In a win for aging services providers, a Texas court has vacated CMS regulations setting minimum staffing standards for nursing homes.
In an opinion and order issued April 7, United States District Court Judge Matthew J. Kacsmaryk struck down the minimum nursing home staffing requirements established by the Centers for Medicare & Medicaid Services (CMS) in a May 2024 rule.
LeadingAge is a co-plaintiff in this lawsuit, and LeadingAge and its members celebrate the outcome. “Our nonprofit, mission-driven members—many of whom have served their communities for decades—understand the true essence of caregiving. Our stance has always been clear: imposing mandates rather than addressing funding adequacy and workforce sufficiency is wrong-headed,” said LeadingAge President and CEO Katie Smith Sloan in a statement. This “ruling is a victory that strengthens our resolve and propels our ongoing advocacy on behalf of our 5,500 members across the country.”
The lawsuit (AHCA, LeadingAge et al. v. Kennedy, Jr., No. 2:24-cv-00114 (N.D. TX)) specifically challenged the requirements that nursing homes must (i) meet or exceed a minimum of 3.48 hours per resident day (HPRD) for total nurse staffing, including a minimum of 0.55 HPRD for registered nurses, and a minimum of 2.45 HPRD for nurse aides; and (ii) have a registered nurse onsite to provide care 24 hours per day, 7 days a week.
After considering the legal arguments presented by the respective parties and the relevant law, the court ruled in our favor, granting the plaintiffs’ motion for summary judgment and denying the government’s cross motion for summary judgment.
In his decision, Judge Kacsmaryk wrote that the staffing provisions are not consistent with Congress’ legislation governing nursing homes, but did not articulate whether the rule was “arbitrary and capricious”.
Other parts of the rule, including the requirements around the facility assessment, still stand. The Trump Administration has 60 days to file an appeal, though such an appeal for this Biden-era regulation seems increasingly unlikely. To read the complete article, please click here.
Despite this development, Michelle Fischbach (R-Minnesota) vowed to continue to advance legislation in anticipation of an appeal. Earlier this week, the Ohio House Finance Committee accepted an omnibus amendment to HB96, Ohio’s biennial budget for SFY 2026-2027, which was then brought to the House floor and passed on Wednesday, April 9. While the two major issues identified by LeadingAge Ohio were further amended, more work remains to be done.
Specifically, the language that severed the relationship between county recorders fees and the Ohio Housing Trust Fund was further amended to give county commissioners authority to direct which housing-related projects the funds are used for. This is despite the protest of housing advocates, who pointed out that many Republican-led rural counties would suffer under the proposal, since they are disproportionately represented among programs funded by the OHTF.
Secondly, the cap on private rooms was raised from 5,000 to 15,000 statewide, even though the Department of Medicaid has already approved an estimated 28,000 private rooms. Currently, we believe this resulted from a misunderstanding regarding the language, since previous legislation estimated only half of approved rooms may be occupied by a Medicaid-eligible individual at any given time. Notably, there was no change to the appropriation tied to this amendment, so it seems likely that it was not intended as a cut to nursing homes.
Additional changes included in the omnibus amendment were sent to LeadingAge Ohio membership in an alert on Tuesday afternoon, and include:
- Electronic Visit Verification: adds language to the bill that prohibits Medicaid payors (ODM, DODD, managed care organizations) from denying claims or conducting audits solely based on EVV data. Prohibits the state from implementing EVV requirements that are more stringent than federal requirements, and requires Medicaid to notify the provider when claims are not supported by EVV data and provide an opportunity for the provider to correct this data.
- Medicaid payments at median: Removes language included in the first House sub bill that would have prohibited providers from billing Medicaid for a service at a level higher than the median payment for the service under Medicare and private health plans.
- Housing Accelerator Fund: Creates a new fund within the Department of Development that makes awards for housing projects to municipalities that adopt “prohousing” policies, which are enumerated in the amendment. The HAF is funded at $2.5 million for each year of the biennium.
- Senior Community Services: Increases funding by $500,000 for each year of the biennium and prohibits ODA from using these funds for administrative purposes.
- MyCare Next Gen: Requires ODM to allow MyCare enrollees to elect a Medicare coordination only dual special needs plans offered by non-MyCare plans, and requires the Director to approve provider contracts to entities not selected to participate in either program and allow those entities to enroll dual eligible individuals and program participants.
- Group VIII: Maintains language related to the transition of the Medicaid expansion program (group VIII), should the federal government decide to fund this program at a level lower than the current 90% match. Additionally, allows the Department of Medicaid to conduct an assessment on the projected impact of the transition on hospitals and federally qualified health centers.
- Helping Ohioans Stay in their Homes: Grants $4 million per fiscal year, via the Department of Development, to a program focused on home repairs.
Questions about the budget may be directed to Eli Faes at efaes@leadingageohio.org. Top You Asked:
What does CMS require for charge nurse coverage and posting, and can the DON serve as charge nurse?
We Answered:
According to CMS guidance in the State Operations Manual Appendix PP, except when waived under paragraph [(e)] of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty. This means each shift based on how the facility defines each shift. CMS directs surveyors to ask nursing staff if they are aware of who is the designated charge nurse on each shift?
CMS defines “Charge Nurse” as a licensed nurse with specific responsibilities designated by the facility that may include staff supervision, emergency coordinator, physician liaison, as well as direct resident care. In the revised QSO-25-14- NH memo, effective April 28, 2025, CMS states facilities may choose to have differing tours of duty (e.g., 8 hour- or 12-hour shifts) for their licensed nursing staff. Regardless of the approach, the facility is responsible for ensuring the 8 hours worked by the RN are consecutive within each 24-hour period. The requirement for 8 consecutive hours of RN services can be met by any RN or multiples of RNs. The hours worked by the DON would be considered applicable towards the requirement.
The facility must designate a registered nurse (RN) to serve as the DON on a full-time basis. Additionally, the facility may permit the DON to serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. Top LeadingAge Ohio staff and association members took to Capitol Hill on Wednesday, April 9, to meet with Ohio’s US Senators and members of the Ohio Congressional delegation as part of the 2025 LeadingAge Leadership Summit in Washington D.C. The Ohio team met with the offices of Senators Jon Husted and Bernie Moreno, and Representatives Joyce Beatty, Shontel Brown, Jim Jordan, Michael Rulli, Mike Carey, Bob Latta, and Mike Turner. Specifically, the Ohio team focused on 1. The future of Medicaid funding, in light of Congress’s goals to cut $880 billion from the budget, 2. The importance of tax-exempt state and local bonds to financing capital projects for non-profit organizations, and 3. Interruptions caused by the upheaval in administrative agencies, resulting from DOGE-driven reductions in force, as well as other programs that are in jeopardy, like the Green Retrofit Program (GRRP) that has ostensibly been cancelled by the Trump Administration.
Advocates also had the opportunity to share the good news of the nursing home staffing rule being vacated earlier in the week, which had been a primary topic of advocacy over the past two years.
LeadingAge Ohio extends its gratitude to member organizations Graceworks, Jennings, National Church Residences, Ohio Masonic Homes, Otterbein SeniorLife, United Church Homes, and United Medical Supply for their involvement in Hill Day. To see photos from the day, visit this LinkedIn post. This is your spring reminder to review your company profile and update staff contacts. Updated contacts mean maximizing your membership, allowing opportunities, resources, and information to reach the right people at your organization.
While updating contacts, make sure that you include key positions that LeadingAge Ohio supports, including your HR managers, activities coordinator, marketing / admissions manager, director and assistant director of nursing, medical directors, administrators, clinical managers and QAPI / compliance professionals! This will ensure they’re receiving information directly from LeadingAge Ohio, so they don’t have to rely on others forwarding key information.
Only authorized contacts from your organization can update the company profile. To find out who your organization’s authorized contacts are, email Molly Homan at mhoman@leadingageohio.org.
Once verified, authorized contacts may visit LeadingAgeOhio.org and log in. Then visit your profile and scroll down to the button that says Update Company Profile. Be sure to save your change at the very bottom of the company profile page! Artificial intelligence is quickly becoming a creative partner in marketing and communications, but its effectiveness depends on the quality of its training—and the clarity of our prompts. At the next Marketing, Communications & Outreach (MCO) Network meeting on Thursday, April 24 at 11:30AM, we’ll examine how to guide AI tools like ChatGPT to support content development that reflects the person-centered values of professionals in aging services.
This session will focus on how communicators can train AI to reflect age-friendly language, avoid ageist tropes, and speak with the dignity and nuance our work requires. It all begins with the prompt. What you ask—and how you ask it—directly influences the response you receive.
We’ll also discuss how to balance automation with intention, including ethical considerations, accuracy checks, and the importance of maintaining a human voice in every message.
If you’ve ever asked, Can ChatGPT do that?—this session will help you ask a better question and receive a better response.
Networks are free for members, but registration is required. With the legalization of marijuana for both medical and recreational use in Ohio, post-acute care employers are navigating uncharted territory. What are your rights? What are your responsibilities? And how do you protect your workplace?
Join attorney Sam Lillard for an eye-opening session that breaks down Ohio’s evolving marijuana laws and what they mean for your organization. This must-attend presentation will cover:
- Ohio vs. federal marijuana laws
- Workers’ compensation implications
- Key legal frameworks you need to know
- Real-world case scenarios with actionable takeaways
Get clear answers to the questions you're already asking—and the ones you haven’t thought of yet. Don’t miss your chance to stay ahead of the curve and keep your workplace informed, compliant, and prepared.
Register here. Top Over the three days of Leadership Summit in DC, members achieved three of four goals: networking with peers; gaining new insights and strategies from high-quality educational opportunities; and visiting with Congressional representatives during Lobby Day. The fourth goal—clarity on issues that are central to our mission—was not easy to find this year. As aging services providers and the people we serve face serious threats on issues that are central to our mission, LeadingAge President and CEO Katie Smith Sloan urges members to identify their levers, tap into their power, and become active members of their communities. Together, she writes, we can become formidable advocates for older adults and potent sources of innovation and change for our nation. As Congress works to advance its newest budget resolution and the possibility of massive cuts to Medicaid loom, LeadingAge’s advocacy drumbeat intensifies. Following her recent warning that “balancing the ten-year budget cycle on the back of the Medicaid program is not a good tradeoff for the American people,” President and CEO Katie Smith Sloan, in an April 1 letter to the Senate Finance Committee, cites several real-world examples from LeadingAge members to illustrate the devastating effects of proposed cuts on older adults they serve in nursing homes and adult day programs.
In meetings with the Ohio delegation at this week’s Hill Day, Republican legislators unanimously articulated support for the Medicaid program, noting that they plan to focus on fraud, waste and abuse in the program and not cuts. However, they expressed openness to restructuring the financing of the program, including adjusting how the federal match is calculated.
Keep up on this and other Budget Reconciliation 2025 issues here. Department of Health and Human Services (HHS) staff began receiving “Reduction-in-Force” emails on April 1, and some Centers for Medicare and Medicaid Services (CMS) office and center directors learned that the number of firings would exceed the originally stated 300 employees. As of April 2, six offices have been significantly reduced or eliminated, including those overseeing minority health outcomes, equal opportunity and civil rights, those dually eligible for Medicare and Medicaid, and the National Institute on Aging at the National Institutes of Health.
For more details and background, see the HHS Reorganization, Staff Cuts, and Impact on Aging Services serial post. Top The Ohio Department of Health is issuing a monthly Ohio RAI Coordinator’s Questions of the Month, highlighting common questions and answers related to coding the Minimum Data Set (MDS).
A1005, Ethnicity, and A1010, Race
Question: Can the social determinants of Health items A1005, Ethnicity, and A1010, Race, be asked and answered on the admission assessment and that answer remain true for the rest of a residents stay? Is it ok to have these questions auto populated for all assessments after the admission assessment? Also, what if the interviews and medical record review are not completed for these two items by the ARD? The item sets do not give an option to dash.
Answer: Assessors should follow the steps for assessment for the social determinants of health (SDOH) items with each assessment. Auto-population of these items is not acceptable. The RAI 3.0 User’s Manual outlines several steps assessors should take to complete the SDOH items. Steps for assessment for item A1005, Ethnicity, begins on page A-17. Steps for assessment for item A1010, Race, begins on page A-20. If the assessor did not ask the resident or the resident’s family during the appropriate assessment period, they should move to the next step in the Coding Instruction (e.g., use medical record documentation).
A0310A 04, Significant Change in Status Assessment
Question: A resident was enrolled in hospice on Dec. 11, 2024, and the interdisciplinary team scheduled a Significant Change in Status Assessment (SCSA) with an Assessment Reference Date (ARD) of Dec. 11, 2024. The resident was disenrolled from hospice on Dec. 12, 2024. Is an SCSA still required for enrollment and/or disenrollment?
Answer: The intent of the SCSA upon enrollment in or change in hospice provider is to ensure coordination of care between the nursing home and hospice. As such, if the resident elect’s hospice and then revokes hospice prior to the ARD of the SCSA, there is no need to complete the SCSA.
GG0130A, Eating
Question: We have a resident who is receiving tube feeding for nutrition and also has an order for ice chips orally. Would the ability to bring the ice chips to the mouth and swallow be evaluated for coding item GG0130A, Eating?
Answer: The intent of item GG0130A, Eating, is to assess the resident’s ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. The clinician should use clinical judgment to determine if the situation of eating ice chips allows the clinician to adequately assess the resident’s ability to complete the activity.
If the clinician determines that this observation is adequate, code based on the type and amount of assistance the resident requires to complete the entire activity. If the clinician determines this situation does not provide adequate information to support determination of a performance code, select an appropriate “activity not attempted” code.
If you have a Question of the Month to submit, please email Cheryl.Moya@odh.ohio.gov and place Question of the Month in the subject line. Top Immigrants make up 28% of the overall direct care workforce for long-term care services (compared to 17% of all adult workers), according to a new research note from KFF. Researchers used the 2023 American Community Survey (ACS) to assess the role that immigrants play in the direct care workforce for LTC services. As of 2023, KFF found there were over 820,000 immigrants working as direct care workers providing long-term care in the U.S. (including over 500,000 naturalized citizens and over 300,000 noncitizen immigrants). Immigrants represent one in three workers (32%) in home care settings and 21% of workers in nursing homes. KFF also found that the share of direct care workers providing LTC services who are immigrants increased from 24% in 2018 to 28% in 2023. These data come at a critical time for foreign-born workers, who some providers tell LeadingAge feel threatened by mass deportation plans even though they are working in the country legally, creating a chilling effect throughout the workplace.
Trump administration campaign promises for increased border control and deportations exist parallel to LeadingAge’s continued advocacy to reform and expand woefully outdated legal immigration pathways to increase the aging services workforce, which is desperately needed as the number of workers in the United States pales in comparison to the number needed to address the care and services needs of today’s and tomorrow’s older adults. The research note points to existing research “that immigration increases the local supply of workers in nursing fields, with the largest effect on the number of nurse aides” and that “increased immigration significantly raises the staffing levels of nursing homes in the U.S., particularly in full time positions” while providing “culturally competent care to an increasingly diverse population of older adults.”
Read the research note here. Top In 2025, a citation for immediate jeopardy was issued due to inadequate monitoring of a medication. In the revised QSO-25-14- NH memo, CMS notes that adverse consequences related to medications are common enough to warrant serious attention and close monitoring, and can range from minimal harm to functional decline, hospitalization, permanent injury, and death. Surveyors are instructed to review documentation to confirm that residents are being adequately monitored and re-evaluated for adverse consequences and the need for tapering.
The immediate jeopardy finding in this case stemmed from the facility’s failure to monitor an anticoagulant medication appropriately. Specifically, not ensuring it was administered at a therapeutic dose or held in a timely manner when adverse effects were present. This citation, along with other recent immediate jeopardy findings, will be discussed on the May 14 Survey Tips and Tactics call.
CMS, in the State Operations Manual Appendix PP, highlights that in 2014, the Department of Health and Human Services, Office of Inspector General (OIG) released its report “Adverse Events in Skilled Nursing Facilities (SNFs): National Incidence Among Medicare Beneficiaries,” which found one in three SNF residents experienced an adverse event or temporary harm event. Thirty-seven percent of these adverse events were related to medications, and 66% of all medication-related events were preventable. Medication-related adverse events included excessive bleeding due to anticoagulant use without adequate monitoring and acute hypoglycemia.
To read the complete Survey Tip of the Week, please click here. Top LeadingAge Ohio Associate Firm First American is hosting a webinar on Tuesday, April 22 at 2:00PM.
CEO Rob Miliam, of zumBrunnen, will explain the essential role of Capital Replacement Analysis (CRA). During this webinar, attendees will learn how to assess and prioritize capital spending within the senior living sector and explore best practices for capital forecasting using reliable data.
Register for this event by clicking here. LeadingAge Ohio holds valuable education webinars and in-person events throughout the year. Opportunities are added weekly. See the complete Schedule of Events. Top
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