Federal regulators concede it may take up to three years to finalize a proposed nursing home staffing rule, according to an extensive document that lays out administration rule-making plans for 2024 and beyond. 

The Fall 2023 Unified Agenda sets September of 2026 as the deadline to finalize the “Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting” proposed this September. The rule would require nursing homes to revamp facility assessments; meet hourly thresholds per-patient, per-day for certified nurse aides and registered nurses; and staff RNs around the clock.

The Centers for Medicare & Medicaid Services received nearly 47,000 public comments on the rule, each of which must be reviewed by the agency before it can move forward with a final rule. The rule also asked for input on alternative approaches to minimum staffing, including a 3.48-hour direct care nursing requirement that could include licensed practical nurses.

Some provider groups have previously estimated that the process might take longer than a year.

But in the latest Unified Agenda — published on the web site of the White House Office of Management and Budget this month but not yet appearing in the Federal Register — officials with the Department of Health and Human Services indicate the review could take even longer. Federal rules allow CMS up to three years to finalize a Medicare rule, and the agency can seek an extension beyond that “under exceptional circumstances.”

While CMS didn’t offer a target date inside the three-year window, the agency said it did “not intend to delay publishing … if we are able to publish it sooner.”

“Strengthening high-quality services for older adults” is one of several priorities laid out by the Department of Health and Human Services in a preview of its rulemaking plans.

“Consistent with the Biden-Harris Administration’s Nursing Home Reform Action Plan, the Department’s Regulatory Plan includes efforts to improve the safety and quality of care in the nation’s nursing homes,” the plan reads. “For example, the Department plans to finalize rules that institute minimum staffing standards in nursing homes, protect residents, and prevent fraud, waste, and abuse, and mandate transparency of ownership, management, and other information regarding Medicare skilled nursing facilities and Medicaid nursing facilities.”

Attention: More changes coming

In addition to those known priorities, the agenda calls for development of a rule requiring staff in long-term care facilities to report to HHS and law enforcement entities “any reasonable suspicion that a crime has been committed against a resident of or an individual who is receiving care from such facility.”

It would also implement requirements of these long-term care facilities to notify such covered individuals of their reporting obligations and prohibit retaliation for making such reports. Rule violations could ultimately result in civil money penalties and exclusion from Medicare participation in federal healthcare programs, HHS said.

The department also said it would comply with a court order and establish new appeals processes related to the three-day stay requirement for skilled nursing coverage under traditional Medicare. HHS said it would create an avenue for appeal for Medicare beneficiaries “who are initially admitted to a hospital as an inpatient by a physician but whose status during their stay is changed to outpatient receiving observation services by the hospital, thereby effectively denying Part A coverage for their hospital stay.”

No timeline was given for that rule.