The Need for Higher Minimum Staffing Standards
in U.S. Nursing Homes
Charlene Harrington1, John F. Schnelle2–4, Margaret McGregor5 and Sandra F. Simmons3,4,6
1

R.N. Professor Emeritus of Nursing and Sociology, Department of Social and Behavioral Sciences, University of California San Francisco,
San Francisco, CA, USA. 2Hamilton Professor of Medicine and Director of the Center for Quality Aging, Department of Medicine, Division
of Geriatrics, Vanderbilt University, Nashville, TN, USA. 3Division of General Internal Medicine and Public Health, Center for Quality Aging,
Vanderbilt University, Nashville, TN, USA. 4Department of Veterans Affairs, Geriatric Research Education and Clinical Center, Tennessee
Valley Healthcare System, Nashville, TN, USA. 5Clinical Associate Professor, Director of Community Geriatrics, University of British Columbia
Department of Family Practice, Vancouver, BC, USA. 6Associate Professor, Department of Medicine, Division of Geriatrics, Vanderbilt
University, Nashville, TN, USA.

ABSTR ACT: Many U.S. nursing homes have serious quality problems, in part, because of inadequate levels of nurse staffing. This commentary focuses on
two issues. First, there is a need for higher minimum nurse staffing standards for U.S. nursing homes based on multiple research studies showing a positive
relationship between nursing home quality and staffing and the benefits of implementing higher minimum staffing standards. Studies have identified the
minimum staffing levels necessary to provide care consistent with the federal regulations, but many U.S. facilities have dangerously low staffing. Second,
the barriers to staffing reform are discussed. These include economic concerns about costs and a focus on financial incentives. The enforcement of existing
staffing standards has been weak, and strong nursing home industry political opposition has limited efforts to establish higher standards. Researchers should
study the ways to improve staffing standards and new payment, regulatory, and political strategies to improve nursing home staffing and quality.
KEY WORDS: nurse staffing, nursing homes, standards, regulations, market incentives
CITATION: Harrington et al. The Need for Higher Minimum Staffing Standards in U.S.
Nursing Homes. Health Services Insights 2016:9 13–19 doi:10.4137/HSI.S38994.
TYPE: Commentary
RECEIVED: January 25, 2016. RESUBMITTED: March 8, 2016. ACCEPTED FOR
PUBLICATION: March 14, 2016.

COPYRIGHT: © the authors, publisher and licensee Libertas Academica Limited.
This is an open-access article distributed under the terms of the Creative Commons
CC-BY-NC 3.0 License.
CORRESPONDENCE: charlene.harrington@ucsf.edu

FUNDING: Authors disclose no external funding sources.

Paper subject to independent expert single-blind peer review. All editorial decisions
made by independent academic editor. Upon submission manuscript was subject to
anti-plagiarism scanning. Prior to publication all authors have given signed confirmation
of agreement to article publication and compliance with all applicable ethical and legal
requirements, including the accuracy of author and contributor information, disclosure of
competing interests and funding sources, compliance with ethical requirements relating
to human and animal study participants, and compliance with any copyright requirements
of third parties. This journal is a member of the Committee on Publication Ethics (COPE).

COMPETING INTERESTS: Authors disclose no potential conflicts of interest.

Published by Libertas Academica. Learn more about this journal.

ACADEMIC EDITOR: Charles Phillips, Editor in Chief
PEER REVIEW: Four peer reviewers contributed to the peer review report. Reviewers’
reports totaled 1,622 words, excluding any confidential comments to the academic
editor.

Introduction

Following a decade of controversies about poor nursing home
care, the U.S. Congress adopted stronger requirements and
oversight of nursing homes with the passage of the Nursing
Home Reform Act in 1987.1 Since 1987, the U.S. Centers for
Medicaid and Medicare Services (USCMS) has developed a
range of new initiatives to improve nursing home quality and
implemented new requirements in the Patient Protection and
Affordable Care Act of 2010.2,3 These efforts have included
revisions in policies and survey procedures, public reporting
of nursing home quality, and other efforts that have resulted
in some positive changes in nursing home care, such as reductions in the use of physical restraints.4
Over the years, U.S. government studies and investigative reports have found that many nursing homes continue to
have serious quality problems.5–11 In the U.S., in 2013, over
120,000 deficiencies were issued to nursing homes for regulatory violations, while 2,466 civil money penalties and 524
denial of payments were issued for serious quality violation.12
Furthermore, 20.5% of nursing homes received deficiencies
for causing the potential for or actual harm or jeopardy to residents in 201413 and 6% of homes were rated as substandard.14
Overall, these regulatory actions show that nursing homes
still need to improve the nursing home quality.

Recently, the U.S. Office of the Inspector General found
that 33% of Medicare nursing home resident sample experienced adverse events, resulting in harm or death during the
first 35 days of a postacute skilled nursing stay.15 Medicare
beneficiaries had over 2.5 million nursing home admissions in
2011, which cost about $28 billion. Sixty percent of the adverse
events in the study were related to substandard treatment,
inadequate monitoring, and/or failures or delays in treatment
by nursing staff and others, costing $2.8 billion for Medicare.15
A separate study found that 25% of Medicare nursing home
residents were readmitted to the hospital for common and preventable problems in 2011 at a cost of $14 billion.16
One important underlying reason for quality problems
is inadequate nurse staffing levels. In addition to reforming the oversight process, the Nursing Home Reform Act of
1987 required nursing homes to have sufficient staff to meet
the needs of residents and one registered nurse (RN) Director
of Nursing on duty for eight hours a day, seven days a week,
and a licensed nurse in evening and night shifts,1 but this
standard has been criticized as inadequate.17,18 Subsequently,
41 states have established higher staffing standards than the
federal standards; however, even with higher standards, most
state standards remain well below the levels recommended by
experts.17,19
Health Services Insights 2016:9

13

 Harrington et al

In 2015, the U.S. government proposed new nursing
home regulations to strengthen the quality of nursing home
care.20 Unfortunately, the proposed regulations do not change
the federal staffing standard, even though the previous standards are considered too low, and resident acuity has increased
dramatically since 1987.21 For example, the percent of total
Medicare resident days classified as needing intensive rehabilitation and nursing care increased from 29 to 79 days between
2002 and 2013.21 Although resident acuity appears to be overstated because nursing homes have incentives for upcoding
acuity to increase revenues, 21 there is clearly increased association with early hospital discharge to nursing homes. Under the
newly proposed regulations, nursing homes would be allowed
to continue to set their own staffing levels without a higher
federal minimum standard than the current requirement.
In the U.S., 15,600 licensed nursing homes must provide
RNs (with a minimum of two to four years of training) and
licensed professional nurses (with one to two years of training)
on staff.22 Licensed residential care homes must also provide
care but are not required to provide registered or licensed
nurses. In some countries such as Canada, nursing homes are
called residential care homes or homes for the aged and are equivalent to nursing homes because they also require registered or
licensed nurses.22 This article focuses on nursing homes that
require licensed nursing staff.
First, this commentary examines the need for higher
federal minimum nursing staff standards for RNs and total
nursing staff in U.S. nursing homes and provides a rationale
for this perspective. Second, this commentary examines the
barriers to adopting higher federal staffing standards in the
U.S. The regulation of nursing home staffing in the U.S. is
expected to be of interest to researchers and policy makers in
other countries that have low nursing home staffing standards
and staffing levels such as in Canada and England.22,23

Part I: Nurse Staffing and Quality

High nurse staffing levels and quality. Over the past
25  years, numerous research studies have documented a
strong positive impact of nurse staffing on both care process
and outcome measures.18 Over 150 staffing studies have been
documented in systematic reviews, conducted primarily in the
U.S. but also including studies in Canada, United Kingdom,
Germany, Norway, and Sweden.24–28 The strongest positive
relationships are found between RNs (with two to four years
of training) and quality, which is stronger than the relationship between licensed vocational/practical nurses (LVNs/
LPNs; who have less training than RNs) and quality. Total
nurse staffing levels (which includes RNs, LVNs/LPNs, and
certified nursing assistants [CNAs; with about two weeks of
training]) are also related to quality.24–28
Although some studies have found mixed results, many
of these had methodological problems with small sample sizes,
single-state analysis, and cross-sectional designs.27 In addition, weak relationships may be found when studies include
14

Health Services Insights 2016:9

nursing homes with extremely low staffing, because evidence
suggests that there is a minimum threshold of staffing that
must be reached before staffing levels show higher quality.17,29
Longitudinal studies and studies that take into account the
complex endogenous relationships between RN staffing, resident acuity, and quality have generally shown strong positive
relationships between staffing and quality of care. 30–32
While a minimum staffing level is a necessary prerequisite to providing good quality of care, nursing staff also must
be well trained and managed. High professional staff mix
(ratios of RN to total staffing levels), low turnover rates, consistency of staffing, and low use of agency staff are all strongly
associated with high quality.33–37 Staffing levels and the other
factors are interrelated. For example, low staffing levels are
associated with high turnover rates and vice versa.38 It is
likely that adequate staffing levels must be addressed before
improvements can be made in other factors such as turnover,
management, and competency.
Implementation of higher minimum staffing
standards improves quality. Many studies have specifically identified the benefits of implementing higher federal
and state staffing standards. The proportion of residents with
pressure ulcers, physical restraints, and urinary catheters
decreased, following the implementation of the U.S. Nursing
Home Reform Act in 1987, in part, due to adoption of the
24-hour licensed nursing standard. 39 Moreover, numerous
studies have consistently shown that higher state minimum
staffing levels (beyond the federal minimum requirements)
have had significant positive effects on staffing levels and
quality outcomes.19,31,40–45 In addition, higher state minimum
RN and total nurse staffing have been shown to have a
stronger effect on nursing home staffing levels than higher
Medicaid payment rates. 31
CMS and experts recommend higher minimum staffing levels. A USCMS study in 2001 established the importance of having a minimum of 0.75 RN hours per resident day
(hprd), 0.55 LVN/LPN hprd, and 2.8 (to 3.0) CNA hprd, for a
total of 4.1 nursing hprd to meet the federal quality standards
(Table 1).17 As part of this study, a simulation model of CNAs
established the minimum number of staff necessary to provide five basic aspects of daily care in a facility with different
levels of resident acuity. The results found that the minimum
threshold for CNA staffing is 2.8 hprd to ensure consistent,
timely care to residents.17
This recommended minimum threshold level was later
confirmed in a 2004 observational study of nursing home
staffing29 and in a reanalysis by Abt Associates in 2011.46
Across the entire distribution of staffing levels, there is a
strong association between higher total staffing levels and
better outcomes as defined by lower survey deficiencies and
improved resident quality measures from the Minimum Data
Set (MDS) (eg, pressure ulcers).4,46,47 Staffing is a better predictor of deficiencies than MDS quality measures, probably
because facility-reported MDS quality measures appear to be

 Higher minimum staffing standards in U.S. nursing homes
Table 1. Nursing hours per resident day reported in all U.S. nursing homes in 2014 compared to recommended minimum staffing levels and
expected staffing levels.
TOTAL NUMBER OF NURSING HOMES
(15,391) AND PERCENTILES

RN HOURS PER
RESIDENT DAY

LVN/LPN HOURS
PER RESIDENT DAY

CNA HOURS PER
RESIDENT DAY

TOTAL NURSING HOURS
PER RESIDENT DAY

90% N = 1,539

1.36

1.26

3.27

5.39

75% N = 3,848

0.98

1.02

2.80

4.55

Mean

1.00

0.90

2.64

4.54

Median N = 7,696

0.72

0.81

2.40

3.97

25% N = 3,848

0.53

0.60

2.08

3.53

10% N = 1,539

0.39

0.39

1.83

3.18

CMS study recommended
minimum standard (2)

0.75

0.55

2.80

4.10

Average CMS expected staffing based
on resident acuity (3)

1.08

0.66

2.43

4.17

Notes: (1) CMS Casper Nursing Home Staffing Data (2014). (2) USCMS. (2001). (3) Abt Associates (2015).
Abbreviations: RN, registered nurses; LVN/LPN, licensed vocational or licensed practical nurse; CNA, certified nursing assistants.

inflated.46,47 Moreover, staffing is a better predictor of hospitalization rates than the MDS quality measures.46
Some experts have recommended higher minimum staffing standards (a total of 4.55 hprd) to improve the quality
of nursing home care, with adjustments for resident acuity
or case mix.48 A number of organizations have endorsed the
minimum of 4.1 hprd standard, have recommended that at
least 30% of total nursing care hours should be provided by
licensed nurses, and have recommended that RNs should be
on duty for 24 hours per day. These organizations include
the American Nurses Association, the Coalition of Geriatric
Nursing Organizations, and the National Consumer Voice for
Quality Long-Term Care.18,49,50
Nurse staffing levels are too low in half of U.S. nursing
homes. Total facility-reported median staffing levels gradually increased from 3.7 hprd in 2009 to 3.97 hprd in 2014 and
RN hours increased from 0.5 to 0.7 hprd in the same period,
with wide variations across states.4,47
In spite of improvements, Table 1 shows that the median
nursing home has RN, CNA, and total staffing levels, which
are below the CMS recommended standard. Table 1 also
shows that nursing homes in the lowest quartile on staffing (n  =  3,848) reported CNA staffing below 2.08 hprd in
2014, which translates into ratios of about 10–11 residents to
one CNA in the day and evening shifts when the most labor
intensive care (eg, feeding assistance and incontinence care)
has to be provided. The lowest quartile of nursing homes also
reported half or less the average RN staffing, which reduces
the probability that CNAs with high workloads are well managed. Nursing homes with low total staffing are highly likely
to have low RN and LVN/LPN nurse staffing as well.46,47
Thus, half of the nursing homes have low staffing and at least
a quarter have dangerously low staffing.
Staffing levels need to be adjusted for resident acuity.
Because it is widely agreed that staffing levels should be

increased beyond the CMS minimum recommended level
when resident acuity levels increase,18,49,50 CMS’s Medicare
Nursing Home Compare Five-Star Rating System developed a method to determine the minimum nurse staffing
levels needed for each U.S. nursing home based on its resident
acuity.51 The staffing star rating is based on two measures:
total nursing hprd (RN + LVN/LPN + CNA hours) and RNspecific hprd. CMS calculates the expected hours of care based
on the resident acuity (case mix) obtained from the Resource
Utilization Group scores reported by each facility and CMS
staff time measurement studies published in 2000.52 The
CMS staffing rating is based on facility staffing compared
with other nursing homes and the staffing thresholds identified in its 2001 staffing study and confirmed in 2011.17,46,47
CMS’s recent analysis of expected staffing levels taking
into account acuity indicates that the average U.S. nursing
home should have 4.17 total nursing hprd, including 1.08 RN
hprd (Table 1). The actual total staffing level for almost 60%
of facilities is below their expected level based on facility case
mix. Almost 80% have RN staffing levels below, 30% have
LVN staffing below, and 54% have CNA staffing below the
expected levels (data not shown).47
The minimum expected staffing based on acuity should
be higher than the recommended minimums. However, the
average expected CNA staffing level of 2.43 hprd is well
below the CMS study that recommended a minimum staffing
level of 2.8 hours. This occurred because the CMS staff time
studies used for the five-star system were based on the usual
staffing reported in a selected sample home without assurance
that the care actually met the quality standards.53 A more
recent time study (called STRIVE) had the same weakness
and did not include nursing management time. Because resident acuity has increased over time,46 CMS needs to update
its staffing time studies for different levels of acuity with the
assurance that resident care actually meets acceptable quality
Health Services Insights 2016:9

15

 Harrington et al

standards. New time studies should be used to develop an
improved methodology for calculating expected nurse staffing
levels based on acuity.

Part II: Barriers to Staffing Reform

Given the existing knowledge about the importance of nurse
staffing to nursing home quality and the low staffing levels in
many nursing homes, why has the U.S. not made more progress in improving staffing levels and nursing home quality?
Perhaps Binstock’s argument that the U.S.’s ideological shift
to neoliberalism beginning in the late 1970s (that portrays
old-age benefits as burdensome and focuses on free market
policies) can explain the unwillingness to enact stronger regulatory and staffing requirements.54 Many economic, political,
public policy, and sociological theories could help understand
the failure to adopt staffing reform. While it is beyond the
scope of this commentary to discuss the theoretical issues,
some barriers are discussed below.
Economic issues. Since the passage of the U.S. 1987
Nursing Home Reform Act, the primary policy focus has been
on controlling health expenditures including nursing home
costs, and increased staffing standards appear to conflict with
cost controls. To control costs, the U.S. Congress adopted
Medicare (for aged and disabled) prospective payment rates
for nursing homes in 1997. These rates have been higher than
the cost of providing care, and Medicare profit margins have
been extremely high for many years (ranging from 10% to 21%
annually between 2000 and 2014 and over 13% in 2014). 21
Total profit margins are lower when all payer revenues are
considered, and Medicare appears to be cross-subsidizing the
low state Medicaid rates.21,55
Medicare does not conduct financial audits and has no
limits on administrative costs and profits, which are often
hidden in public reports.21,56,57 The Medicare payment system, which pays higher rates for higher resident acuity, gives
the facilities incentives to upcode resident acuity, especially
because CMS did not audit resident assessments for accuracy,
which CMS plans to implement in the future. 2 Prospective
payment also allows the facilities to keep staffing levels low
because their payment rates are not directly tied to nurse staffing levels.
The U.S. Congress has given state Medicaid programs (for
low-income populations) wide discretion in setting nursing
home payment rates, which have been lower than Medicare
rates and vary by state. Studies show a positive relationship
between higher Medicaid funding, increased staffing,58 and
higher quality.59 Nevertheless, state Medicaid programs have
financial incentives to keep payment rates low, which can have
a negative impact on staffing levels, especially in facilities
with high proportions of Medicaid residents. State Medicaid
reimbursement methods have been found to be overly complex and burdensome and have failed to achieve policy goals
of improving quality.60 Moreover, there are incentives for
cost-shifting between Medicare and Medicaid fee-for-service
16

Health Services Insights 2016:9

policies, which both focus on overall cost controls rather than
quality outcomes.61
Under current federal and state payment systems, nursing
homes are able to make choices on how to allocate their
resources with few regulatory restrictions. In 2010, California
nursing homes spent only 36% of total revenues (including
Medicare and Medicaid) on staffing and over 20% on administration and profits.56,57
About 70% of U.S. nursing homes are for-profit facilities with an orientation to maximizing profits for owners and
shareholders.13 The profit incentive has been shown to be
directly related to low staffing. For-profit nursing homes and
for-profit chains operate with lower staffing and more quality
deficiencies (violations) compared with nonprofit facilities.62–64
Facilities with the highest profit margins have been found to
have the poorest quality.65
Recognizing nursing home quality problems, the U.S.
Affordable Care Act (ACA) in 2010 focused efforts on marketbased strategies rather than on regulatory requirements such
as staffing standards. These efforts included increasing public
disclosure of ownership and expenditures, public reporting
using Medicare Nursing Home Compare, quality improvement programs, and pay-for-performance programs.3 Nurse
staffing levels were incorporated as incentives into the public
reporting system and the nursing home pay-for-performance
demonstration.
Recently, nursing home pay-for-performance demonstrations were established in eight states with incentives tied to
fewer deficiencies and higher staffing levels. Unfortunately,
these Medicaid demonstrations failed to consistently achieve
quality improvements and increase staffing levels in nursing
homes, possibly because the incentive bonuses were too low.66
This suggests that regulatory requirements may have more
impact on staffing than market-based policies.
Regulatory enforcement. The CMS is the federal agency
responsible for setting federal nursing home standards and for
regulatory oversight. CMS contracts with state agencies to
carry out the federal guidelines for surveys, complaint investigations, and enforcement compliance. Numerous investigations by governmental and Congressional agencies have
found that U.S. nursing home violations are underidentified,
and serious violations are underrated by state surveyors, while
enforcement varies widely across and within states.5–9 Often
facilities are not given penalties for serious violations, or the
penalties are so minimal that enforcement does not result in
compliance.5–9,67 Moreover, nursing homes are seldom terminated from the Medicare/Medicaid programs as a result of
violations. State political leadership has been found to be a
factor influencing the stringency of nursing home oversight,
where more liberal leadership is associated with stronger
regulation and conservative leadership with less regulation.68
A number of government reports have urged CMS to improve
its regulatory oversight and the consistency of enforcement
across and within states.5–9

 Higher minimum staffing standards in U.S. nursing homes

Within the U.S. regulatory environment, the enforcement
of current staffing requirements has been weak. Deficiencies
for low or inadequate staffing levels are rarely issued by state
inspectors, and CMS does not have the guidelines for penalties for staffing violations.68,69 When the state agencies adopt
stronger enforcement programs, the results show improvement in staffing and quality of care.19,42 To have a stronger
deterrent effect, CMS regulations would need to specify penalties for inadequate staffing levels, such as imposing automatic fines and holds on admissions until acceptable staffing
levels are reached. New approaches are needed to make the
enforcement of existing staffing standards more effective in
improving staffing and quality.
Political influences. Political conflict has been a major
factor preventing the adoption of higher staffing standards
in the U.S. The U.S. nursing home industry has consistently
opposed regulatory requirements and supported higher reimbursement rate policies and payment incentive programs to
improve nursing home quality.70 In contrast, U.S. consumer
advocacy groups have advocated for higher staffing requirements and more aggressive regulatory enforcement to improve
quality.70 Political ideologies are sharply divided between conservative and liberal politicians, where conservatives tend to
strongly oppose regulatory approaches in contrast to liberal
views that tend to support government interventions in the
marketplace.70 The role of ideology and partisanship in an era
of divided government can preclude reaching political consensus on nursing home policies.
Nursing homes, similar to other health-care industries,
attempt to influence public policies through campaign contributions, association lobbying, and educational activities.
Between 2006 and 2009, the health sector contributed
$1.7 billion in lobbying the U.S. Congress and federal agencies.71 The health industry (including nursing homes) contributions were $5 billion from 1990 to 2008.72 In 2013–2014,
the American Health Care Association (AHCA) representing
nursing homes was one of the top 16 health contributors to
federal campaigns.73 These contributions do not include those
made by individual nursing home owners, association lobbying, and industry educational activities.
State campaign contributions in the U.S. have also
involved the nursing home industry. The Kentucky nursing
home industry gave $1.8 million to Kentucky federal and
state politicians over the past decade while lobbying against
bills requiring them to hire more employees, increasing fines
for violations, and prosecuting elder abuse.74 Nursing home
industry campaign contributions were recently documented in
Arkansas for appellate court races75 and in Louisiana campaign races for state policy makers.76
The revolving door of policymakers has been another
long-standing concern, where health policymakers at the federal and state levels leave government to take jobs as lobbyists,
consultants, and strategists. Government often hires health
industry managers into high-level government positions,73

and these managers may have pro-industry and antiregulatory
perspectives and policies. Revolving doors between nursing
home companies/associations and government may occur at
the federal and state levels, and this may explain why public
officials and providers have been found to hold similar views
supporting market-incentive programs rather than regulatory
approaches.70
The imbalance of power between the nursing home
industry and consumer advocates has prevented the establishment of higher federal staffing standards. The AHCA often
hires leading politicians into leadership roles and has a large
staff in Washington, D.C., known for its effective lobbying
campaigns. The reliance of members of Congress on lobbyists
and special interest groups has been well documented.77
Although there has been a large growth in old-age interest groups in the U.S., the effectiveness of their advocacy has
been questionable54 and very few of these advocacy groups
focus on nursing home issues. Consumer organizations that do
advocate for nursing home issues have faced a constant financial struggle to survive. Although consumer advocates were
able to obtain more disclosure requirements for nursing home
ownership and expenditures, payroll reporting of staffing, and
staff criminal background checks in the ACA of 2010, 3 they
have not been able to overcome the strong industry opposition
to higher staffing standards.

Conclusion

Low staffing levels and poor quality of care continue to be
problems in a significant number of U.S. nursing homes,
despite the overall staffing improvements in many homes. The
problems of low nursing home staffing have also been found
in other countries such as the Canada and England.22,23 Compelling evidence supports the need for higher U.S. minimum
nurse staffing standards, adjusted for resident acuity, to ensure
adequate quality of nursing home care as a necessary precondition for making other quality improvements such as in leadership, management, and training. Economic, regulatory, and
political solutions are needed to ensure that all nursing homes
provide safe and high quality of care. Researchers should not
only take up the challenge of studying barriers to reform but
also studying new regulatory, payment, and accountability
strategies to improve nursing home staffing and quality.

Author Contributions

CH wrote the first draft of the manuscript. CH, JFS, MM,
and SFS all contributed to the writing and editing of the manuscript and agreed with the text and conclusions of the paper.
CH, JFS, MM and SFS all reviewed and approved the final
version of the manuscript.
REFERENCES

  1.  Omnibus Budget Reconciliation Act of 1987. Public Law 100-203. Subtitle C:
nursing home reform. Signed by President Obama, Washington, DC, December 22,
1987.

Health Services Insights 2016:9

17

 Harrington et al
  2.  U.S. Centers for Medicare and Medicaid Services. CMS Announces Two Medicare Quality Improvement Initiatives. Newsroom Media Release. 2014.
  3.  Wells J, Harrington C. Implementation of Affordable Care Act Provisions to Improve
Nursing Home Transparency and Quality. Washington, DC: Kaiser Commission
on Medicaid and the Uninsured; 2013.
  4.  Abt Associates Inc. Nursing Home Compare Five-Star Quality Rating System:
Three Year Report. Prepared for CMS. Durham, NC: 2013.
  5.  U.S. General Accounting Office. Nursing Home Quality: Prevalence of Serious
Problems, While Declining, Reinforces Importance of Enhanced Oversight—
Report to Congressional Requesters GAO-03-561. Washington, DC: GAO; 2003.
  6.  U.S. Government Accountability Office. Nursing Homes: Efforts to Strengthen
Federal Enforcement Have Not Deterred some Homes from Repeatedly Harming Residents. GAO-07-241. Washington, DC: GAO; 2007.
  7.  U.S. Government Accountability Office. CMS’s Specific Focus Facility Methodology Should Better Target the Most Poorly Performing Facilities Which
Tend to be Chain Affiliated and for-Profit. GAO-09-689. Washington, DC:
GAO; 2009.
  8.  U.S. Government Accountability Office. Nursing Homes: Addressing the Factors Underlying Understatement of Serious Care Problems Requires Sustained
CMS and State Commitment. GAO-10-70. Washington, DC: GAO; 2009.
  9.  U.S. Government Accountability Office. Nursing Home Quality: CMS Should
Continue to Improve Data and Oversight. GAO-16-33. Washington, DC: GAO;
2015.
 10.  Propublica. Popular Blood-Thinner Causing Deaths and Injuries in Nursing Homes.
Washington: 2015. Available at: http://www.washingtonpost.com/national/
health-science/popular-blood-thinner-causing-deaths-injuries-in-nursinghomes/2015/07/12/be34f580-1469-11e5-89f3-61410da94eb1_story.html
  11.  Thomas K. Medicare Star Ratings Allow Nursing Homes to Game the System.
New York: New York Times; 2014.
 12.  U.S. Centers for Medicare and Medicaid Services. Nursing Home Penalty Data
2014. Baltimore, MD: CMS; 2014. Available at: https://data.medicare.gov/
Nursing-Home-Compare/Penalty-Counts/t8q7-k6ku
  13.  Harrington C, Carrillo H, Garfield R. Nursing Facilities, Staffing, Residents, and
Facility Deficiencies, 2009 Through 2014. Washington, DC: Kaiser Family Foundation; 2015. Available at: www.kff.org
  14.  U.S. Centers for Medicare and Medicaid Services. Nursing Home Data Compendium 2013 Edition. Baltimore, MD: CMS; 2014.
  15.  U.S. Office of the Inspector General. Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries. OEI-06-11-00370.
Washington, DC: OIG; 2014.
  16.  U.S. Office of the Inspector General. Medicare Nursing Home Resident Hospitalization Rates Merit Additional Monitoring. OEI-06-11-00040. Washington, DC:
OIG; 2013.
  17.  U.S. Centers for Medicare and Medicaid Services, Abt Associates Inc. Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes. Report to Congress:
Phase II Final. Volumes I-III. Baltimore, MD: CMS; 2001.
  18.  Institute of Medicine. Keeping Patients Safe: Transforming the Work Environment
of Nurses. Washington, DC: National Academy of Medicine; 2004.
  19.  Lin H. Revisiting the relationship between nurse staffing and quality of care in
nursing homes: an instrumental variables approach. J Health Econ. 2014;37:13–24.
  20.  U.S. Department of Health and Human Services. Medicare and Medicaid programs: reform of requirements for long-term care facilities. Proposed Rules 42
CFR Parts 405, 431, 447. Fed Regist. 2015;80(136):42168–42269.
  21.  Medicare Payment Advisory Commission (MedPac). Report to Congress: Medicare Payment Policy: Skilled Nursing Facility Services, Chapter 8. Washington, DC:
MedPac; 2015:181–209.
  22.  Harrington C, Choiniere J, Goldmann M, et al. Nursing home staffing standards
and levels in six countries. Image J Nurs Sch. 2012;44(1):88–98.
 23.  McGregor MJ, Murphy JM, Poss JW, et al. 24/7 registered nurse staffing
coverage in Saskatchewan nursing homes and acute hospital use. Can J Aging.
2015;34(4):492–505. doi: 10.1017/S0714980815000434.
  24.  Backhaus R, Verbeek H, van Rossum E, Capezuti E, Hamer JPH. Nursing staffing impact on quality of care in nursing homes: a systemic review of longitudinal
studies. J Am Med Dir Assoc. 2014;15(6):383–393.
  25.  Bostick JE, Rantz MJ, Flesner MK, Riggs CJ. Systematic review of studies of
staffing and quality in nursing homes. J Am Med Dir Assoc. 2006;7:366–376.
  26.  Castle N. Nursing home caregiver staffing levels and quality of care: a literature
review. J Appl Gerontol. 2008;27:375–405.
  27.  Dellefield ME, Castle NG, McGilton KS, Spilsbury K. The relationship between
registered nurses and nursing home quality: an integrative review (2008–2014).
Nurs Econ. 2015;33(2):95–108, 116.
  28.  Spilsbury K, Hewitt C, Stirk L, Bowman C. The relationship between nurse staffing and quality of care in nursing homes: a systematic review. Int J Nurs Stud. 2011;
48(6):732–750. doi: 10.1016/j.ijnurstu.2011.02.014.
  29.  Schnelle JF, Simmons SF, Harrington C, Cadogan M, Garcia E, Bates-Jensen B.
Relationship of nursing home staffing to quality of care? Health Serv Res. 2004;
39(2):225–250.

18

Health Services Insights 2016:9

  30.  Castle NG, Anderson RA. Caregiver staffing in nursing homes and their influence on quality of care. Med Care. 2011;49(6):545–552.
 31.  Harrington C, Swan JH, Carrillo H. Nurse staffing levels and Medicaid
reimbursement rates in nursing facilities. Health Serv Res. 2007;42:1105–1129.
 32. Konetzka RT, Stearns SC, Park J. The staffing outcomes relationship in
nursing homes. Health Serv Res. 2008;43(3):1025–1042. doi: 10.1111/j.
1475-6773.2007.00803.x.
  33.  Castle N. Use of agency staff in nursing homes. Res Gerontol Nurs. 2009;2(3):
192–201.
  34.  Castle N, Engberg J. The influence of staffing characteristics on quality of care in
nursing homes. Health Serv Res. 2007;42:1822–1847.
  35.  Castle N, Engberg J. Further examination of the influence of caregiver staffing
levels on nursing home quality. Gerontologist. 2008;48:464–476.
  36.  Castle N, Engberg J. The influence of agency staffing on quality of care in nursing
homes. J Aging Soc Policy. 2008;20(4):437–453.
  37.  Castle NG, Engberg J, Men A. Nurse aide agency staffing and quality of care in
nursing homes. Med Care Res Rev. 2008;65(2):232–252.
  38.  Harrington C, Swan JH. Nurse home staffing, turnover, and casemix. Med Care
Res Rev. 2003;60(2):366–392.
  39.  Zhang ZX, Grabowski DC. Nursing home staffing and quality under the nursing home reform act. Gerontologist. 2004;44:13–23.
 40.  Bowblis JR. Staffing ratios and quality: an analysis of minimum direct
care staffing requirements for nursing homes. Health Serv Res. 2011;46(5):
1495–1516.
  41.  Mueller C, Arling G, Kane R, Bershadsky J, Holland D, Joy A. Nursing home
staffing standards: their relationship to nurse staffing levels. Gerontologist. 2006;
46(1):74–80.
 42.  Mukamel DB, Weimer DL, Harrington C, Spector WD, Ladd H, Li Y. The
effect of state regulatory stringency on nursing home quality. Health Serv Res.
2012;47(5):1791–1813.
  43.  Park J, Stearns SC. Effects of state minimum staffing standards on nursing home
staffing and quality of care. Health Serv Res. 2009;44(1):56–78.
  44.  Tong PK. The effects of California minimum nurse staffing laws on nurse labor
and patient mortality in skilled nursing facilities. Health Econ. 2011;20:802–816.
  45.  Zhang ZX, Unruh L, Liu R, Wan TTH. Minimum nurse staffing ratios for
nursing homes. Nurs Econ. 2006;24(2):78–93.
  46.  Abt Associates Inc. Nursing Home Staffing Study TEP Presentation. Prepared
for the CMS Medicare Nursing Home Compare 5-Star TEP Panel. Durham,
NC: Abt Associates Inc; 2011.
  47.  Abt Associates. Analysis of www.data.medicare.gov (5-Star Archived Data) and the
Medicare Cost Report Data. Durham, NC: 2015. Available at: https://www.cms.
gov/Research-Statistics-Data-and-Systems/Downloadable-Public-Use-Files/
Cost-Reports/?redirect=/CostReports/
  48.  Harrington C, Kovner C, Kayser-Jones J, et al. Experts recommend minimum
nurse staffing standards for nursing facilities in the United States. Gerontologist.
2000;40(1):1–12.
 49.  American Nurses’ Association. Nursing Staffing Requirements to Meet the
Demands of Today’s Long-Term Care Consumer Recommendations from the
Coalition of Geriatric Nursing Organizations (CGNO). Position Statement.
2014. Available at: www.nursingworld.org
 50. Coalition of Geriatric Nursing Organizations (CGNO). Nursing Staffing
Requirements to Meet the Demands of Today’s Long-Term Care Consumer Recommendations. 2013. Available at: http://nadona.org/pdfs/CGNO%20Nurse%20
Staffing%20Position%20Statement%201%20page%20summary.pdf
 51.  U.S. Centers for Medicare and Medicaid Services. Medicare Nursing Home
Compare. 2015. Available at: http://www.medicare.gov/NursingHomeCompare/
search.aspx?bhcp=1
 52.  U.S. Centers for Medicare and Medicaid Services. Nursing and Therapy Minutes (Used in Calculating Preliminary Rates: April 10, 2000. Federal Register PPS
Update. 2000. Available at: https://www.cms.gov/Medicare/Medicare-Fee-forService-Payment/SNFPPS/index.html
  53.  Fries BE, Schneider DP, Foley WJ, Gavazzi M, Burke R, Cornelius E. Refining
a case-mix measure for Nursing Homes Resource Utilization Groups (RUG-III).
Med Care. 1994;32(7):668–685.
  54.  Binstock RH. From compassionate ageism to intergenerational conflict? Gerontologist. 2010;50(5):574–585.
  55.  Troyer JL. Cross-subsidization in nursing homes: explaining rate differentials
among payer types. South Econ J. 2002;68(4):750–773.
 56.  Harrington C, Ross L, Kang T. Hidden owners, hidden profits and poor
nursing home care: a case study. Int J Health Serv. 2015;45(4):779–800. doi:
10.1177/0020731415594772.
  57.  Harrington C, Ross L, Mukamel D, Rosenau P. Improving the Financial Accountability of Nursing Facilities. Washington, DC: Kaiser Commission on Medicaid
and the Uninsured; 2013.
  58.  Mukamel DB, Kang T, Collier E, Harrington C. The relationship of California’s
Medicaid reimbursement system to nurse staffing levels. Med Care. 2012;50(10):
836–842.

 Higher minimum staffing standards in U.S. nursing homes
  59.  Mor V, Gruneir A, Feng Z, Grabowski DC, Intrator O, Zinn J. The effect of state
policies on nursing home resident outcomes. J Am Geriatr Soc. 2011;59(1):3–9.
  60.  Miller EA, Mor V, Grabowski DC, Gozalo PL. The devil’s in the details: trading
policy goals for complexity in Medicaid nursing home reimbursement. J Health
Polit Policy Law. 2009;34(1):93–135.
  61.  Grabowski DC. Medicare and Medicaid: conflicting incentives for long-term
care. Milbank Mem Fund Q Health Soc. 2007;85(4):579–610.
  62.  Comondore VR, Devereaux PJ, Zhou Q , et al. Quality of care in for-profit and
not-for-profit nursing homes: systematic review and meta-analysis. BMJ. 2009;
339:b2732.
 63.  Harrington C, Olney B, Carrillo H, Kang T. Nurse staffing and deficiencies
in the largest for-profit chains and chains owned by private equity companies.
Health Serv Res. 2012;47(1 pt I):106–128.
 64.  Stevenson D, Bramson JS, Grabowski DC. Nursing home ownership trends
and their impacts on quality of care: a study using detailed ownership data from
Texas. J Aging Soc Policy. 2013;25:30–47.
  65.  O’Neill C, Harrington C, Kitchener M, Saliba D. Quality of care in nursing
homes: an analysis of the relationships among profit, quality, and ownership.
Med Care. 2003;41(12):1318–1330.
  66.  Werner RM, Konetzka RT, Polsky D. The effect of pay-for-performance in nursing homes: evidence from state Medicaid programs. Health Serv Res. 2013;48(4):
1393–1414.
  67.  Harrington C, Stockton J, Hoopers S. The effects of regulation and litigation
on a large for-profit nursing home chain. J Health Polit Policy Law. 2014;39(4):
781–809.
  68.  Harrington C, Tsoukalas T, Rudder C, Mollot RJ, Carrillo H. Variation in the
use of federal and state civil money penalties for nursing homes. Gerontologist.
2008;48(5):679–691.

 69.  Edelman T. Deficiencies in Nursing Facilities: Rarely Cited, Seldom Sanctioned. Washington, CD: Center for Medicare Advocacy; 2014. Available
at: http://www.medicareadvocacy.org/staffing-deficiencies-in-nursing-facilitiesrarely-cited-seldom-sanctioned/
  70.  Miller EA, Mor V, Clark M. Reforming long-term care in the United States:
findings from a national survey of specialists. Gerontologist. 2010;50(2):238–252.
 71.  Steinbrook R. Lobbying, campaign contributions, and health care reform. N
Engl J Med. 2009;361:e52.
 72.  Americans for Campaign Reform. Health Industry Money in Politics. Concord,
NH: ACR; 2010. Available at: http://www.acrreform.org/research/healthcareindustry-money-in-politics/
 73.  Open Secrets.org: Center for Responsive Politics. Health Lobbying. Washington, DC: 2014. Available at: http://www.opensecrets.org/industries/indus.
php?ind=H
  74.  Cheves J. Nursing Home Industry Spends Big on Ky. Politicians. Industry Spends to
Lobby Against Staffing Rules and Stricter Oversight. 2010. Available at: Kentucky.
com; http://www.kentucky.com/2010/08/22/1402320/nursing-home-industryspends-big.html
  75.  Brantley M. Nursing Home Industry Pours Big Money into Arkansas Appellate
Court Races. Little Rock, AR: Arkansas Blog, Arkansas Times; 2014.
  76.  Zurik L. Nursing Homes Pump Millions into Campaigns While Benefiting from
Favorable State Policies. The Times-Picayune; 2013. Available at: NOLA.com
 77.  Weissert CS, Weissert WG. Governing Health: The Politics of Health Policy.
Baltimore: Johns Hopkins University Press; 2002.

Health Services Insights 2016:9

19