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Some Nursing Homes' Reported Staffing Levels in 2018 Raise Concerns; Consumer Transparency Could Be Increased

Issued on  | Posted on  | Report number: OEI-04-18-00450

Report Materials


Nurse staffing is a key contributor to the quality of care provided in nursing homes. This review, initiated before the COVID-19 pandemic emerged, focuses on staffing data from 2018. However, the 2020 pandemic reinforces the importance of adequate staffing for nursing homes, as inadequate staffing can make it more difficult for nursing homes to respond to infectious disease outbreaks like COVID-19.

Consumers need meaningful information about nurse staffing at nursing homes to make informed care decisions. CMS created the Payroll-Based Journal (PBJ)-a system containing self-reported provider data-to collect nursing homes' daily staffing hours. CMS uses the PBJ data to calculate Staffing Star Ratings reported on the public Nursing Home Compare website. CMS requires a minimum number of daily hours for different types of nurses (nursing homes must have a registered nurse (RN) on staff at least 8 hours each day and licensed nurses on staff around the clock). However, CMS does not use PBJ data to enforce these daily Federal staffing requirements, nor does it regularly publish day-to-day nurse staffing on Nursing Home Compare.


We analyzed nursing homes' 2018 daily staffing data from the PBJ. We determined how frequently nursing homes reported daily staffing levels below federally required levels in 2018 and identified quarterly trends. We compared nursing homes' quarterly Staffing Star Ratings to their daily staffing levels. To discuss residents' experiences with daily fluctuations in nurse staffing, we electronically surveyed 20 Local Long-Term Care Ombudsmen.


Of 12,862 nursing homes, 7 percent (943) reported 30 or more days in 2018 on which staffing was below at least 1 required staffing level. Additionally, another 7 percent of nursing homes (900) reported between 16 and 29 days with staffing below required levels in 2018. This raises concerns that some nursing homes may not have fully met their residents' needs in 2018. CMS implemented a policy in 2018 to downgrade nursing homes' Staffing Star Ratings to 1 Star for having at least 7 total days within a quarter with no reported RN time. Following CMS's announcement of this policy, 27 percent fewer nursing homes reported days with no RN time. At the same time, 7 percent more nursing homes reported days with some RN time, although less than the required 8 hours per day. These trends suggest overall improvements in staffing levels. Finally, we found that daily staffing levels reported by individual nursing homes often did not match their Staffing Star Rating published on Nursing Home Compare. While some nursing homes' reported staffing levels varied considerably from day to day, other nursing homes' daily staffing levels were more consistent.


We recommend that CMS: (1) enhance efforts to ensure nursing homes meet daily staffing requirements and (2) explore ways to provide consumers with additional information on nursing homes' daily staffing levels and variability. While CMS did not explicitly state concurrence with the recommendations, CMS outlined the actions it has taken and plans to take to achieve the recommendations' goals.