On April 22, 2024, the Centers for Medicare & Medicaid Services (CMS) released its final rule on Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting. The regulation establishes the first-ever federal minimum staffing levels for nursing homes (NHs) and introduces requirements to enhance facility assessments and state reporting on the percentage of Medicaid payments spent on direct care in institutional settings.
This Better Care Playbook blog post reviews existing regulations on NH staffing and outlines CMS’ new staffing requirements, including how states will need to respond. It also highlights research findings that are important for state and federal policymakers to understand related to NH staffing.
Background
Adequate staffing in 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. 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.
Federal Approaches to Nursing Home Staffing
The federal government historically has not had a minimum NH staffing requirement. Instead, each NH has been 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, the current federal regulation does not specify how to translate resident acuity assessments into appropriate facility staffing levels. 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 CMS’ recent final rule on transparency may help.
What’s in CMS’ Final Rule on Minimum Staffing?
The final rule on Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting now sets a federal minimum across all states, which requires NHs to:
- Have an RN on duty 24 hours per day, seven days a week;
- Maintain a minimum overall nursing staffing ratio of 3.48 HPRD — including 0.55 RN HPRD and 2.45 nurse aide (NA) HPRD, with the remaining 0.48 HPRD being any combination of RN, LPN/LVN, or NA hours;
- Make annual acuity adjustments to their staffing based on an assessment of their residents’ needs, though the rule does not stipulate how to use individual resident assessments to translate into overall facility staffing levels; and
- Apply for exemption waivers if they cannot meet the new minimums, contingent on meeting the defined hardship exemption criteria.
These staffing minimums will be implemented on a staggered timeline (detailed in the final rule) over a period of five years for rural facilities and three years for non-rural facilities.
The rule also requires states to:
- Report what percent of Medicaid payments in NHs and intermediate care facilities for individuals with intellectual disabilities (ICFs/IID) are spent on compensation for direct care workers and support staff;
- Make this institutional payment information available on public-facing websites; and
- Provide exemptions for Indian Health Service and Tribal health programs from these reporting requirements.
States will need to comply with these payment transparency requirements beginning four years after the effective date of the final rule.
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 NH.
- In 2001, CMS commissioned a study by Abt Associates Inc. 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 through 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 NHs for those whose needs are more complex. - 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. - 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 five 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. - 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 required in CMS’ final rule and could be difficult for facilities to achieve 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 states consider how to set minimum standards for nursing facilities in response to CMS’ new rule and 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?
All states will need to respond to CMS’ new rule in a variety of ways, depending on whether they currently have staffing standards in place, as outlined below:
- 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’ final 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 go beyond 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 rule for LPNs, so states can incorporate LPN minimums into their own requirements.
- States will need to continue to address the direct care workforce shortage. Currently, more than 79 percent of NHs in the country would not meet the staffing standards that are in CMS’ final 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.
- 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 federal rule specifies things like minimum staffing, acuity adjustments and exemption waivers, but is not proscriptive about how those would be implemented or overseen by state survey agencies. State survey agencies are therefore in the position to develop new survey and oversight procedures related to CMS’ rule. For example, states may need to establish procedures for reviewing exemption 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. States can also establish a standardized procedure for using resident acuity assessments to translate those into staffing minimums that meet the needs of the residents.
- States will need to establish processes for collecting and reporting on Medicaid payments spent on compensation to direct care workers and support staff in NHs and ICFs/IID. They may need to enhance existing data collection and reporting processes or create new ones, including a mechanism for publicly sharing this information with the public. This may require further coordination with facilities, surveyors, and Medicaid agencies.
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 meeting CMS’ new staffing requirements and adjusting acuity processes.