OIG Calls on CMS to Crack Down on Nursing Home Staffing, Increase Consumer Transparency

The Centers for Medicare & Medicaid Services (CMS) should be doing more to enforce proper staffing levels at nursing homes, while providing more detailed information about nurse coverage hours to the public, the federal government’s top health care watchdog found in a new report.

About 7% of the nation’s nursing facilities failed to meet one of two key staffing requirements for at least 30 total days in 2018, the Department of Health and Human Services (HHS) Office of the Inspector General (OIG) determined; another 7% logged between 16 and 29 days with non-compliant staffing levels.

“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,” the OIG observed in its report, released last week. “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.”


Under federal law, nursing home operators must have a registered nurse (RN) in place eight hours per day, with another type of licensed nurse — RNs, licensed practical nurses (LPNs), or licensed vocational nurses (LVNs) — available around the clock.

Many nursing homes have historically struggled with maintaining appropriate staffing levels, prompting CMS to implement stricter punishments in 2018: Any facility with seven or more days per quarter without any RN coverage would automatically receive a one-star staffing rating, one of the components of its overall five-star quality rating from CMS.

That push appeared to work. The number of nursing homes reporting RN staffing under that threshold decreased by 27%, while 7% more indicated an increase in total days with some RN coverage — but under the eight-hour-per-day requirement.


“These trends suggest overall improvements in staffing levels,” OIG reported. “However, the nursing homes reporting days with greater than zero hours but less than the required eight hours of RN time appear to be falling short of meeting staffing requirements in ways that this penalty does not address.”

CMS cracked down further on the RN issue in March 2019, handing out one-star staffing ratings to any provider with four or more days without an RN on staff.

But in the OIG’s view, CMS must go further. The quarterly data, the watchdog agency argued, does not capture day-to-day variations in staffing coverage that could adversely affect resident safety.

“Some nursing homes’ reported staffing levels varied considerably from day to day, while other nursing homes’ daily staffing levels were more consistent,” the OIG concluded. “Presenting only quarterly staffing averages does not enable consumers to identify and consider daily staffing differences when choosing a nursing home.”

For that reason, the OIG suggested that CMS use payroll-based journal (PBJ) data to target underperforming facilities for enforcement and improvement; under PBJ rules, implemented in 2018, operators must provide CMS with a daily record of how many hours each employee worked.

The OIG also recommended that CMS provide more detailed staffing information on Nursing Home Compare, its consumer-facing website for potential residents an their families.

“CMS could explore ways to show the frequency with which each nursing home reported staffing below required daily Federal levels during a given quarter or how nursing homes’ weekend staffing compares to that of other nursing homes with the same Staffing Star Rating,” the OIG concluded.

In each of its investigative reports, OIG allows the subject agency to respond; CMS acknowledged the need for sufficient staffing at nursing facilities, but largely defended its work to boost enforcement and transparency in the two years since the data in the OIG report was recorded.

“CMS’ approach to oversight of nursing homes, including their staffing levels, is constantly evolving, and CMS is continuously looking for ways to improve our oversight approach to nursing home safety and quality,” administrator Seema Verma wrote in the agency’s formal response to OIG’s recommendations.

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