The Centers for Medicare & Medicaid Services increased its hourly requirement for direct care in its final nursing home staffing rule but said it would exempt registered nurse coverage eight out of 24 hours a day “under certain circumstances.”

The April 22 rule boosted the required direct care per patient from 3.0 hours to 3.48 hours per day. Three hours must be split between RNs (at least 0.55) and CNAs (at least 2.45), with the  rest provided by a mix of CNAs, RNs or licensed practical nurses.

The rule was immediately criticized by skilled nursing providers as not being responsive enough to the needs of operators, who have warned in thousands of public comments about reduced access at facilities where more staff cannot be hired.

Mark Parkinson, CEO of the American Health Care Association, called the final rule “unconscionable” and said it made requirements “even more out of touch and out of reach.” n