University of Minnesota Long Term Care Resource Center
http://www.sph.umn.edu/hpm/ltcresourcecenter/
612-624-5171

Nursing Services

Description of Federal Requirements
Comparison of State Requirements
Table Comparing States

Complete Transcript of State Requirements on Nursing Services (PDF)

Federal Regulations & Related F-tags for 483.30 Applicable Federal Regulation
Nursing Services
(a) Sufficient Staff | F353
(b) Registered Nurse | F354
(c) Nursing Facilities | F355
(d) Waiver of Requirements | F355
 
  • 483.30 Nursing Services
  • 483.20 Resident Assessment
  • 483.25 Quality of Care
  • 483.60 Pharmacy Services
  • 483.75 Administration
  • Description of Federal Requirements    (TOP)    (NEXT)

    The Federal regulation, 483.30, which specifically concerns Nursing Services, requires generally that the facility provide services by licensed nurses and other nursing personnel (e.g., nurses’ aides) in sufficient numbers to provide nursing care to all residents in accordance with their care plans.  Licensed nurses include both Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs)

    A facility must have at least one licensed nurse serving on each “tour of duty.”  Further, the facility must designate an RN to be on duty providing direct care for 8 consecutive hours seven hours a week, as well as an RN to serve as director of nurses (DON). The DON may not be counted as the RN on duty in nursing homes with more than 60 beds.  The rule also details circumstances under which both the requirement for an RNs every day and an RN as DON can be waived in rural areas, and the safeguards that must be provided in that case—essentially the facilities with the waivers must provide on-call access to an RN at all times. The facility must post the following information on a daily basis: name; current date; total number and actual hours worked by categories to include registered nurses, LPNs, certified nurse aides; and resident census. The daily postings must be: clear and readable; in a prominent place readily accessible to residents and visitors; provide upon oral or written request staffing data and data must be retained for a minimum of 18 months or as required by State law, whichever is greater.

    Our review of Nursing Services in this section is largely limited to State variation in or extension of the actual provisions of 483.30.  Given the centrality of nursing to care in a nursing home, other Federal regulations contain many references to the role and function of licensed nurses in general, RNs in particular, and nurse’s aides.  For example, the Resident Assessment regulation, 483.20, on coordination (h) requires that an RN conduct or coordinate each assessment with the appropriate participation of health professionals, and (i) that an RN sign and certify that the assessment is completed.  Section (k) on comprehensive care plans, states that such plans are prepared by an interdisciplinary team that includes the attending physician, an RN with responsibility for the resident, and other staff from other disciplines as appropriate to the needs, and, if practicable the resident and his/her family or legal representatives.  Thus an RNs have oversight and sign-off responsibility for the assessment and care-planning process; for that reason, those facilities that choose to have a position called MDS Coordinator (which is not federally mandated) usually seek an RN for the role, although they may utilize LVNs or LPNs as part of an MDS Coordination team.   Under Administration (483.75), long sections of the Federal Regulations deal with the competence of nurse’s aides and mandated training for nurse’s aides, and under Quality of Care (483.25) references are made to the roles of nurses in delivering the expected quality of care.

    The DON is mentioned elsewhere in the Federal regulations.  For example, under Pharmacy Services (483.60), the consultant pharmacist must report any irregularities to the attending physician and the DON.  Under Administration (483.75) (q), on quality assessment and assurance, the facility must have a Quality Assurance Committee and the DON is a mandated member.  Finally, under administration, registered nurses and licensed nurses (like all other professionals) must meet any credentialing or licensure requirements of the State where the nursing home is located.

    Comparison of State Requirements    (TOP)    (NEXT)

    NOTE:  The examples below may not list all States with similar language; always check your state for specifics

    Typically, state rules reiterate the federal requirement that staffing be adequate to meet residents’ needs.  States may express those general requirements a little more fully than the general federal statement.  For example, Massachusetts requires that all facilities shall provide appropriate, adequate and sufficient nursing services to meet the needs of patients or residents and to assure that preventive measures, treatments, medications, diets, restorative services, activities and related services are carried out, recorded and reviewed.  Further, Massachusetts indicates that nursing care shall be an integral part of total health care and shall emphasize the promotion of health, the prevention and treatment of disease and disability, and the teaching counseling and emotional support of patients.  Similarly, in New York, the facility shall have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. The facility shall assure that each resident receives treatments, medications, diets and other health services in accordance with individual care plans.

    One of the most frequent type of state requirements for nursing services establish specific nursing-staff-to-resident ratios.  Most states have established at least some such ratios; these are described below in another section, See Nursing Services-Staffing Ratios.  Also, states often enunciate of requirements for Directors of Nursing , including role specification; these are described in another section, See Nursing Services-Director of Nursing.

    Some States go beyond federal requirements for nurses without establishing specific ratios.  For example, a licensed nurse may be required for each unit rather than just for each tour of duty.  Some States specify that each floor shall be staffed separately and include licensed personnel. In Arkansas, for example, in multi-story homes, each floor should be staffed as an individual unit. In North Carolina, a multi‑storied facility shall have at least one direct‑care staff member on duty on each patient care floor at all times.  In Wyoming, each nursing station shall be staffed separately and shall have a separate staffing pattern, and in Kansas, the same number of licensed nurses must be employed as nursing units on day shift. South Carolina specifies the maximum size of a nursing unit before extra staff is needed, stating that if a nursing station serves more than forty-four residents, then that station is required to have two licensed nurses on all shifts. Although perhaps it should be self-evident, a number of State rules specify that nursing staff must be awake and dressed when on duty.

    No state actually required permanent assignment of nursing staff to residents, but some language hints at that idea.  For example, in Massachusetts, assignment of nursing staff within a SNCFC shall be made so that each patient is cared for by at least some nursing personnel who are assigned to care for him on a continuing basis.  In New Mexico, not only must there be  sufficient nursing service personnel assigned to care for the specific needs of each resident on each tour of duty, but also that those personnel shall be briefed on the condition and appropriate care of each resident prior to beginning hands-on care of residents.

    In Rhode Island, no nursing staff shall regularly be scheduled for double shifts.  Also Rhode Island requires that at least one individual who is certified in Basic Life Support must be available twenty-four hours a day (24 hrs./day) within the facility. Many states require job descriptions and written policies.  Kansas requires that direct care staff shall wear identification badges to identify name and position.

    A number of States specify that those providing nursing not provide other kinds of services not usually defined as nursing,    Some States simply say that nursing personnel they shall provide nursing services on a “full-time” basis, but others are more specific about tasks that nursing staff should not perform.  For example, in Massachusetts, nursing personnel shall not perform housekeeping, laundry, cooking or other such tasks normally performed by maintenance or other personnel.  In Kansas, nursing personnel must not be routinely assigned housekeeping, laundry or dietary duties. In Michigan, an employee designated as a member of the nursing staff shall not be engaged in providing basic services such as food preparation, housekeeping, laundry, or maintenance services, except in an instance of natural disaster or other emergency reported to and concurred in by the department.  In Wyoming, full-time or part-time members of the nursing staff shall be primarily engaged in providing nursing services and only in rare and exceptional circumstances shall be involved in food preparation, housekeeping, laundry, or maintenance services. When that occurs, proper infection control procedures shall be adhered to at all times. [NH Regs Plus Comment: Because many facilities have considered creating “universal workers” with broadened job descriptions that can encompass light housekeeping, personal laundry, food preparation, and food service, specific prohibiting language could create a chilling effect, and require waivers of regulation to implement,  The reason for considering the  “universal worker” is to create a more natural life situation for residents and primary, intimate relationships with their caregiving staff, usually at the CNA level.  Sometimes the universal worker idea is combined with household models where residents and their caregivers alike have access to residential-style kitchens and laundries.]

    Much of the variation relates to specific roles and expected responsibilities of charge nurses, licensed nursing staff, and CNAs.  Sometimes the responsibilities are arrayed according to nursing care and basic hygiene.  Some States have enunciated responsibilities for specific functions such as restorative nursing, drug administration, and the like.  Often the basic care expectations are spelled out in considerable detail, related to matters such as the number of baths, foot and nail care, and the like.  These details are also described under the regulations for Quality of Care,  Rehabilitation Services, and Assessment (which includes Care Planning).  Several States each refers to rules for student nurses, for nurses hired by residents as private duty nurses or sitters, and for advance practice nurses. A few States mention the circumstances under which nurses can and should pronounce death.  Rhode IslandTennessee, and Oregon all mention the nurse role in discharge planning.  Oregon asked for a post-discharge plan of care to be developed which will assist the resident to adjust to his/her new living environment.  Oddly, the regulation asserts that a post-discharge plan is not required when the resident is discharged to acute care or to the morgue.

    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 Nursing Services by State (with a link to each State's specific language).  Link to a downloadable PDF document containing all State requirements on Nursing Services.

    483.30 Nursing Services

    State Goes beyond Federal Regulations? Subjects Addressed: How State Differs From or Expands On Federal Regulations
    Alabama No Echoes federal regulations.
    Alaska Yes RN intensity;  nursing requirements when the facility shares the same building as a hospital; duties of DON; nursing roles in medication administration; transfusions.
    Arizona Yes DON role; Documentation of nursing personnel on duty.
    Arkansas Yes DON credentials; DON responsibilities; charge nurse responsibilities; organization of nursing staff; charting & summary charting frequency; observations; routine care; ADON; transfusions; nurses’ aides prohibited from working on dietary, laundry, or housekeeping functions,
    California Yes Nurse-to-resident ratios; nursing services roles; daily care; DON role; feeding assistants
    Colorado Yes Nurse-to-resident ratios; Nurse roles; definition of rural facility.
    Connecticut Yes Nurse-to-resident ratios; DON credentials; DON responsibility; Licensed nurse staffing; ADON
    Delaware Yes Nurse-to-resident ratios; DON roles; rehabilitation roles
    District of Columbia Yes Specific on DON; requirements for ADON in facilities with 100 or more beds; nurse-staff ratios; role of licensed nurse; temporary nurse employees.
    Florida Yes Nurse-to-resident ratios, RN & LPN hours; delegation; feeding assistants; mentoring and QA
    Georgia Yes Nurse-to-resident ratios; DON roles; DON for multiple facilities; dining assistants; lines of authority clearly stated.
    Hawaii Yes Duties of nursing services; physical restraints.
    Idaho Yes Nurse-to-resident ratios; DON duties; charge nurses; waiver of requirements for RNs
    Illinois Yes Nurse-to-resident ratios; Nursing roles; Restorative nursing; Expected nursing outcomes; DON role; DON credentials; DON staffing
    Indiana Yes DON credentials; DON duties; waivers.
    Iowa Yes Nurse-to-resident ratios; Duties of Supervising Nurse; waivers for Supervising Nurse; intensity of licensed nurse service; required nursing services; care planning; restorative nursing; nursing notes;  routine care.
    Kansas Yes Nurse-to-resident ratios; DON authority; same number of licensed nurses as nursing units on day shift; nursing personnel not to be assigned routine housekeeping, laundry or dietary duties; ID badges.
    Kentucky Yes Rehabilitation nursing.
    Louisiana Yes Nurse-to-resident ratios
    Maine Yes Nurse-to-resident ratios; DON credentials; DON roles; DON deployment; task assignment; feeding assistants.
    Maryland Yes Nurse-to-resident ratios; DON roles; DON relief; DON vacancy; charge nurse duties; coordination between nursing and dietary; charge nurse duty; DON continuing education; reporting of concerns about care quality
    Massachusetts Yes Nurse-to-resident ratios; DON deployment; Supervisory nurses deployment; Charge nurse deployment; nursing care plan; nursing staff not assigned to housekeeping, laundry and dietary duties; Restorative nursing care; Dietary supervision; routine nursing duties.
    Michigan Yes Nurse-to-resident ratios; nursing staff deployment
    Minnesota Yes Nurse-to-resident ratios; DON credentials; DON role; adequate and proper nursing care; Rehabilitation nursing care.
    Mississippi Yes Nurse-to-resident ratios; minimum staffing
    Missouri Yes General certification requirements including request for a waiver of nurse staffing requirements; administration and resident care requirements.
    Montana Yes Nurse-to-resident ratios; minimum standards.
    Nebraska Yes Nurse-to-resident ratios; Medicaid/treatment nurse on each shift; ADON in facilities of 180+; staff resources and responsibilities.
    Nevada Yes Credentials of DON
    New Hampshire Yes Credentials of DON; nursing notes
    New Jersey Yes Nurse-to-resident ratios; DON credentials; nursing care definitions linked to staffing ratios; staff educator
    New Mexico Yes Nurse-to-resident ratios; DON duties; DON relief; charge nurse duties; charge nurse credentials; staff meetings & communication; records
    New York Yes CNA curriculum; CNA registry. Effective 12/19/2007 nursing services requirements.
    North Carolina Yes Nurse-to-resident ratios; DON role; nursing roles; nursing deployment
    North Dakota Yes DON responsibility
    Ohio Yes Nurse-to-resident ratios; advance practice nurses; personnel requirements.
    Oklahoma Yes Nurse-to-resident ratios; Nursing roles; DON responsibilities; DON deployment; CNA registry and credentials; nursing students; medication aides; in-service education; flexible staff-scheduling.
    Oregon Yes Nurse-to-resident ratios; DON credentials; DON responsibility; DON backup; RN care manager training; RN care manager role; delegation; waiver of DON/RN requirements; certified medication aides; CNA requirements and role; conditions to be prevented; restraints; restorative nursing; care plan; discharge plan
    Pennsylvania Yes Nurse-to-resident ratios; DON role
    Rhode Island Yes Written policies and job descriptions; DON credentials; DON role; DON backup; master plan of staffing and relief staff; care plans; basic hygiene.
    South Carolina Yes Nurse-to-resident ratios; DON backup; RNs per nursing station; shifts; staff training.
    South Dakota Yes Nursing staff required policies and procedures.
    Tennessee Yes Nurse-to-resident ratios; organized nursing services; DON roles; non-employees working nursing shifts; non employees as private sitters; nursing care responsibilities; routine care; conditions whereby nurses can determine and pronounce death.
    Texas Yes Nurse-to-resident ratios; DON responsibilities; Waivers of DON or nurse ratios; Nursing practices; Nursing delegation; Pronouncement of death; Nursing receipt of orders; Student nurses; Special nurses and sitters.
    Utah Yes Staff and personnel; nursing care responsibilities; qualified supervisors.
    Vermont Yes Nurse-to-resident ratios.
    Virginia Yes DON role; DON vacancies; no temporary DON for more than 90 days; no agency personnel as DON; nurse responsibilities; CNA credentials; CAN responsibilities; weekly staffing schedules maintained.
    Washington Yes RN supervising nurse deployment and responsibility 16 hours a day, 7 days a week; DON role.
    West Virginia Yes Nurse-to-resident ratios; DON duty schedule; Alzheimer’s special care unit requirements.
    Wisconsin Yes Nurse-to-resident ratios; DON credentials; DON role; licensed nurse qualifications; licensed nurse roles; staff meetings; communication on individual residents.
    Wyoming Yes Nurse-to-resident ratios;  DON roles; nursing roles; age for direct care workers; restorative nursing care; dietary supervision; staff development; staff orientation; administration of drugs.

    Complete Transcript of State Requirements on Nursing Services    (TOP)

    Sub-pages of
    Nursing Services

    Staffing Ratios

    Director of Nursing