January 24, 2002
NURSING HOME MINIMUM STAFFING REQUIREMENTS
By: Saul Spigel, Chief Analyst
You asked about minimum staffing requirements for nursing homes in other states.
Enclosed is OLR report 2000-R-1006, which provides additional background information on this topic.
Thirty-six states set minimum staffing levels for nursing homes according to an October 2001 Health Policy Tracking Service issue brief. We examined 10 of these: three states that enacted minimum standards in 2001 (Arkansas, California, and Florida), four in the Northeast (Maine, Massachusetts, New Jersey, and Pennsylvania), and three whose proportion of residents over age 65 is similar to Connecticut's (Iowa, Kansas, and West Virginia).
The states take two basic approaches to minimum staffing requirements. Most require direct care staff (i.e., nurses, nursing assistants, and aides) to provide a minimum number of care hours to patients each day, others set a specific direct care staff-to-patient ratio. Some states use a combination. Table 1 compares required hours of direct patient care; Table 2 shows staff-to-patient ratio requirements. In addition, several states require a minimum number of registered or licensed practical nurses (RN or LPN) to be on duty or on call at all times.
Table 1: Minimum Direct Care Hours Per Patient Per Day
2.3 hrs/day in 2002 for certified nursing assistants (CNAs), rising to 2.6 hrs/day in 2003 and 2.9 hrs/day in 2004 and beyond
1.0 hr/day for licensed nurses
2.6 hrs/day in Level I homes (0.6 by a nurse)
2.0 hrs/day in Level II homes (0.6 by a nurse)
1.4 hrs/day in Level III homes (0.4 by a nurse)
2.5 hrs/day plus 0.75 to 1.50 hrs depending on patient nursing needs; RNs or LPNs must provide at least 20% of care hours
2.0 hrs/day; nurses must provide at least 20% of care hours
1.85 hrs/day; 2.0 hrs daily average per week
2.0 hrs/day (0.4 by an LPN)
Table 2: Minimum Staff-to-Patient Ratios
1:7 day shift in FY 2001-02, dropping to 1:6 in FY 2003-04
1:10 evening shift in FY 2001-02, dropping to 1:9 in FY 2002-03
1:16 night shift in FY 2001-02, dropping to 1:14 in FY 2002-03
1:40 for licensed nurses on the day and evening shifts
1:80 for licensed nurses on the night shift
1:20 for CNAs
1:40 for licensed nurses
1:5 day shift
1:10 evening shift
1:15 night shift
1:20 for nursing staff
OTHER STATES' MINIMUM STAFFING REQUIREMENTS
Arkansas' new law phases in new staffing ratios over three years. During FY 2001-02, nursing homes must maintain the following direct care staff-to-patient ratios: 1:7 on the day shift, 1:10 on the evening shift, and 1:16 on the night shift. There must be one licensed nurse for each 40 patients during the day and evening shifts, and one for each 80 patients on the night shift. All homes must have at least one licensed nurse on duty during all shifts.
In FY 2002-03, the ratios drop to: 1:9 on the evening shift and 1:14 on the night shift. The day shift ratio remains 1:7, and the licensed nurse-to-patient ratios remain the same.
Beginning July 1, 2003, the day shift staff-to-patient ratio drops to 1:6. The evening and night shift ratios remain the same as do the nurse-to-patient ratios (AK, Act 1397 of 2001).
California's new law requires the Department of Health Services to develop regulations, which must become effective by August 1, 2003, that establish direct care staff-to-patient ratios. In no case can the regulations require less than the current 3.2 nursing hours of care per patient day. The regulations must set separate minimum standards for licensed nurses and for other direct caregivers such as certified nurse assistants and psychiatric technicians.
The law further requires the department, in consultation with other entities, to review those standards for sufficiency by January 1, 2006 and every five years thereafter and revise the ratios, if necessary (Cal Health and Safety Code § 1276.65, as amended by Assembly Bill 1075).
Florida's 2001 legislation sets separate minimum patient care hour staffing standards for nurses and certified nursing assistants (CNAs). Like Arkansas, they are phased in over three years. The legislation required the Agency for Health Care Administration to adopt regulations setting minimum daily resident care hours for CNAs at 2.3 hours in 2002, 2.6 hours in 2003, and 2.9 hours in 2004 and afterward. It sets a minimum CNA-to-patient ratio of 1:20. Licensed nurses must provide a minimum of one hour a day in direct service to residents, and a facility must have at least one licensed nurse for every 40 residents.
The regulations must permit counting nurses' hours as part of the CNA staffing minimums as long as the nurses are performing CNA duties for their entire shift and the facility meets the minimum 1:40 nurse-to-resident ratio. Nurses counted toward the CNA minimum cannot be counted towards the licensed nurse minimum ratio (FSA § 400.23, as amended by Ch. 2001-45).
Effective July 1, 2001, Maine began requiring the following direct care staff-to-patient ratios: 1:5 on the day shift, 1:10 on the evening shift, and 1:15 on the night shift. Direct care staff include RNs, LPNs, and CNAs.
Regulations also set minimum requirements for licensed nurse coverage, which vary by facility size and shift. Homes must have at least one licensed nurse on duty during each shift. During the day shift, a single charge nurse in facilities with 20 or fewer beds can fulfill this requirement. Facilities with between 20 and 50 beds must have an additional nurse on day shift duty; larger facilities must add one nurse for each 50 beds. On the evening shift, one licensed nurse is needed for every 70 beds. In facilities with over 100 residents, one of those nurses must be a registered nurse. On the night shift, one licensed nurse is needed for every 100 beds, and a registered nurse must be present if there are more than 100 beds (Code Me. Rules 10-144, Ch. 110, 9.A).
Massachusetts categorizes nursing homes into three types and establishes minimum staff levels for each.
n Level I facilities provide intensive skilled nursing, including restorative services. They must provide a total of 2.6 hours of nursing care per patient day. At least 0.6 hours must be by a licensed nurse and 2.0 hours by ancillary nursing personnel.
n Level II skilled nursing facilities, which provide general nursing services, must provide a total of two hours of nursing care per patient day. At least 0.6 hours must be by a licensed nurse and 1.4 hours by ancillary nursing personnel.
○ A level II facility for children must provide a total of five hours of nursing care per patient day. In units with fewer than 40 beds, licensed nurses must provide at least 1.8 to 2.1 hours of care; in larger units, nurses must provide at least 1.4 to 1.8 hours of care. Ancillary nursing personnel provide the balance of care hours.
○ A level II facility for AIDS patients must provide 4.4 hours of nursing care per patient day. Licensed personnel must provide at least two hours of this care; ancillary personnel provide the rest.
n Level III facilities, which provide supportive nursing care, must provide a total of 1.4 hours of nursing care per patient day. Licensed nurses must provide at least 0.4 hours, ancillary nursing personnel provide the balance (105 CMR 150.007).
New Jersey requires 2.5 hours of basic nursing care per patient per day plus additional hours of care depending on specialized services individual patients may require. For example, a patient needing wound care must receive an extra .75 hours of care daily, a patient using a respirator must receive 1.25 hours, and a patient needing intravenous therapy must receive 1.5 hours. RNs and LPNs must provide at least 20% of these care hours. At least one registered nurse must be on duty during day shifts, and at least one must be on duty or on call during evening and night shifts (N.J.A.C. 8:39-25.2).
Pennsylvania uses a combination of direct care hours and specific staff-to-patient ratios. It requires 2.7 hours of direct resident care daily. At least one nursing staff employee must be on duty for each 20 residents, and at least two nursing service personnel must be on duty at all times.
Regulations also set specific nurse-to-patient ratios, depending on the facility census and shift. The ratios range from one RN or LPN on each shift in facilities with fewer than 150 residents to two RNs on each shift in facilities with 251 to 500 residents, and eight RNs on the day shift in facilities with 1,001 or more residents (28 PA Code §211.12).
Iowa requires two hours of daily nursing care for patients who need an intermediate level of care. This minimum drops to 1.7 hours daily if the state's medical assistance rate payment for the facility drops below the 74th percentile. Qualified nurses must provide at least 20% of this care. The health services supervisors' (an RN in facilities with 75 or more beds; an RN or LPN in smaller facilities) weekly hours count toward this 20%. Facilities with 75 or more beds must have a qualified nurse on duty at all times. The Department of Inspections and Appeals can require a facility to provide staffing above the minimum level based on the needs of its individual residents (481 IAC 58.11(2)).
Kansas uses a combination of direct care hours and specific staff-to-patient ratios. Nursing homes must provide at least 1.85 hours of direct care staff time per resident during any 24-hour period and must average two hours daily each week. Each separate nursing unit in the home must have one nursing staff member for every 30 residents or fraction thereof.
At least two nursing personnel must be on duty in the facility at all times. An LPN must be on duty all the time, while an RN must be on duty at least eight consecutive hours each day (K.A.R. 28-39-154).
Nursing homes must provide an average of two hours per resident per day of nursing personnel time, unless an unforeseeable emergency occurs. An LPN must provide at least 0.4 hours of this care, with the balance provided by aides. In homes with fewer than 60 beds, the nursing director's time can count toward the minimum, in larger homes it cannot. Non-nursing personnel, private duty nurses, volunteers, or contracted nurses who are “available” or “on call” do not count in meeting this minimum. And no one can be counted toward the minimum for two consecutive shifts unless the facility demonstrates extenuating circumstances and only if it is a non-routine occurrence (W. Va Code St. R. § 64-13-9).