Court Strikes Down Nursing Home Minimum Staffing Rule

On April 7, 2025, the United States District Court for the Northern District of Texas ruled in favor of the American Health Care Association (“AHCA”) in its lawsuit against Health and Human Services (“HHS”) Secretary Robert F. Kennedy Jr. The court struck down a Centers for Medicare & Medicaid Services (“CMS”) rule that mandated minimum staffing levels in nursing homes, deeming it inconsistent with statutes passed by Congress.​

The contested CMS rule required nursing facilities to maintain specific staffing thresholds to receive Medicare and Medicaid reimbursements, requiring: (1) a registered nurse onsite 24 hours per day, for seven days a week; (2) a minimum of 3.48 hours per resident day for total nurse staffing; (3) a minimum of 0.55 hours per resident day for registered nurses; and (4) 2.45 hours per resident day for nurse aides. AHCA challenged these mandates, arguing that CMS exceeded its statutory authority and that the rule imposed undue burdens on providers without sufficient evidence of improved patient outcomes.​

In its decision, the court held that CMS’s authority did not extend to creating new minimum staffing ratios, especially those that conflict with clear statutory language. For example, Congress specified that nursing homes need only eight hours of RN coverage per day; yet, CMS tried to increase that minimum to 24 hours per day. Citing recent opinions from the Supreme Court of the United States, the district court held that, while agencies may add detail to and enforce statutes, that “does not extend to replacing Congress’s number with a different one.” Stating what should be obvious, the court observed that agencies lack authority to amend statutes. The ruling emphasized that while CMS can set standards for quality care, it cannot dictate specific staffing levels, as such decisions are better suited to state regulation and individual facility discretion.​

This order underscores the judiciary’s role in delineating the boundaries of federal regulatory power. It also highlights the ongoing debate over federal versus state control in healthcare administration and the balance between regulatory oversight and operational flexibility for healthcare providers.​ In recent years, the Supreme Court has issued several opinions reigning in the powers of the administrative state, including the ability to issue rules on major questions, as well as the ability of agencies to demand judicial deference to agencies’ interpretation of their rules. The district court’s decision invokes those opinions and demonstrates the continued shift toward more judicial accountability for agencies when issuing rules.

The decision has significant implications for nursing homes nationwide, as it removes federal requirements that could have strained resources and impacted operational autonomy. Facilities now have greater flexibility to determine staffing based on their unique needs and circumstances, potentially leading to more tailored and efficient care delivery.​ Moreover, CMS itself projected the cost of the staffing mandate at over $4 billion, while industry experts placed the true cost at almost double that amount. When coupled with the already existing national staffing shortage, this decision spells relief for all sectors of the healthcare industry, not just nursing homes.

CMS has not indicated plans to appeal the decision, and reports indicate that it will not. The ruling stands as a pivotal moment in healthcare regulation, reaffirming the limits of federal authority and the importance of state and local governance in managing healthcare services.