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Nursing Services
Staffing Ratios

Description of Federal Requirements  [TOP]

Federal regulations have almost no requirements for accelerating nursing staff according to the size of the facility or any other resident characteristics.  Federal requirements call for a sufficient number of staff to accomplish the care plans, one RN in an 8 hour period (largely during the day shift), one licensed nurse (i.e. an RN or an LPN) on every tour of duty, and a Director of Nurses (DON) who is an RN.  The only reference to size of the facility is the proviso that the DON may not count as the registered nurse on duty if the facility has 60 or more beds.  Federal law also requires that dedicated assistants with feeding not count as part of the nursing staff if the State has requirements as to the ratio of nursing staff to residents. 

Comparison of State Requirements  [TOP]

Eighteen (18) States have no numerical ratios for nurse staffing, although some of these states require more licensed and/or registered nursing presence than is required by federal regulation.  The remaining 32 States have established a required ratio of staff to residents. In those cases, the State almost always specifies the proportion of nursing time that must be fulfilled by licensed staff, and some States further differentiate between RN and other licensed staff.  Typically, the State regulation specifies which licensed personnel cannot count towards the ratio (usually the DON, and sometimes the ADON, the nurse educator, and other supervisory personnel).  Maryland describes how to count ward clerk personnel into the overall ratio at 50% of time provided in nursing units.  Some States—e.g. Georgia, specify that dining assistants not be counted in the ratio; Vermont specified that activity staff and meal preparation staff do not count, whereas other States seem to take that for granted.  Maine specifies that private duty nurses are not included in calculating the ratio.  Some States specify adjustments that can be made to reduce the nursing-staff-to-residents ratio if the residents attend other treatment programs during the day—a circumstance more likely for residents in mental retardation or developmental disability facilities or special mental health programs.  Indiana requires a ratio requirement for licensed staff only.  Florida established a phase-in process for bringing the staffing ratio up in 3 stages from 2.3 hours of nursing staff per resident day in 2002 to 2.9 by July 2006.

Some states simply specify the total nurse staff ratio, for example, 1.5 total hours per resident per day in Louisiana, 2 hours per resident in Minnesota,  2.5 hours direct care and treatment staff per resident per day in Delaware,  2.7 hours per resident in Pennsylvania,  2.8 hours per resident in Mississippi, and 3.0 in California and Vermont.  More commonly States specify the proportion of the hours that must be fulfilled by licensed personnel as opposed to CNAs; for example, Iowa requires 2 hours per resident day, 20% of which is licensed staff.   The notion that 20% of the nursing time be supplied by licensed staff is a common formula; after the elaborate case-mix adjusted formula of New Jersey is applied, then 20% of the hours must be fulfilled by licensed staff.  Some States establish their instructions slightly differently; for example, Georgia calls for 2 hours direct nursing per patient day, and states that for every 7 total nursing staff, 1 must be RN or licensed nurses.    Sometimes States provide elaborate instructions for how to calculate the ratio, and also specify that it is the ratio of actual hour worked rather than hours scheduled that shall be counted.  In a requirement that seems somewhat ambiguous, Kansas calls for a minimum of weekly average of 2.0 hours of direct care staff/resident and a daily average of no less than 1.85 hours/24 hour period. 

At least 9 States specify or suggest the ratios per shift.  New Mexico offers suggested ratios by shift and Illinois gives a desirable range for each shift, allowing for some facility variation—i.e., at least 40% of the minimum required hours shall be on the day shift, at least 25% of the minimum required hours shall be on the evening shift, and at least l5% of the minimum required hours shall be on the night shift.  Illinois’ staffing provisions are adjusted by case mix and quite complex, with additional variations for facilities with more than 250 beds.  Others state provide the specific ratio required for  each kind of personnel by each shift (Connecticut, Michigan, Oklahoma, Oregon, and South Carolina).   Some States merely refer to day, evening, and night shifts, whereas others actually provide the time periods for those shift; Connecticut distinguishes between staffing from 7 a.m. to 9 p.m. and 9 p.m. to 7 a.m., although these times might cross shifts.  South Carolina refers to 3 shifts, but then explains how to calculate ratios if the facility is using 12 hour shifts.  Montana and West Virginia provide tables to indicate the minimum number of staff members of each type of training to be slotted into each shift.  Montana’s provisions are particularly elaborate.

[NHPlusComments.  The elaboration of staffing ratios per shift has the perhaps unintended effect of fixing the conventional 3-shift pattern, and, in some cases, even the timing of those patterns and discouraging alternative ways of staffing. This may be contrary to the individualization of shifts seen in  some facilities in the midst of culture change—either the creation of unconventional shifts, or even the individualization of shifts for particular works so as to create a greater presence at peak times of activities.  If each staff member’s day, evening, and night shifts  are construed somewhat differently, compliance with shift-specific staffing ratios is difficult.  Obviously States that provide  overall ratios per-resident-per-day offer the facility more opportunity to creatively organize staff to meet resident needs. Further, it should be noted that there is an absence of any empirical data to support staff complements that are higher between 7 a.m. and 3. pm., say, than between 3 pm. and 11 a.m.]

Several States add a caveat that notwithstanding the mandated ratios, the State may require additional staff. Massachusetts states that the minimum staffing patterns and nursing care hours as contained herein shall mean minimum, basic requirements.  It anticipates that additional staff will be necessary in many facilities to provide adequate services to meet patient needs.  Illinois anticipates “occasional differences of opinion between facility staff and Department surveyors regarding the level of care an individual resident may require” because the ratio is calculated based on assessments of level of care needs.  The rules require that when such differences occur, the surveyor shall determine whether or not the resident is receiving appropriate care.  If the resident is, the surveyor shall accept the facility's level of care determination in determining the number of nursing hours to be provided by the facility.  In Kansas, the licensing agency may require an increase in the number of nursing personnel above minimum levels under certain circumstances, including: (i) location of resident rooms; (ii) locations of nurses' stations; (iii) the acuity level of residents; or (iv) that the health and safety needs of residents are not being met.  In Nebraska, based upon the physical layout of the nursing facility, the licensing agency may increase the nursing care per resident ratio.

The States also allow for lowering the required ratio.  For example, in Maryland, facilities not participating in Medicare or Medicaid and with 40 beds or fewer may request an exception to the required staffing.  If it discerns no hazard to residents, the Department may grant such exceptions based on information that includes;  1) Size of the facility; (2) Geographic location of the facility; (3) Admission policies of the facility; (4) Existing staffing pattern of the facility; and (5) Number of volunteers in the activity program.

Wisconsin enunciates a more permissive policy towards counting non-nursing staff in nursing ratios. In Wisconsin, when determining staff time to count toward satisfaction of the minimum nursing service hours in this section, the follow­ing duties of non−nursing personnel, including ward clerks, may be included:  a. Direct resident care, if the personnel have been appropri­ately trained to perform direct resident care duties; b. Routine completion of medical records and census reports, including copying, transcribing, and filing; c. Processing requests for diagnostic and consultative ser­vices, and arranging appointments with professional services; d. Ordering routine diets and nourishments; and e. Notifying staff and services of pending discharges.  On the other hand, no services provided by volunteers may be counted toward satisfaction of nursing staff requirements.

[Summarized: August, 2006]
 

Table Comparing States  [TOP]

Note: If the States in this table are not hyper-linked, their provisions do not appear to address the topic, and therefore, do not alter the Federal Regulatory scope.  The Table summarizes content on Administration by State (with a link to each State's specific language).  Link to a downloadable PDF document containing all State regulation on Nursing Services is at the bottom of the Table.

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Complete Transcript of State Requirements on Nursing Services-Staff Ratios