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Few would dispute that nursing facilities must employ a sufficient number of professional nurses and well-trained, well-supervised, and well-compensated paraprofessional nursing staff in order to be able to provide high quality care and quality of life to residents.  The question is how to achieve this universally-acknowledged standard.

Federal law sets out few requirements for nurse staffing.  With respect to numbers of staff, the Nursing Home Reform Law (1987) requires that facilities employ a registered nurse (RN) eight consecutive hours, seven days a week,[1] licensed nurses (RNs and licensed practical nurses or licensed vocational nurses) 24 hours a day,[2] and, otherwise, “sufficient” nursing staff to meet residents’ needs.[3]  With respect to staff competency, the Director of Nursing must be a registered nurse (RN)[4] and nurse aides must receive at least 75 hours of training and demonstrate competency before providing care to residents.[5] 

These federal standards, which have not been updated since the Reform Law was implemented in October 1990, have not been sufficient to ensure a competent, stable workforce.  More than a decade ago, a report by Abt Associates for the Centers for Medicare & Medicaid Services (CMS) found that 97% of nursing facilities failed to meet one or more staffing requirements to prevent avoidable harm to residents and, in a simulation study, that 91% lacked sufficient staff to meet five key care process; more than 40% of facilities would need to increase aide staff by 50% or more; and more than 10% of facilities would need to increase aide staff by more than 100%.[6]

In the absence of strong federal standards, states, over the years, have used a variety of approaches, often in combination, to strengthen the nursing workforce in nursing facilities.  Some states have focused directly on improving staffing levels by mandating explicit staffing ratios.  Other states have created financial incentives to facilities to increase staffing, using wage pass-throughs, or increases in Medicaid rates, or pay-for-performance bonuses.  Public reporting of staffing information uses a market-based approach.  A fourth approach addresses workforce issues by proposing more and better training and calling for career ladders that would enable aides to improve their skills and advance into professional positions.

With funding from a CyPres award in Lavender v. Skilled Healthcare LLC (Calif. Super. Ct., Humboldt Co.), Case No. DR060264, the Center for Medicare Advocacy is looking at the broad variety of state approaches and their effectiveness, or lack of effectiveness, in achieving improved staffing levels and competencies.  The project will issue a series of short papers on the state approaches, with a bibliography for each.  It will also interview national experts in the field and report on their observations and recommendations on the most and least promising approaches to improving nurse staffing. 

Toby S. Edelman
June 18, 2014

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[1] 42 U.S.C. §§1395i-3(b)(4)(C)(i), 1396r(b)(4)(C)(i)(II) , Medicare and Medicaid, respectively; 42 C.F.R. §483.30(b)(1).
[2] 42 U.S.C. §§1395i-3(b)(4)(C)(i), 1396r(b)(4)(C)(i)(I); 42 C.F.R. §483.30(a)(1).
[3] 42 U.S.C. §§1395i-3(b)(4)(C)(i), 1396r(b)(4)(C)(i)(I); 42 C.F.R. §483.30(a)(1).
[4] 42 C.F.R. §483.30(b)(1).
[5] 42 U.S.C. §§1395i-3(f)(2)(A)(i)(II), 1396r(f)(2)(A)(i)(II) (federal standards for nurse aide training); 42 C.F.R. §483.152(a)(1) (75 hours), §483.154 (competency evaluation).   
[6]Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes