Attorney General Mayes Urges Federal Government to Implement Stronger Minimum Staffing Standards in Nursing Homes

PHOENIX – Attorney General Kris Mayes today joined a coalition of 15 state attorneys general to urge the U.S. Department of Health and Human Services and the Centers for Medicare and Medicaid Services’ (CMS) to promulgate a rule requiring stronger minimum staffing requirements for long-term care facilities. 

The letter submitted on Monday by the coalition, responds to a proposal by CMS to adopt a rule requiring nursing facilities to have minimum staffing levels for certified nursing assistants (CNAs) and registered nurses (RNs), as well as requiring nursing facilities to have at least one RN working onsite 24 hours per day. 

"Chronic understaffing in nursing homes has dire consequences for residents. Too many facilities, driven by profit margins, continue to admit residents without ensuring adequate staff to provide necessary care," said Attorney General Mayes. "I commend CMS for its efforts to enhance the quality of care in long-term care facilities. However, more rigorous standards are needed to bolster the proposed staffing standards and truly meet the practical and critical needs of patients – and ensure patient safety is at the forefront of nursing home operations."

State attorneys general are charged with protecting the safety and well-being of residents of nursing facilities.  Their Medicaid Fraud Control Units, as well as consumer protection sections in some offices, have authority to investigate and prosecute those responsible for committing abuse or neglect of residents and misappropriation of residents’ funds in these facilities. 

In their letter, the coalition responds to CMS’s proposal to require 2.45 hours per resident day (HPRD) of care from CNAs and 0.55 HPRD from RNs.  The AGs instead recommend that CMS adopt a minimum staffing standard ratio of 4.1 HPRD (with 2.8 HPRD for CNAs, 0.75 HPRD for RNs, and 0.55 HPRD for LPNs).  This standard is consistent with the results of CMS’s 2001 staffing study, which found that 4.1 HPRD was the staffing threshold below which quality of care for long-term care patients was compromised.    

The letter further points out that the proposed minimum staffing rule does not include any minimum staffing requirements for licensed practical nurses (LPNs). Without such a requirement, the AGs argue that CMS’s proposed rule could incentivize many nursing facilities to operate only with RNs and CNAs to reach those federally mandated levels, which would, in turn, result in the assignment of even more duties to already overburdened RN staff. 

The coalition also urges CMS to limit the availability of exemptions from the minimum staffing thresholds. While the letter acknowledges the existence of workforce shortages throughout the country in long-term care facilities, the coalition urges CMS to narrow exemptions based on workforce shortages to true emergencies, which would avoid incentivizing for-profit facility owners to operate homes without appropriate staffing in order to siphon Medicare and Medicaid funds from the homes for their personal profit. 

Earlier this year, Attorney General Mayes announced a new Elder Affairs Unit focused on stopping and preventing elder abuse. Arizonans can learn more about the work of the unit and report instances of abuse by visiting

Joining AG Mayes in the letter supporting the CMS proposed rule are the attorneys general of California, Delaware, Illinois, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Mexico, New York, Oregon, Pennsylvania, Rhode Island, and Vermont.