Nursing homes across the country are regulated by the federal Centers for Medicare and Medicaid Services, known as “CMS.” CMS makes monthly public reports on each nursing home in the nation, concerning quality of care, for the benefit of consumers who are covered by the Medicare program.1 Those reports include the adequacy and quality of staffing at each nursing home, including the seventy-nine such facilities operating in Rhode Island.

In order to assess the baseline quality of staffing in our state’s nursing homes, we looked at the CMS national and state reports on staffing for February 2020, the most recent data available prior to the disruption caused by COVID.

1 Consumers can access that information at the CMS Nursing Home Compare website. Relevant data sets are published monthly on the CMS website The staffing quality ratings appear in the spreadsheet entitled “Provider Info”.

Measuring Adequacy and Quality of Staffing

CMS rates each nursing home on the quality of its staffing using a Five Star system, where Five Stars is the highest possible rating, and One Star the lowest. The ratings are derived on the basis of (i) registered nurse (RN) hours per resident per day; and (ii) total nursing hours (RN, licensed practical nurse (LPN), and nurse aide) per resident day, all adjusted on the basis of the nursing needs of the facility’s residents. RN hours per day are weighed more heavily than nurse aide hours due to the higher skill level. The adjustment to reflect the actual nursing needs of the residents (termed the “case mix” adjustment) is particularly important in measuring staff adequacy, because nursing homes care for two very distinct populations. Some nursing home patients are admitted for skilled rehab stays. These individuals arrive from a hospital following strokes, cardiac events, or surgeries such as knee or hip replacement. They stay for a few days to weeks, and are covered by the limited Medicare skilled nursing facility benefit.

A second, and much larger group is the “long stay” residents – those who cannot be safely cared for at home. They were predominantly healthy and productive members of society when they were younger, but now are generally quite helpless, and rely completely on others for care. These individuals have their stays covered by Medicaid.

The Medicare-covered patients need significantly more nursing care than the Medicaid-covered residents, and they are distributed unevenly throughout the state. A nursing home’s staffing needs depend on the needs of its particular residents, and in large part on how many “skilled” Medicare patients it admits, in contrast to Medicaid patients.2

In addition, there exists variation within those subgroups. Rhode Island has a disproportionately older group of Medicaid-covered residents, who are frailer and more likely to suffer from dementia than the Medicaid population in other states.3 CMS views their actual nursing needs as less intense than is the case for younger, sicker Medicaid-covered residents in other states.

2 There is great variety in the distribution of these patients among facilities, with some having markedly higher Medicare census than others. The Medicare program pays substantially higher rates for the care provided to the “skilled rehab” residents, since these patients require more nursing care. This is why, for example, some Rhode Island nursing homes are able to provide 4.1 or more direct care hours per day. They have a higher number of “skilled” patients among their residents, with correspondingly higher revenues.

3 CMS measures the nursing needs of residents via a reporting system termed the “Minimum Data Set” or “MDS.” This is a detailed report on the clinical condition of each nursing home resident, which facilities are required to submit to CMS upon the resident’s admission and periodically thereafter.

Results: CMS Staffing Ratings

As noted above, CMS rates nursing facilities using a Five Star system, with Five Stars being the highest possible rating for staffing quality.4 All in all, Rhode Island nursing homes score low for total direct care hours per day, high for RN hours per day, and high for staffing adequacy matched to resident needs, with the result that our average “star” rating for staffing is among the highest states.

By cherry picking a single data element, hours of direct care per resident day, the advocates for a minimum staffing rule make it seem as though Rhode Island’s nursing home staffing is substandard. When all relevant measures are considered, as performed by the federal CMS, this is clearly not the case.

4 A detailed explanation of how the staffing rating is calculated appears on pp 6-10 of the October 2020 CMS Five Star Technical Users Guide.