Federal Minimums: Hours Per Resident Day (HPRD)
In April 2024, the Centers for Medicare & Medicaid Services (CMS) finalized new minimum staffing standards for Medicare and Medicaid-certified nursing facilities to set a national baseline for nursing care. These rules mandate a specific number of Hours Per Resident Day (HPRD) to improve the safety and quality of care. The total nursing care requirement is 3.48 HPRD, delivered by a combination of registered nurses (RNs), licensed practical nurses (LPNs)/licensed vocational nurses (LVNs), and nurse aides (NAs).
The 3.48 HPRD breakdown
The required 3.48 HPRD includes:
- RNs: At least 0.55 HPRD.
- Nurse Aides: At least 2.45 HPRD.
- Other Nursing Staff: The remaining 0.48 HPRD can be RNs, LPNs/LVNs, or NAs.
24/7 RN on-site requirement
The CMS rule also requires an RN to be onsite 24/7 and available for direct resident care. This differs from the previous rule of an RN on duty for only eight hours a day and aims to reduce safety issues, especially during off-hours.
The Role of State Regulations
Many states have staffing requirements that may be stricter than federal minimums, sometimes including specific staff-to-resident ratios based on the time of day. Facilities must comply with both federal and state regulations, following the stricter standard.
Factors Influencing Staffing Needs Beyond Minimums
High-quality care often requires staffing beyond minimums, influenced by:
- Resident Acuity: More medically complex residents require more staff.
- Facility Assessment: Annual assessments must consider resident needs to adjust staffing.
- Skill Mix: The right combination of RNs, LPNs, and CNAs is crucial.
- Staff Turnover: High turnover negatively impacts care continuity.
Comparison of Minimums vs. Recommended Staffing
Experts often suggest higher staffing than federal minimums for optimal care and outcomes. Studies indicate a link between higher staffing and better quality.
| Feature | CMS Minimum Standard | Expert-Recommended Staffing (Pre-Mandate Studies) |
|---|---|---|
| Total Nurse HPRD | 3.48 | A 2001 CMS report suggested a minimum of 4.1 HPRD to meet clinical needs. A 2023 study suggested a range from 4.29 to 6.77 HPRD depending on resident acuity. |
| RN HPRD | 0.55 | Numerous studies have associated higher RN presence with higher quality of care and fewer deficiencies. |
| Nurse Aide HPRD | 2.45 | Higher staffing levels for nurse aides have also been associated with fewer deficiencies and improved resident outcomes. |
| 24/7 RN Onsite | Required | Long recommended by organizations like the Institute of Medicine to ensure consistent quality of care. |
The Consequences of Understaffing
Inadequate staffing can result in delayed care, decreased hygiene, increased risk of neglect or abuse, negative impact on mental health, and higher rates of hospitalizations, pressure ulcers, and weight loss.
Conclusion
Determining how many staff should be in a nursing home depends on federal rules, state laws, and facility needs. While the new CMS mandate sets a baseline, exceeding minimums is often necessary for high-quality care, especially for residents with greater needs. Families should consider staffing levels, quality of care, staff morale, and a facility's history. Staffing data is available on Medicare's Care Compare website.
Additional Considerations
Workforce challenges persist despite regulations. The CMS rule includes hardship exemptions. The best facilities prioritize exceeding minimums and involve residents, families, and staff in assessments.
- Disclaimer: A federal judge blocked the enforcement of the CMS staffing mandate in April 2025 due to concerns about CMS authority. Enforcement is halted pending potential appeals. Consult official CMS and court updates for the latest status.
How to Check Staffing Levels
To check staffing levels, families can use:
- Medicare Care Compare: Provides staffing ratings and HPRD data.
- State Health Departments: Can confirm state-specific requirements.
- Direct Inquiry: Ask the facility about their staffing plan.
Conclusion
The right staffing level is a mix of federal and state rules, and facility needs. Higher staffing, especially for RNs, correlates with better outcomes. The federal mandate is a floor, not a ceiling. Use available data and ask questions to make informed decisions for loved ones.
