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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. 

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.


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.

Resident Voices on Staffing

Research and Reports

  • 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 nursin ghome 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.