Quality of care in long-term care settings has been perceived as an ongoing concern that the Centers for Medicare & Medicaid Services (CMS) aims to solve with its proposed staffing mandate.
The proposed rule calls for a minimum of 3.0 hours per patient day of direct care, of which 0.55 hours would be provided by a registered nurse and 2.45 hours by nurse aides. It also would require 24/7 RN coverage — triple the current standard — that would go into effect two years after the rule is finalized for urban providers and a year later for rural providers.
Current staffing requirements for direct care staff vary from state to state, as some have no additional staffing requirements and other states require more than 3.5 hours of nursing services per patient per day. Studies conducted in the United States typically have found a relationship between the quantity of staff and quality of care measures, in contrast to providers outside of the US that did not find an association between the two factors.
My research conducted a quantitative correlation research design using secondary data from CMS Region 7 made up of 1,395 facilities caring for almost 60,000 residents with either no direct care minimum staffing mandate (Missouri and Nebraska) or required 2.2 hours per patient day (Iowa and Kansas).
The current breakdown of states (DC included) and their mandated nurse hours per patient day are: No minimum — 15 states; 1.99 hours or less — two states; 2.0-2.4 hours — 13 states; 2.5-2.99 hours — eight states; 3.0-3.49 — six states; 3.5 or more hours — seven states.
The dataset consisted of scores from 1 to 5, with 5 being the best from CMS’s 5-Star Overall Quality of Care rating. A Spearman’s Rank Correlation ρ determined that a correlation existed between staffing ratios and quality of care rating. However, a Mann-Whitney U test concluded that there was not a significant difference between the groups with no minimum staffing requirements and states with minimum staffing requirements.
Limitations of this study are concerns with the overall survey process including timing of surveys, accuracy of self- reported data, recertifications and complaint investigations, staffing shortages, and comparability with CMS’s 10 regions.
My hope from conducting this research is for policy makers to realize that staffing numbers or minimums is not the answer to improving nursing home quality. Many other factors have to be considered, including turnover rates of staff, acuity of patients and accuracy of self-reported data.
Melissa Reed, DHA, is a licensed nursing home administrator with over 20 years experience in the State of Iowa and has been employed in her current position of administrator at Solon Retirement Village in Iowa for 15 years.
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