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What Nursing Home Staff Levels Are Required?

Nursing homes are notoriously understaffed. Studies have shown that more staff leads to better care, but employees are often overworked and turnover can be high. When choosing a nursing home, one of the most important details is the staff to patient ratio, but what staffing levels are required by law?

Federal law requires Medicare and Medicaid certified nursing homes to have an registered nurse (RN) director of nursing (DON); an RN on duty at least 8 hours a day, 7 days a week; and a licensed nurse (RN or LPN) on duty the rest of the time. However, there are no minimum staffing levels for nurse's aides, who provide most of the day-to-day care. Instead, nursing homes are required "to provide sufficient staff and services to attain or maintain the highest possible level of physical, mental, and psychosocial well-being of each resident." In addition, nursing homes must provide a minimum of 75 hours of training for the aides.

The important factor in improving quality of care is the amount of nurse time each patient receives. If a nursing home met only the federal nurse staffing requirements described above, a resident would receive 20 minutes of nurse time per day. In 2000, the Centers for Medicare and Medicaid Services (CMS) reported that the preferred minimum staffing level was when nursing home residents received three hours of total staff time per day -- two hours of nursing assistant time and one hour of licensed nurse time. The optimum staffing level, according to the CMS, is one hour of licensed nurse time and three hours of nursing assistant time.

Most states have standards that are higher than the federal requirements, but still fall short of the levels recommended by the CMS. According to a recent study, the key to improving nursing home staffing levels is increasing state standards. The study by Charlene Harrington, a UCSF School of Nursing professor, found that states with the highest standards for nursing staff levels are the only states where nursing homes have enough staff to prevent serious safety violations. According to the study, the act of raising the state minimum staffing ratio has a direct impact on the quality of care nursing home residents receive.

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