Staffing for nursing homes

Federal law requires all nursing homes to provide enough staff to safely care for residents. However, there is no current federal standard for the best nursing home staffing levels. The staffing rating takes into account differences in the levels of residents' care needs in each nursing home. For example, a nursing home with residents that have more health problems would be expected to have more nursing staff than a nursing home where the residents need less health care.

Medicare makes available the amount of staff turnover at a facility. Low turnover indicates that facilities generally retain their staff for longer periods of time. Lower turnover is preferred because staff who work in facilities for longer periods of time may become more familiar with the residents and the facility’s operating procedures. This can help staff to better understand residents’ preferences and needs, and more readily identify and care for a resident’s condition.

Each nursing home reports daily staffing hours to Medicare. Medicare calculates a ratio of staffing hours per resident day, the percent of nurse staff that stop working at the facility (turnover), and the number of administrators who have left the facility within a given year. These types of staff are included in the nursing home staffing information:

• Registered Nurse (RN): Registered nurses (RNs) are responsible for the overall delivery of care to the residents.
• Licensed Practical Nurse (LPN) and Licensed Vocational Nurse (LVN): LPNs/LVNs provide care under the direction of an RN. Together, RNs and LPNs/LVNs make sure each resident's plan of care is being followed and their needs are being met. Nursing homes must have at least one RN for at least 8 straight hours a day, 7 days a week, and either an RN or LPN/LVN on duty 24 hours per day.
• Certified Nurse Aides (CNAs): CNAs work under the direction of a licensed nurse to assist residents with activities of daily living. All CNAs must have completed a nurse aide training and competency evaluation program within 4 months of their employment. They must also pursue continuing education each year. CNAs provide care to nursing home residents 24 hours per day, 7 days a week.
• Physical therapist (PT): PTs help residents improve their movement and manage their pain. PTs test muscle strength, the amount of flexibility in joints, and a resident's ability to walk or move. PTs often work with other providers, like doctors, nurses, and occupational therapists to create individualized therapy plans to address and restore the resident's physical function and well-being.
• Administrator: Each nursing home must have an administrator that is licensed according to each state’s requirements. Administrators are responsible for the overall management of the facility.

Staffing hours per resident per day is the total number of hours worked by each type of staff divided by the total number of residents. Nurse staff turnover is the percent of nurse staff that stop working at the facility within a given year. Administrator turnover is the number of administrators who have left a facility within a given year. Because these measures are averages, they don't necessarily show the number of staff present at any given time, or reflect the amount of care given to any one resident.

The staffing rating is based on these measures:

1. Registered Nurse (RN) hours per resident per day in a three-month period;
2. Total staffing hours per resident per day in a three-month period. Total nurse staffing includes:
   1. RNs
   2. Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs); and
   3. Certified Nurse Aides (CNAs) and nurse aides in training
3. Total nurse staffing hours per resident per day on the weekend in a three-month period;
4. Total nurse staff turnover within a given year;
5. RN turnover within a given year; and
6. Number of administrators who have left the nursing home within a given year.

Staffing data are adjusted for the needs of the nursing home residents. A nursing home receives points based on how they perform on each staffing measure (some measures are weighted more than others). The points for each measure are totaled, and the nursing home is assigned ratings based on thresholds for each rating category. Nursing homes may be assigned a 1 star rating if they don't have an RN onsite every day, don't submit staffing data, or if their data can't be verified.

For more in-depth information of the star rating system, view the Technical Users' Guide (PDF).