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Nursing Home Staffing


Low Staffing and Turnover in Nursing Homes

Covid-19 and its many implications has and continues to profoundly impact nursing homes. Quality of care, infection control measures, shortages of personal protective equipment, staffing, deaths, and turnover are all affected.

One of the easiest quality related measures to track is staffing. Even before 2020, The Centers for Medicare and Medicaid Services focused on nursing home staffing. Using payroll-based journal (PBJ) data, CMS identified facilities in each state with the fewest number of staff on duty.

The method of verifying staffing levels using data collection started on July 1, 2016. Nursing homes are required to electronically submit direct care staffing information to the Payroll-Based Journal system. The system must receive data by the end of the 45th calendar day after the last day in each fiscal quarter.

Until CMS instituted this system, nursing homes could provide unverified reports of staffing, resulting in concerns among attorneys and others that the data was inaccurate.

Plaintiff and defense attorneys have long wondered if the facilities were gaming the system by reporting their own staffing data. There is a powerful incentive to do so – rating systems, admissions to nursing homes, and confidence of investors are affected by perceived quality of care.

Because of the data reported to CMS about staffing, the lowest staffed facilities were singled out for surprise inspections on weekends. The State Operations Manual issued by CMS required state surveyors to conduct at least 10% of surveys on the weekend or during the off hour. And if an incident occurred, the state surveyors make an inspection on the shift in which the incident occurred, and that could be evening or night shift.

What about turnover?
Staffing a long-term care facility can be extraordinarily difficult. Working in a nursing home is associated with difficult, physically taxing work. Sicker residents are entering long term care facilities with complex needs. Insufficient or inadequately trained staff struggle to deliver care to these residents. One great challenge includes admission of residents with psychiatric disorders which increases the challenges, including posing risks to other residents.

Researchers at UCLA and Harvard used the PBJ data to study turnover in more than 15,000 facilities, totaling 492 shifts worked by 4.4 million nursing home staffers. Here are some key findings from their study, which were released in March 2021:

  • Facilities with the lowest one-star ratings from CMS had median turnover of 135.3%.
  • The best 5-star facilities had turnover of 76.7%.
  • For-profit and chain-owned facilities had greater turnover.
  • Facilities in low-income areas and with low-income residents had greater turnover.

The authors of the massive data analysis confirmed what many industry leaders and attorneys suspect:

  • For-profit chains may fail to support the needs of nursing staff.
  • Chain-owned facilities may impose stricter standardization and oversight of their employees.
  • Staff working in low-income areas and those with more residents covered under Medicaid may receive less pay and benefits, leading to turnover. High Nursing Staff Turnover In Nursing Homes Offers Important Quality Information | Health Affairs

The Office of the Inspector General released a comprehensive report in March 2021 which acknowledged that the Covid-19 pandemic had an impact on nursing home oversight, as well as reinforcing the importance of adequate staffing.

OIG concluded, and CMS concurred with these 4 recommendations:

  1. CMS provide data to consumers on nurse staff turnover and tenure, as required by Federal law.
  2. CMS ensure the accuracy of non-nurse staffing (such as physical therapists) data used on Care Compare.
  3. CMS consider the residents’ level of need when identifying nursing homes for weekend inspections.
  4. CMS take additional steps to strengthen oversight of nursing home staffing. CMS Use of Data on Nursing Home Staffing: Progress and Opportunities To Do More, OEI-04-18-00451 (

It is a dilemma. Nursing homes need oversight. CMS is charged with overseeing the care. Plaintiff and defense attorneys know that staffing is critical; insufficient staffing has been linked to poor quality care, leading to issues such as pressure injuries and falls among other problems, and spread of Covid within nursing homes. Vulnerable debilitated nursing home residents are at risk for bad outcomes without sufficiently trained staff overseen by registered nurses.

At OnPointLNC, we receive many requests for nursing home experts just because of this high-risk environment and the poor outcomes that develop.
We’d love it if all nursing home residents received adequate care, but that seems to be an unattainable dream.

In the meantime, need a nursing home expert? Give us a call.\

Kimm Ebersole, MHA, BSN, RN
Business Development

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