On April 7, 2025, Judge Matthew Kacsmaryk of the Northern District of Texas vacated two provisions of a major 2024 CMS nurse staffing regulation requiring nursing homes to have an RN on site 24 hours a day, 7 days per week and setting minimum staffing standards based on a facility’s number of residents (the Order). In the Order, the court ruled that the two nurse staffing provisions would be vacated not just for the immediate parties involved but on a nationwide basis.
The Biden Administration announced its intent in 2022 to establish minimum nursing home staffing requirements. After CMS published a research study on the topic in June 2023, CMS issued a proposed rule in September 2023 proposing several staffing requirements, including the two requirements vacated in the Order. First, the proposed rule required an RN to be on site 24 hours per day, 7 days per week to provide skilled nursing care to all residents. Second, the proposed rule set minimum nurse staffing standards for all skilled nursing facilities, requiring 0.55 hours per resident day (HPRD) for RNs and 2.45 HPRD for nurse assistants.
In May 2024, after receiving over 46,000 comments on the proposed rule, CMS promulgated its Final Rule, implementing the two requirements in the proposed rule with slight modifications. The Final Rule staggered the deadlines for rural and nonrural nursing facilities to comply with the requirements over a period of five years (starting in 2026), added a total nurse staffing standard of 3.48 total nurse staffing hours per resident day (HPRD), and included some exemptions from the standards.
The American Health Care Association filed suit to challenge the Final Rule in May 2024, challenging the requirement that an RN be on site 24/7 at all SNFs (the 24/7 Requirement) and that all SNFs meet the minimum staffing hours per resident day requirements (the HPRD Requirements). In August 2024, the State of Texas also challenged the requirements, and the cases were consolidated. The plaintiffs and CMS each filed cross-motions for summary judgment, on which the court ruled in its Order.
In its Order, the court held that CMS exceeded its statutory authority with the 24/7 Requirement. The court stated that Congress had mandated “nursing homes use the services of a registered professional nurse for at least 8 consecutive hours a day, 7 days a week.” This statutory mandate did not, the court concluded, authorize CMS to impose an hours requirement higher than 8 hours for RNs in nursing homes. Because Congress set a clear numerical baseline of 8 hours per day for RNs, the court ruled that CMS was not free to amend the statute and replace 8 hours a day with 24 hours a day. The court rejected more general authorities that CMS invoked to support the 24/7 Requirement.
Similarly, for the HPRD Requirements, the court rejected CMS’s argument that it had broad authority to implement requirements to protect the health and safety of nursing home residents. The court ruled that the HPRD Requirements failed to consider the nursing needs of a facility’s residents as required by Congress.
The court also considered arguments that the plaintiffs raised under the Major Questions Doctrine (a doctrine prohibiting agencies—except in “certain extraordinary circumstances”—from making decisions of vast economic and political significance without an express delegation of authority from Congress) and arbitrary and capricious rulemaking. However, because the 24/7 Requirement and HPRD Requirements directly contravened Congress’s statutory mandate, the court concluded it did not need to address those arguments.
In deciding what relief to grant, the court vacated the 24/7 Requirement and the HPRD Requirements with nationwide effect. It did not rule on other provisions of the Final rule.
A copy of the court’s memorandum opinion and order is available here.
