Long-term care workforce shortages exist in in all states, exacerbated by an increasingly older U.S. population with complex care needs and high turnover rates that have not recovered since the COVID-19 pandemic. Within this space, nursing facilities are facing unique pressure through proposed federal rules that may increase demand for long-term care professionals.
Since 1996, research has identified nursing staffing levels as a critical factor in quality of care in nursing facilities. A 2001 study by the Centers for Medicare & Medicaid Services (CMS) recommended a total of 4.1 hours of nursing care per resident per day (HPRD), including:
- 0.75 hours provided by a registered nurse (RN).
- 0.55 hours provided by a licensed professional nurse (LPN) or licensed vocational nurse (LVN).
- 2.8 - 3.0 hours provided by a certified nursing assistant (CNA).
The federal government historically has not set HPRD or staffing ratio requirements. States may set minimum staffing requirements, and most fall short of recommended staffing levels.
Proposed Federal Staffing Requirements
Federal law currently requires nursing homes that receive reimbursement from Medicaid or Medicare to provide 24-hour licensed nursing services, which are “sufficient to meet the nursing needs of [their residents].”
In September 2023, CMS issued a proposed rule that would establish the first minimum staffing levels for nursing facilities. The rule would require 24/7 RN staffing and set HPRD requirements for RNs and CNAs, but does not include requirements for LPNs or LVNs. All facilities would have to complete an individual needs assessment within 60 days following publication of the final rule. Urban and suburban facilities would have three years following publication to implement staffing requirements; rural facilities would have up to five years. The proposed rule would permit a hardship exemption if a facility can document the unavailability of a local nursing workforce and good faith efforts to hire and retain staff.
According to KFF, over 80% of nursing facilities would need to hire nursing staff to meet the required number of hours for registered nurses and nurse aides if the rule were to pass. In more than half of states, less than one-quarter of nursing facilities would meet the proposed staffing requirements.
Existing State Staffing Requirements
In addition to federal requirements, states may set additional nursing facility requirements through “sufficient staffing” standards, staffing ratios or HPRD requirements, as shown in the map below.
State Staffing Requirements for Nursing Facilities
Note: NCSL is in the process of obtaining the statutes from territories and will update when they are available.
States generally include language aligning with federal requirements that an RN must be on-duty for eight consecutive hours per day, seven days per week. States may distinguish staffing ratios or HPRD requirements by shift (Arkansas), level of care (Massachusetts) or the number of residents (Idaho).
At least 16 states include unspecified sufficient staffing requirements, and at least 34 states and the District of Columbia define a staffing ratio or HPRD requirement in statute. Oregon defines minimum staffing ratios for nursing facilities based on day, evening and night shifts, but notes that these “numbers represent a minimum staffing requirement, not sufficient staffing.” States may include direct bedside care provided by the director of nursing or charge nurse in staffing requirements (New Mexico), or they may exclude these positions from staffing ratio and HPRD requirements (Kansas).
State Actions to Bolster the Long-Term Care Workforce
States are turning to recruitment and retention strategies to bolster long-term care staffing in years to come. Understanding the magnitude and unique challenges of the long-term care workforce is often an important step for states. Several have required statewide studies on the topic, including Colorado, Florida, Maryland and Minnesota.
Many states collaborate with local education institutions to establish career pathway programs into and throughout long-term care occupations. Following a study of health professions in 2018, Indiana’s largest community college, Ivy Tech, leveraged data to create a CNA bridge program toward a “Certificate in Pre-Nursing Studies.” This is considered a pathway into the Practical Nursing and Associate of Science in Nursing programs. Washington launched the Long-Term Care Project in July 2022, creating an apprenticeship with local community and technical colleges to provide on-the-job training for CNAs and home care aides to become LPNs.
Direct care jobs tend to pay wages near or below the poverty threshold. Women of color comprise nearly half of the direct care workforce and are more likely than men or white women to rely on some form of public assistance, such as food and nutrition assistance. Higher wages and benefits have been shown to improve recruitment outcomes and retention rates in long-term care settings, and state Medicaid programs have significant leverage as the primary payer for long-term care. At least 19 states are leveraging Medicaid reimbursement to increase provider payment rates and wages in long-term care settings.