Centers for Medicare & Medicaid Services Staffing Study to Inform Minimum Staffing Requirements for Nursing Homes
In February 2022, President Biden announced a comprehensive set of reforms to improve the safety and quality of nursing home care, hold nursing homes accountable for the care they provide, and make the quality of care and facility ownership more transparent so that potential residents and their loved ones can make informed care choices. One key initiative within the President’s strategy is to establish new minimum staffing requirements so every nursing home has sufficient staff who are adequately trained to provide the safe and quality care residents need. Evidence has shown that adequate staffing is closely linked to the quality of care residents receive. The COVID-19 Public Health Emergency (PHE) has highlighted and exacerbated the long-standing staffing challenges experienced in many facilities, creating an urgent need to address this issue for the well-being of all individuals residing in our nation’s federally certified nursing homes and the workers who care for them.
The Centers for Medicare & Medicaid Services (CMS) has launched a multi-faceted approach aimed at determining the minimum level and type of staffing needed to enable safe and quality care in nursing homes. This effort includes issuing a Request for Information (which occurred earlier this year as a part of the Fiscal Year 2023 Skilled Nursing Facility Prospective Payment System Proposed Rule) and conducting a new study. The information obtained through these efforts will inform future proposed rulemaking on minimum staffing requirements, which CMS plans to issue in Spring 2023. Facilities will be held accountable if they fail to meet this standard.
Are there federal nursing home staffing standards currently in place? Federal law currently requires Medicare and Medicaid-certified nursing homes to provide 24-hour licensed nursing services, which are “sufficient to meet nursing needs of [their] residents” and must use the services of a registered professional nurse at least 8 consecutive hours a day, seven days a week. Additionally, regulations specify that nursing homes are required to conduct an annual facility assessment, which considers resident needs and staff ability to provide care. In determining what 24-hour services provide “sufficient” staff—meaning registered nurses (RNs), licensed practical and vocational nurses (LPNs and LVNs), and certified nurse aides (CNAs)—facilities must account for individual resident assessments and plans of care, in addition to the facility assessment.
CMS currently posts staffing data for all facilities on the Care Compare website, including resident census data and data on the hours of care provided per resident per day. Some States may also have minimum staffing requirements for nursing homes.
Despite these existing requirements, understaffing continues to be a concern. For that reason, CMS believes it essential to patient safety that it conduct the new rulemaking to establish more specific, detailed, and quantitative minimum staffing requirements.
What did CMS learn from the Request for Information? The agency initially published a Request for Information (RFI) soliciting public comments on minimum staffing requirements in April 2022, within the Fiscal Year 2023 Skilled Nursing Facility Prospective Payment System Proposed Rule. The feedback received has and will be used to inform the research study design and proposals for minimum direct care staffing requirements in nursing homes in 2023 rulemaking. This RFI was a first step to facilitate a holistic approach to advancing future changes in these areas. The public comment period closed on June 10, 2022, and CMS received over 3,000 comments from a variety of interested parties including advocacy groups; long-term care ombudsmen; industry associations (providers); labor unions and organizations; nursing home staff and administrators; industry experts and other researchers; family members, and caretakers of nursing home residents.
Industry associations and nursing home resident advocates provided divergent views on the establishment of minimum staffing levels. Nursing home resident advocacy groups and family members of residents were generally strongly supportive of establishing a minimum staffing requirement, while other industry and provider groups expressed significant concern.
We received many comments on the RFI from members of the public identifying themselves as family members or caretakers of residents living in nursing homes. The vast majority of those comments voiced concerns related to residents not receiving adequate care due to chronic understaffing in facilities. Multiple comments stated that residents will go entire shifts without receiving toileting assistance, leading to falls or increased presence of pressure ulcers. Another commenter, whose parents live in a nursing home, noted that they visit their parents on a daily basis to ensure the provision of quality care and reported that staff in the facility have stated that they are overworked and understaffed.
Commenters offered recommendations for implementing minimum staffing requirements. Some commenters suggested that CMS focus on implementing an acuity staffing model per shift instead of a minimum staffing requirement, while some recommended a staff to patient ratio instead. . Others recommended that minimum staffing levels be established for residents with the lowest care needs, assessed using the MDS 3.0 assessment forms, citing concerns that acuity-based minimums will be more susceptible to gaming. Some commenters also stated that the following factors should be considered: Medicaid census, facility size, ownership status (profit or non-profit), amount of skilled nursing facility competition in the area, and, community poverty and Medicare census rates. Other commenters representing advocacy groups stated that resident acuity should be a primary determinant in establishing minimum staffing standards, noting that Medicare pays nursing homes based on resident acuity level.
CMS also received comments on factors impacting facilities’ ability to recruit and retain staff, with most commenters in support of creating avenues for competitive wages for nursing home staff to address issues of recruitment and retention. Industry commenters stated that staffing in nursing homes has not rebounded as well as it has in other care settings and recruiting remains a challenge, raising concerns that facilities will have to close because they are unable to meet minimum staffing levels. Advocacy groups also had staffing shortage concerns, but observed that, in their view, staffing has always been a challenge and emphasized that while additional efforts are needed to bolster the workforce, it should not deter CMS from setting minimum staffing levels in nursing homes. Additionally, some commenters noted that evidence shows that most facilities have adequate resources to increase their staffing levels without additional Medicaid resources.
Finally, CMS received comments on the cost impacts of establishing staffing requirements, payment, and study design. Others pointed to the variability of the various states’ Medicaid labor reimbursement and suggested that Medicaid rates in many states do not keep pace with rising labor costs. Commenters provided robust feedback on the action design and method for implementing a staffing requirement, with some noting that resident acuity could change on a daily basis and recommending that CMS establish benchmarks, rather than absolute values, in staffing requirements.
While there are a variety of opinions among stakeholders on establishing minimum staffing requirements, it is CMS’ goal to consider all perspectives, as well as findings from the staffing study, as it crafts future minimum staffing requirements that advance the public’s interest of safe, quality care for residents.
What will the staffing study look like? CMS will be conducting a mixed methods study with qualitative and quantitative elements to inform the minimum staffing proposal. Qualitative analysis will include primary data collected during site visits, including interviews, surveys, and observation data in nursing homes. Quantitative analysis will use secondary data, including Medicare Payroll-based Journal (PBJ) data, Minimum Data Set (MDS), and Medicare claims.
This staffing study seeks to help identify a minimum staffing level, which would include RN, LPNs/LVNs, and CNAs, that will establish a threshold below which residents would be at substantially increased risk of not receiving the safe and quality care they deserve. Importantly, this study is on an accelerated timeline and seeks to build on, not replace, previous studies.
What else is included in the study? Launched in August 2022 and expected to continue through the winter, the staffing study is comprised of four main parts: literature review, site visits, quantitative analyses, and cost analyses – all further described below.
- Literature review
The study team is currently reviewing existing literature to summarize the evidence of the relationship between minimum staffing in nursing homes and the safety and quality of care, as well as clarify the relative strengths and weaknesses of the available literature.
- Site visits to nursing homes and related analyses
The contracted researchers are conducting site visits to 75 nursing homes throughout the country. Initial visits to 50 out of the 75 nursing homes will provide important information to guide the development of the proposed minimum staffing standards, and visits to the remaining 25 facilities will help validate the initial findings as part of CMS’s iterative policy process.
Nursing homes were selected in 15 states: CA, CO, FL, IL, MA, MD, MO, NC, NY, OH, PA, TX, VA, WA, and WY. Nursing home selection was performed objectively using a process to ensure national representation, and resulted in a cross-section of size, ownership type, geographic location, Medicaid population, and Five-Star Quality Rating System staffing and overall ratings
Onsite interviews, surveys, and direct observations of nursing home staff will provide qualitative, contextual information to inform the establishment of minimum staffing requirements. Interviews with nursing home leadership, direct care staff (including RNs, LPNs/LVNs, and CNAs), and residents and their family members will be conducted to better understand the relationship between staffing levels, staffing mix (what types of staff are present), and resident outcomes and experiences (i.e., clinical outcomes, safety, health disparities) using rich contextual information collected during the interviews. Additionally, observational data will be collected onsite using trained clinicians who will observe and record time spent on care provision, including taking care to differentiate time spent on care provision from time spent on administrative nursing. These data will enable the development of a simulation model to examine the impact of different staffing levels and patient acuity levels on the quality and timeliness of care. This simulation model is important to ensure that the staffing study reflects not just what staffing levels exist currently as a descriptive model, but also what staffing levels are needed for safe, quality care for patients at varying acuity levels.
Research questions will address not only what level of staffing is needed, but also the impact on quality of care, any barriers to implementation, and any potential unintended consequences of imposing minimum staffing requirements.
- Quantitative analyses
As part of the staffing study, quantitative analyses will be conducted to identify staffing levels associated with improved quality of care and resident safety in nursing homes. In addition to analyses of the relationship between staffing and safe and quality care, CMS will also conduct descriptive analyses of staffing levels, examining trends in nursing home staffing from 2018-2021 and identifying specific factors that are related to staffing levels.
- Cost analyses
In conducting the cost-benefit analysis required for any rulemaking, including the staffing requirement, CMS must evaluate any associated incremental costs that facilities would likely face. Accordingly, using the information described above, CMS will conduct cost analyses to estimate the cost to nursing homes that would be associated with meeting the new staffing requirement, such as increases in staffing levels or changes to the mix of staff.
What are the next steps and how can I get involved? This is an important body of work that will ensure nursing home residents are receiving the safe and quality care that they deserve. CMS appreciates the interest shown by so many stakeholders to date during the RFI process and looks forward to further engagement on this issue. For nursing homes selected to participate in the site visit aspect of the study, CMS encourages active participation to ensure your perspectives are captured. CMS is also conducting a stakeholder listening session on August 29, 2022 from 1-2:30 p.m. EST to provide information on the study and solicit additional stakeholder input on minimum staffing requirements. We encourage any interested party to register early for this event as there will be a maximum limit of 3,000 participants. More information and the registration link for the event is available here: https://abtevents.webex.com/abtevents/j.php?RGID=r8e7713354ab6b79a94b9e3dd4d265ce9
Of course, once CMS issues its proposal for minimum staffing requirements in Spring 2023, that proposal will go through the notice-and-comment rulemaking process—providing further opportunities for all interested parties to weigh in.
 87 FR 22720, pages 22771-22772: https://www.federalregister.gov/documents/2022/04/15/2022-07906/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities
 Fiscal Year 2023 Skilled Nursing Facility Prospective Payment System Proposed Rule:https://www.federalregister.gov/documents/2022/04/15/2022-07906/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities
 Social Security Act, sections 1819 and 1919
 Social Security Act, sections 1128I(g)(4), 1819, and 1919
 Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes, 2001: https://www.justice.gov/sites/default/files/elderjustice/legacy/2015/07/12/Appropriateness_of_Minimum_Nurse_Staffing_Ratios_in_Nursing_Homes.pdf; and the 2005 Staff Time and Resource Intensity Verification (STRIVE) Project: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/TimeStudy