The hundreds of thousands of residents and staff who died during the COVID-19 pandemic revealed problems in nursing home operations that could not be ignored. The deaths led to President Biden’s comprehensive nursing home reform agenda in 2022, which recognized the essential need to increase the numbers of nursing staff. After a lengthy rulemaking process, the Administration published a modest final nurse staffing rule in May 2024, which, among other provisions, required all nursing homes to meet minimal numerical staffing standards (3.48 hours per resident day (HPRD), including 0.55 of registered nurse (RN) coverage and 2.45 HPRD of certified nurse aide time; RN coverage around the clock. Researchers at the University of Pennsylvania calculated that implementation of the rule would save 13,000 residents’ lives each year and reduce adverse outcomes. Over the decades, multiple studies had confirmed the need for higher staffing levels to improve nursing home quality and reduce avoidable poor outcomes for residents. Research documenting fewer COVID-19 cases and deaths with higher levels of RNs confirmed the need for better staffing levels. Despite the undisputed need for improved staffing and the modesty of the final rule, challenges to the rule continue unabated. These challenges include litigation, legislation, and a soon-to-be-issued regulation.
Litigation
The nursing home industry and its state supporters filed three cases in federal court challenging the rule – two in Texas that were consolidated (American Health Care Association v. Becerra, Case No. 2:24-cv-00114-Z (N.D. Tex. May 23, 2024), and State of Texas v. United States Department of Health and Human Services, Civil Action No. 2:24-cv-00171 (N.D. TX Aug. 14, 2024)) and another in Iowa (State of Kansas v. Becerra, Civ. A. No. C24-110-LTS-KEM (N.D. Iowa, Oct. 8, 2024). The courts vacated the numerical requirements of the final rule (in Texas, on April 7, 2025; in Iowa, on June 18, 2025). The federal government initially appealed the decisions, but has now dismissed its appeals (Fifth Circuit, on Sep. 19, 2025, Eighth Circuit, No. 25-2643, on Oct. 3, 2025). The litigation is concluded.
For more on litigation, see:
- “Residents’ Advocates Reject Industry Complaints About Nursing Home Staffing Rule” (CMA Alert, May 9, 2024)
- “CMS Publishes Final Rule On Nurse Staffing Standards” (CMA Alert, May 23, 2024)
- “Lawsuit Filed Challenging Final Nurse Staffing Rule for Nursing Facilities” (CMA Alert, Jun. 6, 2024)
- “Nursing Home Industry Files Third Legal Challenge to Nurse Staffing Rule” (CMA Alert, Oct. 17, 2024)
- “Federal Court in Texas Vacates President Biden’s Staffing Rule for Nursing Homes” (CMA Alert, Apr. 10, 2025)
- “HHS Appeals Decision Vacating Staffing Rule for Nursing Homes” (CMA Alert, Jun. 5, 2025)
Budget law
Section 71111 of the budget law, Public Law 119-21, expressly delays implementation and enforcement of the staffing rule, published at 89 Fed. Reg. 40876 (May 10, 2024), for 10 years. The delay is the first provision under Subchapter B, “Preventing Wasteful Spending,” under the Medicaid provisions of the budget law.
Regulation
Meanwhile, the Administration appears about to issue an interim final rule to repeal the Biden staffing rule. That rule is under review by the Office of Management and Budget.
October 16, 2025 – T. Edelman