Lawmakers Implement Stricter Nursing Home Staffing Ratios in Early COVID-19 Hotspot

One of the states hit hardest in the early weeks of the coronavirus pandemic has implemented stricter rules around nursing home staffing, set to take effect early next year.

Starting February 1, nursing homes in New Jersey must have one certified nursing assistant (CNA) per eight residents during day shifts, one direct caregiver for every 10 residents during the evenings, and one for every 14 during the overnights under new regulations signed into law last week.

During the evening and overnight hours, the direct caregivers can include CNAs, licensed practical nurses, or registered nurses, so long as at least half are CNAs.


“Sadly, too many nursing homes are run by companies more interested in making money than protecting patients,” New Jersey governor Phil Murphy said in a statement late last week, according to a report from “These long-sought reforms will help bring accountability to the industry and protect residents, staff, and family members with a loved one living in a long-term care facility.”

The new law will also establish a retention and recruitment task force in order to help nursing home operators find sufficient candidates to meet the new requirements; operators in the state had indicated that they could not implement the stricter care ratios without workforce development assistance, noted.

Operators will end up spending $30 million, or $5 per resident day, to meet the new rules, the Health Care Association of New Jersey told the publication.


Staffing has emerged as a key indicator of COVID-19 outbreak risk in nursing homes, with one study finding that a facility’s federal staffing performance was the only reliable predictor of coronavirus cases among the other Centers for Medicare & Medicaid Services (CMS) five-star quality domains.

“Across 8 states, high-performing NHs for nurse staffing had fewer COVID-19 cases than low-performing NHs,” the study, published online by the JAMA Network, determined. “In contrast, there was no significant difference in the burden of COVID-19 cases between high- vs low-performing NHs for health inspection or quality measure ratings. These findings suggest that poorly resourced NHs with nurse staffing shortages may be more susceptible to the spread of COVID-19.”

A separate study from the University of Chicago found a more complex picture, with better-staffed facilities showing a lower probability of wider outbreaks and COVID-19 deaths — but also a higher likelihood of at least one positive case, which the researchers speculatively attributed to increased traffic in and out of facilities with more total workers.

“We find a nuanced story: Staffing levels may play one role (or no role) in the probability that COVID-19 gets into a nursing home, and another role in trying to stem transmission and deaths once it is in,” the UChicago researchers concluded.

Staffing shortages have been a persistent problem in nursing homes across the country, with resident advocates calling on the federal government to implement stricter rules and more closely enforce existing regulations. Industry leaders — at least prior to the pandemic — in response have pointed to low unemployment figures, competition from retail and foodservice jobs, and insufficient Medicaid rates as reasons for subpar staffing coverage.

The Department of Health and Human Services (HHS) Office of the Inspector General (OIG) this past summer called on CMS to more closely scrutinize day-to-day fluctuations in nurse staffing and increase enforcement in a review of the agency’s policies from 2018.

“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.”