New data resource reveals highly variable staffing at nursing homes

By | July 4, 2019

Researchers who analyzed payroll-based staffing data for U.S. nursing homes discovered large daily staffing fluctuations, low weekend staffing and daily staffing levels that often fall well below the expectations of the Centers for Medicare and Medicaid Services, all of which can increase the risk of adverse events for residents.

A study published in the July issue of Health Affairs paints a picture of the staffing levels of nurses and direct care staff at nursing homes based on a new CMS data resource, the Payroll-Based Journal, or PBJ. CMS has been collecting data from nursing homes since 2016 to meet a requirement of the Affordable Care Act, and PBJ data has been used in the federal Five-Star Quality Rating System for Nursing Homes since April 2018.

Medicare has no minimum staff-to-resident ratio standard for nursing homes, and the only staffing requirements are that a registered nurse must be present for eight hours a day, or the equivalent of one shift, and an RN or licensed practical nurse must be present at a facility at all times.

As part of its quality rating system, CMS compares nursing homes’ actual staffing to expected levels based on the acuity of residents in the facility. Using PBJ data from more than 15,000 nursing homes, the research team discovered that 54% of facilities met the expected level of staffing less than 20% of the time during the one-year study period. For registered nurse staffing, 91% of facilities met the expected staffing level less than 60% of the time.


The team also looked at day-to-day staffing fluctuations over the one-year period, and the findings were troubling.

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Relative to weekday staffing, the PBJ data showed a large drop in weekend staffing in every staffing category. On average, weekend staffing time per resident day was just 17 minutes for RNs, nine minutes for LPNs and 12 minutes for nurse aides.

Unlike previous nursing home staffing data that was self-reported by facilities and covered only a narrow window of time around a facility’s annual recertification survey, PBJ data is linked to daily payroll information for several staff categories and cover the entire year. This distinction is critical, the researchers wrote, because the older data were “subject to reporting bias” and “rarely audited to ensure accuracy.”

The new PBJ data offers a more transparent and accurate view of nursing home staffing, and the authors are hopeful that future research will be better positioned to understand the implications of staffing fluctuations on residents’ well-being. They said “these new staffing data also offer tools for regulators and other oversight agencies to monitor what nursing homes are doing day in and day out.”


Although current and future residents and their families might not be inclined to dive into the PBJ data, staffing information for all Medicare- and Medicaid-certified nursing homes is available on Medicare’s Nursing Home Compare website, as well as a wealth of other information searchable by city and by facility, such as inspection reports and other quality measures.

In April, CMS released a major overhaul to the 5-star rating program for Nursing Home Compare that has resulted in an estimated 37 percent of skilled nursing facilities losing one or more stars. The reason for the drop is not related to quality of care, but due to CMS methodology changes, with the agency raising the bar in the three domains used for the ratings in quality, staffing and survey results.

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