What to Know about Nursing Home Staffing Minimums

Emma Rauscher and Carrie Graham, Center for Health Care Strategies
A nursing home staff member/caretaker wheels an elderly white woman into her room at a nursing home facility.

Adequate staffing in nursing homes (NHs) is one of the primary drivers of better quality of care and reduced incidence of abuse and neglect of residents. NH staffing issues have gained national attention especially during the height of the COVID-19 pandemic, which caused more than 169,000 deaths in NHs to date. COVID prompted an exodus of many nurses out of the NH industry due to infection risk, low wages, and difficult working conditions.

The federal government and states both have a role in overseeing NH quality and staffing. The Centers for Medicare & Medicaid Services (CMS) creates the requirements that NHs must meet if they receive any Medicare or Medicaid funding. States can also add their own regulations to supplement federal rules and are tasked with licensing, oversight surveys, and complaint investigations to ensure NHs meet both state and federal standards.

This Better Care Playbook blog post outlines some of the current rules on NH staffing, research findings that are important for policymakers to understand when setting NH staffing rules, and implications of new proposed federal staffing rules.

Federal Approaches to Nursing Home Staffing

The federal government historically has not had a minimum NH staffing requirement. Instead, each NH is required to have one director of nursing and one registered nurse (RN) on duty eight hours a day, seven days a week and one licensed nurse (RN or licensed vocational or practical nurse (LVN/LPN)) on evenings and nights. Current federal law requires that NHs provide services to meet the care needs of each individual resident. While each NH must assess each resident’s “acuity” using CMS' Patient Driven Payment Model assessment system to receive reimbursement, federal regulations do not specify how to translate the assessments into a facility-wide staffing standard. Additionally, the federal government has encouraged more robust NH staffing by increasing Medicare reimbursement rates, and including a staff turnover measure in the Skilled Nursing Facility value-based payment program.

State Approaches to Nursing Home Staffing

 In 2021, 36 of 50 states had laws requiring minimum nurse staffing standards for NHs. These standards vary widely, from Washington, DC requiring 4.1 total nursing hours per resident per day (HPRD) to Arizona requiring less than one total nursing HPRD. Only six states require an RN to be on duty 24 hours per day.

States are currently using various policies to try to both require and incentivize higher staffing — these can include penalties for low staffing, minimum wage requirements, wage pass-through payments, and other incentives. Wage pass-through payments — where Medicaid funding is designed to go more directly to direct care workers — have been shown to increase CNA HPRD. Additionally, some states have passed laws requiring direct care ratios that call for NHs to spend a specific percentage of their total revenue on resident direct care rather than profits. Enforcement of these requirements are difficult due to issues with ownership and cost transparency, but a new CMS rule may help.

What’s in the Federal Government’s Proposed Rule on Minimum Staffing?

In September 2023, CMS issued a proposed rule that would, if finalized, require a federal minimum staffing level for NHs. The proposed rule would require NHs to:

  • Have an RN on duty 24 hours per day;
  • Maintain a minimum overall nursing staffing ratio of 3.0 HPRD — including 0.55 RN HPRD and 2.45 nursing assistant (NA) HPRD;  
  • Make annual acuity adjustments to their staffing based on an assessment of their residents’ complex care needs, though the proposed rule does not stipulate how to use individual resident assessments to translate into overall facility staffing levels.
  • Apply for staffing waivers if they cannot meet the new minimum, contingent on demonstrating that they have made a good faith effort to recruit staff and meet four hardship exemption criteria.

What Research Informs Minimum Staffing Standards and Acuity Adjustments?

Decades of research link improved NH quality of care with higher staffing levels — especially higher staffing of RNs — and poor quality, mortality, and neglect with lower staffing. Below are four key studies that contribute to our understanding of what staffing is necessary to meet residents’ needs and how to do acuity adjustments. The studies below vary in the types of nurses included (NA, RN, and/or LVN/LPN); they also vary in the outcomes examined (staffing impact on increased quality vs. staffing that is sufficient to reduce omitted/delayed care) and whether the studies adjust results by the acuity levels of nursing facility residents. Finally, the studies vary in whether they assess the timing required for task by simulations of nursing tasks versus observing real-life nurses performing tasks inside a nursing home.

  1. In 2001, CMS commissioned a study by Abt Associates that analyzed existing NH staffing and quality data to determine the thresholds at which additional staffing hours stopped resulting in any additional quality benefits for residents. This study also modeled five commonly performed care processes to calculate the minimum NA staffing levels needed to deliver these processes to all residents on a timely basis. 

    Results and Takeaways: The staffing minimums recommended by this study were 2.8 NA HPRD, .55 LPN HPRD, and .75 RN HPRD for a total of 4.1 nursing HPRD for long-stay residents (typically funded by Medicaid and lower acuity), and 2.8 NA HPRD, .55 LPN HPRD, and .55 RN HPRD for a total of 3.9 nursing HPRD for short-stay residents (typically funded though Medicare post-acute rehabilitation benefit and higher acuity). This study may underestimate current staffing needs because levels of acuity in NHs are much higher now than they were in 2001. This is partly because of the increased availability of home- and community-based services for Medicaid enrollees who have long-term care needs. Thus, Medicaid enrollees who have fewer skilled needs may now receive care at home or in assisted living facilities, reserving nursing homes for those whose needs are more complex.
  2. In 2016 Schnelle et al. conducted a simulation study on staffing levels for NAs. This study used similar care task categories to the 2001 Abt study and accounted for facility-level acuity in its simulation model to measure care time required for activities of daily living (ADLs) across different staff workload levels.

    Results and Takeaways: This study confirmed that the minimum staffing for NAs should be at least 2.8 HPRD for facilities with low acuity and 3.6 HPRD for facilities with high acuity in order to keep rates of omitted ADL care below 10 percent. This study did not assess clinical care delivered by RNs or LPNs. Additionally, researchers observed simulations of tasks rather than real-life completion of tasks, which can obscure results given staff productivity may be lower when faced with interruptions that slow down tasks when working with real residents.
  3. In 2023, CMS commissioned a study specifically to inform the new transparency rule. Conducted by Abt Associates, it included both a quantitative analysis of staffing and quality data, as well as a simulation that used real-life observations of the time required for licensed nurse staff (including RNS and LPNs) to complete five clinical care tasks. Researchers used these real-life observations and other existing data to determine the effect of different staffing levels on quality. The study defined quality as percent of delayed or omitted clinical care.

    Results and Takeaways: The quantitative analysis showed that higher staffing levels resulted in better quality and safety outcomes for residents. The simulation showed that staffing levels between 1.4 and 1.7 licensed nurse HPRD are sufficient to keep rates of omitted and delayed clinical care below 5 percent. They incorporated the results of the 2016 study to conclude that a staffing level between 3.8 and 4.6 total nursing staff HPRD would keep rates of omitted and delayed ADL and clinical care below 10 percent. The real-life observations only measured five care tasks out of dozens of tasks performed by licensed nurses, did not distinguish between RNs and LPNs, and did not use patient- or facility-level acuity data to adjust the time needed.
  4. A 2023 study by Harrington developed a process for translating individual resident acuity assessments into overall staffing standards for facilities. The study calculated appropriate staffing levels across six levels of collective acuity (an “aggregation of individual residents’ assessments and care needs”). 

    Results and Takeaways: The study outlined a five-step process for NHs to determine appropriate staffing levels based on a facility’s collective resident acuity and care needs. The study recommended a range from 4.29 total HPRD for a facility with a low acuity overall census to 6.77 HPRD for one with the highest acuity census. This study also distinguishes between RNs and LPNs and gives ranges for each. These staffing levels, even for the lowest acuity facilities, are much higher than what is proposed in CMS’ proposed rule and could be difficult for facilities due to workforce shortages.

While there are clear differences in the above studies’ results, they each clearly show the link between higher nurse staffing and better quality. As the federal government and states consider how to set minimum standards for nursing facilities based on resident acuity, they can use these studies as a guide and may consider sponsoring further research to solidify their regulations.

What’s Next?

CMS is currently reviewing more than 46,000 public comments they received on the proposed Minimum Staffing rule, and will likely revise and publish a final rule in 2024. All states will need to respond to this rule in a variety of ways, depending on whether they currently have staffing standards in place, as outlined below: 

  1. States will need to ensure that NHs are staffed at least to the CMS required staffing level. As detailed above, the overall nursing staffing ratio of .55 RN HPRD in CMS’ proposed rule is lower than suggested in many studies, lower than the national average staffing levels for RNs, and lower than 13 states already require. States therefore have an opportunity to set their own staffing requirements that further clarify federal minimums to ensure that NH residents in their state are getting high-quality care free from neglect. Notably, there is no staffing level in the proposed rule for LPNs, so states can incorporate LPN minimums into their own requirements.
  2. States will need to continue to address the direct care workforce shortage. Currently, an estimated 81 percent of nursing homes in the country would not meet the staffing standards that are in CMS’ proposed rule, and there are simply too few nurses and CNAs available in many areas. Thus, to prevent closures in the short term, states will need to develop procedures for staffing waivers, standards for setting hardship exemptions, and invest in increased wages, training, and reimbursement to grow the workforce and help facilities meet these standards.
  3. States may need to change licensing and oversight procedures to ensure that NHs meet federal staffing minimums as well as any additional state staffing rules. The proposed federal rule specifies things like minimum staffing, acuity adjustments and staffing waivers, but is not proscriptive about how those would be implemented or overseen by state survey agencies. If the final rule is similarly vague, state survey agency may be in the position to develop new survey and oversight procedures. For example, if staffing waivers are allowed in the final rule, states may need to establish procedures for reviewing staff waiver applications to determine if NHs are making a good faith effort to recruit staff and meet the exemption criteria. States may put a limit on the number of waivers an individual NH can apply for. If acuity adjustments are required by the final rule, states may need to establish a procedure for using resident acuity assessments to translate those into staffing minimums that meets the needs of the residents.

While waiting for CMS to finalize a minimum staffing rule, states can work to review and apply findings from the studies discussed above, or conduct their own studies to help inform their state’s priorities and approaches to staffing requirements and acuity adjustment processes.