APPENDIX I

You asked for information on states with laws addressing staffing levels in nursing homes.

BACKGROUND

The majority of states, 36, have established some type of staffing requirements or standards for nursing homes. The requirements are found in either statute or regulation (e.g., Public Health Code) and vary considerably. These standards generally require nursing homes to (1) provide a certain number of nursing care hours per patient day, (2) maintain a certain staff-to-patient ratio, or (3) maintain certain types of staff (e.g. registered nurses) to provide care. Table 1 following, derived from a recent Program Review and Investigations Briefing Paper on "Staffing Levels in Nursing Homes" (September 12, 2000), summarizes these state requirements by category.

TABLE 1: States' Nursing Home Staffing Requirements

Hours of Nursing Care Per Patient Day:

California Illinois Michigan Pennsylvania

Colorado Indiana Minnesota Tennessee

Connecticut Iowa Mississippi Texas

Delaware Kansas Montana Washington

Florida Louisiana Nevada West Virginia

Georgia Maryland New Jersey Wisconsin

Idaho Massachusetts North Carolina Wyoming

Staff Members to Resident Ratio:

Arkansas Maine Oklahoma Texas

Kansas Michigan Oregon West Virginia

Louisiana Ohio South Carolina

RN 24-hours 7 days a Week:

California Hawaii Rhode Island

Colorado Maryland

Connecticut Pennsylvania

Note: some states appear in more than one category because they have more than one type of requirement.

Source: HCFA, Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes, Report to Congress, July 2000, as reported by the Program Review and Investigations Committee in its "Staffing in Nursing Homes" Briefing Paper, September 12, 2000.

RECENT STATE ACTIVITY

States have implemented a range of requirements that address minimum standards for nursing care. During 2000, five states (California, Delaware, Kentucky, Maryland, Minnesota), enacted laws addressing staffing ratios in long-term care facilities according to NCSL's Health Policy Tracking Service. California requires the state Department of Health Services to determine the need for any increase in the minimum number of nursing hours per patient day in skilled nursing facilities beyond the 3.2 minimum specified in existing law, and make recommendations by May 1, 2001.

A new Delaware law sets a new minimum staffing standard for nursing services by direct caregivers (includes certain licensed and certified nursing personnel) of 3.0 hours of direct care per resident per day. This takes effect March 1, 2001, with additional minimum ratio requirements for nursing staff distribution according to their shift. It also provides for adjusting Medicaid reimbursements to reflect the costs associated with increased staffing levels (Senate Bill 115). The law provides for an incremental increase in the new minimum staffing standard over three years from the initial 3.0 hours of direct care per resident per day when the standard takes effect in 2001 to 3.28 the next year, and up to 3.67 hours by 2003. Also, the Delaware Nursing Home Residents Quality Assurance Commission will assess and review the efficacy of each of these increases to determine their effect on quality of care.

In Minnesota, a new law prohibits including resident attendants as staff for the purpose of meeting minimum staffing requirements in nursing homes (Minn. Stat. § 144A.04).

The Kentucky and Maryland laws created task forces to examine staffing issues in the states' long-term care facilities.

Michigan is currently considering, but has not yet passed, legislation that would incrementally increase staff-to-patient ratios from at least 2.75 hours of direct patient care per day in 2001 to 3.0 hours of direct patient care per day by 2002 (H 4362).

FEDERAL GUIDELINES

The federal government established guidelines in l987 that required nursing facilities to provide residents with licensed nursing services 24 hours per day. The law specifies that a registered nurse must be on duty for at least eight of those 24 hours, seven days per week. The l987 guidelines derived from a National Institute of Medicine report that found a "disturbing state of patient care in nursing homes" (see Nursing Home Staff Ratios, Health Policy Tracking Service Issue Brief, October 3, 2000). Congress responded by folding these nursing home guidelines into its omnibus budget reconciliation act (PL 100-203). Since l987, many states have moved beyond this federal minimum to enact their own minimum staffing laws.

FEDERAL NURSING HOME STUDY

In July of this year, the federal Health Care Financing Administration (HCFA) reported to Congress on the staffing situation in the nation's nursing homes. It found that over half of nursing homes had too few staff to ensure a minimum quality of care for patients. The report states that patients in understaffed nursing homes were at greater risk for preventable health conditions that led to hospitalization, such as pneumonia, urinary tract infections, sepsis (a life-threatening infection originating in the blood), congestive heart failure, and dehydration.

This study, which took eight years to complete, suggests staffing requirements necessary to provide a minimum quality of care, below which quality may be "seriously impaired." Suggested staff levels include two hours of nurse aide care per resident day, 45 minutes of care per resident day from a licensed practical nurse or RN, and 12 minutes of care per resident day from an RN. Another part of the study identified a minimum level for nurse aide staff needed to provide optimal care to patients-2.9 hours of care per resident day. HCFA found that over 90% of nursing homes in the United States fall below this level, and about half of these would have to double nurse aide staff to reach this threshold (see NCSL/Health Tracking Service Issue Brief).

JK:ts

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