Most for-profit nursing home industry administrators receive a staffing budget based on finances, not acuity or clinical need. 

The Centers for Medicare & Medicaid Services’ final minimum staffing rule requires evidence-based, data-driven minimum staffing levels, below which even low-acuity facilities would struggle to deliver quality care. This minimum was a necessary but not sufficient step toward quality. 

The most important element in the rule was the requirement to ensure an effective facility assessment led by the director of nursing in collaboration with the medical director. This should form the basis for determining a facility’s staffing needs—not an arbitrary budget produced by individuals with no expertise in long-term care medicine or nursing care.

CMS, in its recent guidance, states that “the facility assessment is intended to help facilities identify the appropriate amount of staff and resources needed.” The guidance also states that “if surveyors find that residents’ needs are not being met due to insufficient staffing, the facility will be cited for noncompliance.”

The facility assessment shouldn’t be seen as onerous. Expecting a nursing home to deliver high-quality, safe care requires a comprehensive assessment of residents based on their acuity and complexity by the clinical leaders to determine the level of and type of staffing resources necessary. The guidance is aligned with the recommendations made in AMDA’s Position Paper on Staffing. 

Some of the key elements are:

  • The care required by the resident population, using evidence-based, data-driven methods that consider the types of diseases, conditions, physical and behavioral health needs, cognitive disabilities, overall acuity, and other pertinent facts informed by individual resident assessments
  • The staff competencies and skill sets that are necessary to provide the level and types of care needed for the resident population
  • The physical environment, equipment, services and other physical plant considerations
  • Any ethnic, cultural or religious factors that may potentially affect the care provided by the facility

Combining clinical leadership with ownership accountability for determining appropriate staffing, the guidance calls for including the active involvement of a member of the governing body, the medical director, an administrator, and the director of nursing, and direct care staff, including but not limited to RNs, LPNs/LVNs, NAs and representatives of the direct care staff. 

Finally, “the facility must also solicit and consider input received from residents, resident representatives, and family members.”

Harrington et al. provide an evidence-based roadmap for how to determine appropriate staffing levels through a five-step process. The first step begins with six basic nursing acuity levels consistent with the Medicare Patient Driven Payment Model (PDPM) categories from highest to lowest: (1) Extensive Services, (2) Special Care High, (3) Special Care Low, (4) Clinically Complex, and the non-Medicare groups: (5) Behavioral Symptoms and (6) Reduced Physical Functioning. 

These categories identify both the licensed nursing care needs and the CNA care needs. Based on a summary of individual resident assessments, each facility can determine its aggregate resident acuity level. 

The second step is using original facility payroll data (rather than the electronically reported PBJ data) and verifying the names and types of staff that worked in direct care to determine actual staffing levels. Some state Medicaid cost reports provide productive or actual nursing hours (rather than paid hours) and are more accurate than the staffing data on CMS Form 671. 

The third step is to use the simple guide developed by the authors of the paper for recommended staffing levels for six levels of acuity. The authors drew on existing research as well as actual PBJ staffing distributions in subacute facilities. They developed a table that crosswalks Resource Utilization Group (RUG)-IV classifications to the PDPM groups and recommends nurse staffing levels in hours per resident day.

Step four is aligned with oversight. Unfortunately, state surveyors often do not examine resident acuity and staffing levels. Nevertheless, each facility must set priorities for its performance improvement activities that focus on high-risk, high-volume or problem-prone areas; consider the incidence, prevalence and severity of problems in those areas; and assure health outcomes, resident safety, resident autonomy, resident choice and quality of care.

Each facility must also establish a quality assurance and performance improvement (QAPI) program and develop and implement appropriate plans of correction. Where nursing homes are not able to reduce errors, adverse incidents, and improve quality, inadequate staffing levels may be the fundamental underlying problem. 

Step five is to evaluate gaps between actual and appropriate staffing levels. If a facility’s staffing meets levels recommended by experts and expected staffing time for resident acuity but still has quality problems based on quality indicators, then the types of nursing staff, staff competency levels, turnover and retention rates, types of patients admitted, facility resources, and management practices should be examined and improved as necessary.

If nursing home leaders consistently determine appropriate staffing levels using an evidence-based approach led by the director of nursing and medical director, we could all be on the road to true quality improvement.

Michael Wasserman, MD, CMD, is a geriatrician and member of the Board of Directors for PALTmed (The Post-Acute and Long-Term Care Medical Association).

Deb Bakerjian, PhD, APRN, FAANP, FGSA, FAAN, is a family nurse practitioner and Clinical Professor specializing in the quality and safety of older adults in long-term care.

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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