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On October 4, 2016, the Centers for Medicare & Medicaid Services (CMS) published revised Requirements of Participation (RoP) for skilled nursing facilities (Medicare) and nursing facilities (Medicaid).[1]  Although the substantive standards for nurse staffing are unchanged, CMS’s reorganization of the RoPs included moving the nurse staffing requirements to a different section[2] and moving standards for nurse aides from the administration RoP to the nursing RoP.[3]  The revised RoPs introduce a “competency-based staffing approach” to nurse staffing, instead of a minimum nurse staffing standard or ratio that many residents’ advocates support. 

The nursing RoP became effective November 28, 2016, with the exception of the facility assessment requirement, which establishes the competency-based staffing approach and becomes effective November 28, 2017.

Numbers of staff: As before, facilities must employ a registered nurse (RN) at least eight consecutive hours on the day shift,[4] licensed nurses (RNs and licensed practical nurses or licensed vocational nurses) 24 hours a day,[5] and “sufficient” staff to meet residents’ needs.[6]

Nurse aides: Nurse aide proficiency requires that aides “demonstrate competency in skills and techniques necessary to care for residents’ needs, as identified through resident assessments, and described in the plan of care.”[7]  Requirements for hiring and using nurse aides are unchanged, although moved into the nursing RoP.[8]

Competency-based staffing approach

A new section under the Administration RoP requires a facility to “conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies.”[9]  The assessment must be reviewed and updated, as necessary, and at least annually.[10]  Among six specified areas of concern that must be addressed, the assessment must include “the staff competencies that are necessary to provide the level and types of care needed for the resident population.”[11]

CMS gives somewhat contradictory and ambiguous explanations of the facility-wide assessment process.  On the one hand, CMS describes the assessment as a central feature of its revisions to the RoPs, suggesting that the requirement is new and significant.  On the other hand, CMS describes the assessment as a common business practice that is already often used by facilities for strategic planning and capital budget planning.

Whether the requirement for a facility assessment is new or not, it is difficult to see how assessment of staffing needs on an annual basis is sufficient to address a facility’s changing resident population and fluctuating staffing needs.                                 


Toby S. Edelman
March 15, 2017




[1] 82 Fed. Reg. 68688 (Oct. 4, 2016).
[2] The nurse staffing rules were moved from §483.30 to §483.35.
[3] Nurse aide rules were moved from §483.75 to §483.35(c).
[4] 42 C.F.R. §483.35(b)(1).
[5] §483.35(a)(1).
[6] §483.35(a)(1).
[7] §483.35(c).
[8]  §483.35(d).
[9] §483.70(e).
[10] §483.70(e).
[11] §483.70(e)(1)(iii).



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