In the ever-evolving landscape of skilled nursing facilities, staffing requirements remain a focal point of discussion and debate.
With the Centers for Medicare & Medicaid Services setting forth minimum staffing mandates, there’s a growing conversation about how these requirements align with, or diverge from, the Five-Star Staffing metrics used to evaluate SNFs.
As we explore the nuances of these metrics, it’s essential to understand the implications for compliance, performance and the quality of care provided to residents.
CMS’s minimum staffing requirements: An overview
CMS’s minimum staffing requirements are designed to ensure that nursing homes maintain a baseline level of care for their residents. These mandates are measured in total nurse hours per resident day (HPRD) and are intended to create a foundation upon which SNFs can build their staffing models.
There has been a plethora of commentary on these staffing requirements, and it’s clear that the issue is far from settled. Proponents argue that minimum staffing standards are necessary to protect residents and ensure quality care. On the other hand, critics suggest that a one-size-fits-all approach may not account for the needs of different facilities and populations and is ultimately unfunded during a time of staffing shortages across all industries.
Adding a layer of complexity to this discussion is the US Supreme Court decision on June 28, 2024, which overturned the Chevron doctrine. This 40-year-old legal precedent had required courts to defer to regulatory agencies when interpreting ambiguous laws. The court’s decision could significantly impact the enforcement of CMS’s staffing mandates, as judicial scrutiny of regulatory interpretations may increase.
The alignment — or misalignment — between Five-Star and minimum staffing
Given the differing objectives of CMS’s minimum staffing requirements and the Five-Star Staffing ratings, the question arises: Should there be better alignment between the two? Although both metrics speak to nursing home staffing, they appear to serve distinct purposes.
As of CMS’s July 2024 Provider Information file, 58% of SNFs are compliant with Phase 2 of the CMS staffing requirements, which mandate at least 3.48 HPRD. (Note that our analysis excluded the 24/7 RN staffing requirement due to the unavailability of this specific data within the Payroll-Based Journal submissions.) Compliance varies significantly by ownership type: 51% of for-profit SNFs meet Phase 2 requirements, while 79% of nonprofits are compliant.
When comparing Five-Star Staffing ratings with CMS minimum staffing requirements:
| CMS Five-Star Staffing Star Rating | Percentage Compliant with 3.48 HPRD |
| 1 star | 22% |
| 2 stars | 45% |
| 3 stars | 68% |
| 4 stars | 89% |
| 5 stars | 99% |
This data reveals that compliance and noncompliance with CMS staffing requirements can occur across all levels of Five-Star ratings. This conclusion highlights the challenge of fully aligning the two metrics and raises critical questions: How can consumers use these metrics to make informed decisions about care? And how can nursing home providers leverage this information to improve their staffing models?
Reconciling two staffing metrics
It’s important to recognize that the Five-Star Staffing Domain and CMS staffing minimums are not meant to align perfectly. In fact, 16% (n=2,316) of SNFs rated 1 or 2 stars in the Five-Star Staffing Domain still met CMS Phase 2 minimum staffing requirements.
This discrepancy highlights the distinct purposes of these metrics. The Five-Star system is adjusted for resident acuity, reflecting the complexity and needs of the population served, whereas the CMS staffing minimum is intended to ensure a baseline standard of care.
With the CMS facility assessment requirements taking effect on Aug. 8, 2024, providers are expected to adjust their staffing levels based on this new assessment process rather than relying solely on the minimum requirements. Theoretically, the Five-Star and CMS staffing measures will be reconciled during the survey process, so providers should proactively consider staffing adequacy and competencies, particularly if they meet the minimum CMS requirements but have low Five-Star Staffing ratings.
Success in both metrics — CMS minimum staffing and Five-Star Staffing — is essential, but keep in mind that SNF providers must also consider state-level staffing requirements and ensure that their “staffing story” is both data-driven and evidence-based. The ultimate goal is to provide high-quality care that meets regulatory requirements and the needs of residents.
In conclusion, while the Five-Star Staffing Domain and CMS staffing minimums may not align perfectly, understanding their differences and using them in tandem can help providers make more informed staffing decisions.
As the regulatory landscape continues to evolve, SNFs must stay vigilant, adapt their staffing models, and prioritize both compliance and quality care.
Steven Littlehale is a gerontological clinical nurse specialist and chief innovation officer at Zimmet Healthcare Services Group.
The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.
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