On June 20, 2025, a federal judge in Iowa “made a final determination that CMS lacked the authority to promulgate the HPRD [hours per resident day] requirements and 24/7 RN requirement” and therefore found “that the appropriate remedy in this context is to vacate the 24/7 RN and HPRD requirements.”
Background
During the Biden Administration, CMS issued a notice of a proposed rule in September 2023 containing four main proposals: (1) a requirement that a RN must be on site for 24 hours per day, 7 days a week, (2) total minimum nurse staffing standards of 0.55 HPRD for RNs and 2.45 HPRD for Nurse Aids (NAs), (3) enhanced facility assessment requirements and (4) Medicaid reporting requirements.
On May 10, 2024, CMS issued the Final Rule that includes: (1) a requirement that a RN be on site 24 hours per day, 7 days per week, (2) minimum nursing staffing standards of 3.48 for total nurse staffing HPRD, which must include a minimum of 0.55 RN HPRD and 2.45 NA HPRD, (3) revision of the existing facility assessment requirements and (4) Medicaid institutional payment transparency reporting requirements. Additionally, to ease some of the Final Rule’s financial burden, CMS dedicated over $75 million “to launch an initiative to help increase the long-term care workforce.” Moreover, the Final Rule provided additional time and flexibility for LTC facilities to implement the changes, including staggered implementation dates over a five-year period and providing exemptions from the minimum staffing standards.
Each of the four Final Rule requirements has a different implementation timeline. The 24/7 RN requirement must be implemented by May 11, 2026, for non-rural facilities and by May 10, 2027, for rural facilities. The HPRD requirements must be implemented by May 10, 2027, for non-rural facilities and by May 10, 2029, for rural facilities. The EFA requirement took effect on August 8, 2024, for all facilities. The Medicaid transparency reporting requirements must be implemented by all states and territories with Medicaid-certified facilities by May 10, 2028.
A lawsuit was filed in which the plaintiffs argued that the Final Rule is unlawful and should be vacated in its entirety. Specifically, the plaintiffs contended that it contradicts the Medicare and Medicaid statutes and that CMS does not have authority to impose the 24/7 RN and HPRD requirements. If upheld, the plaintiffs argued that the Final Rule raises constitutional doubt regarding the statutes. Additionally, the plaintiffs asserted that the Final Rule violates the major questions doctrine as it has “enormous economic and political significance and intrudes on state authority.” Finally, the plaintiffs contended that the Final Rule runs afoul the APA’s arbitrary and capricious standard as CMS departed from past practice without explanation, did not consider reliance interests and failed to consider important aspects of the problem. As such, the plaintiffs sought the entry of summary judgment, a declaration that the Final Rule is unlawful and vacatur of it.
On June 20, 2025, an Iowa federal judge issued a Memorandum Opinion and Order in which he stated: “the 24/7 RN provision replaces the Congressionally-established floor of “at least 8 hours per day” with a floor of 24 hours per day. This is impermissible … the Medicare and Medicaid statues specify RN staffing details—requiring “at least 8 hours per day”—which CMS effectively overruled with the 24/7 RN requirement … CMS does not have the authority to rewrite a statute so as to replace one term with another … the 24/7 RN requirement exceeds CMS’s statutory authority.”
“Like the 24/7 RN requirement, the HPRD requirements do not plainly conflict with the statutory text. Nonetheless, the requirements set a floor not provided by the statute … there is a difference between the Secretary’s authority to impose requirements for providers (as provided in the statute) and the authority to mandate a specific number of providers (as mandated by the Final Rule) … I find that the HPRD requirements do not conflict with the statutory requirements to provide “24-hour licensed nursing services which are sufficient to meet the nursing needs of its residents” … Although CMS included more-specific quantitative requirements in the HPRD provisions than in the regulations regarding dietician and infection control staffing, the same general principle applies – an agency is permitted to quantify a general statutory directive through rulemaking. As such, I find that the HPRD requirements do not conflict with the Medicaid and Medicare statutes.”
“I find that this is an extraordinary case. The $43 billion cost, the risk of widespread LTC facility closures and the fact that many states have adopted their own staffing standards while Congress has not done so all support finding this to be an extraordinary case … Because I find that this is an extraordinary case, I must determine whether CMS had clear authorization to promulgate these staffing requirements … CMS’s general rulemaking power to promulgate “such other requirements as the Secretary deems necessary” does not constitute clear authorization to mandate rigid staffing requirements for LTC facilities. Therefore, I find that CMS did not have authority to promulgate the 24/7 RN requirement and the HPRD requirements pursuant to its health and safety rulemaking authority.”
The Iowa federal judge concluded: “I have made a final determination that CMS lacked the authority to promulgate the HPRD requirements and 24/7 RN requirement … Because I have found that the Final Rule is severable (see supra section V.B.), I find that the appropriate remedy in this context is to vacate the 24/7 RN and HPRD requirements. This vacatur applies writ large and is not limited to the plaintiffs in this case.”
Source State of Kansas v. Robert F. Kennedy, Jr., No. C24-110-LTS-KEM, United States District Court for the Northern District of Iowa Cedar Rapids Division.
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