Skip to main content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.


The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

State Experiences with Minimum Nursing Staff Ratios for Nursing Facilities: Findings from Case Studies of Eight States

Publication Date
Oct 31, 2003

U.S. Department of Health and Human Services

State Experiences with Minimum Nursing Staff Ratios for Nursing Facilities: Findings from Case Studies of Eight States

Executive Summary

Jane Tilly, Dr.P.H., Kirsten Black, M.P.P., and Barbara Ormond, Ph.D.
The Urban Institute

Jennie Harvell
U.S. Department of Health and Human Services

November 2003

This report was prepared under contract #HHS-100-97-0010 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and the Urban Institute. For additional information about the study, you may visit the DALTCP home page at or contact the ASPE Project Officer, Jennie Harvell, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. Her e-mail address is:

Research presented in this report was supported by the Office of Disability, Aging and Long-Term Care Policy, within the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services (HHS), contract number HHS-100-97-0010. Inferences and conclusions drawn are solely those of the authors and do not necessarily reflect the views of the Urban Institute, the Technical Advisory Group, or HHS.

In an effort to improve the quality of care in nursing homes, Congress passed the Nursing Home Reform Act of 1987, requiring, in part, nursing homes that wish to be certified for participation in Medicare or Medicaid to provide a minimum of eight hours per day of registered nursing (RN) service and 24 hours per day of licensed nursing (LN) service. Regulations implementing this legislation also require, "sufficient nursing staff to attain or maintain the highest practicable ... well-being of each resident." However, the Nursing Home Reform Act and resultant regulations do not mandate a specific staff-to-resident ratio or a minimum number of hours per resident day for resident care, and concerns about the quality of care in nursing homes have continued.

The Department of Health and Human Services (DHHS) has sponsored research examining the relationship between the level of nursing staff and the quality of resident care in nursing homes. Recently, the Centers for Medicare and Medicaid Services (CMS) reported the findings of research conducted by Abt Associates in their Phase I and Phase II studies. These reports find a relationship between staffing levels and quality of care and evidence of critical thresholds for nursing staff, below which nursing home residents are at risk for serious quality-of-care problems, and above which no measurable increases in quality of care are observed with additional nursing staff.

Despite improvements in both the data and the analysis from the Phase I to the Phase II studies, DHHS expressed concerns about Phase II's findings. In a letter from DHHS Secretary Tommy Thompson to Congress, Thompson pointed out that the relationship between the number of staff and the quality of care is complex, listing several important staffing issues related to nursing home quality of care that the Phase I and II studies do not adequately address. Subsequently, the DHHS Office of the Assistant Secretary for Planning and Evaluation (ASPE) determined that more information about nursing home staffing requirements was needed.

The purpose of this study is to identify states with established minimum nursing staff ratios for nursing homes and examine those states' experiences with implementing or modifying these standards. A review of the published and unpublished literature on state standards identified 36 states with established minimum ratios in 2003, with the District of Columbia scheduled to implement its ratios in 2005. Twenty-three states have changed their minimum nursing staff ratios since 1997. Three of these states--Arizona, Missouri, and Nevada--previously had staffing ratios but no longer do. The 14 states, and the District of Columbia until 2005, that do not have minimum nursing staff ratios use the federal nursing staff requirements for Medicaid and Medicare participating facilities, or have state professional coverage standards for nursing home licensure that are similar to or exceed the federal requirements. These professional coverage standards are not the focus of this study.

We chose 10 states out of the total 23 with recent changes in their minimum nursing staffing ratios to find out why the states set, modified, or eliminated their staffing ratios; how the standard in question was implemented; how compliance was monitored; and the perceived effects of the standards. The 10 case study states--Arkansas, Arizona, California, Delaware, Minnesota, Missouri, Nevada, Ohio, Vermont, and Wisconsin--represent a diverse group in terms of population size and geographic area. Of these states, Vermont instituted new staffing ratios; Arkansas, California, Delaware, Minnesota, Ohio, and Wisconsin modified existing ratios; and Arizona, Missouri, and Nevada eliminated their ratios.

Research methods involved guided discussions with state officials and key stakeholders. The stakeholders were chosen to represent those affected by the nursing staff standards--consumers, nursing homes, and their employees. Discussants were sent a project description and a copy of the discussion guide we used during the telephone conversations. Discussants were assured that we would not identify or quote anyone by name.

In eight of the 10 states, we were able to have discussions with most state officials and key stakeholders. However, we were not able to hold a sufficient number of discussions in Arizona and Nevada to include these states in the analysis. In Arizona, key state officials had no knowledge of the circumstances surrounding the elimination of the minimum staffing ratios in 1997, and stakeholders told us they had come into their positions after 1997. In Nevada, state officials were not available for interviews. However, we were able to hold a discussion with one key Nevada stakeholder who provided us with some insight into why this state eliminated its staffing ratio.

Findings from our research reveal that staffing ratios can be implemented or removed in different ways, including through passage of new legislation, as part of new regulations, through written administrative policy or procedures, and/or through the Medicaid reimbursement structure. The state authority establishing the ratios often affects how easy it is to modify or eliminate them.

Among the eight case study states, all but Vermont had some form of a minimum staffing ratio in place prior to the changes in their requirements. Recent changes to state ratios typically came about as a reaction to publicity about quality problems in nursing homes and with the goal of improving the quality of resident care in nursing facilities. However, we found considerable variation across the study states in the type of ratio, measurement of the ratio, adjustment for case mix, monitoring and enforcement of the ratio, and payment for ratios.

Three of the study states--California, Minnesota, and Vermont--use an hours per resident day only (hprd) approach, with the level set at about 3.0 hprd. Another three study states--Delaware, Ohio, and Wisconsin--use a combination hprd and staff-to-resident ratio, which is a compromise that adds to the complexity of the system. Arkansas was the only case study state to use a staff-to-resident ratio only.

The time period to which hprd ratios apply is also a matter of some controversy among stakeholders. Five of the six study states with the hprd have opted to calculate compliance over a 24-hour period. Some observers advocate calculations over a 24-hour period to ensure adequate staffing on all days, particularly weekends, while others generally prefer calculations over a week or more (as in Vermont) to ensure flexibility.

Most observers agreed that adjustment of the ratios to take into account resident case mix would be ideal but recognized that this would add more complexity to the ratios, and few had suggestions about how to form a case-mix adjusted ratio. Only two states--Minnesota and Wisconsin--have adjusted their hprd requirements for resident case mix. Wisconsin's standard has three hprd categories (intensive skilled nursing care, skilled nursing care, and intermediate care) that are based on resident need. Minnesota recently rescinded a case-mix adjusted ratio that relied on data from the state's mandatory resident assessment instrument. Currently, Minnesota is studying how to implement a new case-mix adjusted ratio to accompany its new case-mix reimbursement system. The outcome of this state's study could shed some light on this particular aspect of ratios.

In addition to the variation in ratios, we saw variation in the enforcement of the standards across the states. States generally rely on the state licensing process for monitoring and enforcement of staffing ratios, because meeting the minimum ratios is part of state nursing home licensure and regulatory requirements. In addition to the survey process, Arkansas and Vermont periodically review monthly staffing data submitted by facilities, which helps state officials monitor staffing ratios. Most states also monitor staffing when investigating any complaints about poor quality of care that may be related to insufficient staffing. Nursing facilities that are not in compliance with a staffing ratio receive a deficiency citation and are generally required to submit a plan of correction only when the problem is not severe or has not resulted in serious harm to residents. If the harm is serious or the problem persistent, more severe remedies are available, including directed plans of correction, fines, and restrictions on new admissions. No information was provided regarded states use of these more severe penalties.

Observers had contradictory comments about the use of federal and state staffing standards. For example, most stakeholders agreed that when Missouri eliminated its staffing ratio, staffing and quality did not change as a result. In fact, some discussants suggested that the number of citations for staffing-related quality of care problems had increased, not because there were more quality problems but because it was easier to cite staffing problems under the federal standard of having "sufficient staff" than under the old staff-to-resident ratio. In contrast, stakeholders in other states believed that it is easier to cite a facility for insufficient staff when a ratio exists.

Eight study states have some form of data collection on nursing staff, although the content of the state data sets and the years for which data are available vary widely. The data most often come from Medicaid cost reports, but in Wisconsin and Delaware data are also available from an annual survey of facilities. Arkansas and Vermont collect data from the monthly staffing reports that facilities submit. California has the most extensive and most readily available data, derived from an annual report that merges Medicaid cost reporting with a state public disclosure report.

Most states have not used their data to examine the effects of changes to their staffing ratios, vis-à-vis either the level of staffing or quality. Most respondents were unwilling even to speculate about whether an effect could be found in the data and there are documented limitations associated with current data sources such as OSCAR and MDS. Some state officials said, and the data from California and Wisconsin support the contention, that the implementation or strengthening of a staffing ratio has resulted in increased staffing in nursing facilities overall. Advocates and ombudsmen generally say that it is too early to tell whether ratio changes have had any effect, while providers tend to say that most facilities in the state were already staffing above the new ratios, so there has been no effect. Furthermore, while it might be possible in some states to link the state staffing data to deficiency data, the problem of how to interpret any changes in deficiency citations would remain. Factors such as increased administrative attention to selected care areas and training provided to surveyors on citation practices may increase deficiency citations in those areas.

Although a few advocates complained of lax enforcement and a few providers complained of inadequate reimbursement, for the most part, the implementation of new ratios in three states ran relatively smoothly. These states--California, Ohio, and Wisconsin--had made incremental changes to their existing ratios. Those states where implementation was more controversial include Arkansas, Delaware, and Vermont. These states made more comprehensive changes to staffing requirements, involving phase-in periods, implementing standards by shift, or implementing a new system altogether, as in Vermont. Concern over reporting requirements and delayed increases in Medicaid reimbursement for nursing facilities were some of the implementation issues these states encountered. In most states, observers did not report a statewide shortage of certified nurse assistants (CNAs). However, certain rural and urban areas experience difficulty in recruiting these workers. Most providers asserted that a licensed nurse shortage continues to be somewhat problematic for their facilities but does not appear to have affected their ability to comply with the ratios for these professionals. Observers in some states reported that facilities' use of agency personnel increased as a direct result of changes to minimum staffing requirements, while others said this had not occurred in their states.

Other staffing-related initiatives included increased Medicaid nursing home reimbursement through a variety of mechanisms, such as a bed tax, quality improvement fee, or wage pass-through. Surprisingly, some of the states did not measure whether the funding was spent as intended. Several case study states also have undertaken various special studies or programs to examine issues such as staffing shortages and recruitment and retention in their long-term care labor market, and to provide recommendations to address these problems.

Most observers agreed that minimum ratios can help impose a standard on those facilities where staffing falls below the ratios. Thus, staffing ratios may serve as a minimum bar for facilities, not a standard that most need to strive to reach. Observers also asserted that facility staffing is not the only factor that affects the quality of care that nursing home residents receive. Other factors such as staff training and facility management also affect quality, and when asked for recommendations for the federal level, very few stakeholders called for national standards.

The Full Report is also available from the DALTCP website ( or directly at