WASHINGTON, DC — Attorneys general from 18 states have requested the Centers for Medicare and Medicaid Services to establish nursing home staffing requirements specifically targeting for-profit facilities that demonstrate high-risk financial and ownership practices, according to a letter submitted to the federal agency.
The proposed rule comes in the wake of the recent repeal of the federal nursing home staffing mandate and would require 3.48 nurse staffing hours per patient day, broken down to include at least 0.55 hours for registered nurses and 2.45 hours for certified nursing assistants, as reported by Skilled Nursing News. Unlike the repealed federal mandate, this recommendation would apply only to for-profit nursing homes exhibiting specific risk factors rather than all facilities nationwide.
According to the attorneys general, the targeted rule would apply to facilities with related-party real estate arrangements, management or staffing fees paid to affiliates, related-party therapy services, collusive loans, or private equity ownership. Government-owned, nonprofit, and tribal nursing homes would be exempt from the requirements, along with hardship and exemption provisions that were included in the original staffing mandate.
"As state Attorneys General, we agree that safe, high-quality care is essential for all people living in nursing homes nationwide," the attorneys general wrote in their letter to CMS. The officials noted that nursing home owner fraud schemes exist nationwide and require significant resources to investigate and prosecute.
The states cited several high-profile criminal cases to support their position, including proceedings involving Florida nursing home owner Philip Esformes and former Skyline Healthcare owner Joseph Schwartz, according to the letter. These cases often involved large-scale Medicare and Medicaid fraud, tax crimes, and bankruptcies following asset stripping, frequently with private equity involvement.
Research linking private equity ownership to negative outcomes played a central role in the states' argument. According to the attorneys general, a recent study found a 10 percent increase in mortality for Medicare patients under private equity ownership. An updated 2023 study by the National Bureau of Economic Research estimated that private equity ownership in nursing homes cost over 22,000 American lives during a 12-year sample period, as reported in the letter.
The proposed staffing levels align with standards already adopted by California, New York, and Massachusetts, and are consistent with federal statutory requirements, the attorneys general stated. They argued the rule would not be overly burdensome since national average staffing already exceeds this level.
However, the proposal has drawn skepticism from industry experts and associations. Chris Puri, an attorney at law firm Bradley Arant, questioned whether CMS would give the recommendation serious consideration, pointing to two federal courts that struck down the original rule.
"It's hard to understand what would change with another narrower rule that seems to raise an equal protection issue by singling out one class of provider," Puri stated in comments to Skilled Nursing News. He noted the proposal does not address the fundamental problem that sufficient staff are not available, regardless of whether facilities are governmental, nonprofit, or for-profit operations.
Rachel Reeves, spokesperson for the American Health Care Association and National Center for Assisted Living, urged policymakers to move beyond what she characterized as failed policies. "We must shift our focus to more commonsense efforts that will support all providers in their recruitment and retention efforts," Reeves stated, adding that the organization stands ready to work with policymakers on strengthening the nursing home workforce and quality care.
In addition to the staffing proposal, the attorneys general strongly urged CMS to lift its indefinite suspension of nursing home ownership, managerial, and related-party disclosure requirements. According to the letter, improved transparency and enforcement are needed to address fraud schemes involved in opaque financial arrangements.
CMS has indicated it welcomes commentary from stakeholders following the repeal of the nursing home staffing mandate as the agency determines next steps, according to reports.
The attorneys general argued that implementing a tailored staffing rule would protect residents and safeguard Medicare and Medicaid funds while deterring abusive profit-extraction practices. Such requirements could help reduce facility closures and bankruptcies that often follow questionable ownership practices, according to the states' position.
Federal law requires nursing homes participating in Medicare and Medicaid to provide sufficient staffing to meet residents' needs, though specific numerical requirements had been a subject of debate. The original federal staffing mandate was repealed after facing legal challenges from multiple states and industry groups.
Resources for Families
Families concerned about staffing levels or care quality at nursing homes can contact the National Long-Term Care Ombudsman Resource Center at 1-800-677-1116. Ombudsmen advocate for residents and investigate complaints about care in nursing homes and assisted living facilities.
Concerns about potential fraud or abuse can be reported to state attorneys general offices or the U.S. Department of Health and Human Services Office of Inspector General. State survey agencies conduct regular inspections of nursing homes to ensure compliance with federal and state regulations.
Families should review facility inspection reports and staffing data, which are publicly available through the Medicare.gov Nursing Home Compare website. This resource provides information about health inspections, staffing levels, and quality measures for all Medicare and Medicaid-certified nursing homes.
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