Federal Minimum Staffing Standards
The Centers for Medicare & Medicaid Services (CMS) released a final rule in April 2024 establishing the first-ever federal minimum staffing levels for nursing facilities that receive Medicare or Medicaid funding. These standards aim to improve the quality of care and are being implemented on a staggered timeline.
The CMS rule mandates specific hours per resident per day (HPRD) for different nursing staff roles, including a minimum of 3.48 total nursing HPRD, 0.55 RN HPRD, and 2.45 Nurse Aide (NA) HPRD. The remaining 0.48 HPRD can be covered by any combination of RNs, LPNs, LVNs, or NAs. A key requirement is having an RN on-site 24/7, a significant change from the previous eight-hour requirement. Facilities must also conduct an assessment to determine if they need to exceed these minimums based on resident needs. Exemptions may be available under specific hardship conditions.
The Role of Resident Acuity in Staffing
Resident acuity, which is the complexity of residents' medical conditions, significantly impacts staffing needs beyond the federal minimums. Facilities with higher acuity residents require more staff to ensure safe and quality care. Studies suggest that appropriate staffing for high-acuity residents is often higher than federal minimums. Facilities are required to use a facility assessment to determine if their staffing should exceed the minimums based on their residents' acuity.
State-Specific Staffing Regulations
Many states have their own staffing regulations that complement or exceed the new federal minimums. These state standards can vary significantly, including different HPRD or staff-to-resident ratios for specific shifts, meaning a nursing home's location influences its staffing requirements. Some states had higher HPRD requirements or specific CNA ratios even before the federal rule.
Federal vs. State Nursing Home Staffing Standards
| Feature | Federal (CMS) Standard (Effective 2024-2029) | State Standards (Varies by Location) |
|---|---|---|
| Total HPRD | Minimum 3.48 total nursing HPRD. | Varies widely; some states have higher minimums (e.g., D.C. has 4.1 HPRD). |
| RN HPRD | Minimum 0.55 RN HPRD. | Many states have no specific RN HPRD minimums, focusing instead on on-site requirements. |
| NA HPRD | Minimum 2.45 NA HPRD. | Varies widely; some states have shift-specific ratios or different HPRD requirements. |
| 24/7 RN | Required to have an RN on-site 24/7. | Historically, only six states required a 24/7 RN presence before the new federal rule. |
| Acuity Assessment | Required to perform facility assessments to determine if staffing needs exceed minimums based on resident needs. | Some states may have similar requirements or programs to incorporate acuity, but the federal rule now mandates this. |
| Implementation | Staggered implementation timeline (2-5 years) with potential exemptions. | Varies by state; some states may have already met or exceeded the new federal requirements. |
Additional Considerations for Staffing
A nursing home requires various support staff beyond direct care nurses. These roles, while not typically part of HPRD calculations, are crucial for overall quality and operation. Essential positions include a licensed administrator, therapists (physical, occupational, speech), social workers, dietary staff (chefs, cooks, dietitians), and support services like housekeeping and maintenance. Factors like facility ownership, staff turnover, and wages also influence staffing levels and quality. High turnover and low wages can worsen staffing shortages, while supportive work environments help retain staff.
Conclusion
Determining the required number of staff for a nursing home involves considering the new federal minimum standards from CMS, which include 3.48 HPRD and 24/7 RN presence, alongside state-specific regulations. Resident acuity is a significant factor, as higher needs demand higher staffing levels. Prospective residents and their families should investigate a facility's specific staffing, review its facility assessment, and compare it against federal and state benchmarks to ensure comprehensive and high-quality care. {Link: Better Care Playbook https://bettercareplaybook.org/_blog/2023/11/what-know-about-nursing-home-staffing-minimums-implications-new-federal-rules}
Factors Influencing Nursing Home Staffing
- Federal Mandates: CMS sets minimum hours per resident day (HPRD) for facilities receiving federal funding.
- Resident Acuity: The complexity of residents' medical needs affects the required number of staff.
- State Regulations: Many states have their own, often higher, staffing rules or ratios.
- Exemptions: Facilities, particularly rural ones, may qualify for exemptions under specific conditions.
- Facility Assessment: Nursing homes must assess resident needs to determine if staffing should exceed minimums.
- Type of Staff: Requirements differentiate between RNs, LPNs, and CNAs.
- Support Personnel: Essential non-nursing staff like therapists and social workers are also required.
