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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).
The following staffing standards statistics are summarized primarily from a December 2010 study, “Nursing Home Staffing Standards in State Statutes and Regulations”, by Charlene Harrington, Ph.D. R.N.
Federal Staffing Standards
Section 483.30: Nursing Services requires that "... the facility must have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care..."
MA Staffing Standards
Section 150.007: Nursing Services requires that "...all facilities provide appropriate, adequate and sufficient nursing services to meet the needs of patients or residents and to assure that preventive measures, treatments, medications, diets, restorative services, activities and related services are carried out, recorded and reviewed..." Also, "...the minimum staffing patterns and nursing care hours [in this section are] minimum, basic requirements. Additional staff will be necessary in many facilities to provide adequate services to meet patient needs..."
MA regulations define four levels of long-term care facilities. Nursing homes fall under Level 1 or 2 facilities (Section 150.001-Definitions: Levels of Long-Term Care Facilities or Units).
In 1998, the National Consumer Voice for Quality Long-Term Care ("Consumer Voice", formerly NCCNHR) developed minimum nurse staffing ratios in consultation with long-term care experts. The Consumer Voice 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 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.
The Long Term Care Community Coalition (“LTCCC”) conducted a study, entitled "LTCCC urges New York State leaders to consider costs of Poor Care", that outlined 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.
In 2014, the Consumer Voice launched a national staffing campaign. The short-term goal of the Campaign is to educate residents, families and the public, along with members of Congress, about the need for increased staffing in nursing homes. The long-term goal of the Campaign is passing legislation to mandate that every day, each resident receives at least 4.1 hours of nursing care (certified nursing assistants, licensed practical nurses and registered nurses). As stated above, current federal regulations only require nursing homes to provide "sufficient" nursing staff to meet residents' needs. According to the 2002 U.S. Department of Health and Human Services Dept. mentioned earlier and other research, higher levels of staffing are associated with better care.
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.