 2,698,591,967 4,307,501,380
----------------------------------------------------------------------------------------------------------------
b. Minimum Nurse Staffing Requirement of 3.48 Total Nurse Staffing
HPRD, 0.55 RN HPRD, and 2.45 NA HPRD Savings
(1) 3.48 Total Nurse Staff HPRD Requirement Savings
To estimate the savings from removing the 3.48 total nurse staff
HPRD requirement, we first calculated each facility's savings from not
needing to hire nurse staff to meet the requirement. Then, we
aggregated the savings across all facilities for a total savings of
approximately $1.37 billion annually for all facilities if these
requirements had gone into effect in 2024.
The requirement that nursing homes provide 3.48 total nurse staff
HPRD included a phased-in implementation that requires non-rural
facilities to meet the requirement by May 11, 2026, and rural
facilities meeting the requirement by May 10, 2027. We also assumed
that facilities would begin hiring staff to meet this requirement in
the year prior to the implementation deadline. As such, we calculated
savings separately for rural and non-rural facilities. We estimate
savings over 10 years starting in 2025 when this interim final rule
with comment period removes the requirement. We include a 2.31 percent
annual increase in real wage rates starting in 2025, which is the same
wage increase used to estimate the requirement's cost in the 2024
Minimum Staffing final rule (89 FR 40975). As Table 3 shows, we
estimate that removing this requirement will result in average annual
savings of approximately $1.75 billion and $17,460,934,208 over 10
years.
Table 3--Annual and 10-Year Savings From Removing the 3.48 Total Nurse Staff HPRD Requirement, by Rural/Non-
Rural Location
----------------------------------------------------------------------------------------------------------------
3.48 Total nurse staff
Year Calendar year ------------------------------------ Total savings
Rural Urban
----------------------------------------------------------------------------------------------------------------
Year 1.................................. 2025 $0 $1,315,408,430 $1,315,408,430
Year 2.................................. 2026 288,696,914 1,345,794,365 1,634,491,279
Year 3.................................. 2027 295,365,813 1,376,882,215 1,672,248,028
Year 4.................................. 2028 302,188,763 1,408,688,194 1,710,876,957
Year 5.................................. 2029 309,169,323 1,441,228,891 1,750,398,215
Year 6.................................. 2030 316,311,135 1,474,521,279 1,790,832,414
Year 7.................................. 2031 323,617,922 1,508,582,720 1,832,200,642
Year 8.................................. 2032 331,093,496 1,543,430,981 1,874,524,477
Year 9.................................. 2033 338,741,756 1,579,084,237 1,917,825,993
Year 10................................. 2034 346,566,690 1,615,561,083 1,962,127,773
-----------------------------------------------------------------------
10-Year Total Savings............... ................ 2,851,751,812 14,609,182,396 17,460,934,208
----------------------------------------------------------------------------------------------------------------
(2) 0.55 RN HPRD and 2.45 NA HPRD Requirements Savings
To estimate the savings from removing the 0.55 RN HPRD requirement
and the 2.45 NA HPRD requirement, we first calculated each facility's
savings from not needing to hire RNs to meet the RN HPRD requirement
and NAs to meet the 2.45 NA HPRD requirement. We then aggregated the
savings across all facilities for a total savings of approximately
$2.91 billion annually for all facilities if these requirements had
gone into effect in 2024.
The requirement that nursing homes provide 0.55 RN HPRD and 2.45 NA
HPRD included a phased-in implementation that requires non-rural
facilities to meet the requirement by May 10, 2027, and rural
facilities meeting the requirement by May 10, 2029. We also assumed
that facilities would begin hiring staff to meet this requirement in
the year prior to the implementation deadline. As such, we calculated
savings separately for rural and non-rural facilities. We estimate
savings over 10 years starting in 2025 when this interim final rule
with comment period removes the requirement. We include a 2.31 percent
annual increase in real wage rates starting in 2025, which is the same
wage increase used to estimate the requirement's cost in the 2024
Minimum Staffing final rule (89 FR 40975). As Table 4 shows, we
estimate that removing these requirements will result in average annual
savings of approximately $3.3 billion and $33,004,996,355 over 10
years.
[[Page 55693]]
Table 4--Annual and 10-Year Savings From Removing the 0.55 RN and 2.45 NA HPRD Requirements, by Rural/Non-Rural Location
--------------------------------------------------------------------------------------------------------------------------------------------------------
0.55 RN HPRD 2.45 NA HPRD requirement
Year Calendar ---------------------------------------------------------------------- Total savings
year Rural Urban Rural Urban
--------------------------------------------------------------------------------------------------------------------------------------------------------
Year 1............................................... 2025 $0 $0 $0 $0 $0
Year 2............................................... 2026 0 1,096,966,133 0 1,772,028,616 2,868,994,750
Year 3............................................... 2027 0 1,122,306,051 0 1,812,962,477 2,935,268,528
Year 4............................................... 2028 210,818,944 1,148,231,321 410,835,718 1,854,841,911 3,624,727,894
Year 5............................................... 2029 215,688,862 1,174,755,464 420,326,023 1,897,688,759 3,708,459,108
Year 6............................................... 2030 220,671,275 1,201,892,315 430,035,554 1,941,525,369 3,794,124,513
Year 7............................................... 2031 225,768,781 1,229,656,028 439,969,375 1,986,374,605 3,881,768,790
Year 8............................................... 2032 230,984,040 1,258,061,082 450,132,668 2,032,259,859 3,971,437,649
Year 9............................................... 2033 236,319,771 1,287,122,293 460,530,733 2,079,205,061 4,063,177,858
Year 10.............................................. 2034 241,778,758 1,316,854,818 471,168,993 2,127,234,698 4,157,037,267
--------------------------------------------------------------------------------------------------
10-Year Total Savings............................ ......... 1,582,030,432 10,835,845,505 3,082,999,063 17,504,121,355 33,004,996,355
--------------------------------------------------------------------------------------------------------------------------------------------------------
Table 5 summarizes the total savings from removing the 24/7 RN
requirement, as well as the 0.55 RN, 2.45 NA, 3.48 total nurse staffing
HPRD requirements, and the information collection costs as outlined in
Table 1, but not the regulatory review costs which we discuss in more
detail later in this section. Overall, we estimate that rescinding
these requirements will result in approximately $5.51 billion in annual
savings for nursing home providers with total savings over 10 years
estimated at $55,089,104,265.
[[Page 55694]]
Table 5--Annual and 10-Year Savings From Removing the 24/7 RN, 3.48 Total Nurse Staff, 0.55 RN and 2.45 NA HPRD Requirements, by Rural/Non-Rural Location
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
0.55 RN and 24/7 RN requirement 3.48 Total nurse staff 0.55 RN HPRD 2.45 NA requirement
Calendar 2.45 NA HPRD ------------------------------------------------------------------------------------------------------------------------------------
Year year collection of Total savings
information Rural Urban Rural Urban Rural Urban Rural Urban
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Year 1................................................. 2025 $28,423,085 $0 $242,980,786 $0 $1,315,408,430 $0 $0 $0 $0 $1,586,812,302
Year 2................................................. 2026 29,079,658 162,877,843 248,593,642 288,696,914 1,345,794,365 0 1,096,966,133 0 1,772,028,616 4,944,037,172
Year 3................................................. 2027 29,751,398 166,640,321 254,336,155 295,365,813 1,376,882,215 0 1,122,306,051 0 1,812,962,477 5,058,244,430
Year 4................................................. 2028 30,438,656 170,489,712 260,211,321 302,188,763 1,408,688,194 210,818,944 1,148,231,321 410,835,718 1,854,841,911 5,796,744,539
Year 5................................................. 2029 31,141,789 174,428,024 266,222,202 309,169,323 1,441,228,891 215,688,862 1,174,755,464 420,326,023 1,897,688,759 5,930,649,338
Year 6................................................. 2030 31,861,164 178,457,312 272,371,935 316,311,135 1,474,521,279 220,671,275 1,201,892,315 430,035,554 1,941,525,369 6,067,647,338
Year 7................................................. 2031 32,597,157 182,579,676 278,663,727 323,617,922 1,508,582,720 225,768,781 1,229,656,028 439,969,375 1,986,374,605 6,207,809,991
Year 8................................................. 2032 33,350,151 186,797,266 285,100,859 331,093,496 1,543,430,981 230,984,040 1,258,061,082 450,132,668 2,032,259,859 6,351,210,402
Year 9................................................. 2033 34,120,540 191,112,283 291,686,689 338,741,756 1,579,084,237 236,319,771 1,287,122,293 460,530,733 2,079,205,061 6,497,923,362
Year 10................................................ 2034 34,908,724 195,526,977 298,424,651 346,566,690 1,615,561,083 241,778,758 1,316,854,818 471,168,993 2,127,234,698 6,648,025,392
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
10-Year Total Savings.............................. ......... 315,672,322 1,608,909,413 2,698,591,967 2,851,751,812 14,609,182,396 1,582,030,432 10,835,845,505 3,082,999,063 17,504,121,355 55,089,104,265
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
[[Page 55695]]
2. Costs From Removing LTC Staff Requirements
To estimate the cost for removing the comprehensive minimum
staffing standard requirements, we use the same methodology and data
sources used to estimate the savings for these requirements in 2024
Minimum Staffing final rule (89 FR 40955). We refer readers to that
rule's regulatory impact analysis for a detailed discussion on the data
sources and methodology. As we detailed in that final rule, the
financial savings for Medicare that we estimated from these
requirements are related to the 0.55 RN HPRD requirement that is phased
in over a 5-year period starting in May 2024. Since more than a year
has passed since the requirements were finalized and we estimated no
savings during the first 2 years after finalization, the cost for
removing this requirement will be higher than its estimated savings in
the 2024 Minimum Staffing final rule (89 FR 40878). Overall, we
estimate that removing this requirement will cost Medicare $326 million
annually and $3,255,827,043 over 10 years.
Table 6--Costs for Removing 0.55 RN HPRD Requirement
------------------------------------------------------------------------
Year Calendar year Medicare costs
------------------------------------------------------------------------
Year 1............................ 2025 $0
Year 2............................ 2026 361,758,560
Year 3............................ 2027 361,758,560
Year 4............................ 2028 361,758,560
Year 5............................ 2029 361,758,560
Year 6............................ 2030 361,758,560
Year 7............................ 2031 361,758,560
Year 8............................ 2032 361,758,560
Year 9............................ 2033 361,758,560
Year 10........................... 2034 361,758,560
-------------------------------------
10-Year Total Savings......... ................. 3,255,827,043
------------------------------------------------------------------------
3. Transfers Associated With Rescinding the LTC Minimum Staffing
Requirements
In the regulatory impact analysis for the 2024 final rule (see 89
FR 40909), we explained that there is uncertainty about the degree to
which LTC facilities would bear the cost of meeting the minimum
staffing and 24/7 RN requirements and how much of the costs would be
passed onto payors (including Medicaid, Medicare, private insurers, and
nursing facility residents). We assumed that LTC facilities would
generally have 3 possible approaches to addressing the increased costs
associated with the higher staffing levels: (1) reduce their margin or
profit; (2) reduce other operational costs; and (3) increase prices
charged to payors. LTC facilities may use some combination of these
approaches, and those approaches could vary by facility and over time.
These decisions could depend on a number of factors, including: the
current margin levels of a facility; the cost increase due to the
staffing requirements relative to current costs and revenues; the
current level of operational costs; and the ability to negotiate prices
with payors.
Furthermore, we noted in the 2024 final rule that if costs were to
be passed through to payors then we could estimate those costs would be
passed to payors at a distribution rate of--Medicaid 67 percent;
Medicare 11 percent; and Other Payors/Residents 22 percent.\12\ Given
the variety and uncertainty regarding transfers to payors and to
preserve continuity between the estimates discussed in the 2024 final
rule and the savings estimated in this IFC, we have not estimated
transfers associated with the 24/7 RN, 3.48 total nurse staff HPRD,
0.55 RN HPRD, and the 2.45 NA HPRD requirements, including potential
transfers associated with Medicare, Medicaid, and other non-Medicare/
Medicaid payors avoiding increases in payment rates in response to the
repeal of the 2024 requirements.
---------------------------------------------------------------------------
\12\ Based on facility level data on the percentage of resident
days paid for by Medicaid, Medicare, and other payors, we estimated
the potential share of costs for each payor by weighting each
facility's increased costs by the percentage of resident days paid
for by each payor type.
---------------------------------------------------------------------------
D. Alternatives Considered
In developing this interim final rule with comment period, we
considered feedback from interested parties following the publication
of the final rule that established the staffing standards we are now
removing. Specifically, long-term care facilities, especially those
within rural and tribal communities, raised significant concern that
these standards could increase the risk of facility closure. In
addition, a legislative moratorium precludes the agency from enforcing
these standards until 2034. While we considered retaining the rules
without enforcement until the end of the moratorium in 2034,
ultimately, we decided to remove these requirements to avoid unintended
implementation challenges and confusion for LTC facilities.
E. Regulatory Review Cost Estimation
Due to the uncertainty involved with accurately quantifying the
number of entities that will review the rule, we assume that 75 percent
of all long-term care facilities will review this interim final rule
with comment period. We acknowledge that this assumption may understate
or overstate the costs of reviewing this interim final rule with
comment period. It is also possible that other individuals and
providers will review this interim final rule with comment period. For
these reasons we believe that the number of Medicare and Medicaid-
certified long-term care facilities (n = 14,752) would be a fair
estimate of the number of reviewers of this rule. We welcome any
comments on the approach in estimating the number of entities which
will review this proposed rule. We also recognize that different types
of entities are in many cases affected by mutually exclusive sections
of this interim final rule with comment period, and therefore, for the
purposes of our estimate, we assume that each reviewer reads
approximately 75 percent of the interim final rule with comment period.
We seek comments on this assumption.
Using the wage information from the Bureau of Labor Statistics
(BLS) May 2024 Occupational Employment and Wage Statistics for medical
and health service managers (Code 11-9111), we estimate that the cost
of reviewing this interim final rule with comment period
[[Page 55696]]
is $132.44 per hour, including overhead and fringe benefits (https://www.bls.gov/oes/current/oes_nat.htm). Assuming an average reading speed
of 250 words per minute, we estimate that it would take approximately
([7,000 words/250 words per minute] x 75 percent) 22 minutes for the
staff to review 75 percent of this interim final rule with comment
period. For each entity that reviews the interim final rule with
comment period, the estimated cost is $48.56 (0.37 hours x $132.44).
Therefore, we estimate that the total cost of reviewing this regulation
is $716,357 ($[48.56] x [14,752]).
F. Accounting Statement
As required by OMB Circular A-4 (available online at https://www.whitehouse.gov/wp-content/uploads/2025/08/CircularA-4.pdf), we have
prepared an accounting statement in Table 6 showing classification of
the costs and benefits associated with the provisions of this interim
final rule with comment period. This includes the total savings from
removing the 24/7 RN and the 3.48 total nurse staff HPRD, 0.55 RN HPRD,
and 2.45 NA HPRD requirements as provided in Table 5, as well as the
increased in Medicare spending as provided in Table 6, and the total
cost for the regulatory review that we estimated at $716,357. There are
zero dollars in transfer estimates in the statement. This statement
provides our best estimate for the Medicare and Medicaid provisions of
this rule.
Table 7--Accounting Statement
----------------------------------------------------------------------------------------------------------------
Units
-----------------------------------------------
Category Estimates Discount rate
Year dollar (%) Period covered
----------------------------------------------------------------------------------------------------------------
Benefits:
Annualized Monetized ($million/year)........ 5,412 2024 3 2025-2034
Annualized Monetized ($million/year)........ 5,282 2024 7 2025-2034
Costs:
Annualized Monetized ($million/year)........ 321 2024 3 2025-2034
Annualized Monetized ($million/year)........ 314 2024 7 2025-2034
----------------------------------------------------------------------------------------------------------------
G. Regulatory Flexibility Act (RFA)
The RFA requires agencies to analyze options for regulatory relief
of small entities, if a rule has a significant impact on a substantial
number of small entities. For purposes of the RFA, we estimate that
almost all Skilled Nursing Facilities (NAICS 623110) are considered
small businesses either by the Small Business Administration's size
standards with total revenues of $34 million or less in any single year
or by their non-profit status. Individuals and states are not included
in the definition of a small entity. According to the 2022U.S. Census
Bureau,\13\ in 2022 Skilled Nursing Facilities (NAICS 623110) had
revenues of approximately $137.05 billion. Updated for inflation, this
is approximately $155.01 billion in 2024 dollars.\14\ As its measure of
significant economic impact on a substantial number of small entities,
HHS uses a change in revenue of more than 3 to 5 percent with an
emphasis in the guidance on increased costs due to regulation. Since
this interim final rule with comment period does not impose any new
costs on nursing homes and is estimated to save them an average of $5.5
billion annually during the first 10 years due to the removal of the
24/7 RN requirement as well as the 0.55 RN, 2.45 NA, and 3.48 total
nurse staff HPRD staffing requirements and associated collection of
information costs as indicated in Table 5, it will not have a
significant economic impact on a substantial number of small businesses
or other small entities as measured by a change in revenue of 3 to 5
percent. Therefore, the Secretary has certified that this interim final
rule with comment period will not have a significant economic impact on
a substantial number of small entities.
---------------------------------------------------------------------------
\13\ U.S. Census Bureau. ``2022 SUSB Annual Data Tables by
Establishment Industry.'' https://www.census.gov/data/tables/2022/econ/susb/2022-susb-annual.html. Accessed on August 20, 2025
\14\ Bureau of Economic Analysis. ``National Income and Product
Accounts.'' https://apps.bea.gov/iTable/?reqid=19&step=3&isuri=1&1921=survey&1903=13#eyJhcHBpZCI6MTksInN0ZXBzIjpbMSwyLDMsM10sImRhdGEiOltbIk5JUEFfVGFibGVfTGlzdCIsIjEzIl0sWyJDYXRlZ29yaWVzIiwiU3VydmV5Il0sWyJGaXJzdF9ZZWFyIiwiMjAyMSJdLFsiTGFzdF9ZZWFyIiwiMjAyNCJdLFsiU2NhbGUiLCIwIl0sWyJTZXJpZXMiLCJBIl1dfQ== (Accessed
August 18, 2025).
---------------------------------------------------------------------------
In addition, section 1102(b) of the Act requires us to prepare a
regulatory impact analysis if a rule may have a significant impact on
the operations of a substantial number of small rural hospitals. This
analysis must conform to the provisions of section 604 of the RFA. For
the purposes of section 1102(b) of the Act, we define a small rural
hospital as a hospital that is located outside of a metropolitan
statistical area and has fewer than 100 beds. This interim final rule
with comment period does not impose any costs on small rural hospitals.
These proposals pertain solely to SNFs and NFs. Therefore, the
Secretary has certified that this interim final rule with comment
period will not have a significant impact on the operations of a
substantial number of small rural hospitals.
H. Unfunded Mandates Reform Act (UMRA)
Section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA) also
requires that agencies assess anticipated costs and benefits before
issuing any rule whose mandates require spending in any 1 year of $100
million in 1995 dollars, updated annually for inflation. In 2025, that
threshold is approximately $187 million. This interim final rule with
comment period does not mandate any requirements for State, local, or
tribal governments, or for the private sector.
Therefore, no analysis is required under the UMRA.
I. Federalism
Executive Order 13132 establishes certain requirements that an
agency must meet when it promulgates an interim final rule (and
subsequent final rule) that imposes substantial direct requirement
costs on state and local governments, preempts state law, or otherwise
has Federalism implications. This interim final rule with comment
period will not have a substantial direct effect on state or local
governments, preempt states, or otherwise have a Federalism
implication.
J. E.O. 14192, ``Unleashing Prosperity Through Deregulation''
Executive Order 14192, titled ``Unleashing Prosperity Through
[[Page 55697]]
Deregulation'' was issued on January 31, 2025, and requires that ``any
new incremental costs associated with new regulations shall, to the
extent permitted by law, be offset by the elimination of existing costs
associated with at least 10 prior regulations.'' We followed the
implementation guidance from OMB-M-25-20 (https://www.whitehouse.gov/wp-content/uploads/2025/02/M-25-20-Guidance-Implementing-Section-3-of-Executive-Order-14192-Titled-Unleashing-Prosperity-Through-Deregulation.pdf) when estimating the interim final rule's impact
related to the executive order. Specifically, we used a 7 percent
discount rate when estimating the cost savings and counted savings only
from removing the minimum staffing requirements. We did not include
increased costs to Medicare since the OMB guidance indicates that
benefits from regulation should not be counted as ```negative cost
savings' when deregulating.''
Using the totals in Table 5, we estimate that for the purposes of
E.O. 14192, the deregulatory efforts in this interim final rule with
comment period will result in annual cost savings of $5.28 billion
(calculated with a 7-percent discount rate) over a perpetual time
horizon.
In accordance with the provisions of E.O. 12866, this interim final
rule with comment period was reviewed by the Office of Management and
Budget.
VII. Response to Comments
Because of the large number of public comments we normally receive
on Federal Register documents, we are not able to acknowledge or
respond to them individually. We will consider all comments we receive
by the date and time specified in the ``DATES'' section of this
preamble, and, when we proceed with a subsequent document, we will
respond to the comments in the preamble to that document.
Mehmet Oz, Administrator of the Centers for Medicare & Medicaid
Services, approved this document on November 26, 2025.
List of Subjects in 42 CFR Part 483
Grant programs--health, Health facilities, Health professions,
Health records, Medicaid, Medicare, Nursing homes, Nutrition, Reporting
and recordkeeping requirements, Safety.
For the reasons set forth in the preamble, the Centers for Medicare
& Medicaid Services amends 42 CFR part 483 as follows:
PART 483--REQUIREMENTS FOR STATES AND LONG TERM CARE FACILITIES
0
1. The authority citation for part 483 continues to read as follows:
Authority: 42 U.S.C. 1302, 1320a-7, 1395i, 1395hh, and 1396r.
Sec. 483.5 [Amended]
0
2. Section 483.5 is amended by removing the definition of ``Hours per
resident day''.
0
3. Section 483.35 is revised to read as follows:
Sec. 483.35 Nursing services.
The facility must have sufficient nursing staff with the
appropriate competencies and skills sets to provide nursing and related
services to assure resident safety and attain or maintain the highest
practicable physical, mental, and psychosocial well-being of each
resident, as determined by resident assessments and individual plans of
care and considering the number, acuity and diagnoses of the facility's
resident population in accordance with the facility assessment required
at Sec. 483.71.
(a) Sufficient staff. (1) The facility must provide services by
sufficient numbers of each of the following types of personnel on a 24-
hour basis to provide nursing care to all residents in accordance with
resident care plans--
(i) Except when waived under paragraph (e) of this section,
licensed nurses; and
(ii) Other nursing personnel, including but not limited to nurse
aides.
(2) Except when waived under paragraph (e) of this section, the
facility must designate a licensed nurse to serve as a charge nurse on
each tour of duty.
(3) The facility must ensure that licensed nurses have the specific
competencies and skill sets necessary to care for residents' needs, as
identified through resident assessments, and described in the plan of
care.
(4) Providing care includes but is not limited to assessing,
evaluating, planning and implementing resident care plans, and
responding to resident's needs.
(b) Registered nurse. (1) Except when waived under paragraph (e) or
(f) of this section, the facility must use the services of a registered
nurse for at least 8 consecutive hours a day, 7 days a week.
(2) Except when waived under paragraph (e) or (f) of this section,
the facility must designate a registered nurse to serve as the director
of nursing on a full-time basis.
(3) The director of nursing may serve as a charge nurse only when
the facility has an average daily occupancy of 60 or fewer residents.
(c) Proficiency of nurse aides. The facility must ensure that nurse
aides are able to demonstrate competency in skills and techniques
necessary to care for residents' needs, as identified through resident
assessments, and described in the plan of care.
(d) Requirements for facility hiring and use of nursing aides--(1)
General rule. A facility must not use any individual working in the
facility as a nurse aide for more than 4 months, on a full-time basis,
unless that individual--
(i) Is competent to provide nursing and nursing related services;
and
(ii)(A) Has completed a training and competency evaluation program,
or a competency evaluation program approved by the State as meeting the
requirements of Sec. Sec. 483.151 through 483.154; or
(B) Has been deemed or determined competent as provided in Sec.
483.150(a) and (b).
(2) Non-permanent employees. A facility must not use on a
temporary, per diem, leased, or any basis other than a permanent
employee any individual who does not meet the requirements in
paragraphs (d)(1)(i) and (ii) of this section.
(3) Minimum competency. A facility must not use any individual who
has worked less than 4 months as a nurse aide in that facility unless
the individual--
(i) Is a full-time employee in a State-approved training and
competency evaluation program;
(ii) Has demonstrated competence through satisfactory participation
in a State-approved nurse aide training and competency evaluation
program or competency evaluation program; or
(iii) Has been deemed or determined competent as provided in Sec.
483.150(a) and (b).
(4) Registry verification. Before allowing an individual to serve
as a nurse aide, a facility must receive registry verification that the
individual has met competency evaluation requirements unless the
individual--
(i) Is a full-time employee in a training and competency evaluation
program approved by the State; or
(ii) Can prove that he or she has recently successfully completed a
training and competency evaluation program or competency evaluation
program approved by the State and has not yet been included in the
registry. Facilities must follow up to ensure that the individual
actually becomes registered.
[[Page 55698]]
(5) Multi-State registry verification. Before allowing an
individual to serve as a nurse aide, a facility must seek information
from every State registry established under sections 1819(e)(2)(A) or
1919(e)(2)(A) of the Act that the facility believes will include
information on the individual.
(6) Required retraining. If, since an individual's most recent
completion of a training and competency evaluation program, there has
been a continuous period of 24 consecutive months during none of which
the individual provided nursing or nursing-related services for
monetary compensation, the individual must complete a new training and
competency evaluation program or a new competency evaluation program.
(7) Regular in-service education. The facility must complete a
performance review of every nurse aide at least once every 12 months,
and must provide regular in-service education based on the outcome of
these reviews. In-service training must comply with the requirements of
Sec. 483.95(g).
(e) Nursing facilities: Waiver of requirement to provide licensed
nurses on a 24-hour basis. To the extent that a facility is unable to
meet the requirements of paragraphs (a)(1) and (b)(1) of this section,
a State may waive the requirements with respect to the facility if--
(1) The facility demonstrates to the satisfaction of the State that
the facility has been unable, despite diligent efforts (including
offering wages at the community prevailing rate for nursing
facilities), to recruit appropriate personnel;
(2) The State determines that a waiver of the requirement will not
endanger the health or safety of individuals staying in the facility;
(3) The State finds that, for any periods in which licensed nursing
services are not available, a registered nurse or a physician is
obligated to respond immediately to telephone calls from the facility;
(4) A waiver granted under the conditions listed in paragraph (e)
of this section is subject to annual State review;
(5) In granting or renewing a waiver, a facility may be required by
the State to use other qualified, licensed personnel;
(6) The State agency granting a waiver of such requirements
provides notice of the waiver to the Office of the State Long-Term Care
Ombudsman (established under section 712 of the Older Americans Act of
1965) and the protection and advocacy system in the State for
individuals with a mental disorder who are eligible for such services
as provided by the protection and advocacy agency; and
(7) The nursing facility that is granted such a waiver by a State
notifies residents of the facility and their resident representatives
of the waiver.
(f) SNFs: Waiver of the requirement to provide services of a
registered nurse for more than 40 hours a week. (1) The Secretary may
waive the requirement that a SNF provide the services of a registered
nurse for more than 40 hours a week, including a director of nursing
specified in paragraph (b) of this section, if the Secretary finds
that--
(i) The facility is located in a rural area and the supply of
skilled nursing facility services in the area is not sufficient to meet
the needs of individuals residing in the area;
(ii) The facility has one full-time registered nurse who is
regularly on duty at the facility 40 hours a week; and
(iii) The facility either--
(A) Has only patients whose physicians have indicated (through
physicians' orders or admission notes) that they do not require the
services of a registered nurse or a physician for a 48-hours period; or
(B) Has made arrangements for a registered nurse or a physician to
spend time at the facility, as determined necessary by the physician,
to provide necessary skilled nursing services on days when the regular
full-time registered nurse is not on duty;
(iv) The Secretary provides notice of the waiver to the Office of
the State Long-Term Care Ombudsman (established under section 712 of
the Older Americans Act of 1965) and the protection and advocacy system
in the State for individuals with developmental disabilities or mental
disorders; and
(v) The facility that is granted such a waiver notifies residents
of the facility and their resident representatives of the waiver.
(2) A waiver of the registered nurse requirement under paragraph
(f)(1) of this section is subject to annual renewal by the Secretary.
(g) Nurse staffing information--(1) Data requirements. The facility
must post the following information on a daily basis:
(i) Facility name.
(ii) The current date.
(iii) The total number and the actual hours worked by the following
categories of licensed and unlicensed nursing staff directly
responsible for resident care per shift:
(A) Registered nurses.
(B) Licensed practical nurses or licensed vocational nurses (as
defined under State law).
(C) Certified nurse aides.
(iv) Resident census.
(2) Posting requirements. (i) The facility must post the nurse
staffing data specified in paragraph (g)(1) of this section on a daily
basis at the beginning of each shift.
(ii) Data must be posted as follows:
(A) Clear and readable format.
(B) In a prominent place readily accessible to residents and
visitors.
(3) Public access to posted nurse staffing data. The facility must,
upon oral or written request, make nurse staffing data available to the
public for review at a cost not to exceed the community standard.
(4) Facility data retention requirements. The facility must
maintain the posted daily nurse staffing data for a minimum of 18
months, or as required by State law, whichever is greater.
Robert F. Kennedy, Jr.,
Secretary, Department of Health and Human Services.
[FR Doc. 2025-21792 Filed 12-2-25; 8:45 am]
BILLING CODE 4120-01-P