​​KFF: Only 29% of Nursing Homes Would Meet 4-Hour Federal Staffing Mandate

Ahead of the federal nursing home minimum staffing ratio proposal, a KFF analysis released Friday suggests that less than a third of the nation’s nursing homes would even come close to meeting forthcoming minimum staffing requirements.

The analysis from KFF found nearly all facilities would meet a 2.5 or fewer hour per resident day (HPRD) staffing requirement, while 85% of SNFs say they could handle 3.0 HPRD. Worryingly, close to half, or 45% of SNFs say they could not meet a 3.5 HPRD requirement, and only 29% would meet 4.0 HPRD.

Moreover, there was a “wide variation” across the country, KFF found, if facilities were required to meet staff levels exceeding 3.0 HPRD.


The Centers for Medicare & Medicaid (CMS) has long advocated for higher staffing standards. In a report issued to Congress in 2001, CMS recommended a daily minimum standard of 4.1 hours of total direct care nursing time per resident: 2.8 hours from certified nursing assistants; 0.75 hours from RNs; and 0.55 hours from licensed practical/vocational nurses.

The KFF report also shed light on what workforce levels would be manageable, and what facility characteristics would lend themselves to higher clinician levels.

Fewer for-profit facilities would be able to meet any required staffing level above 2.5 HPRD, KFF found, compared to non-profit and government nursing facilities.


Meanwhile, the differences in ownership status, as it relates to ability to staff at certain levels, is less noticeable when the hours are adjusted for resident health and frailty.

For perspective, the last time the Centers for Medicare & Medicaid Services (CMS) in 2001 explored a potential daily minimum standard, they came up with 4.1 total hours, split between 2.8 hours from CNAs, 0.75 hours from RNs and 0.55 hours from LPNs.

Federal standards established in the 1987 Nursing Home Reform Act – and regulation updates made by the Obama administration in 2016 – currently require the equivalent of just 0.3 HPRD for a 100-bed facility. Licensed nursing services should be provided 24 hours per day, 7 days a week, with an RN on duty 8 hours per day, 7 days a week. SNFs must also appoint a director of nursing and have a full-time registered dietician on staff, per current federal guidelines.

“The proposed rule is likely to strengthen the HPRD minimum requirement and could potentially include additional nurse staffing requirements,” KFF researchers said in the analysis. “If the proposed rule includes requirements related to the types of nurses facilities must employ (and the hours they must work) or adjusts the number of required nurses based on patient health and frailty, fewer nursing facilities would meet a given requirement than are shown here.”

And, the rule may require SNFs employ additional staff beyond CNAs, RNs and LPNs, but such requirements were outside of the scope of analysis, according to the KFF study.

Between July 2021 and July 2022, 19% of SNFs failed to have sufficient staff with appropriate competencies and skill sets, according to KFF.

“This grouping of deficiencies captures more than just failing to meet the 0.3 HPRD requirement and includes other deficiencies such as the failure to ensure proper training for nurse aides,” according to the report. “The vast majority of these deficiencies were not associated with harm to patients.”

About 83% of residents currently live in a SNF with at least 3.0 HPRD, while only half of skilled nursing residents live in facilities that achieve 3.5 HPRD, according to the KFF analysis. Moreover, about 23% of SNF residents right now in the country live in a facility that has staffing levels of 4.0 or greater.

KFF adjusted the numbers for current resident frailty and health levels, or case mix adjustment, and found that even fewer facilities would be able to meet a 3.0 HPRD requirement – only 70% compared to 85% if acuity and changing resident populations aren’t on the table.

By state, 100% of Alaska facilities would meet a 4.0 HPRD requirement, compared to just 12% of facilities in Texas, KFF analysts found. This has to do with current state staffing requirements, as some states like Alaska already go well beyond current federal standards with facility HPRD ranging between 4.7 and 12.7, KFF said in its report.

Looking ahead, if CMS moves ahead with its proposed minimum staffing mandate, SNFs will absolutely need to hire more staff to meet it but “the extent of the challenge will depend on the specifics of the new requirement,” KFF concluded.

The analysis brought up variables mentioned by operators in previous Skilled Nursing News articles, including a potential long phase-in of the requirement, if certain staff are weighted differently in the mandate, if nonclinical staff will be counted, and whether acuity will be taken into account.

Impact on Medicaid programs

KFF also considered how the mandate could have ripple effects on state Medicaid programs. Potential increases in nursing home staffing requirements could increase overall costs – a difficult ask for sometimes chronically underfunded Medicaid programs to absorb such costs without commensurate federal financial support.

Unlike the federal government, states need to meet balanced budget requirements, KFF said, which would translate to cuts in other areas of spending or raising taxes to pay the state share of additional nursing home costs.

“It is not clear how these costs will be financed, but they are likely to be passed on to public and private payers for nursing facility services, including residents and their family members who paid $45 billion in out-of-pocket costs for care in nursing homes and other institutional LTSS settings in 2020,” KFF researchers said.

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