In the updated Nursing Home Five-Star Quality Rating System that was launched this past summer by the Centers for Medicare & Medicaid Services (CMS), achieving a top-rated staffing star is harder than ever before.
In order to receive a five-star rating for staffing under Nursing Home Compare, facilities need to achieve over 0.710 hours per resident, per day of staffing with registered nurses (RNs) and administrative nurses and 4.418 for total nursing, including RNs, licensed practical nurses (LPNs), and certified nurse assistants (CNAs).
These staffing levels are higher than what was required in order to achieve a five-star staffing rating in the previous system.

Link Found Between Staffing, Outcomes

According to the Five-Star Technical User’s Guide, there is considerable evidence for a strong correlation between nursing home staffing levels, staffing stability, and resident outcomes. However, staffing that enhances a facility’s five-star rating, fits the facility budget, and meets the residents’ needs is not necessarily easy to achieve.
Administrators and directors of nursing spend countless hours each year budgeting, scheduling, and managing staffing levels in order to provide quality nursing care to their residents.
Many facilities instruct their staffing coordinators to staff by hours per resident, per day and might adjust the schedule down, if census drops, and up if it increases.
But simply using hours per resident, per day alone may not be enough to meet residents’ needs—and certainly may not help a nursing home achieve a five-star rating.
Enhanced staffing management that assists facilities to balance resident needs within budgetary constraints utilizes four faces of staffing: hours per patient day, ratios, acuity, and average wage. When all four elements of staffing are considered together, managers can have increased confidence in the adequacy of their staffing.

Element 1: Hours Per Patient Day

A simple calculation is used to determine the number of hours needed to care for the residents. For example, if the direct care nursing budget is 0.80 RNs per patient day (PPD), 0.45 LPNs PPD, and 2.60 CNAs PPD, the total nursing direct care hours per patient day should be 3.85 (see box, right).

The budgeted hours per patient day is then multiplied by the census to determine the total number of hours by job category that is allowed in a 24-hour period.
The hours per patient day (HPPD) are usually fixed for a year, based on the established numbers in the annual budget. It is recommended that the HPPD ratios be evaluated and adjusted periodically so that staffing levels are realigned when acuity changes.
Many states require a minimum number of staffing hours per patient day, but those levels are significantly below what is needed to care for most residents and won’t reflect an acceptable staffing star.

Element 2: Staff-To-Resident Ratios

Once the determination has been made about how many HPPD are needed based on census, it is important to establish the ratio of licensed staff and non-licensed staff needed for the number of residents.
Several common theories exist with regard to allocation of staff members by shift, but a facility’s staffing plan should be specific to the organization’s own needs. In some facilities, a formula is used that allocates 50 percent of the staff to the day shift, 33 percent to the evening shift, and 17 percent to the night shift.
Another way to determine the staffing ratio is to establish the number of caregivers needed for the number of residents in each care group.
For example, on day shift, one CNA for eight to 10 residents; on evening shift, one CNA for 10 to 12 residents; and on the night shift, one CNA for 12 to 14 residents.
When determining staffing ratios, include calculating ratios by resident units and the different shifts separately.
The ratios that a facility establishes can vary based on the type of residents a facility specializes in caring for and by the residents’ dependencies. For instance, with a specialized unit for dementia, more support may be required on the evening and night shifts, particularly from CNAs. On a unit that focuses on medically complex residents, an added emphasis might need to be placed on licensed hours.

Element 3: Resident Acuity

Staffing by acuity utilizes resource utilization groups (RUGs) III or RUGs IV levels to determine the level of care needs a facility population represents. This element focuses on adjusting staffing levels to take into account changes in RUG levels and to anticipate the needs of the residents as census varies.
As nursing homes care for more complex residents, adjusting for acuity becomes more critical.
Understanding RUGs and what each level represents related to resident needs can be difficult to determine. Most facilities do not have mechanisms in place to calculate and make acuity adjustments.
Staffing studies conducted by CMS provide statistics on the amount of RN, LPN, and CNA hours utilized to create the case-mix index for Medicare RUG levels.
Some states also have developed case-mix index measures that can be used by facilities to determine nursing hours by RUG category. The state and federal information can be a starting point to establish acuity averages and staffing hours.

Element 4: Average Wage

The fourth element for balancing staffing according to resident needs is the average cost of the employee wages for the hours determined necessary. Establish the average wage for RN, LPN/licensed vocational nurse, CNA, and medication aides based on payroll records. Include pool or contract nursing expense and overtime for regular staff in the average wage calculation as well.
It is also advisable to separate the average wage calculation by each job category.
Once the average wage is determined, it can be multiplied by the HPPD to ensure that staffing is in line with the facility budget.

Pulling It All Together

Each of the four elements involves separate calculations and tracking system tools. Excellent communication between all decision makers regarding resident care needs is paramount to successful staffing.
Finally, employing these four elements effectively is doomed for failure if residents’ voices and choices in their care are not taken into consideration.
While utilizing the four faces of staffing, be sure to create work routines and the mix of licensed and non-licensed nursing staff schedules around residents’ wishes and goals.
■ Centers for Medicare & Medicaid Services, Five-Star Quality Rating:
■ Frandsen, B., and Arellano, M., (2012) “Human Resource Management,” Denver, AANAC.
Judi Kulus, NHA, RN, MAT, C-NE, RAC-MT, is vice president of curriculum development for the American Association of Nurse Assessment Coordination. She can be reached at (800) 768-1880.