Research and Studies of PBJ Data

🎓 Review studies of payroll-based journal data & how the media reported research findings

How is PBJ Data Being Studied and Analyzed?

Payroll-based journal data is publicly available to anyone at data.cms.gov.  Academic researchers, policy and patient advocates and the media began analyzing and publishing studies of PBJ data in 2018.  With the COVID pandemic, there was even more interest in how nursing homes manage staffing.

PBJ Central is cataloguing all known published studies of payroll-based journal data to see how PBJ data is used and interpreted.

Important Caveats

We recommend all readers fully understand the research methodology before extrapolating the findings of these studies.  Some differences may include:

  • Studies may take different approaches on how data is included vs. excluded
  • Data may be aggregated, grouped or summarized differently
  • Methodologies used to calculate staff tenure or turnover are not all the same
  • Submission errors by nursing homes may sometimes be interpreted as accurate when it should have been excluded.  CMS provides no means for facilities to go back and correct erroneous data once the submission deadline is passed.
  • CMS audits help facilities uncover errors which only get fixed in upcoming submissions, not retroactively
  • AHCA and Leading Age continue to advocate for improvements to the worked hours totals as CMS’ meal break policy and removal of salaried overtime hours may result in undercounting actual direct care hours in some facilities

PBJ Research Published in 2023

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AHCA & CLA | Staffing Mandate Analysis In-Depth Analysis on Minimum Nurse Staffing Levels & Local Impact | Updated Sep 2023, Dec 2022, Jul 2022

Staffing Mandate Analysis In-Depth Analysis on Minimum Nurse Staffing Levels and Local Impact.” CliftonLarsonAllen, 20 Sep. 2023, https://www.ahcancal.org/News-and-Communications/Fact-Sheets/FactSheets/CLA%20Staffing%20Mandate%20Analysis%20-%20September%202023.pdf

Updated September 2023| Updated December 2022Published July, 2022

On April 11, 2022, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would update Medicare payment policies and rates for skilled nursing facilities for Fiscal Year 2023. Of particular interest, CMS opened up the Minimum Staffing debate with a specific request for input on establishing minimum staffing requirements for LTC facilities.

The largest nursing home association, AHCA, together with a prominent industry consultant CliftonLarsonAllen, completed a financial cost analysis of CMS’ FY 2023 Proposed Rule to evaluate the financial impact upon the skilled nursing industry.

The September 2023 update changed to using CMS’ proposed staffing levels of 3.0 HPPD and compared itself as 60% higher industry cost than CMS identifies as the industry cost in its proposed rule.

Related News Coverage

    JAMA | Examination of Staffing Shortages at US Nursing Homes During the COVID-19 Pandemic | July 2023

    Brazier, Joan F., et al. “Examination of Staffing Shortages at US Nursing Homes During the COVID-19 Pandemic.” JAMA Network Open, vol. 6, no. 7, American Medical Association, July 2023, p. e2325993. https://doi.org/10.1001/jamanetworkopen.2023.25993.

    Staffing shortages have been widely reported in US nursing homes during the COVID-19 pandemic, but traditional quantitative research analyses have found mixed evidence of staffing shortfalls.

    In this study, qualitative and quantitative data from 40 US nursing homes were integrated to assess staffing levels during the pandemic. Short-term compensatory strategies were used by administrators to comply with minimum staffing regulations and offset staffing shortages.

    Findings from this study suggest that staffing shortages during the COVID-19 pandemic placed strain on nursing homes.

    Published July 27, 2023

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    JAMA | Association of Receipt of Paycheck Protection Program Loans With Staffing Patterns Among US Nursing Homes | July 2023

    Travers, Jasmine, et al. “Association of Receipt of Paycheck Protection Program Loans With Staffing Patterns Among US Nursing Homes.” JAMA Network Open, vol. 6, no. 7, American Medical Association, July 2023, p. e2326122. https://doi.org/10.1001/jamanetworkopen.2023.26122.

    Did staffing hours change among nursing homes that received forgivable loans through the Paycheck Protection Program (PPP), which required recipients to appropriate 60% to 75% of the loan toward staffing?

    In this economic analysis of 6008 US nursing homes, 12 weeks after PPP loan receipt, nursing homes that received a PPP loan experienced increases in certified nursing assistant hours per week and licensed practical nurse hours per week compared with nursing homes that did not receive a PPP loan. No association was found between PPP loan receipt and registered nurse staffing hours per week.

    Published July 27, 2023

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    CMS & ABT Associates | Nursing Home Staffing Study: Comprehensive Report | June 2023

    Nursing Home Staffing Study: Comprehensive Report.”ABT Associates, Jun. 2023,  https://kffhealthnews.org/wp-content/uploads/sites/2/2023/08/Abt-Associates-CMS-NH-Staffing-Study_Final-Report_-Apndx_June_2023.pdf

    A comprehensive report prepared under contract to CMS by ABT Associates summarizes results from a Nursing Home Staffing Study including reseach activities between May and December of 2022.  The report presents options for minimum nurse staffing requirements for consideration by the Centers for Medicare & Medicaid Services to prepare a minimum staffing regulation.

    This study was posted in error by CMS, and discovered by KFF Health News and offers a rare insight into the deliberations and considerations used by CMS in constructing Rules of Participation.  Due to the controversial nature of a minimum staffing rule, the industry and advocates interpreted the findings in this report in variouis ways.

    Related News Coverage

      JAMDA | New Dimensions of Staffing Patterns in Nursing Homes and Nursing Home Quality: Comparing Staffing Instability to Staffing Turnover | May 2023

      Sinha, Soham, et al. “New Dimensions of Staffing Patterns in Nursing Homes and Nursing Home Quality: Comparing Staffing Instability to Staffing Turnover.” Journal of the American Medical Directors Association, vol. 24, no. 8, Elsevier BV, Aug. 2023, pp. 1099-1105.e7. https://doi.org/10.1016/j.jamda.2023.04.009.

      This study examines how measures of staffing—turnover and instability—are associated with one another and how they independently contribute to quality of care in nursing homes.  A total of 11,840 nursing homes nationally reporting data on daily staffing and staffing turnover.
      For the 11,840 nursing homes in the study, there was a weak positive correlation between turnover and instability, with some overlap between nursing homes with high instability and high turnover. Regression analysis revealed that staffing instability and turnover contributed independently to nursing home quality, with instability having a stronger association with some measures of quality and turnover with others. Staffing instability was positively and more strongly associated with long-stay residents’ decline in activities of daily living levels and receipt of antipsychotic drugs and short-stay residents’ functioning at discharge. Turnover was positively and more strongly associated with long-stay residents’ prevalence of pressure ulcers and worsening mobility, and short-stay residents’ hospitalizations.
      Instability and turnover in total nursing home staffing independently contribute to nursing home quality. This suggests that adding measures of staffing instability to the existing measures of average staffing and staff turnover in NHCC may enhance the report card’s value for providers engaged in quality improvement and consumers searching for high-quality nursing homes.

      Published July 27, 2023

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      JAMDA | Staffing Shortages, Staffing Hours, and Resident Deaths in U.S. Nursing Homes During the COVID-19 Pandemic | May 2023

      Joshi S. “Staffing Shortages, Staffing Hours, and Resident Deaths in U.S. Nursing Homes During the COVID-19 Pandemic.” Journal of the American Medical Directors Association (2023), doi: https://doi.org/10.1016/j.jamda.2023.04.020.

      Staffing shortages at nursing homes during the COVID-19 pandemic may have impacted care providers’ staffing hours and affected residents’ care and outcomes. This study examines the association of staffing shortages with staffing hours and resident deaths in nursing homes during the COVID-19 pandemic.

      Our results showed that self-reported staffing shortages were associated with a statistically significant decrease in staffing hours and with a statistically significant increase in resident deaths. These results suggest that addressing staffing shortages in nursing homes can save lives.

      Published May 08, 2023

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      Health Affairs | Understanding Nursing Home Spending And Staff Levels In The Context Of Recent Nursing Staff Recommendations | Feb 2023

      Bowblis, John R., et al. “Understanding Nursing Home Spending and Staff Levels in the Context of Recent Nursing Staff Recommendations.” Health Affairs, vol. 42, no. 2, Health Affairs (Project Hope), Feb. 2023, pp. 197–206. https://doi.org/10.1377/hlthaff.2022.00692.

      This study examined the proportion of facility revenues spent on nursing staff, as well as nursing staff levels in hours worked and paid per resident day, in 2019.

      Nationally, the median proportion of revenues spent on nursing staff was 33.9 percent, and median nursing staff levels were 3.67 hours worked and 4.08 hours paid per resident day. Facilities with higher shares of Medicaid residents spent a larger share of revenues on nursing staff but had lower staffing levels. States varied significantly with respect to median spending on nursing staff (26.8–44.0 percent of revenues) and median nursing staff levels (3.2–5.6 hours worked and 3.6–5.7 hours paid per resident day).

      These findings indicate that raising the proportion of revenues spent by nursing homes on nursing staff to a regulated minimum would not guarantee the achievement of adequate nursing staff levels unless it was paired with other regulatory mechanisms.

      Published February,  2023

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      Health Affairs | The Role Of Real Estate Investment Trusts In Staffing US Nursing Homes | Jan 2023

      Braun, Robert Tyler, et al. “The Role of Real Estate Investment Trusts in Staffing US Nursing Homes.” Health Affairs, vol. 42, no. 2, Health Affairs (Project Hope), Feb. 2023, pp. 207–16. https://doi.org/10.1377/hlthaff.2022.00278.

      REIT investment was associated with average relative staffing increases of 2.15 percent and 1.55 percent for licensed practical nurses (LPNs) and certified nursing assistants (CNAs), respectively.

      After the three largest REIT deals were excluded, REIT investments were associated with an overall 6.25 percent relative decrease in RN staffing and no changes in LPN and CNA staffing. Larger deals resulted in increases in LPN and CNA staffing, with no changes in RN staffing; smaller deals appeared to replace more expensive and skilled RN staffing with less expensive and skilled staff.

      Published January 25, 2023

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      JAMA | Association of Staffing Instability With Quality of Nursing Home Care | Jan 2023

      Mukamel DB, Saliba D, Ladd H, Konetzka RT. Association of Staffing Instability With Quality of Nursing Home CareJAMA Netw Open. 2023;6(1):e2250389. doi:10.1001/jamanetworkopen.2022.50389

      This study examined whether staffing instability, defined as the percentage of days below average staffing levels, is associated with nursing home quality when controlling for average staffing levels.

      Findings included: staffing instability of licensed practical nurses and certified nurse aides was associated with lower quality across standard quality measures.

      This study suggests that holding average staffing levels constant, day-to-day staffing stability, especially avoiding days with low staffing of licensed practical nurses and certified nurse aides, is a marker of better quality of nursing homes. Future research should investigate the causes and potential solutions for instability in staffing in all facilities, including those that may appear well-staffed on average

      Published January 10, 2023

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      OIG | More Than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the COVID-19 Pandemic | Jan 2023

      Office of the Inspector General. “More Than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies.” Department of Health and Human Services, 19 Jan. 2023, oig.hhs.gov/oei/reports/OEI-02-20-00491.asp, January 2023.

      This is the second report in the series and builds on the first OIG report by focusing on nursing homes themselves. It looks at the extent to which they had residents who were diagnosed with COVID-19 or likely COVID-19, and the characteristics of nursing homes with extremely high infection rates. The third report will feature specific challenges nursing homes faced and the strategies they used to deal with them.

      For-profit nursing homes made up a disproportionate percentage of the nursing homes with extremely high infection rates during both surges. Other characteristics varied by surge. For example, urban nursing homes were more likely to have extremely high infection rates during the first surge, but rural nursing homes were more likely to have extremely high rates during the second surge.

      Related News Coverage

      Released January, 2023

      OIG Work Plan | Assessment of CMS's Early Use of Payroll-Based Journal Data To Improve Enforcement of Nursing Home Staffing Standards | Started Jan 2023

      Office of the Inspector General. “Assessment of CMS’s Early Use of Payroll-Based Journal Data To Improve Enforcement of Nursing Home Staffing Standards” Department of Health and Human Services, OEI-04-22-00550, January 2023.

      October 2022, CMS began to provide State Survey Agency surveyors (State surveyors) with extracts of Payroll-Based Journal (PBJ) staffing data for use in annual nursing home certification surveys (also known as “inspections”). CMS instructed State surveyors to use this data to investigate specific instances of noncompliance with hourly staffing standards (for example, the requirement to have a registered nurse on duty for a minimum of 8 hours per day). Additionally, CMS instructed State surveyors to review PBJ data for indications of whether a nursing home has met the requirement to have sufficient staffing.

      Our objective is to assess the early results of CMS’s strategy to use PBJ data to improve the enforcement of Federal nursing home staffing standards by State surveyors. We will review CMS’s plan for monitoring the success of the strategy and explore State surveyors’ experiences with using the data in their surveys.

      Expected Issue Date 2024
      Announced January, 2023

      Published in 2022

      MEDPAC | Nursing facility staffing | Sep 2022

      Linehan, Kathryn and Stubbs, Lauren. “Nursing Facility Staffing.” The Medicare Payment Advisory Commission, 2022. 

      Federal staffing requirements have been unchanged since 1987.  38 states and DC have implemented stricter minimum staffing requirements than federal requirements.

      The PBJ system has improved the accuracy of nursing facility staffing data. This report analyzed 2019-2021 PBJ data to show aggregate, sector-wide trends in total staffing, total resident days, staffing level and mix changes and changes in use of contract staff.

      Published September 29, 2022

       

      Related News Coverage

      J Am. Geriatrics | Severe neighborhood deprivation and nursing home staffing in the United States | Aug 2022

      Falvey, Jason R., et al. “Severe Neighborhood Deprivation and Nursing Home Staffing in the United States.” Journal of the American Geriatrics Society, Wiley, Aug. 2022, https://doi.org/10.1111/jgs.17990.

      Significant staffing disparities were observed within facilities located in severely deprived neighborhoods. Targeted interventions, including workforce recruitment and retention efforts, may be needed to improve staffing levels for nursing homes in deprived neighborhoods.

      Published August 8, 2022

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      JAMDA | Association between long-term care facility staffing levels and antipsychotic use in US long-term care facilities | Aug 2022

      Chappell, Victoria, et al. “Association Between Long-Term Care Facility Staffing Levels and Antipsychotic Use in US Long-Term Care Facilities.” Journal of the American Medical Directors Association, 2022. Crossref, www.jamda.com/article/S1525-8610(22)00501-1/fulltext. 

      This study sought to examine the association between staffing and antipsychotic prescribing in LTC facilities.

      These findings provide support for policy-based interventions to decrease antipsychotic use in LTC facilities by improving staffing skill mix and staffing levels. The results may also inform nursing staff education and training on antipsychotic prescribing practices

      Published August 1, 2022

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      JAMA | Association of State COVID-19 Vaccine Mandates With Staff Vaccination Coverage and Staffing Shortages in US Nursing Homes | Jul 2022

      McGarry BE, Gandhi AD, Syme M, Berry SD, White EM, Grabowski DC. Association of State COVID-19 Vaccine Mandates With Staff Vaccination Coverage and Staffing Shortages in US Nursing Homes. JAMA Health Forum. 2022;3(7):e222363. doi:10.1001/jamahealthforum.2022.2363

      This cohort study of nursing homes in 38 states found that states with a vaccine mandate experienced an increase in staff vaccination coverage compared with facilities in states with no mandate and no worsening of reported staffing shortages following the mandates.

      These findings suggest that given the waning vaccine-induced immunity and low booster dose coverage among nursing home staff in many parts of the US, state mandates for booster doses may be warranted to improve and sustain vaccination coverage in nursing homes.

      Published July 29, 2022

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      JAMA | Staffing Patterns in US Nursing Homes During COVID-19 Outbreaks | Jul 2022

      Shen, Karen, et al. “Staffing Patterns in US Nursing Homes During COVID-19 Outbreaks.JAMA Health Forum, vol. 3, no. 7, 2022, p. e222151. Crossref, jamanetwork.com/journals/jama-health-forum/fullarticle/2794538.

      Findings In this cohort study of 2967 nursing homes in 2020, owing to increased absences and departures, there were statistically significant declines in staffing levels during a severe COVID-19 outbreak that remained statistically significantly reduced 16 weeks after the outbreak’s start. Facilities temporarily increased hiring, contract staff, and overtime to bolster staffing during outbreaks, but these measures did not fully replace lost staff, particularly certified nursing assistants.

      Published July 22, 2022

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      J Am. Geriatrics | Association between staff turnover and nursing home quality – evidence from payroll-based journal data | May 2022

      Zheng, Qing, et al. “Association between Staff Turnover and Nursing Home Quality – Evidence from Payroll‐based Journal Data.Journal of the American Geriatrics Society, 2022. Crossref, agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17843.

      Staff turnover is considered an important indicator of nursing home quality. We used auditable staffing data from the Centers for Medicare & Medicaid Services (CMS) Payroll-Based Journal (PBJ) system to calculate turnover measures for nurse staff and administrators and examined the relationship between turnover and nursing home quality.

      Mean annual turnover rates were about 44% for RNs and 46% for total nurse staff. On average, there was one administrator leaving each nursing home during this period although about half of nursing homes had no administrator turnover.

      Turnover rates varied greatly across nursing homes. For-profit and larger nursing homes had higher turnover rates. Higher turnover was consistently associated with lower quality of care.

      Conclusions
      Our study highlights the importance of staff turnover due to its relationship to nursing home quality. In January 2022, CMS started posting turnover measures on Care Compare to allow consumers to use this information in their assessment of nursing home quality and to motivate nursing homes to implement innovative strategies to retain staff. While these actions are challenging, they are nonetheless warranted for improving the quality of care for nursing home residents.

      Published May 7, 2022

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      PBJ Central Notes

      This study is of particular interest as it was funded by a grant from CMS.  Authors include Evan Shulman, currently Director of the Nursing Homes division at CMS and three employees of ABT Associates, a CMS contractor working on the Five Star Quality Rating System since 2008

      Innov Aging | The Need for an Economically Feasible Nursing Home Staffing Regulation: Evaluating an Acuity-Based Nursing Staff Benchmark | Mar 2022

      John R Bowblis, PhD, The Need for an Economically Feasible Nursing Home Staffing Regulation: Evaluating an Acuity-Based Nursing Staff Benchmark, Innovation in Aging, Volume 6, Issue 4, 2022, igac017, https://doi.org/10.1093/geroni/igac017

      Despite concerns about the adequacy of nursing home (NH) staffing, the federal agency responsible for NH certification and regulation has never adopted an explicit quantitative nursing staff standard. A prior study has proposed a benchmark for this purpose based on the 1995/97 Staff Time Measurement (STM) studies. This article aims to assess the extent to which NHs staff to this proposed STM benchmark, the extent to which regulators already implicitly apply the STM benchmark, and compute the additional operating expenses NHs would incur to adhere to the STM benchmark.

      Published March 21, 2022

      JAMA | Daily Variation in Nursing Home Staffing and Its Association With Quality Measures | Mar 2022

      Mukamel DB, Saliba D, Ladd H, Konetzka RT. Daily Variation in Nursing Home Staffing and Its Association With Quality Measures. JAMA Netw Open. 2022;5(3):e222051. doi:10.1001/jamanetworkopen.2022.2051

      Is daily variation in nursing home staffing associated with quality, and does it offer additional information to measures of average staffing levels? This quality improvement study of 13 339 nursing homes found that daily variation of staffing was significantly associated with the 5-Star Survey and Quality Measures rankings. There was little agreement between the variation and the average staffing measures on quality decile rankings of nursing homes, suggesting that staffing variation provides new quality improvement information.

      Published March 14, 2022

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      MACPAC | State Policy Levers to Address Nursing Facility Staffing Issues | Mar 2022

      Medicaid and CHIP Payment and Access Commission. “State Policy Levers to Address Nursing Facility Staffing Issues”. https://www.macpac.gov/wp-content/uploads/2022/03/State-Policy-Levers-to-Address-Nursing-Facility-Staffing-Issues.pdf.  Accessed December 2022.

      Many nursing facilities have fewer direct care staff than needed to meet the care needs of their residents, a problem more common in nursing facilities that serve a high share of Medicaid-covered residents. Because such facilities also have a higher share of Black and Hispanic residents, the low staffing rates in these facilities contribute to health disparities. The COVID-19 pandemic exacerbated these disparities further. (Weech-Maldonado 2021).

      Although the federal government plays an important role in monitoring compliance with its staffing standards, states can also help address staffing challenges in several ways, including:

      • increasing Medicaid payment rates to help facilities hire more direct care staff and pay them higher wages;
      • changing Medicaid payment methods to incentivize facilities to spend more of their revenue on staff (e.g., wage pass-through payment policies that require facilities to spend a specified portion of the Medicaid rate on staff wages); and,
      • requiring that facilities meet minimum staffing standards that exceed federal requirements.

      MACPAC has documented state policies related to nursing facility staffing in State Policies Related to Nursing Facility Staffing (MACPAC 2022). This brief provides background information about staffing challenges before the COVID-19 pandemic, summarizes current state policies related to staffing, and discusses prior research about the effectiveness of these policies.

      Published March, 2022

      Related MEDPAC Publications

      Published in 2021

      Health Svcs Res | Association between nursing home staff turnover and infection control citations | Sept 2021

      Loomer, Lacey, et al. “Association between Nursing Home Staff Turnover and Infection Control Citations.” Health Services Research, vol. 57, no. 2, 2021, pp. 322–32. Crossref, onlinelibrary.wiley.com/doi/10.1111/1475-6773.13877.

      We estimated the association between nurse turnover and the probability of an infection control citation and the scope of the citation while controlling for nursing home fixed effects. Our turnover measure is the percent of the facility’s nursing staff hours that were provided by new staff (less than 60 days of experience in the last 180 days) during the 2 weeks prior to the health inspection. We calculated turnover for all staff together and separately for registered nurses, licensed practical nurses (LPNs), and certified nursing assistants.

      Published September 6, 2021

      GAO | Additional Reporting on Key Staffing Information and Stronger Payment Incentives Needed for Skilled Nursing Facilities | Aug 2021

      Government Accountability Office. “Additional Reporting on Key Staffing Information and Stronger Payment Incentives Needed for Skilled Nursing Facilities” GAO-21-408 August 9, 2021.

      CMS has taken important steps to build a new source for data on nursing home staffing and to use these data to better inform consumers and improve nursing home oversight. CMS provides the public with some of this staffing information on the Care Compare website. There, consumers can use Staffing Star Ratings to compare nurse staffing between nursing homes. Additionally, CMS has implemented a robust process to ensure the reliability of this nurse staffing information.

      However, CMS has opportunities to better use the staffing information that nursing homes report. Specifically, the staffing information that CMS provides on Care Compare could be more useful to consumers if it included data on nurse staff turnover and tenure, as required by Federal law. CMS reported that the COVID-19 pandemic delayed its progress to implement these requirements.

      Recommendations provided include:

      • CMS should report weekend decreases in RN and total nurse staffing levels on Care Compare
      • CMS should report minimum RN and total nurse staffing thresholds below which SNF residents are at increased risk of quality problems on Care Compare
      • CMS should assess the feasibility of incorporating into the Five-Star System staffing ratings information on weekend decreases in RN and total nurse staffing levels

      Published March 9, 2021, Revised August 10, 2021

      Health Affairs | Larger Nursing Home Staff Size Linked To Higher Number Of COVID-19 Cases In 2020 | July 2021

      McGarry, Brian E., et al. “Larger Nursing Home Staff Size Linked To Higher Number Of COVID-19 Cases In 2020.” Health Affairs, vol. 40, no. 8, 2021, pp. 1261–69. Crossref, www.healthaffairs.org/doi/abs/10.1377/hlthaff.2021.00323?journalCode=hlthaff.

      Staff in skilled nursing facilities (SNFs) are essential health care workers, yet they can also be a source of COVID-19 transmission. We used detailed staffing data to examine the relationship between a novel measure of staff size (that is, the number of unique employees working daily), conventional measures of staffing quality, and COVID-19 outcomes among SNFs in the United States without confirmed COVID-19 cases by June 2020. By the end of September 2020, sample SNFs in the lowest quartile of staff size had 6.2 resident cases and 0.9 deaths per 100 beds, compared with 11.9 resident cases and 2.1 deaths per 100 beds among facilities in the highest quartile. Staff size, including staff members not involved in resident care, was strongly associated with SNFs’ COVID-19 outcomes, even after facility size was accounted for. Conventional staffing quality measures, including direct care staff-to-resident ratios and skill mix, were not significant predictors of COVID-19 cases or deaths. Reducing the number of unique staff members without decreasing direct care hours, such as by relying on full-time rather than part-time staff, could help prevent outbreaks.

      Published July 14, 2021

      Health Affairs | Nursing Home Staffing Levels Did Not Change Significantly During COVID-19 | May 2021

      Werner, Rachel M., and Norma B. Coe. “Nursing Home Staffing Levels Did Not Change Significantly During COVID-19.” Health Affairs, vol. 40, no. 5, 2021, pp. 795–801. Crossref, www.healthaffairs.org/doi/10.1377/hlthaff.2020.02351.

      Prior research and the popular press have anecdotally reported inadequate nursing home staffing levels during the COVID-19 pandemic. Maintaining adequate staffing levels is critical to ensuring high-quality nursing home care and an effective response to the pandemic. We therefore sought to examine nursing home staffing levels during the first nine months of 2020 (compared with the same period in 2019), using auditable daily payroll-based staffing data from the Centers for Medicare and Medicaid Services.

      We found that the total number of hours of direct care nursing declined in nursing homes during the COVID-19 pandemic, as did the average nursing home census. When we accounted for changes in census, the number of nurse staff hours per resident day remained steady or, if anything, increased slightly during the pandemic. The observed increases in staff hours per resident day were small but concentrated in nursing homes operating in counties with high COVID-19 prevalence, in nursing homes with low Medicaid census (which typically have more financial resources), and in not-for-profit nursing homes (which typically invest more in staffing).

      These findings raise concerns that although the number of staff hours in nursing homes did not decline, the perception of shortages has been driven by increased stresses and demands on staff time due to the pandemic, which are harder to quantify.

      Published May, 2021

      Related News Coverage

      OIG | CMS Use of Data on Nursing Home Staffing: Progress and Opportunities To Do More | Mar 2021

      Office of the Inspector General. “CMS Use of Data on Nursing Home Staffing: Progress and Opportunities To Do MoreDepartment of Health and Human Services, OEI-04-18-00450. 9 March 2021.

      CMS has taken important steps to build a new source for data on nursing home staffing and to use these data to better inform consumers and improve nursing home oversight. CMS provides the public with some of this staffing information on the Care Compare website. There, consumers can use Staffing Star Ratings to compare nurse staffing between nursing homes. Additionally, CMS has implemented a robust process to ensure the reliability of this nurse staffing information.

      However, CMS has opportunities to better use the staffing information that nursing homes report. Specifically, the staffing information that CMS provides on Care Compare could be more useful to consumers if it included data on nurse staff turnover and tenure, as required by Federal law. CMS reported that the COVID-19 pandemic delayed its progress to implement these requirements.

      Published March 9, 2021

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      Health Affairs | Medicare’s New Patient Driven Payment Model Resulted In Reductions In Therapy Staffing In Skilled Nursing Facilities | Mar 2021

      McGarry, Brian E., et al. “Medicare’s New Patient Driven Payment Model Resulted In Reductions In Therapy Staffing In Skilled Nursing Facilities.” Health Affairs, vol. 40, no. 3, 2021, pp. 392–99. Crossref, www.healthaffairs.org/doi/full/10.1377/hlthaff.2020.00824.

      Medicare’s Patient Driven Payment Model (PDPM) significantly altered the way skilled nursing facilities (SNFs) are paid, removing the financial incentive to maximize the volume of therapy services delivered to patients. Using federal payroll-based staffing data, we examined the effect of the PDPM on SNF therapy and nursing staff hours. After PDPM implementation, which took effect October 1, 2019, SNFs significantly reduced their therapy staff hours. Physical therapist and occupational therapist staffing levels were reduced by 5–6 percent during October–December 2019 relative to pre-PDPM levels, and physical therapy assistant and occupational therapist assistant levels were reduced by about 10 percent. These reductions were concentrated among contracted employees and were larger in SNFs with higher shares of Medicare-eligible short-stay residents. No meaningful increases in nursing staff in response to the PDPM were found. Further research is needed to determine the effect of these therapy staff reductions on SNF patient outcomes.

      Published March, 2021

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      Health Affairs | High Nursing Staff Turnover In Nursing Homes Offers Important Quality Information | Mar 2021

      Gandhi, Ashvin, et al. “High Nursing Staff Turnover In Nursing Homes Offers Important Quality Information.” Health Affairs, vol. 40, no. 3, 2021, pp. 384–91. Crossref, www.healthaffairs.org/doi/abs/10.1377/hlthaff.2020.00957.

      Nursing staff turnover has long been considered an important indicator of nursing home quality. However, turnover has never been reported on the Nursing Home Compare website, likely because of the lack of adequate data. On July 1, 2016, the Centers for Medicare and Medicaid Services began collecting auditable payroll-based daily staffing data for US nursing homes. We used 492 million nurse shifts from these data to calculate a novel turnover metric representing the percentage of hours of nursing staff care that turned over annually at each of 15,645 facilities. Mean and median annual turnover rates for total nursing staff were roughly 128 percent and 94 percent, respectively. Turnover rates were correlated with facility location, for-profit status, chain ownership, Medicaid patient census, and star ratings. Disseminating facilities’ nursing staff turnover rates on Nursing Home Compare could provide important quality information for policy makers, payers, and consumers, and it may incentivize efforts to reduce turnover.

      Published March, 2021

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      Published in 2020

      OIG | Some Nursing Homes’ Reported Staffing Levels in 2018 Raise Concerns; Consumer Transparency Could Be Increased | Aug 2020

      Office of the Inspector General. “Some Nursing Homes’ Reported Staffing Levels in 2018 Raise Concerns; Consumer Transparency Could Be IncreasedDepartment of Health and Human Services, OEI-04-18-00450. 3 August 2020.

      Nurse staffing is a key contributor to the quality of care provided in nursing homes. This review, initiated before the COVID-19 pandemic emerged, focuses on staffing data from 2018. However, the 2020 pandemic reinforces the importance of adequate staffing for nursing homes, as inadequate staffing can make it more difficult for nursing homes to respond to infectious disease outbreaks like COVID-19.

      We analyzed nursing homes’ 2018 daily staffing data from the PBJ. We determined how frequently nursing homes reported daily staffing levels below federally required levels in 2018 and identified quarterly trends. We compared nursing homes’ quarterly Staffing Star Ratings to their daily staffing levels. To discuss residents’ experiences with daily fluctuations in nurse staffing, we electronically surveyed 20 Local Long-Term Care Ombudsmen.

      Published August 3, 2020

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      Geriatr Res | Impact of Medication Assistant use on nursing home staffing levels and inspection results | Sep 2020

      Crogan NL and Simha A. Impact of Medication Assistant Use on Nursing Home Staffing Levels and Inspection Results. Gerontol Geriatr Res. 2020; 6(1): 1044

      The purpose of this case study is to describe inspection outcomes 1-2 years after the addition of Medication Assistants (MAs) and the reduction of Licensed Practical Nurses (LPNs) to the staffing model in one rural eastern Washington nursing home.

      Published September 17, 2020

      Health Svcs Insights | Appropriate Nurse Staffing Levels for U.S. Nursing Homes | Jun 2020

      Harrington, Charlene, et al. “Appropriate Nurse Staffing Levels for U.S. Nursing Homes.Health Services Insights, vol. 13, 2020, p. 117863292093478. Crossref,www.ncbi.nlm.nih.gov/pmc/articles/PMC7328494.

      US nursing homes are required to have sufficient nursing staff with the appropriate competencies to assure resident safety and attain or maintain the highest practicable level of physical, mental, and psychosocial well-being of each resident. Minimum nurse staffing levels have been identified in research studies and recommended by experts. Beyond the minimum levels, nursing homes must take into account the resident acuity to assure they have adequate staffing levels to meet the needs of residents. This paper presents a guide for determining whether a nursing home has adequate and appropriate nurse staffing. We propose five basic steps to: (1) determine the collective resident acuity and care needs, (2) determine the actual nurse staffing levels, (3) identify appropriate nurse staffing levels to meet residents care needs, (4) examine evidence regarding the adequacy of staffing, and (5) identify gaps between the actual staffing and the appropriate nursing staffing levels based on resident acuity. Data sources and specific methodologies are analyzed, compared, and recommended. The goal is to assist nursing home nurses and administrators to ensure adequate nursing home staffing levels that protect resident health, safety, and well-being.

      Published June 29, 2020

      Published in 2019

      Innov. Aging | Payroll-based Staffing Measures for Nursing Homes | Nov 2019

      Williams, Christianna, et al. “Payroll-Based Staffing Measures for Nursing Homes.” Innovation in Aging, vol. 3, no. Supplement_1, 2019, p. S62. Crossref, www.ncbi.nlm.nih.gov/pmc/articles/PMC6846848.

      The Centers for Medicare & Medicaid Services (CMS) developed the Payroll-Based Journal (PBJ) system for nursing homes to electronically submit direct care staffing information based on payroll and other auditable data. In spring 2018, CMS started reporting PBJ-based staffing measures on Nursing Home Compare. The objective of this research is to examine nursing home staffing patterns using PBJ data. We created measures of staffing hours per resident day, using PBJ staffing information and resident census calculated from MDS assessments. We examined how PBJ staffing levels varied for different types of nursing homes and the relationship between staffing and performance on other parts of CMS’s Five-Star Quality Rating System. We also examined weekday/weekend variation in staffing levels. We tracked about 15,650 nursing homes from 2017 to 2018. The average staffing level was 3.85 hours per resident day, of which 0.66 hours were for RNs. Average staffing levels were higher for smaller, non-profit, and hospital-based facilities. 

      Published November 8, 2019

      Health Affairs | Daily Nursing Home Staffing Levels Highly Variable, Often Below CMS Expectations | Jul 2019

      Geng, Fangli, et al. “Daily Nursing Home Staffing Levels Highly Variable, Often Below CMS Expectations.Health Affairs, vol. 38, no. 7, 2019, pp. 1095–100. Crossref, www.healthaffairs.org/doi/10.1377/hlthaff.2018.05322.

      Staffing is an important quality measure that is included on the federal Nursing Home Compare website. New payroll-based data reveal large daily staffing fluctuations, low weekend staffing, and daily staffing levels often below the expectations of the Centers for Medicare and Medicaid Services (CMS). These data provide a more accurate and complete staffing picture for CMS and consumers.

      Published July, 2019

      Related News Coverage

      Strat Mgt | Under pressure: Reputation, ratings, and inaccurate self-reporting in the nursing home industry | Jul 2019

      Ody‐Brasier, Amandine, and Amanda Sharkey. “Under Pressure: Reputation, Ratings, and Inaccurate Self‐reporting in the Nursing Home Industry.” Strategic Management Journal, vol. 40, no. 10, 2019, pp. 1517–44. Crossref, onlinelibrary.wiley.com/doi/abs/10.1002/smj.3063.

      This paper examines firms’ strategic responses to reputational pressures in a critical healthcare domain—the U.S. nursing home industry. We investigate whether organizations improved in terms of care quality following an exogenous change in the required number of nursing hours associated with star-based ratings to which nursing homes are subject. We show that although firms at risk of losing a star tended to self-report higher staffing levels after the policy change, these reported increases were not associated with improvements in an important patient outcome—bedsores. These findings are consistent with false reporting of staffing data, or insufficient or ineffective hiring practices. Although we cannot definitively establish the existence of false reporting, supplementary analyses offer little support for the latter two possibilities.

      Published July 18, 2019

      Related News Coverage

      Published in 2018

      Ctr Medicare Advocacy | Special Focus Nursing Facilities that “Have Not Improved:” Poor Care for Residents, Overall Ratings Artificially Boosted by 5-Star Ratings in Self-Reported Quality Measures| Aug 2018

      Edelman, Toby. “Special Focus Nursing Facilities That ‘Have Not Improved:’ Poor Care for Residents, Overall Ratings Artificially Boosted by 5-Star Ratings in Self-Reported Quality Measures.” Center for Medicare Advocacy, 15 Aug. 2018, medicareadvocacy.org/special-focus-nursing-facilities-that-have-not-improved.

      The Centers for Medicare & Medicaid Services (CMS) identifies some of the worst performing nursing facilities in the country as Special Focus Facilities (SFFs).  This Report looks at one of the four categories of SFFs – those that “have not improved” – and how they game and manipulate CMS’s Five-Star Quality Rating System.

      As discussed more fully below, the most striking finding in this analysis is that 13 of 33 SFFs (39%) that CMS identified as not having improved had five stars in their self-reported quality measures domain, leading to an upward adjustment from one star to two stars for their overall ratings.

      Published August 15, 2018

      New York Times & Kaiser Health | It’s Almost Like a Ghost Town.’ Most Nursing Homes Overstated Staffing for Years | Jul 2018

      Rau, Jordan. “‘It’s Almost Like a Ghost Town.’ Most Nursing Homes Overstated Staffing for Years.” The New York Times, 7 July 2018, www.nytimes.com/2018/07/07/health/nursing-homes-staffing-medicare.html.

      Also published as:

      “‘Like A Ghost Town’: Erratic Nursing Home Staffing Revealed Through New Records.” Kaiser Health News, 13 Jul. 2018, khn.org/news/like-a-ghost-town-erratic-nursing-home-staffing-revealed-through-new-records.

      Medicare has lowered its star ratings for staffing levels in 1 in 11 of the nation’s nursing homes — almost 1,400 of them — because they either had inadequate numbers of registered nurses or failed to provide payroll data that proved they had the required nursing coverage, federal records released last week show.

      Medicare only recently began collecting and publishing payroll data on the staffing of nursing homes as required by the Affordable Care Act of 2010, rather than relying as it had before on the nursing homes’ own unverified reports.

      The payroll records revealed lower overall staffing levels than homes had disclosed, particularly among registered nurses.

      Published July, 2018

      Related News Coverage

      Kaiser Health | Look-Up: How Nursing Home Staffing Fluctuates Nationwide | May 2019

      Look-Up: How Nursing Home Staffing Fluctuates Nationwide.” Kaiser Health News, 3 May 2019, khn.org/news/look-up-how-nursing-home-staffing-fluctuates-nationwide.

      This tool shows how Medicare rates overall staffing and registered nurse staffing by facility.  It also shows the average number of residents that each nurse and aide must care for on the best- and worst-staffed days.  You can sort the facilities by column or hover over them on the interactive maps to view staffing levels.

      Published May 2, 2019

      Related News Coverage

      Kaiser News | Nursing Facilities, Staffing, Residents and Facility Deficiencies, 2009 Through 2016 | Apr 2018

      Nursing Facilities, Staffing, Residents and Facility Deficiencies, 2009 Through 2016.” KFF, 3 Apr. 2018, www.kff.org/medicaid/report/nursing-facilities-staffing-residents-and-facility-deficiencies-2009-through-2016.

      Nursing facilities are one part of the long-term care delivery system that also includes home and community based services, but their relatively high cost has led them to be the focus of much attention from policymakers. Medicaid plays a major role in financing nursing facility care in the United States, and policy proposals to limit federal financing for Medicaid may lead to cuts in eligibility or scope of coverage for long-term care services. In addition, regulations effective November 2016 aimed to address longstanding challenges in quality and safety in nursing facilities. As the demand for long term care continues to increase and policy proposals and regulations unfold, the characteristics, capacity, and care quality of facilities remain subjects of concern among consumers and policy makers.  

      Published April 3, 2018

      Published in 2017

      Med. Care Res | Nursing Home Response to Nursing Home Compare: The Provider Perspective | Aug 2017

      Perraillon, Marcelo Coca, et al. “Nursing Home Response to Nursing Home Compare: The Provider Perspective.” Medical Care Research and Review, vol. 76, no. 4, Aug. 2019, pp. 425–443, doi:10.1177/1077558717725165.

      Nursing Home Compare (NHC) publishes composite quality ratings of nursing homes based on a five-star rating system, a system that has been subject to controversy about its validity. Using in-depth interviews, this study assesses the views of nursing home administrators and staff on NHC and unearth strategies used to improve ratings. Respondents revealed conflicting goals and strategies. Although nursing home managers monitor the ratings and expend effort to improve scores, competing goals of revenue maximization and avoidance of litigation often overshadow desire to score well on NHC…

      First Published August 11, 2017

      Health Affairs | Use of Nursing Home Compare Website Appears Limited By Lack of Awareness and Initial Mistrust of the Data | April 2016

      Konetzka, R. Tamara, and Marcelo Coca Perraillon. “Use of Nursing Home Compare Website Appears Limited by Lack of Awareness and Initial Mistrust of the Data.” Health Affairs, vol. 35, no. 4, Project HOPE, Apr. 2016, pp. 706–13. https://doi.org/10.1377/hlthaff.2015.1377.

      In December 2008 the Centers for Medicare and Medicaid Services (CMS) launched a five-star rating system of nursing homes as part of Nursing Home Compare, a web-based report card detailing quality of care at all CMS-certified nursing homes. Questions remain, however, as to how well consumers use this rating system as well as other sources of information in choosing nursing home placement.

      This study found that consumers were receptive to using Internet-based information about quality as one source of information but that choice was limited by the need for specialized services, proximity to family or health care providers, and availability of Medicaid beds. Consumers had a positive reaction when shown Nursing Home Compare; however, its use appeared to be limited by lack of awareness and, to some extent, initial lack of trust of the data. Its findings suggest that efforts to expand the use of Nursing Home Compare should focus on awareness and trust. Useful additions to Nursing Home Compare might include measures of the availability of activities, information about cost, and consumer satisfaction.

      First Published April, 2016

      Data Lookups with Payroll-Based Journal Data

      Pro Publica Nursing Home Inspect

      Use this database to compare nursing homes based on the deficiencies cited by regulators and the penalties imposed in the past three years. This database will allow you to: search nearly 80,000 nursing home inspection reports to look for trends or patterns; evaluate nursing homes near you; and find nursing homes that have been cited for deficiencies in infection control.

      USA Today's Nursing Home Ratings and COVID Rates

      USA TODAY compiled data filed by more than 15,000 homes and, for the first time, published indicators of how each performed in a five-month surge of COVID infections and deaths starting October 2020. This tool also shows ratings that correspond to federal recommended staffing. See how they fared during COVID’s winter surge, 2020-21

      More Resources in the PBJ Library

      Five Star QRS Technical Users’ Guide

      CMS QSO Memorandums and Guidance

      Payroll-Based Journal (PBJ) Policy Manual

      PBJ Resources for Providers from CMS

      Studies and Research Using PBJ Data