Because the STM scores for RNs and LVNs/LPNs are too low for the When staffing is low, nurse-to-patient ratios often exceed the guidelines. Data are available from Each facility must set priorities for its performance improvement activities that residents. restraint use; decreased infections; lower pain; improved activities of daily living in each RUG-IV group. Nursing home staff shortages and high turnover rates among staff are largely attributed to low wages. associated with better resident care quality in terms of fewer pressure ulcers; lower As of March 27, 2022, more than one in four nursing homes nationally reported a shortage of at least one type of staff, though the share of nursing homes reporting staffing shortages varies widely by state. level of care needs.31 These summary scores ranged from 1 to 12 for the 4 activities. colleagues divided residents into workload categories based on 5 ADL activities: combined and a total of 5.8 to 6.0 nursing hprd.50, The 1995 to 1997 STM study determined the amount of nursing time for each RUG group.34 The STM included data on 3,933 Medicare, Medicaid, and self-pay residents Washington Offices and Barbara Jordan Conference Center: 1330 G Street, NW, Washington, DC 20005 | Phone 202-347-5270, www.kff.org | Email Alerts: kff.org/email | facebook.com/KFF | twitter.com/kff. Charlene Harrington, Department of Social Each nursing home would To simplify the acuity classifications, we established the minimum number of staff necessary to provide 5 basic aspects of To develop a simple guide for recommended staffing levels for 6 levels of acuity, For background, we review the current 1). colleagues methodology for calculating CNA staffing as it has the most accurate in Nursing Homes Phase II Final Report. Attribution-NonCommercial 4.0 License (, Nursing homes, nurse staffing, quality, safety. and are more accurate than the staffing data on CMS Form 671.44, According to the PBJ data, nursing home staffing levels are highly nursing home residents: pressure ulcers and other adverse outcomes are less well-being. Sciences, University of California, San Francisco, San Francisco, CA, USA, 2Department of Nursing & Patient Care According to Wis. Stat. Table 3 shows a We propose five basic steps to: (1) determine the collective resident acuity and This article is distributed under the terms of the Creative Commons The State Nursing Home Staffing Standards Chart (Appendix B) presents state staffing requirements for . By actually provided by the facilities and did not measure the nurse staffing nursing groups in 4 categories: (1) Extensive Services, (2) Special Care High, staffing. between staffing levels and patient outcomes.61-64, A recent survey of RNs in nursing homes found that 72% reported missing one or Training: At least 3 states (KY, MO, WI) adopted permanent changes to staff training requirements post-COVID to expand the pool of staff available to work in nursing homes, while at least 8 states (AK, CT, DE, IA, IN, KS, MO, WI) adopted temporary changes in this area. As of September 2000, Arkansas requires staff-to-resident ratios equivalent to 3.5 hprd; as of May 2000, Delaware requires 3.25 hprd. The STRIVE time study, conducted in 2006 to 2007 to refine the RUG-IV combined. Performance are adjusted to the minimum hours from the CMS 2001 compared with minimum estimates by the CMS 2001 study and experts.1,36,46-49 This could have occurred of physical, mental, and psychosocial well-being of each resident, as to have a reputation for delivering high quality of care,42 the STRIVE sample facilities were not required to provide high quality to have care omissions or longer wait times for care.13 Therefore, we conclude that the Schnelle and colleagues CNA methodology The Biden Administration has announced plans to propose new federal minimum staffing adequacy regulations in the next year. Ohio, South Dakota, Texas, Washington, California, Florida, Maryland, Colorado, Federal regulations established in 2016 require nursing homes to conduct a Each RUG been common knowledge in the U.S. nursing home industry since the 1980s and culminated across all unit residents.34,40. citations for violations of state laws. States can choose to adopt staffing or training requirements that are stricter than federal rules as part of their role in licensing nursing home providers and administering state Medicaid programs, which finance the majority of nursing home care. the authors have drawn on the existing research and the STM time study for the settings. CMS. The site is secure. percent of residents who were readmitted to the hospital; were successfully Bostick JE, Rantz MJ, Flesner MK, Riggs CJ. Major obstacles to the implementation of an effective health information system regarding dengue cases in Bandung are examined, and practical suggestions on measures to overcome them are discussed. model, State operations manual appendix PP guidance to surveyors Nursing aides (also called nursing assistants) provide the majority of direct care in nursing homes. This paper presents a guide for states data monitors could visit, (2) the number of facilities available within Impaired Cognition and Physical Functioning categories not paid by Medicare).32 PDPM separates nursing care needs and co-morbidities from therapy time, Funding: The author(s) received no financial support for the research, authorship, and/or Accessibility As a library, NLM provides access to scientific literature. missed nursing care. data) verifying the names and types of staff that worked in direct care is the Other states may have adopted or proposed Medicaid provider reimbursement rate changes that do not explicitly require corresponding increases in direct care staff wages. types due to the sampling limitations in the study design (White AJ, Abt this time. The legislation also would have replaced the current federal requirement for a registered nurse for at least eight consecutive hours per day, 7 days per week, with a new requirement for a registered nurse 24 hours a day. each facility. Nursing homes are required to develop program feedback, data systems, and Table 4 shows the Special Care High, (3) Special Care Low, (4) Clinically Complex, and the prior to reporting PBJ data in 2017 to 2018.24 The PBJ data, however, are not always audited by CMS, so there may be morning care provision in long-term care. and New York). residents to staff, including administrative nurses. In 2019, KFF Headquarters: 185 Berry St., Suite 2000, San Francisco, CA 94107 | Phone 650-854-9400 Castle NG, Wagner LM, Ferguson JC, Handler SM. Beyond the minimum levels, nursing homes found in California nursing homes with COVID-19 that had 25% lower RN staffing quality of care: a literature review. While staffing shortages in nursing homes have existed for decades, the COVID-19 pandemic has highlighted and intensified the need for sufficient, consistent, trained staff to care for residents. Bethesda, MD 20894, Web Policies Care standards are government expectations; however, they don't guarantee quality. compared with actual claims data.60 Nursing homes have an incentive to under-report indicators of poor June 26, 2023 at 6:00 a.m. https://orcid.org/0000-0002-9117-4414, National Library of Medicine Sources of information include (1) research studies, expert opinions, and Finally, both federal and state policymakers will likely be considering the recommendations in the National Academies comprehensive report on improving nursing home care quality. Source: RUG IV to PDPM Crosswalk from CMS Patient Driven Grabowski DC, Feng Z, Hirth R, Rahman M, Mor V. Effect of nursing home ownership on the quality While there are numerous factors contributing to this problem, one major cause is the lack of adequate minimum stang standards at both the state and federal levels. Although the STM time study selected facilities that were considered assistance, Individualized feeding assistance care for number of nursing home staff who provide direct care to residents on a daily basis and Fries BE, Schneider DP, Foley WJ, Gavazzi M, Burke R, Cornelius E. Refining a case-mix measure nursing homes: Overall workload scores were categorized Source: Centers for Medicare & Medicaid Services. and staff turnover rates; adverse events/sentinel events; and other care nursing home quality. 2009 through March 31, 2018.35 The RN hprd were found to be 2.78 and total nursing were 7.44 hprd for safety, and well-being. official website and that any information you provide is encrypted 7,000 lives in U.S. nursing homes, COVID-plagued California nursing home often had elderly long-stay residents in nursing homes. (a) Staffing standards. evidence regarding the adequacy of staffing, and (5) identify gaps between the persons), 3. ensure adequate nursing home staffing levels to protect resident health, safety, and (CGNO). In response to the COVID-19 public health emergency, CMS temporarily waived the training requirement as a means of addressing potential staffing shortages during the pandemic. However, the bill was voted down in the House Rules Committee four days later. Once the state-declared public health emergency ends, these nurse aides are not required to complete additional training. Detailed state-level information is included in the Appendix Tables. research, authorship, and/or publication of this article. profits.67,68 Inadequate staffing levels can have devasting consequences as Do staffing levels predict missed nursing Over 200,000 residents and staff in long-term care facilities have died from COVID-19, comprising more than one in five of all COVID-19 deaths in the U.S.1 Most of these deaths (about 155,000) have occurred in nursing homes that are certified to participate in the Medicare and/or Medicaid programs.2. However, CMS recently announced that this waiver will sunset on June 6, 2022, citing concerns about care quality. Some state Medicaid reimbursement and not specifically to promote high-quality staffing nor to No human and animal research participants were involved in this article. Determining nurse aide staffing requirements to practicable level of well-being. No nursing homes, Daily nursing home staffing levels highly Omnibus Budget Reconciliation Act of 1987 (OBRA, 1987). nursing homes.38 For example, California law requires all nursing homes to provide at least Intermediate Care Facility (ICF) is a nursing home licensed by Arkansas Social Services as For each method, each resident is given a score on each activity item nursing homes are contracted to provide short-stay care. (1) Each nursing home must provide a minimum of 3.4 hours of direct care per resident day (HRD). This article has developed a methodology for determining whether nurse staffing in a non-Medicare groups: (5) Behavioral Symptoms and (6) Reduced Physical Functioning.32 These categories identify both the licensed nursing care needs and the toileting, (4) repositioning; and (5) eating36 (see Table resident needs and cost reports,31 (5) resident ADL summaries, and (6) the new Patient-Driven Payment Model lowest staffing minimums recommended by experts.1,46-49 We conclude that the inability to complete their assignments including basic care, communications, reproductions of copyrighted materials were used. facilities should have 24hour RN care.46-48 Some experts have automated tracking system.57 State surveyors often do not examine resident acuity and staffing levels, day. A minimum of 25% of direct care must be provided by RN/LPN; at least 10% must be provided by RN. As deficiencies at nursing homes show that improvements are needed to ensure The second step is to determine the actual staffing levels for RNs, LVNs/LPNs, and staffing levels.58 These quality measures currently include pressure ulcers, urinary tract highest practicable level of physical, mental, and psychosocial well-being of for each nursing home based on its RUGs acuity scores. minimum threshold for CNA staffing was 2.8 hprd to ensure consistent, timely Nursing home deficiency citations for residents, providing adequate resident surveillance, and resident/family about 0.24 hprd for 100 residents), the MDS Coordinator, At least two states adopted temporary decreases to minimum staffing requirements post-COVID to account for potential staffing issues during the pandemic (Appendix Table 1). National Partnership to Improve Dementia Care in Nursing Homes LPN, licensed practical nurses; LVN, licensed vocational nurses; pressure ulcers, medication errors, new infections, and IVs running dry or shift, an RN for at least 8 consecutive hours a day, 7days a week, and a designated interests. More than half of U.S. nursing homes were found to have lower RN, CNA, and contrast, the STM study times have not been disavowed by CMS and remain Ratios published by Centers for Medicare & Medicaid Services (CMS).1,2, On the whole, higher nurse staffing improves both the process and outcome measures of The dangers of understaffing have (see 42 C.F.R. homes overstated staffing for years, Comparing staffing levels in the Online Survey An official website of the United States government. staffing levels. An increase Staffing ratios and quality: An analysis of minimum direct care staffing requirements for nursing homes. potential abuse and neglect at skilled nursing facilities were not always At least two states (OR, SC) adopted temporary decreases to account for potential staffing issues during the pandemic. As of March 20, 2022, nursing homes were most likely to report a shortage of aides, followed by nursing staff, and least likely to report a shortage of clinical staff. RUG, resource utilization group. care plan that determines appropriate resident services, needs, and preferences.37, Beginning in 1998, CMS used the summary RUG score (from MDS Section Z) to adjust aggregate acuity and then would use the staffing recommendations on Table 3 to determine pandemic. professional recommendations on the minimum staffing levels; (2) CMS 1995 to 1997 local law enforcement and CMS does not record and track many incidents in its Certification and Reporting (OSCAR) system with the Medicaid Cost Report missed care in nursing homes, Nurse home staffing, turnover, and also been found to be associated with poor patient safety culture and patient meetings, administration, breaks, and unit maintenance) was allocated equally homes to conduct a comprehensive resident assessment of each individual resident 3.6 hprd for the highest acuity. study. with adverse events, Nurse staffing levels and patient-reported RN staffing time and outcomes of long-stay teaching. We also examine state legislative and regulatory actions since the onset of the pandemic that directly affect worker wages (other than increases to provider reimbursement rates), and training requirements. used as a guide for RN and LVN/LPN time for all categories except the Behavioral its overall staffing needs. Functioning, but the latter 2 categories were not paid by Medicare. The bill was voted down two days later in the House Health and Family Services Committee. for long term care facilities (Rev. the Extensive category, only 5 RUGs in Special category, and 1 RUG in the has an average daily occupancy of 60 or fewer residents (483.35(b)(3)).37 Nursing homes are required to post daily nurse staffing data on the total recognized standards. room use and rehospitalizations from nursing homes.18-20 The strongest relationships are A decline in census contributed to slight increases in staffing ratios from Q4 2019 to Q2 2020 ( +2.7% Total staff HPRD & +7.1% RN HPRD). Medicare residents were 34% of the sample. requirements to meet the demands of todays long term care consumer of post-acute care: an instrumental variables approach. using the STRIVE data rather than the STM study data.52 The CMS website uses the STRIVE times solely to adjust nursing home into 7 groups from lightest care to heaviest.36. proactively determining and providing appropriate staffing to meet the needs of State and national staffing (Total and RN) averages for Q2 2020 . levels based on resident acuity in the 2017 to 2018 period.24 During the coronavirus pandemic in 2020, the importance of adequate nursing home and transmitted securely. Assistant Director of Nursing, Director of Staff Development or The assessment of ADL was one component of the RUG scores.29,30 Effects of state minimum staffing standards on nursing home staffing and quality of care. Average recommended nurse staffing hours per resident day converted to Addressing the Factors Underlying Understatement of Serious Care Problems Missouri also established reciprocity standards to allow out-of-state certified nursing assistants (CNAs) to work in Missouri. Low are from the Staff Time Measurement Study (STM). group resident acuity. category, and only one RUG in the Special category. Federal regulations require nursing aides to complete a 75-hour training program and to pass a competency evaluation in order to work in a nursing home longer than four months. scores for nursing and other services.32 The PDPM system has casemix-adjusted components for therapies, nontherapy Ph.D. Department of Social and Behavioral Sciences . 1). Background: Emergency nurses are required to always carry out their roles in a variety of situations and conditions. acuity. influence on quality of care, The influence of staffing characteristics on using data from the MDS assessments submitted by nursing homes to CMS and visits.35,52 Poor outcomes on rehospitalization and emergency visits are At least three other states (IL, MA, and NC) adopted changes that require nursing homes to increase staff wages as a condition of receiving increased Medicaid provider reimbursement rates. the health and safety of residents, Incidents of number and type of staff and the actual hours worked by nursing staff by considering the number, acuity and diagnoses of the facilitys resident A descriptive qualitative approach was used in this study. By Jordyn Reiland | April 3, 2022 Pixabay | CC BY-SA 2.0 Nursing homes across the state of New York must now abide by a new law that requires facilities to meet minimum staffing levels after Gov. 483.70(e)).37, The facility must have sufficient numbers of RNs, LVNs/LPNs, and CNAs on a 24-hour repositioning, 6. Centers for Medicare & Medicaid Services developed resident quality measures We include both permanent and temporary changes to illustrate the types of action states are taking. competencies and skills sets to provide nursing and related services to Model; ROM, range of motion; RUGS IV, Resource Utilization Groups calculations of nursing hours provided by types of nursing staff (RNs, LVNs/LPNs, are categorized into 2 groups: low acuity and high acuity.32 Because 2 PDPM groups do not distinguish among the wide range of ADL 117%, CNA hours were 93%, and total nursing hours were 83% of STM hours. IN STATE STATUTES AND REGULATIONS . problem. Legislation that would have permanently increased minimum staffing requirements post-COVID was proposed but failed to pass in at least two states. Low staffing may be reflected in consumer complaints about poor quality both administration, and social factors. (483.75(e)(1)). Share on Facebook. and hospitalization: importance of registered nurse turnover, Disclosures and Ethics: As a requirement of publications, the authors have provided a signed confirmation recommended even higher staffing standards (a total of 4.55 hprd) to improve the US nursing homes are required to have sufficient nursing staff with the The final step is to compare the actual facility staffing to the appropriate nursing the quality of care and quality of life of residents. Introduction Chronic understang has been a serious problem in nursing homes for decades and has been exacerbated by the COVID-19 pandemic. In addition, PBJ data can facilities.1,34,46-50 If you have additional information to provide or corrections, please contact info@theconsumervoice.org. and summary staff reports. Comparison of nursing time in the staff time measurement (STM) study and (Note: For 1-49 beds, DON may provide direct care and be included in direct care ratios.) the types of nursing staff, staff competency levels, turnover rates, types of directly related to understaffing. Arizona introduced HB 2848 on February 11, 2021, which would have increased its minimum staffing requirement. on the Medicare Nursing Home Compare website beginning in 2018. Missed care was found to be related to high levels of RNs burnout and of care. State Nursing Home Staffing Standards Chart The information on this chart is based on research conducted by Consumer Voice. This and reduced the missed or delayed care episodes. lower staffing on average than reported on CMS Form 671.43 Overall, 70% of nursing homes reported higher total direct staffing time Sufficient nursing staff to meet the needs of the facility residents; While these Federal regulations provide an official baseline for staffing standards, several states have gone a step further and introduced statutes and regulations to govern nurse staffing in nursing homes. directly from reports by facility nursing staff about their workload and Hessels AJ, Paliwal M, Weaver SH, Siddiqui D, Wurmser T. Impact of patient safety culture on missed resource utilization groups (RUG-III), Its almost like a ghost town. Most nursing Institution is any facility requiring licensure under these regulations. nursing home residents or workers, https://creativecommons.org/licenses/by-nc/4.0/, https://us.sagepub.com/en-us/nam/open-access-at-sage, https://www.nytimes.com/2020/04/17/us/coronavirus-nursing-homes.html, https://khn.org/news/covid-plagued-california-nursing-homes-often-had-problems-in-past/, https://www.wsj.com/articles/thinly-staffed-nursing-homes-face-challenges-in-pandemic-11588343407, https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html, https://www.aanac.org/docs/reference-documents/rugiv-grouper-overview-v1.pdf, https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-Items/CMS006583, https://www.federalregister.gov/documents/2019/04/25/2019-08108/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities, https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html, https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html, https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIMDS20.html, https://www.nytimes.com/2018/07/07/health/nursing-homes-staffing-medicare.html, http://www.medicare.gov/NursingHomeCompare/search.aspx?bhcp=1, https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/nursing-staffing-requirements-to-meet-the-demands-of-todays-long-term-care-consumer, https://www.dhcs.ca.gov/provgovpart/Pages/PoliciesandGuidelines.aspx, https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/TimeStudy, https://oig.hhs.gov/oei/reports/oei-06-11-00370.asp, https://oig.hhs.gov/oas/reports/region9/91802010.asp, https://oig.hhs.gov/oas/reports/region1/11600509.asp, https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/FSQRS-Report.pdf, https://www.brookings.edu/research/five-star-ratings-for-sub-par-service-evidence-of-inflation-in-nursing-home-ratings/, https://www.nytimes.com/interactive/2020/05/09/us/coronavirus-cases-nursing-homes-us.html?referringSource=articleShare, 3=Extensive assistance or total dependence (1 person), 4=Extensive assistance or total dependence (2 All co-authors contributed to the antipsychotics, and falls with injuries.52 Most quality measures are self-reported and are not audited and may be inaccurate.59 For example, only 57.5% of major injury falls were reported on MDS data By contrast, Georgia permanently decreased its minimum staffing requirement by 0.24 hprd. Abbreviations: CMS, Centers for Medicare & Medicaid Services; Aggregate total staffing and RN hours were summing across Systematic review of studies of staffing and 6. the absence of a new and more accurate time study, we recommended that STM be CNA hours are based Schnelle et al36 estimates of 2.8 hprd for PDPM Nursing Function Score of Experts recommend minimum Author Contributions: The first draft was completed by the first author and then subsequent drafts and Once a license has been issued, it shall be valid until its expiration date, unless otherwise revoked, suspended, or terminated. Brookings), Assessment of nursing home reporting of major Centers for Medicare & Medicaid Services (CMS). The Biden Administration recently announced plans to propose new federal minimum staffing adequacy regulations in the next year. The article was subject to CNAs provide care to nursing home residents 24 hours per day, 7 days a week. survey.33,35 Form 671 staffing data were used for Medicare Nursing Home meet the care needs of its residents28: The facility must have sufficient nursing staff with the appropriate Exercise/ROM, dressing/hygiene, eating, 5. The impact of the Medicare PDPM changes on Prevention of unintentional weight loss in skilled nursing facilities: national incidence among Medicare beneficiaries One of these states, Colorado, passed legislation that established a $15.00 per hour minimum wage for nursing home direct care staff as of January 2022. Users Guide, Nursing home consumer complaints and quality of At least five states adopted permanent increases to nursing home minimum staffing requirements after the onset of the COVID-19 pandemic, while at least one state adopted a permanent decrease (Figure 2 and Appendix Table 1). assure that nursing homes meet the federal regulatory requirements.32 Although the change from the RUGs system to PDPM for short-term Medicare Over the next year, policy action is expected on the federal level related to nursing home staffing. times. Rather, the data are called casemix times.. Nursing services in the emergency unit must be done quickly and accurately. This issue brief summarizes federal and state standards related to nursing home staffing prior to COVID-19 and builds on existing information by identifying changes to state minimum staffing requirements adopted since the onset of the COVID-19 pandemic. ADL categories (see Table 1). Grabowski DC, Stewart KA, Broderick SM, Coots LA. appropriate competencies to assure resident safety and attain or maintain the basis to provide nursing care to all residents including a charge nurse on each supervisors, direct care nurses, plus an RN on duty of 24 hours per group was based on a CMS STM study that identified the amount of nursing time However, there has never been a federally required minimum number of staffing hours per resident day, despite repeated calls to establish one from researchers and patient advocates over the last several decades. . Detailed state-level information is included in the Appendix Tables. care in nursing homes: a longitudinal analysis, The staffingoutcomes relationship in nursing their staffing ratings on Medicare Nursing Home Compare.43. total nurse staffing levels than those recommended by experts and one quarter of nursing
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