Staffing in Nursing Homes

Chronic understaffing has been a serious problem in nursing homes for decades and has been exacerbated by the COVID-19 pandemic. While there are numerous factors contributing to this problem, one major cause is the lack of adequate minimum staffing standards at both the state and federal levels. Minimum standards ensure that staffing will not fall to a level that would be harmful to residents.

Listen to Nursing Home Residents Talk about Staffing

Report: The Impact of Understaffing on the Daily Lives of Nursing Home Residents

Countless studies have documented that residents who live in understaffed nursing homes are more likely to suffer harm and neglect. Our report brings the focus of the staffing discussion back on residents, surveying over 120 nursing home residents in the fall of 2023, asking for their perspectives on staffing and how they are affected by staffing levels daily. The results were striking.

The majority of residents who responded to the survey, 88%, stated their facilities lacked the staff necessary to meet the needs of the residents living in their facilities.

CMS Releases Proposed Rule on Nursing Home Staffing Standard

The Centers for Medicare & Medicaid Services (CMS) released the long-anticipated Notice of Proposed Rule Making (NPRM) that would implement a minimum staffing standard in nursing homes.

Consumer Voice submitted comments on the rule.

Consumer Voice strongly supports the proposed requirement that a nursing home have at least one registered nurse (RN) on site 24 hours per day, seven days per week. The current requirement of eight hours per day is insufficient and places residents at risk of harm.
While Consumer Voice supports the implementation of a minimum staffing standard, the proposed standard is too low and must be increased.
- Additionally, we oppose the proposal that will permit waivers/exemptions from requiring nursing homes to comply with a minimum staffing standard if they meet certain criteria.
- We urge CMS to reduce the timeframes for implementation and use a phased-in approach; and to adopt a more stringent system for monitoring and enforcing compliance with staffing standards.
Consumer Voice supports increased Medicaid transparency regarding direct care wages but believes more can be done.
While we support the proposed additions to the facility assessment regulation, we note that these additions will only be effective with proper guidance and enforcement.

More than 80 national and state organizations, including Consumer Voice, signed onto a letter regarding the rule. Plus, U.S. Representatives Lloyd Doggett (D-TX), Jan Schakowsky (D-IL), and 101 lawmakers wrote a letter urging CMS to strengthen and finalize the proposed Minimum Staffing Standards for Long-Term Care Facilities rule.

Learn more about Consumer Voice's analysis of the rule.

Watch the webinar reviewing the rule.

Issue Brief: Why Nursing Homes Need a Minimum Staffing Standard

In April 2022, the Centers for Medicare & Medicaid Services (CMS) announced it was beginning the process of implementing a minimum staffing standard for nursing facilities. This standard would require nursing homes to have enough staff to provide each resident with a minimum amount of direct care each day. Since the announcement, CMS has undertaken a study to determine the standard and intends to publish proposed rules in early 2023. When implemented, this standard will be the most significant increase in protections for nursing homes in decades.

Consumer Voice's issue brief examines why staffing is important in nursing homes and what a staffing standard should include.

Report: High Staff Turnover: A Job Quality Crisis in Nursing Homes

Consumer Voice's new report examines how nursing homes with higher staff turnover perform poorly in a variety of measures, how staff turnover harms residents, the causes of high turnover, and offers solutions to this endemic problem, such as:

Increasing staff wages and benefits;
Reducing staff workloads;
Providing on-going training; and
Increasing career advancement opportunities

Response to CMS's Request for Information Regarding a Minimum Staffing Standard in Nursing Homes

On April 15, 2022, the Center for Medicare & Medicaid Services (CMS) published a Notice of Proposed Rule Making (NPRM) that included requests for information regarding the implementation of a minimum staffing standard in nursing homes. CMS states it plans to propose a minimum staffing standard within one year.

Inadequate staffing is the primary driver of poor health outcomes in nursing homes. Consumer Voice strongly supports the proposal for a minimum staffing standard. Read Consumer Voice's comments to CMS.

Report: Staffing Matters

Consumer Voice’s new report looks at federal data regarding nursing home staffing levels and how it affects outcomes for residents. The report found that:

Nursing homes with higher staffing levels have higher overall, health inspection, and staffing ratings.
As staffing levels decrease in nursing homes, the instances of resident abuse rise.
Nursing homes with higher RN staffing levels have higher overall, health inspection, and staffing ratings. They also are less likely to have been cited for abuse.

Report: Inadequate Staffing During the COVID-19 Pandemic and Its Catastrophic Effects on Nursing Home Residents

Consumer Voice’s new report, Inadequate Staffing During the COVID-19 Pandemic and Its Catastrophic Effects on Nursing Homes Residents, looks at federal data regarding nursing home residents and documents the true price of inadequate staffing.

The report found that during the pandemic:

The number of residents experiencing pressure ulcers rose 31%
The number of residents experiencing significant weight loss rose 49%
The number of residents reporting feeling down, depressed, or hopeless rose 40%
The increase in the rate of residents receiving antipsychotic medications jumped 77.5%, while the increase in the rate of residents being diagnosed with schizophrenia rose 54%

On Monday, February 28, 2022, the Biden Administration announced it would be implementing a variety of nursing home reforms, including the creation of a minimum staffing standard in nursing homes. This Consumer Voice report confirms the need for these reforms and the need to address many of the long-standing problems that have plagued nursing homes for decades.

Report: State Nursing Home Staffing Standards

Twenty years after a Centers for Medicare & Medicaid Services (CMS) study found that at least 4.1 hours per resident day (hprd) of direct care nursing staff time are needed just to prevent poor outcomes, state staffing requirements, with a few exceptions, are nowhere near that recommended level. Despite what is known about the relationship between staffing levels and quality care, staffing standards in almost every state remain severely low.

Consumer Voice's 2021 report presents staffing requirements from each state and analyzes how they compare to each other and to levels recommended by research conducted for the federal government.

Residents have waited decades for adequate staffing around the clock. Ongoing and robust advocacy is needed at both the federal and state levels to provide residents with the care to which they are entitled and that they deserve.

Key Highlights from the Report

Relationship Between Staffing and Quality of Nursing Home Care

Minimum Staffing Levels - The many problems residents can experience as a result of inadequate staffing include higher mortality rates; decreased physical functioning; increased antibiotic use; more pressure ulcers; catheterization; urinary tract infections; higher hospitalization rates; and more weight loss and dehydration

Registered Nurse (RN )Time - Studies have shown a relationship between greater RN presence in facilities and higher quality of care.

Evidence-based Staffing Recommendations

Minimum Staffing Levels - A landmark report by CMS in 2001 recommended a daily minimum standard of 4.1 hours of total direct care nursing time per resident.

Twenty-four Hour Registered Nurse - Three Institute of Medicine studies have recommended that at least one RN be on duty at all times.

Federal Statute and Regulation

Neither federal statute nor regulation requires a minimum staffing standard or an RN around the clock. There is no minimum number of direct care nurse and nursing assistant hours per resident per day required by the federal government; nor is there any requirement for a specific ratio of nursing staff to residents.

The chart in Appendix B, State Nursing Home Staffing Standards Chart, presents each state’s staffing regulations. The Guide to the Chart (Appendix A) includes a description of the definitions/terminology used and explains how state standards were converted to hours per resident per day.

Analysis of State Staffing Standards

State Requirements: Total Nursing Staff Time - With one exception - the District of Columbia, state standards fall far short of the recommended staffing standard.

State Requirements by Type of Nursing Staff -

No state standard meets the recommended staffing standard of .75 hours per resident day (hprd) for RNs.
The vast majority of states do not require a specific hprd for Certified Nurse Aides/Nurse Aides (CNA/NAs).
Direct care staff requirements vary across the country. Eighteen states have no direct care minimum requirement.

State Requirements by Shift - Seven states set staffing standards by eight-hour shifts.

Twenty-four Hour Registered Nurse

Only six states require an RN 24/7 at all facilities, regardless of the number of beds. An additional eight states require an RN 24/7 based on facility size.

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Resident Voices on Staffing

Research and Reports

Inadequate Staffing During the COVID-19 Pandemic and Its Catastrophic Effects on Nursing Homes Residents (March 2022)
The Need for Higher Minimum Staffing Standards (2016)
This report eviews how nursing homes have serious quality problems, in part, because of inadequate levels of nurse staffing. The report by Charlene Harrington, John F. Schnelle, Margaret McGregor and Sandra F. Simmons discusses the relationship between nursing home quality and staffing and the barriers to staffing reform. Multiple studies have demonstrated a need for higher minimum nurse staffing standards in nursing homes as it is shown to have a positive relationship with nursing home quality. Yet, many barriers prevent the implementation of higher staffing standards like concerns about cost and enforcement and strong nursing home industry political opposition.
Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes - Report to Congress: Phase II Overview: Background, Study Approach, Findings, and Conclusions This purpose of this report is to complete the Report to Congress that was mandated by Public Law 101-508 which required the Secretary to report to the Congress on the appropriateness of establishing minimum caregiver ratios for Medicare and Medicaid certified nursing homes. A Phase I report of preliminary findings was delivered to Congress in July 2000.
Nurse Staffing Standards Recommended by Consumer Voice: In 1998, Consumer Voice's members approved what are widely known as the Consumer Voice Minimum Staffing Standards for nursing homes.
Consumer Perspective on Quality Care (Executive Summary) This 1985 document is still a seminal study of quality care as defined by the experts -- nursing home residents themselves. It recounts the research, discussions and findings of a Consumer Voice survey of 400 residents in 15 cities and shows their strong endorsement of nurse staffing as the most important component of care.