HHS releases rule repealing federal nursing home staffing mandate, supporting county long term care facilities

Key Takeaways

On December 2, the U.S. Department of Health and Human Services (HHS) published an interim final rule that repeals the federal nursing home staffing mandate, a regulation that would have required long-term care facilities to meet strict minimum staffing levels. The 2023 rule had drawn strong opposition from counties nationwide, particularly those that operate skilled nursing facilities or serve rural communities already grappling with severe workforce shortages. In its repeal notice, HHS acknowledged that the mandate would have disproportionately harmed rural facilities and could have accelerated closures.

NACo has strongly opposed the staffing rule from its earliest stages, submitting formal comments urging HHS to revise or withdraw the mandate due to its impractical standards and the risks it posed to county-run facilities.

Overview of the repeal

HHS’ action fully eliminates the previously finalized staffing mandate. While this rule was delayed through 2034, once implemented it would have:

• Required long-term care facilities to have an average daily nurse staffing level equivalent to at least 0.55 hours per resident, or one registered nurse for every 44 residents
• Required 2.45 nurse aide hours per resident per day, or approximately one aide for every 10 residents
• Required at least one registered nurse to be on site 24 hours a day, seven days a week  
• Did not include new funding for additional staff but sites recent workforce incentive initiatives under HHS
• Included a “hardship exemption” which exempts the facility from punitive assessments for up to 1 year

In repealing the regulation, HHS cited widespread workforce shortages across the long-term care sector and the limited availability of registered nurses in rural and underserved regions. The agency also pointed to the projected financial burden on facilities already operating with thin margins and evidence that many nursing homes, particularly rural facilities, would be unable to meet the mandate without reducing admissions and facing probable closure. The repeal immediately halts implementation and removes the staffing ratios from federal requirements.

County impact

The repeal offers significant relief for counties that own or operate nursing homes, as well as their residents. Without repeal, the mandate would have increased operational costs at a time when facilities already struggle to recruit nurses and Certified Nursing Assistants (CNAs). It also would have reduced bed availability due to the ratio requirements and accelerated facility closures that would have shifted care needs to hospitals or left residents without proper treatment options. With the mandate repealed, counties avoid unnecessarily arduous staffing-ratio requirements and the substantial financial pressures associated with trying to meet them, preserving local flexibility to focus on quality initiatives that reflect community needs rather than federally imposed thresholds.

NACo will continue to work with federal partners to support policies that strengthen the long-term care workforce, sustain county-operated facilities and ensure residents receive high-quality care without jeopardizing access—particularly in rural and underserved communities.