Federal law requires that nursing facilities voluntarily choosing to receive reimbursement from Medicare, Medicaid, or both programs meet certain professional nurse staffing requirements: A registered nurse (RN) must be on-site eight consecutive hours per day and licensed nurses (RNs or licensed practical nurses, LPNs) must be on-site 24 hours per day. In an analysis of 2018 staffing data submitted by 12,862 nursing facilities to the Centers for Medicare & Medicaid Services (CMS) under the Payroll-Based Journal (PBJ) system, the HHS Office of Inspector General finds that more than half the facilities failed to meet professional nurse staffing standards:
- 943 facilities (7%) failed to meet these staffing standards for at least 30 days in 2018.
- These facilities did not have an RN present for at least eight hours for an average of 58 days.
- These facilities did not have licensed nurse services available for at least 24 hours for an average of 15 days.
- 900 facilities (7%) failed to meet these standards between 16 and 29 days in 2018.
- 5,127 facilities (40%) failed to meet these standards between one and 15 days in 2018.
- Most of the noncompliant staffing levels (65%) occurred on weekends.
As OIG recognizes, CMS has long “identified nurse staffing as a vital component of a nursing home’s ability to provide quality care.” New research conducted during the coronavirus pandemic confirms again the critical importance of RN staffing; 20 additional minutes of RN coverage in Connecticut nursing facilities was associated with 22% fewer confirmed cases of COVID-19 and 26% fewer COVID-19 deaths.
As the OIG reports the shortages of professional nurses in nursing homes in 2018, new public policies established in the future must ensure that all facilities have sufficient numbers of professional nurses as well as paraprofessional nurses (certified nurse assistants). Higher staffing standards are essential and these standards need to be effectively enforced.
Aug. 13, 2020
 42 U.S.C. §§1395i-3(b)(4)(C)(i), 1396r(b)(4)(C)(i)(II), Medicare and Medicaid, respectively; 42 C.F.R. §483.35(b)(1).
 42 U.S.C. §§1395i-3(b)(4)(C)(i), 1396r(b)(4)(C)(i)(I), Medicare and Medicaid, respectively; 42 C.F.R. §483.35(a)(1)(i).
 OIG, Some Nursing Homes’ Reported Staffing Levels in 2018 Raise Concerns; Consumer Transparency Could Be Increased, OEI-04-18-00450, p.3 (Aug. 2020), https://oig.hhs.gov/oei/reports/OEI-04-18-00450.pdf.
 Id. 3, 4 (Exhibit 2).
 Id. 1, endnote 1, citing Kramer, A.M., and Fish, R., “The Relationship Between Nurse Staffing Levels and the Quality of Nursing Home Care,” in Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes: Phase II Final Report, Abt Associates, Inc., Winter 2001. This study, also known as the CMS Staffing Study, found a clear association between nurse staffing and nursing home quality of care. CMS, Nursing Home Compare Technical Users’ Guide—April 2019, https://www.cms.gov/Medicare/Provider-Enrollment-andCertification/CertificationandComplianc/downloads/usersguide.pdf. Accessed on November 14, 2019.
 Yue Li, “COVID-19 infections and deaths among Connecticut nursing home residents: facility correlates,” Journal of American Geriatrics Society (2020) (in press)