Staffing
Nursing home staffing standards are covered under both federal and state law. The Federal 1987 Omnibus Budget Reconciliation Act (“OBRA ‘87”) created the national minimum set of standards of care (including staffing standards) and rights for people living in certified nursing facilities. The MA Department of Public Health (“DPH”) oversees state standards of care.
Both Federal and MA laws provide guidance on minimum staffing levels, with the additional caveat of providing sufficient number of staff to meet resident needs. However, studies have shown that in order to protect the health and safety of residents, higher minimum staffing standards are needed (see Recommended Staffing Standards).
Complete - Federal and MA Staffing Standards
- OBRA ’87 – see §430.30
- MA DPH Regulations - see 150.007, page 29
- NH Regulations Plus - federal staffing regulations, a summary of MA DPH staffing regulations, and additional background on staffing issues: Nursing Services-Staffing Ratios.
Summary - Federal and MA Staffing Standards
The following staffing standards statistics are summarized from a January, 2008 update to a May, 2001 study, “Nursing Home Staffing Standards in State Statutes and Regulations”.
Federal Staffing Standards
- 1 Registered Nurse (“RN”) - 8 consecutive hrs/day, 7 days/wk
- 1 Licensed Nurse (“LN”) - 2 remaining shifts, 7 days/wk. LN is an RN or licensed/vocational practical nurse (“LPN/LVN”).
- Director of Nursing (full-time) may serve as Charge Nurse for facilities with 60 or fewer residents.
- Sufficient nursing staff to provide nursing services to maintain the highest levels of physical, mental and psychosocial well-being of residents.
- When these requirements are converted to hours per resident day (“hprd”) for an average 100 resident facility, the total LN requirements approximate 0.30 hprd (30 hours divided by 100 residents).
MA Staffing Standards – More LNs/Staff than federal guidelines:
Nursing homes fall under Level 1 or 2 facilities (definitions on page 5, Section 150.001: Levels of Long-Term Care Facilities or Units).
- Licensed Staff (“RN, LPN/LVN”)
- 1 RN/LPN Charge Nurse 24 hrs, 7 days/wk for each unit.
- 1 DON RN (full-time) and in a single-unit facility, DON may be supervisory.
- Multi-unit facilities: 1 RN (full-time) Day Supervisor for up to 2 units in the same facility.
- Supervisory nurse and charge nurse may be counted in calculation of licensed personnel.
- Direct Care Staff
- Level 1 facility: 2.6 hprd with 0.6 LN personnel
- Level 2 facility: 2.0 hprd with 0.6 LN personnel, exclude DON
- Nurse Assistant Staff (“NA/CNA”): no minimum requirement.
- Sufficient ancillary nursing personnel to meet patient needs.
- LN requirements approximate 0.66 hprd; total care approximates 2.66 hprd.
Recommended Staffing Standards
The second phase of the U.S. Department of Health and Human Services study delivered to Congress on March 19, 2002 states a daily minimum of 4.1 hours of total nursing time (RNs, LPNs and CNAs) is required to avoid common quality of care problems such as bedsores, weight loss, and loss of bodily functions for long-term residents. The report finds that 97% of nursing homes do not provide the minimum threshold of nursing care to avoid at least one of these serious problems. The report also concludes that it takes nursing assistants a minimum of 2.8 to 3.2 hours per day to provide essential services such as dressing and grooming, exercising, feeding, toileting, changing wet clothes, and repositioning. More than 91% of facilities do not have enough nursing assistants to provide these services, which are also critical to avoid costly and painful medical conditions.
In 1998, NCCNHR developed minimum nurse staffing ratios in consultation with long-term care experts. The NCCNHR staffing standards - which call for nursing home residents to receive at least 4.13 hours of direct nursing care (RNs, LPNs, and CNAs) each day - have been validated by the research conducted by independent researchers for a government study, the “Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes”. These standards have been introduced in several congressional bills and used as a framework in the debate in a number of state legislatures that have enacted state staffing standards.
The Long Term Care Community Coalition of New York conducted a study outlining the costs of poor care for consideration in determining New York health care policies for 2004 and beyond. The study showed that while fiscal concerns are commonly relied on as justification for not mandating better nursing home staffing, there is ample evidence indicating that large scale financial benefits could ensue from enhanced staffing levels. The benefits of higher staffing levels for diminishing the human costs of poor care are clear: both residents and workers would have better conditions and less risk of injury if staffing levels increased.
(Study: See www.ltccc.org/news and select "LTCCC urges New York State leaders to consider costs of Poor Care".
Staffing Standards Toolkit
In 2007, the Long Term Care Community Coalition (“LTCCC”) of New York completed a toolkit for citizens, advocacy groups and Long-Term Care Ombudsmen to use to advocate for safe minimum staffing standards. The toolkit includes: issue briefs on the need for minimum staffing standards and on overcoming the challenges (such as putative costs and worker shortages); sample letters to political leaders and new media; and other resources. All materials are free. View the toolkit on
LTCCC’s website at www.nursinghome411.org.