U.S.  Department of Health and  Human Services  
 
Office of Inspector General  
 
 
 
CMS Use  of Data on Nursing 
Home Staffing: Progress and 
Opportunities To Do More 
 
 
Suzanne Murrin  
Deputy Inspector  General  
March, OEI-04-18-00451   U .S. Department of Health and Human Services  
 
Office of Inspector General  
 
R eport  in Brief  
 
March 2021, OEI -04 -18 -00451  
 
Why OIG  Did This Review   CMS  Use of  Data  on  Nursing  Home Staffing:  
This  review  focuses  on  the Centers  for  
Progress  and  Opportunities  To  Do More  
Medicare &  Medicaid Services  (CMSs)  
use of data  on nursing  home  staffing  
What OIG Found  
from  April  2018 through  March  2019  Key Takeaway  
CMS  has  taken important  steps  to  build  a  
before the COVID-19  pandemic.  We 
CMS  has  taken  important  steps   new  source for  data  on  nursing  home  
also  noted  recent  CMS  actions  through 
to  expand  use  of  new  staffing   staffing  and  to  use  these data  to better  
December  2020.      
data  reported  by  nursing homes.   inform consumers and  improve  nursing  
Since  November  2016,  CMS  has   However,  CMS  can  better   home  oversight.   CMS  provides the  
required nursing homes  to  submit   leverage  staffing data  to  provide  public  with  some  of  this  staffing  
payroll-based  staffing  data,  including  consumers  with  required  information on  the  Care Compare  
data  on nurses  and  non-nurses.   In  information and  to  help  State   website.  There,  consumers can  use  
April  2018,  CMS  began  updating   survey  agencies  protect  nursing  Staffing  Star  Ratings  to  compare nurse 
staffing  measures on  Nursing  Home   home  residents.   staffing between  nursing homes.  
Compare,  a  public  website,  with  these   Additionally,  CMS  has  implemented a  
staffing data.  In  December  2020, CMS   robust  process  to  ensure  the  reliability  of this  nurse  staffing  information.     
replaced Nursing Home Compare with  
However,  CMS  has  opportunities  to  better  use  the  staffing  information that  
a  new  website called Care Compare.   
nursing  homes  report.   Specifically,  the staffing information  that  CMS  provides  
Care Compare includes  the  same 
on  Care  Compare could  be  more  useful  to consumers  if  it  included  data  on 
staffing information  that  had been  
nurse staff turnover  and  tenure,  as  required by  Federal  law.   CMS  reported  that  
found  on  Nursing  Home  Compare.   
the  COVID-19  pandemic  delayed its  progress to implement  these  requirements.   
Specifically, consumers  can  search  
nursing  homes  on the  basis  of  location  Additionally,  CMS  can  take  steps  to  increase  the  reliability  of  the  non-nurse  
and compare quality  of care and 
staff  information  (i.e.,  information on physical therapists)  that  CMS  publicly  
staffing.   The usefulness  of this  
reports  on  Care Compare.   Non-nurse  staff  play  a  critical role  in  providing  
information  to  consumers  depends  on  
quality  care.     
the  extent  to  which  it  is  complete  and  
accurate.   Further,  CMS  has  taken an  important  step  to  target  its  oversight  of  nurse  
staffing  by  sharing  information with  State  survey  agencies.  Specifically, to  help  
Further,  CMS  also  works  with  State  
State survey  agencies  target  weekend inspections,  CMS  now  informs the  
survey  agencies  to monitor  nursing  
agencies  as  to  which  nursing homes  reported lower  weekend staffing.  
home  compliance  with  Federal  
However,  CMS  can  take additional  steps  to  improve the effectiveness  of State  
requirements,  including those for  
survey  agencies weekend  inspections  and  strengthen  oversight  of staffing in  
staffing.    
nursing  homes.  
How OIG Did This Review  
What OIG  Recommends  and How the Agency Responded   
We analyzed staffing information  
OIG  acknowledges  the  impact  that  COVID-19 has  had  on nursing  home  
reported by  nursing  homes,  conducted 
oversight  and  on CMSs  priorities  to  help  improve  the  quality  of  care  that  
in-depth  interviews  with subject-matter  
nursing  homes  provide.   We  note  that  the  pandemic  also  reinforces  the 
experts  at  CMS,  and reviewed CMS  
importance of having  adequate  staffing  to respond  to outbreaks  of infectious  
documentation.    
diseases.   We recommend that  CMS  (1)  provide data to consumers  on  nurse  
We also  surveyed State survey  agencies   staff turnover  and tenure,  as  required by  Federal  law;  (2)  ensure the accuracy  of  
to  understand  how  CMS  works  with  non-nurse  staffing data  used  on  Care  Compare; (3)  consider  residents  level  of 
them  to  monitor  compliance  with   need when  identifying nursing homes  for  weekend  inspections;  and  (4)  take 
requirements  for  nursing home staffing  additional steps  to  strengthen oversight  of  nursing  home  staffing.   CMS  
and to  identify  any  gaps  in  oversight  of  concurred  with  all  four  of  our  recommendations.     
nursing  home  staffing.      
     
TABLE OF  CONTENTS  
 
 
 
 
BACKGROUND   1  
Methodology   8  
FINDINGS   10  
CMS  provides consumers with mostbut not allrequired information about staffing in  10  
nursing homes   
CMS has a robust process for ensuring the reliability  of  nurse staffing data, but it lacks   13  
similar  processes for  non-nurse staffing data  
CMS has taken an  important step by using  staffing data to inform State inspections, but  it   16  
has opportunities to  better target oversight  
RECOMMENDATIONS    22  
Provide data  to consumers on nurse staff  turnover and tenure, as required by Federal law   23  
Ensure the  accuracy  of  non-nurse  staffing data used on  Care Compare   23  
Consider residents  level  of need when identifying nursing homes for weekend inspections   23  
Take additional steps to  strengthen oversight of  nursing home  staffing     23  
AGENCY COMMENTS AND OIG RESPONSE    25  
DETAILED METHODOLOGY    26  
APPENDICES    30  
A.   Information about  CMS data checks and audits   30  
B.   Nursing homes reported no hours for some types of non-nurse staff   33  
C.  State-by-State analysis to  identify lower staffed nursing homes  when adjusting for the  36  
relative care needs  among residents  
D.   Data about  the current oversight of nursing homes that frequently reported staffing   38  
levels lower than required levels  
E. Agency Comments   39  
ACKNOWLEDGMENTS AND CONTACT   42  
ABOUT THE OFFICE OF INSPECTOR GENERAL   43  
   
BACKGROUND  
 
 
Objectives  
1.   To assess CMSs progress toward publicly reporting statutorily required  data 
on nursing home staffing.  
2.   To determine  the steps CMS has taken  to ensure  the quality of  nursing-
home-reported data before CMS shares these data  on public websites,  
including Care  Compare.   
3.   To determine the extent to which CMS uses nursing homes self-reported  
staffing  data to monitor  staffing  requirements for nursing homes.  
 
This review  focuses on staffing data reported by nursing homes from April 2018 
through March 2019.1   We  collected and analyzed data about  this time period, which 
preceded  the emergence of  the COVID-19 pandemic.   However, the COVID-19 
pandemic reinforces the importance of sufficient  staffing  for nursing homes, as 
inadequate staffing can make it more difficult for nursing homes to respond to  
outbreaks of infectious diseases like  COVID-19.2, 3   We also include recent  CMS  
actions up until December 2020, when CMS replaced the Nursing Home Compare 
website with Care Compare.  
To help consumers make care decisions, CMS provides nursing home staffing  
information  on  its Care Compare website.4   The  information  includes  Staffing Star  
Ratings and  the amount of nurse and therapist time per resident per day  (see  
Exhibit  1).  CMS provides  such staffing information  to the public because it has long  
identified nurse staffing  as a vital component of  a nursing homes ability to provide  
quality care.5   Until 2018,  CMS relied  on nursing homes self-reported staffing levels 
_____________________________________________________________________________________________________________________________  
1  Nursing homes  refers to both Medicare Skilled Nursing Facilities and Medicaid Nursing Facilities.  
2  Mathews, AW,  and Kamp, J, Coronavirus Hits Nursing Homes Hard, as Staff Combat Infections,  
Shortages,  Wall Street Journal, https://www.wsj.com/articles/coronavirus-hits-nursing-homes-hard-as-
staff-combat-infections-shortages-11585250841?ns=prod/accounts-wsj.  Accessed on April 7, 2020.  
3  Kenan, J, Roubein, R, and Luthi, S, How Public Health Failed Nursing  Homes, Politico, 
https://www.politico.com/news/2020/04/06/public-health-failed-nursing-homes-167372.   Accessed on  
April 7, 2020.  
4  On December  1, 2020, Nursing Home Compare was replaced by Care Compare  
(https://www.medicare.gov/care-compare/), a website that  allows comparison of several provider types,  
including nursing homes.  
5  Kramer, AM, and Fish, R,  The Relationship Between Nurse  Staffing Levels  and the Quality of Nursing  
Home Care, in Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes: Phase II Final  Report, 
Abt Associates, Inc., Winter 2001.  CMS,  Nursing Home Compare Technical Users GuideOctober  2020, 
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/  
downloads/usersguide.pdf.  Accessed on November 17, 2020.  
CMS Use  of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Background |  1   approximately  once a year for the 2 weeks  before an inspection  to  provide consumers  
with information on each nursing homes average  staffing  level.6    
Exhibit 1:  CMS uses nursing home staffing data to inform consumers.  
 
However, CMS  was concerned about the accuracy of nursing homes self-reported  
staffing data.   To improve the accuracy of publicly reported staffing data, CMS created  
a new data collection system called the Payroll-Based Journal (PBJ).7,  8   Nursing homes 
are required to use the PBJ  to  report daily staffing  information based on payroll  
information  every 3  months  (i.e., quarterly).  
In addition to using the PBJ to capture and report  payroll  staffing information,  CMS  
intends to use the system  to better understand  how staffing relates to quality of care.9   
For instance,  CMS  research found that the presence of a registered nurse (RN)  
improves quality of care and outcomes for nursing home residents.10   Furthermore, in 
2018, news organizations  analyzed the publicly  available  PBJ  data and raised concerns 
about residents quality of care after finding substantial variability in nursing homes  
staffing  levels from one day to another.11   Additionally, members of Congress 
_____________________________________________________________________________________________________________________________  
6  Nursing homes used to provide their staffing data using two CMS forms (i.e., CMS-671 and CMS-672).   
CMS,  QSO-18-17-NH Memorandum, https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationGenInfo/Downloads/QSO18-17-NH.pdf. Accessed on September 6, 2019.   
7  The CMS Staffing Studies indicated that staffing data based on payroll recordsin contrast to the  
staffing data that nursing homes self-reportedwere more likely to be complete  and accurate because  
payroll records may be audited.  CMS,  Appropriateness of Minimum Nurse Staffing Ratios in Nursing 
Homes: Phase II Final Report, Abt Associates, Inc., Winter 2001.      
8  CMS,  QSO-18-17-NH Memorandum, https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationGenInfo/Downloads/QSO18-17-NH.pdf.  Accessed on September 6, 2019.  
9  When finalizing new regulations in 2016, CMS stated that collecting and analyzing this  mandatory,  
payroll-based staffing information could greatly assist it in evaluating whether and how  it  should 
establish minimum staffing ratios.  CMS,  Medicare  and Medicaid Programs; Reform of Requirements for 
Long-Term Care Facilities  (final rule), 81 Fed. Reg. 6875568756 (Oct.  4, 2016).  
10  Ibid.  
11  Rau, J,  Its Almost Like a Ghost Town.  Most Nursing Homes Overstated Staffing for Years,  The New 
York Times, July 7, 2018.  Accessed at https://www.nytimes.com/2018/07/07/health/nursing-homes-
staffing-medicare.html  on September 14, 2018.  
CMS Use  of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Background |  2   expressed  concern  about  nursing home  staffing  and  interest in how CMS  uses  the  PBJ 
staffing information.12  
Federal Requirements  for Staffing  in Nursing  Homes  
Nursing homes are federally  required to ensure adequate staffing to promote  high-
quality care for their residents.  Federal staffing requirements address both nurse staff  
and other types of staff (i.e., non-nurse  staff) that  contribute to residents care.   
Federal law  requires that all nursing homes provide sufficient nurse services to safely 
care for and  meet their residents needs.13,  14   More specifically,  Federal  law  requires  
(unless these requirements  are waived) that  nursing homes provide on each day at  
least (a) 8 consecutive hours of RN services and  (b)  around-the-clock  services from  
licensed nurses  and aides.  Nurse staff are a critical component of  the quality  of care  
residents receive because  nurse staff implement  residents care plans to meet  their  
needs and provide most  of the day-to-day care for residents (e.g., assisting them in 
activities like eating, bathing, grooming, dressing, transferring, and toileting).15      
Federal law  also requires that all nursing homes have certain non-nurse staff, 
including nursing home administrators, medical directors, and dietitians.16   
Administrators exercise operational  or managerial control over the nursing home and  
conduct day-to-day operations.17   Medical directors implement  resident care policies 
_____________________________________________________________________________________________________________________________  
12  House Energy and Commerce Subcommittee on Oversight and Investigations,  Examining Federal  
Efforts To Ensure Quality of Care and Resident Safety in Nursing Homes, September 6, 2018.   
https://energycommerce.house.gov/committee-activity/hearings/hearing-on-examining-federal-efforts-
to-ensure-quality-of-care-and.  Letter from Senator Blumenthal and Representative Schakowsky,  
https://schakowsky.house.gov/sites/schakowsky.house.gov/files/migrated/uploads/  
2018.07.31_Letter to CMS on Nursing Home  Staffing Levels  FINAL SIGNED.pdf  and letter from Senator  
Wyden, https://www.finance.senate.gov/imo/media/doc/081418 SNF Staffing Quality Letter.pdf. 
Accessed on  September 14, 2018.  
13  42 CFR  483.35.  Nursing homes must also have sufficient hours of nurse services to meet residents  
needs to attain or maintain  practical physical, mental, and psychological well-being for each resident.    
14  Nursing homes must assess  their residents needs.  Social Security Act,   1819(f)(6)(A-B) and  
1919(f)(6)(A-B), as amended by the Omnibus Budget Reconciliation Act of 1987.  Residents needs are  
assessed with a core set of Minimum Data Set (MDS) assessments that measure several aspects of  
residents needs.  CMS,  Long-Term Care Facility Resident Assessment Instrument 3.0 Users Manual, 
Version 1.17.1,  October 2019,  https://downloads.cms.gov/files/mds-3.0-rai-manual-
v1.17.1_october_2019.pdf.  Accessed on February 20, 2020.  
15  CMS,  Staffing for nursing homes, https://www.medicare.gov/care-compare/resources/nursing-
home/staffing.  Accessed on December 8, 2020.  Additionally, RNs are responsible for overseeing the  
delivery of residents overall care, while licensed practical and vocational nurses care for residents under  
an RNs direction.  Nurse aides work under the supervision of licensed nurses and assist residents with 
the many activities of daily living.  
16  42 CFR  483.70(d),  483.70(h), and 483.60(a).  In lieu of a  dietitian, nursing homes may fulfill this  
requirement with another clinically qualified  nutrition professional.  
17  42 U.S.C. 1320a5(b).  
CMS Use  of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Background |  3   and coordinate medical  care within the nursing home.18   Dietitians or certified dietary 
or food service managers provide food and nutrition services.19     
Further, Federal law requires nursing homes to  perform or obtain additional critical  
services to safely care for and meet their residents needs.  For example, if residents 
require physical therapy or other specialized rehabilitative services, the facility  must  
provide the required services or obtain the required services from a  Medicare and/or 
Medicaid provider.20   Additionally,  nursing homes must employ or obtain the services 
of a pharmacist to provide expertise and manage the records of controlled drugs and  
perform monthly reviews of residents drug regimens.21    
Federal Requirement  for Nursing  Homes  To  Submit  Staffing  
Data  to the  Payroll-Based  Journal  
Nursing homes must submit accurate information on direct-care staffing  to PBJ  each  
quarter.22, 23   This  information must be based on payroll and  other verifiable and  
auditable data in a uniform format as specified by CMS.  The required staffing  
information includes the hours and category of  work an employee performs.24   CMS  
allows  nursing homes to submit staffing information for 40 different types of direct-
care staff, including both nurse  staff  (e.g., RNs; licensed practical and vocational  
nurses;  and aides) and non-nurse staff (e.g., therapists and pharmacists).25   CMS  
requires reporting for all 9 types of nurse staff and for 23 types of non-nurse staff, 
while allowing for voluntary reporting of 8 additional types of non-nurse staff.     
For most staff types, CMS expects nursing homes to report hours that can be verified  
with  a nursing homes  payment records.  This includes  contracted staff that are paid  
through a contracted entity.  This does not include staff paid by Medicare or another 
payer (e.g., physicians, nursing practitioners, hospice nurses).26   However, for therapy 
_____________________________________________________________________________________________________________________________  
18  42 CFR  483.5  
19  42 CFR  483.60(a)(2)-(3).  
20  42 CFR  483.65.  
21  42 CFR  483.45.  
22  Section 6106 of the Patient Protection and Affordable Care  Act instructed the Department of Health 
and Human Services (HHS) to require nursing homes to electronically submit these data  as  codified in  
42  U.S.C.  1320a-7j(g) and implemented in 42  CFR 483.70(q).    
23  Direct  care staff does not include individuals whose primary duty is maintaining the nursing home (e.g.,  
housekeeping).  CMS,  Electronic Staffing Data Submission Payroll-Based Journal: Long-Term Care Facility  
Policy Manual  Version 2.5, https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/NursingHomeQualityInits/Downloads/PBJ-Policy-Manual-Final-V25-11-19-2018.pdf    
Accessed on May 22, 2020.  
24  42 U.S.C. 1320a-7j(g)  
25  CMS,  Electronic Staffing Data Submission Payroll-Based Journal: Long-Term Care Facility Policy Manual, 
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/  
NursingHomeQualityInits/Downloads/PBJ-Policy-Manual-Final-V25-11-19-2018.pdf.  Accessed on  
May  22, 2020.  
26Ibid.  
CMS Use  of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Background |  4   staff (i.e., physical, occupational, speech, and respiratory  therapists), CMS requires 
nursing homes to submit all hours regardless of payer.27    
Additionally, nursing homes must submit  resident  daily  census data and information 
on residents  case needs.  CMS  collects  these data  through resident  assessments 
submitted to the  Minimum Data  Set (MDS).28       
Care Compare and  Nursing  Homes  
Federal Requirements for  Nursing Home  Staffing  Information in  
Care  Compare   
The Social  Security Act sets out requirements for Nursing Home Compare  or a 
successor website, including that it  provide consumers with information in a manner 
that is prominent, updated on a timely basis, easily accessible, readily understandable 
to consumers of long-term care services, and searchable.29, 30   Care Comparewhich 
replaced  Nursing Home Compare  in December 2020,  and to which the Social  Security 
Act requirements listed above still appliesmust  include data about the staffing  in  
each nursing home to help consumers understand the data, as described in  Exhibit  2:    
Exhibit 2.  By law, Care  Compare must provide consumers with three 
aspects  of  staffing data.   
Care Compare must provide:  
   data for each facility about the number of residents and the hours 
of care provided per day;  
   a way for consumers to compare differences in staffing between 
nursing homes and the State average and national average; and  
   data on staffing turnover and tenure.   
Source:  42 U.S.C.  1395i-3(i)(1)(A)(i).  
_____________________________________________________________________________________________________________________________  
27  CMS,  Electronic Staffing Data Submission Payroll-Based Journal: Long-Term Care Facility Policy Manual, 
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/  
NursingHomeQualityInits/Downloads/PBJ-Policy-Manual-Final-V25-11-19-2018.pdf.  Accessed on  
May  22, 2020.   
28  MDS assessments record aspects of residents needs, such as mental and physical functioning; pain;  
medical diagnoses and health  conditions; and medication use.  CMS,  Long-Term Care Facility Resident  
Assessment Instrument 3.0 Users Manual,  Version 1.17.1, October 2019, 
https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_october_2019.pdf.  Accessed on February  
20, 2020.    
29  42 U.S.C. 1395i-3(i)(1)(A)(i)  [The Social Security Act  1819(i)(1)(A)(i)].  Care Compare  allows consumers  
to review  information only about nursing homes participating in Medicare and/or Medicaid.    
30  On December  1, 2020, Nursing Home Compare was replaced by Care Compare  
(https://www.medicare.gov/care-compare/), a  website to compare  providers, including nursing homes.   
CMS Use  of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Background |  5   CMS provides  a Five-Star Quality  Rating System as part of Care  
Compare  
The Five-Star Quality Rating System  includes a set of quality ratings for every nursing  
home that  participates in Medicare or Medicaid.31   CMSs  rating systemupdated  
monthlygives each nursing home an overall rating between 1 and 5 stars (see 
Exhibit  3).32   Each nursing  homes overall quality rating  
is based on individual star ratings of  its performance in  Exhibit 3:  Star Ratings in 
three areas:  Health Inspections, Staffing, and Quality  Care Compare   
Measures.  Consumers can compare nursing homes 
using the Overall Star Rating;  the star ratings for each 
of these three areas;  and additional  information  that 
CMS provides about each of these areas.33   The public 
can also access Data.CMS.gov  to obtain  the  full  
datasets previously used on Care Compare and  
previously used on Nursing Home Compare.34    
The Staffing Star Ratings.  CMS displays  a  Staffing Star  
Rating,  which contributes to the overall quality rating  
that a nursing home receives.  Additionally,  CMS  
provides  information on RN staffing  with  an  RN Star  
Rating.  The  Staffing Star Rating is based on two  
separate measures of nurse staff hours per resident  
that  are associated with quality of care: (1) the RN  Star  
Rating  and (2) the number  of  total nurse staff.35   For  
both RNs and all nurse staff,  CMS obtains the  average  Source:   CMS Care Compare  website. 
https://www.medicare.gov/  
amount of staff hours per resident day (HPRDs)  during  
care-compare/  
a recent 3-month period.   To make  the Staffing  Star  
Ratings more comparable across different nursing homes, CMS then adjusts  the HPRD 
amounts  by the acuity (i.e., the relative level  of  care needs  among residents) of each  
_____________________________________________________________________________________________________________________________  
31  Abt Associates,  Nursing Home Compare Five-Star Quality Rating System: Year Three Report, 
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/  
Downloads/FSQRS-Report.pdf.  Accessed on May 11, 2020.  
32  CMS,  Overall star rating for nursing homes, https://www.medicare.gov/care-compare/resources/  
nursing-home/overall-star-rating.  Accessed  on December 8, 2020.  
33  CMS,  Nursing Home Compare Technical Users GuideOctober 2020, https://www.cms.gov/Medicare/  
Provider-Enrollment-and-Certification/CertificationandComplianc/downloads/usersguide.pdf.  Accessed 
on November  17, 2020.    
34  These archived datasets include the information previously presented in Care Compare  and Nursing  
Home Compare and additional information that CMS uses to calculate the  Staffing Star Ratings, such as  
the acuity-adjusted staff HPRDs for individual nursing homes.  Source: CMS,  Nursing Home including 
rehab services data archive, https://data.cms.gov/provider-data/archived-data/nursing-homes/.  Accessed 
on June 22, 2020.   
35  CMS does not separately report the total nurse measure on Care Compare.  
CMS Use  of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Background |  6   nursing home.36   The RN Star Rating  and the total nurse  measure  do not assess 
compliance with Federal staffing requirements.    
Other Staffing Information. CMS  also provides the public  with additional details  
about the average amount of staff HPRDs  on  Care  Compare.  For example, CMS  
presents the RN HPRDs, total nurse HPRDs,  and  physical therapist HPRDs.  
Requirements  That  CMS  Ensure the  Completeness  and  Accuracy  
of Staffing Data  
CMS must adhere to guidelines that  ensure the information it provides to the  public is 
objective (i.e., accurate, reliable, and  unbiased).37   Guidelines from the Department of  
Health and  Human Services (HHS) specify  a variety of techniques (e.g., checks for 
completeness, internal controls, checks for consistency, and  audits) that  CMS  takes  to 
promote the completeness and accuracy of information provided  by third parties,  
such as nursing homes.38    
State Survey Agencies  Monitor  Nursing  Homes  Compliance 
With  Staffing  Requirements  
State survey agencies (SSAs)  monitor compliance with nursing home Federal  staffing  
requirements by conducting health inspections that determine whether  facilities  
provide  sufficient  nursing staff  with the appropriate training  and skills to  provide 
adequate care.39   SSAs are required to conduct health and safety inspections at least  
every 15 months on behalf  of  CMS  and may inspect nursing  homes more often if  a  
nursing home is performing poorly, or  if there are complaints or facility-reported  
incidents.  Using the Federal governments requirements, SSA inspection teams review  
many aspects of  quality of  life in the nursing home,  such as (a) the care of residents 
_____________________________________________________________________________________________________________________________  
36  CMS,  Nursing Home Compare Technical Users GuideOctober 2020, https://www.cms.gov/Medicare/  
Provider-Enrollment-and-Certification/CertificationandComplianc/downloads/usersguide.pdf.  Accessed  
on November  17, 2020.  
37  OMB Final Rule.  67 Fed. Reg. 8451 (Feb. 22, 2002).   Guidelines for Ensuring and Maximizing the Quality,  
Objectivity, Utility, and Integrity of Information Disseminated by Federal Agencies; Republication.  
38  HHS, HHS Guidelines  for Ensuring and Maximizing the Quality, Objectivity, Utility, and Integrity of 
Information Disseminated to the Public, October 1, 2002,  https://aspe.hhs.gov/report/hhs-guidelines-
ensuring-and-maximizing-quality-objectivity-utility-and-integrity-information-disseminated-public. 
Accessed on May 20, 2020.  
39  The Federal  requirement to have sufficient nurse staffing is  at 42 CFR 483.35.  CMS provides State  
inspectors with a survey pathway to guide their oversight of this requirement.  CMS,  LTC Survey Pathways  
(ZIP file):  Sufficient and Competent Nurse Staffing Review, https://www.cms.gov/Medicare/  
Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes.  Accessed on  
March  4,  2020.    
CMS Use  of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Background |  7   and the processes used to give that  care;  (b) how the staff and residents interact;  and  
(c)the overall nursing home environment.40     
During health inspections, the SSA inspection team considers whether staffing levels 
can be linked to resident complaints, quality of care, or quality-of-life  concerns.41   For  
instance, the SSA  inspection  team may observe how nurse staff transfer and position 
residents or whether nurse staff use appropriate infection-control  techniques.42   The 
SSA  inspection team also interviews a portion of  each nursing homes residents to  
determine whether  there are enough staff  to meet  the residents  needs and concerns.  
If the SSA inspection team identifies  potential deficiencies, then a designated  team 
member will interview nurse staff and may review documents to decide  whether 
a  nursing home meets or does not meet Federal staffing requirements.43      
Prior OIG  Work  on Nursing  Home Staffing  
In August 2020, OIG  issued the report  Some Nursing Homes Reported Staffing Levels  
in 2018 Raise Concerns;  Consumer Transparency  Could  Be Increased.44   This report  
found that  7  percent  of nursing homes  reported staff  levels that fell  below required  
Federal staffing levels on at least 30  total days in 2018.  Additionally,  the report noted  
that daily staffing variations are not  transparent  to consumers because CMSs Star  
Rating  System ranks nursing homes on their average  staffing  levels each quarter.  
Methodology  
We analyzed multiple data sources from CMS that pertain to  staffing data and  its  
oversight of  nursing home staffing.   While our primary period of review  was April 1, 
2018, to  March 31, 2019, we also included recent  CMS actions up until  
December  2020.   
As part of data collection efforts for our three objectives, we conducted two  
interviews with subject-matter experts  at CMS  in March 2019 and July 2019 to  better 
_____________________________________________________________________________________________________________________________  
40  The Federal  requirements for nursing homes are at 42 CFR pt. 483,  subpt. B.  A CMS manual provides  
guidance to State insepctors in how to oversee the Federal  requirements.  CMS.  State Operations 
ManualAppendix PP,  430,  https://www.cms.gov/Regulations-and-Guidance/Guidance/  
Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf.  Accessed on February 26, 2020.  This manual  
refers the State inspectors to use various survey pathways to guide their oversight of these requirements.  
CMS,  LTC Survey Pathways  (ZIP file),  https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/GuidanceforLawsAndRegulations/Nursing-Homes.  Accessed on March  4, 2020.  
41  CMS,  LTC Survey Pathways  (ZIP file):  Sufficient and Competent Nurse Staffing Review,  
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/  
Nursing-Homes.  Accessed on March  4, 2020.    
42  Ibid.  
43  Ibid.    
44  OIG,  Some Nursing Homes Reported Staffing Levels in 2018  Raise Concerns; Consumer Transparency  
Could Be Increased, OEI-04-18-00451, August 2020.   https://oig.hhs.gov/oei/reports/oei-04-18-00450.asp  
CMS Use  of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Background |  8   understand  how CMS uses the staffing information  and  to determine what  
documentation we would collect from CMS.      
To assess CMSs progress toward publicly reporting data  on nursing home staffing, 
we reviewed (1) information on  CMSs  Care  Compare website and (2) CMS  
documentation from its engagement with technical experts and stakeholders.   
To describe the steps CMS has taken to ensure the quality of  nursing home staffing  
data, we reviewed (1) information on CMSs  Care  Compare website  and  (2) CMS 
documentation on quality of provider-reported  data on nurse staffing.  We also used  
public-use  files from CMSs website  to determine how many nursing homes did not  
submit any hours for specific types of non-nurse staff.   We focused our review on the 
following kinds of non-nurse staff:  
   physical therapists (a staffing type that CMS prioritizes for inclusion in Care 
Compare)   
   non-nurse staff that we categorized as other types of critical non-nurse staff:  
o   non-nurse staff required  by all nursing homes (administrators, medical  
directors, and dietitians)  
o   workers who  provide required services (pharmacists)  
In addition, we included  other non-nurse staff, such as social  workers and activity 
staff, in our analysis.    
To determine the extent to which  CMS uses nursing  home staffing data to help  
monitor staffing requirements, we reviewed (1)  information on CMSs website and  
(2)  CMS documentation regarding the inspections conducted by SSAs.  We also 
surveyed 10 selected SSAs to understand their perspectives regarding the inspection 
process and  the use of nursing home staffing information to inform inspections.  
Additionally, we conducted analysis of  CMS datasets, including  public-use  files with  
nurse  staffing data  and  both public and nonpublic datasets  about SSA inspections.  
See the Detailed  Methodology for more information.  
Limitations  
Part of this  analysis is based on staffing data that nursing homes submitted to the 
Payroll-Based Journal.  We did not  verify the accuracy of this  self-reported  
information.  
Additionally, we did not independently verify SSA responses to our survey.  
Standards  
We conducted this study in accordance with the Quality Standards for Inspection  and  
Evaluation  issued by the Council  of the Inspectors General  on Integrity and Efficiency. 
CMS Use  of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Background |  9    
FINDINGS  
 
 
CMS  provides consumers  with  mostbut  not allrequired  
information about  staffing in nursing  homes   
Federal law  requires CMS  to provide specific aspects  of staffing data for each nursing  
home  on  Care  Compare.  These aspects  include (1) data about the number of  
residents and hours of care provided per day;  (2) a  way for consumers to compare 
staffing data;  and (3) data on  staffing turnover and tenure.45   CMS provides  
consumers with the first two  aspects  of  this  required staffing information, with some 
limitations, but  has not yet provided consumers with data on turnover and tenure.  
CMS reported that the lack of  data  on  staff  turnover and tenure is due in part to  the 
COVID-19 public health emergency.   Specifically, CMS  noted  that COVID-19 delayed  
its  planned  updates for 2020.  
CMS provides  consumers with  most  required data about  staffing  
in nursing homes,  but  the  data could be improved to  enable  
more  effective comparisons   
Via Care Compare, CMS provides  consumers with two required  aspects  of staffing  
data.   Specifically,  Care Compare  provides  consumers with (1) staffing data for  
individual nursing  homes, presenting it in (2)  a  way that enables  consumers to  
compare differences among  nursing homes.46    
On Care Compare, CMS  provides consumers with Staffing Star Ratings  and summary  
staffing data  for individual nursing homes, thereby generally addressing  two of  the 
required  aspects  of staffing data.  The Staffing Star Ratings allow  consumers to 
broadly compare nurse staffing  across  nursing homes.  For example, CMS  uses the 
Staffing Star Rating system to indicate both that  higher star ratings result from higher 
staffing  levels and that higher staffing levels may improve care for residents.  CMS  
adjusts the ratings on the basis of  acuity, which increases the comparability of the 
ratings for staffing.  The summary staffing data  include  information about the number 
of residents and the average nurse staffing hours per resident  per day (HPRDs),  
_____________________________________________________________________________________________________________________________  
45  For more  details, see Exhibit 2 on page 5.    
46  CMS has provided this information  nursing home staffing data since 2008.  See CMS,  Nursing Home  
Compare: The First Four Years of the Five-Star Quality Rating System, https://www.cms.gov/Medicare/  
Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/  
2013-The-First-Four-Years-of-Five-Star.pdf. Accessed on August 6, 2020.   Additionally, CMS continued 
to provide this  information about  nursing home staffing once it transitioned to using the  PBJ as the  
source of staffing data for nursing homes.  See CMS,  QSO-18-17-NH Memorandum, 
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/  
Downloads/QSO18-17-NH.pdf.  Accessed on September 6, 2019  
CMS Use  of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Findings  | 10   as  required.  CMS updates the Staffing Star Ratings and  summary data  about staffing  
in  Care Compare every 3 months using  data  from the  Payroll-Based Journal  (PBJ).  
However, while  Care Compare includes summary staffing data in HPRDs for each 
nursing home, the data may not allow consumers to see meaningful differences in 
staffing between nursing homes.  This is because CMS does not adjust the HPRDs 
presented on Care  Compare for acuity, which can limit  the usefulness of  these data  
for consumers to conduct comparisons.47    
Additionally, consumers may not  fully understand the relationship between nurse 
staffing and  resident  quality of care  because CMS describes this relationship more 
generally on Care Compare  than  it does in other guidance.  Specifically, on Care 
Compare,  CMS explains that higher staffing levels may mean that residents receive 
higher quality of care.48   However, in publicly available guidance to SSAs,  CMS more 
definitively explains that  staffing  in nursing homes has a substantial impact on the 
quality of care and outcomes residents experience.49   If consumers do not  
understand  the direct  relationship between staffing and quality of care,  they are 
missing important information about how much importance to place on staffing  
levels when selecting a nursing home.    
CMS has  not yet  provided  consumers with  required  data on  
turnover and tenure among  nurse staff  in nursing homes   
While  CMS  has not yet provided consumers with the required data on turnover and  
tenure, CMS noted that it has made progress toward reporting these measures  in the 
future.  As of  December  2020, CMS  
had  not posted staff turnover or  The Difference Between Turnover and  Tenure  
tenure data on  Care Compare.   A 
CMS may measure turnover over a shorter 
2010 Federal law requires CMS to  
period (e.g., 3 or 6 months) than tenure (e.g., 
post turnover and tenure  data  in  Care  
12  months  or longer).  However, CMS has not  
Compare, and CMS received  funding  
yet published definitions of turnover and  
in 2014 to  start building  the system 
tenure.  
necessary to  calculate and report  
_____________________________________________________________________________________________________________________________  
47  CMS provides public files at  Data.CMS.gov, which can be used to compare different nursing homes on 
their acuity adjusted staff hours per resident per day.  These files do not provide the public with State  
averages that are acuity adjusted, which limits the ability of the public to understand the  extent that 
average nurse  staffing levels differ by State.   CMS,  Provider information, https://data.cms.gov/provider-
data/dataset/4pq5-n9py.  Accessed on December 8, 2020.  
48  CMS,  Care Compare, https://www.medicare.gov/care-compare.  Accessed  on November  30, 2020.  
49  CMS,  QSO-18-17-NH Memorandum, https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationGenInfo/Downloads/QSO18-17-NH.pdf.  Accessed on September 6, 2019.   
Additionally, CMS  informs nursing homes that staffing is one of the vital  components of a nursing  
homes ability to provide  quality care.  CMS,  Staffing Data Submission Payroll Based Journal  (PBJ), 
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/  
NursingHomeQualityInits/Staffing-Data-Submission-PBJ.  Accessed on Oct. 27, 2020.  
CMS Use  of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Findings  | 11   these data.50, 51   CMS  reported that  it  has not presented turnover and tenure data  in  
Care Compare partially because of COVID-19responding  to COVID-19 became a 
top  priority for CMS, thereby delaying  its planned updates for 2020.   
CMS improved its  data-reporting  process  to help it calculate turnover and tenure.  
CMS changed its data-reporting  process in November 2017, allowing  it to track when 
an individual employee worked at  a  nursing home.  Doing so enabled CMS to  
overcome prior technical challenges and work  toward  calculating  both turnover and  
tenure.52   Before  November 2017, the  unique employee identification numbers at  
some  nursing homes  changed when nursing homes changed payroll vendors.  
Therefore, the data that such nursing homes submitted to  CMS  after changing their 
payroll vendors  incorrectly implied  that all employees were new.  To address this 
problem, CMS  added in November  2017 a  voluntary data-submission  step to allow  
nursing homes to link  old employee identification numbers to new employee  
CMS has  
identification numbers.  This linking  capability resulted in employee identification 
gathered more  
numbers that track a worker within a  single nursing home.53    
than  2 years of 
nurse staffing  
Currently, CMS has gathered more than 2 years of data since nursing homes began 
data to calculate 
submitting more reliable employee ID numbers (covering the time period from 
turnover and   October 2017 through December 2019).54   This ability to track individual employees 
tenure.  
across time is fundamental for CMS to be able to  calculate turnover and tenure.   
CMS has taken  additional steps to  introduce turnover  data  but not tenure data.   
CMS has taken steps to introduce turnover data  in Care  Compare.  Prior to the 
declaration  of the COVID-19 public health emergency  in early 2020, CMS anticipated  
releasing turnover data  in late-2020.   CMS now reports that  it  plans  to introduce 
turnover data  in 2021.55   However, CMS has not taken steps to introduce tenure  data 
in Care Compare.   
_____________________________________________________________________________________________________________________________  
50  The U.S. Code (42 U.S.C. 1395i-3(i)(1)(A)(i)) requires turnover and tenure  data to be posted  to Care  
Compare no later than the date on which CMS implemented the requirement to collect staffing data.   
OIG interprets  the statute as giving CMS the authority to decide  when it fully implemented the  
requirement to collect staffing data.  
51  The Improving Medicare Post-Acute Care Transformation Act of 2014 provided funding for the  
creation of the  PBJ.  
52  CMS previously required nursing homes to submit the end  and start dates for each employee, but CMS  
no longer requires these data,  in part because of concerns with the reliability of the reported data.  
53  However, a nurse who works in multiple nursing homes could have a  different identification number  
for each nursing home.  It is CMSs understanding that it does not have the authority to require nursing  
homes to use the same unique identifier for  an employee who works at multiple nursing  homes.  
54  CMS added this data-reporting feature in November 2017.  By February 14, 2018, nursing  homes used  
the updated system to submit staffing data  covering the time period from  October through 
December  2017.  CMS required nursing homes to submit staffing data for  each 3-month  period from 
October 2017 through December 2019.  
55  Additionally, CMS did not require submissions of PBJ data for January to March 2020 because of  
COVID-19, although CMS reinstated the requirement to submit PBJ data for April 2020 and later.  CMS,  
 
 
CMS Use  of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Findings  | 12   During the period  of our review (the staffing data from  April 2018 to March 2019), 
CMS  analyzed  staffing data and  continued to refine its data on  staff turnover.  In 
2017, CMS presented outside experts with both (1) potential  ways to define turnover 
and (2) preliminary data  analysis.  The experts provided feedback to CMS, including  
descriptions of how turnover among certain staff types can impact quality of care.  In 
2019, CMS  continued refining its preliminary data  on  staff  turnover.  
Although  CMS has made progress in  defining and publicly posting  data on staff  
turnover, CMS did not  analyze data or work with these outside experts to define staff  
tenure.  In interviews with OIG, CMS  reported that it decided  to first develop and  
introduce turnover data  before working on tenure  data.  CMS prioritized turnover 
data before tenure data because the Payroll-Based Journal (PBJ)  is a new  source of  
staffing  information and because  turnover measures staff retention over a shorter 
amount of  time.  
CMS  has  a  robust  process  for ensuring  the reliability of  nurse 
staffing data,  but  it  lacks  similar processes  for  non-nurse 
staffing data  
CMS uses several tools to check the accuracy and completeness of  nurse  staffing data.   
These actions include checks for highly improbable nurse staffing  and targeted audits 
of the nurse staffing  data that nursing homes submit.  However, CMS does not take 
similar steps to ensure the  accuracy and  completeness of  non-nurse  staffing  data.   
Because CMS publicly reports data on non-nurse staffing for consumers to consider in 
selecting a nursing home, it is important that these data  be  accurate  and complete.  
CMS has a  robust process  to ensure  the accuracy  and 
completeness  of  nurse  staffing  information    
CMS has instituted checks to ensure that reported nurse staffing data are accurate.  
For example, CMS checks for data abnormalities, such as nursing homes reporting  
improbably high or low  levels  for  nurse staffing.  CMS excludes nursing homes with 
these data abnormalities from the publicly reported PBJ data  (i.e., the public use files)  
on  Data.CMS.gov, to ensure the publicly provided information  are accurate.  On Care 
Compare, these nursing  homes  with  data abnormalities  do not  have their average  
staff hours per resident  published,  nor do they receive a Staffing Star Rating based  on  
_____________________________________________________________________________________________________________________________  
Long Term Care Facilities (Skilled Nursing Facilities and/or Nursing Facilities): CMS Flexibilities to Fight  
COVID-19, https://www.cms.gov/files/document/covid-long-term-care-facilities.pdf, accessed on  
April  15, 2020;  and CMS,  QSO 20-34-NH, https://www.cms.gov/files/document/qso-20-34-nh.pdf, 
accessed on June 26, 2020.   
CMS Use  of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Findings  | 13   their average staffing  and acuity.56   Additionally, CMS has contracted auditors to  
assess and improve the accuracy of nurse staffing data, and these auditors  performed  
nurse staffing audits at  an average of 390 nursing homes each quarter from Q2 2018 
through Q1 2019.  Nursing homes that do not pass the audit are downgraded to  
a  1-star  Staffing Rating.  For additional information on  CMSs actions to  improve  the 
accuracy and completeness of the staffing  information, see Appendix A.    
CMS  also uses Care Compare as a tool to improve the completeness of nurse staffing  
data.  For example, CMS  downgrades the Staffing Star Ratings to 1 star for nursing  
homes that do not successfully submit any nurse staffing data.  Additionally, CMS  
downgrades the Staffing Star Ratings to 1 star for nursing homes that report 4 or 
more days per quarter with no  RN hours.57   CMS reported that this policy encouraged  
nursing homes to submit complete nurse data for each day.  Additionally, a CMS  
policy memorandum says that the policy seeks to  reduce  the number of days when  
nursing homes do not  have an RN.58    
Additionally, CMS regularly monitors the completeness of the nurse staffing  
information that nursing homes submit.  Specifically, CMS routinely reviews various 
measures of data completeness after nursing homes quarterly submissions of data,  
monitoring trends across quarters.  These measures focus on the number of nursing  
homes that submitted data about nurse staff.  For example,  CMS monitors how many 
nursing homes report 4 or more days in a quarter with no  RN hours.  According to  
CMS documentation, this number decreased  by nearly 50 percent during  the period  
of our review (i.e., from  1,491 nursing homes in Q2 2018 to  845 nursing  homes in 
Q1  2019).59   
CMS does not  have a robust process  to ensure  the  accuracy and  
completeness of  staffing information for non-nurse staff   
It is important that the public receive reliable information on non-nurse staff, and  
Federal guidelines require CMS to ensure the reliability of the data  that  it  provides to  
_____________________________________________________________________________________________________________________________  
56  Instead, these nursing homes have Data Not Available displayed on Care  Compare for their average  
staff hours.  Additionally, these nursing homes have Data  Not Available displayed for their Staffing Star  
Ratings, unless a  nursing home reported 4 or more days with no RN hours  or did not pass an audit of its  
PBJ staffing data, in which case its Staffing Star Rating is downgraded to 1  star.  
57  In June 2018,  CMS began its policy to downgrade nursing  homes Staffing Star Ratings if they reported  
7 or more days in a quarter with no RN hours.  In April 2019, CMS strengthened its criteria  for  
downgrading nursing homes, from 7 days with no RN hours  to 4 days with no RN hours.   CMS,  
QSO-18-17-NH Memorandum, https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/  
SurveyCertificationGenInfo/Downloads/QSO18-17-NH.pdf,  accessed on September 6, 2019; and  CMS,  
QSO-19-08-NH Memorandum, https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/  
SurveyCertificationGenInfo/Downloads/QSO19-08-NH.pdf,  accessed on Oct. 2, 2019.  
58  CMS,  QSO-18-17-NH Memorandum, https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationGenInfo/Downloads/QSO18-17-NH.pdf.  Accessed on September 6, 2019  
59  CMS provided  documentation to OIG including Excel  workbooks, which CMS uses to monitor various  
measures of completeness for the quarterly PBJ data submissions.    
CMS Use  of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Findings  | 14   the public.60   However, CMS does not take steps to ensure the accuracy of the 
physical therapist data  that it publicly reports on Care Compare, nor does CMS ensure 
the completeness of  data for  other non-nurse staff  data that the public can access.   
CMS does not take steps to ensure  the accuracy of  physical-therapist  staffing  
information reported on Care Compare. CMS  uses a robust process to review nurse  
staffing  information that it reports on Care Compare.  However, CMS does not take 
similar steps for non-nurse  staffing  information also reported on the website;  
currently, this information includes  only physical therapists.61   For example, CMS does 
not audit  the physical-therapist  staffing information reported by nursing homes and  
included on Care Compare.  Because CMS does not use any accuracy checks on these 
data, we cannot determine whether the data reported on Care Compare are accurate.   
Publicly reported staffing data  for  all therapists appear  more complete than  
staffing  data for other  non-nurse staff.  CMS publicly reports staffing data for 
non-nurses  on  Data.CMS.gov, including  all  types of therapists.  However, for non-
nurse staff aside from therapists, these data may not reflect hours that staff were paid  
by third parties.  According to CMS documentation, some non-nurse staff  may be 
paid by third parties (e.g. physicians being paid by Medicare for physician services)  
instead of being paid either directly or indirectly by the nursing home.62    These hours 
that such staff  are paid  by third parties are not included in the staff  hours reported in 
the PBJ.  This exception does not apply  to therapistsi.e., physical, occupational,  
speech, and respiratory  therapists.  CMS requires nursing homes  to report hours  for  
therapists  regardless of  payer.63    
As a result, publicly reported staffing data for therapists appear more complete than 
staffing data for other non-nurse staff.  For example, in Q1 2019, approximately 
94  percent  of nursing homes (14,190 of 15,058) reported at least some physical  
therapy hours in CMSs public dataset on Data.CMS.gov. In contrast, 48  percent  of  
nursing homes did not  report any hours for at  least one type of  other critical  
non-nurse  staff, including  staff required by all nursing homes (i.e., administrators, 
medical directors, and dietitians) and  workers who  provide required services (i.e., 
pharmacists).   This analysis of  the publicly reported staffing data does not  reveal  
whether these critical non-nurse staff were present in these nursing homes.  See 
Appendix B for information about how many nursing homes did not report data for 
non-nurse staff types and for CMS requirements to  submit  these  data.  
_____________________________________________________________________________________________________________________________  
60  For more  details on the Federal requirements for CMS to ensure data reliability, see page 7 of this  
report.  
61  CMS does not report staffing  hours on Care Compare for other types of therapists (i.e., occupational,  
respiratory, and speech therapists).  
62  CMS,  Electronic Staffing Data Submission Payroll-Based Journal: Long-Term Care Facility Policy Manual, 
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/  
NursingHomeQualityInits/Downloads/PBJ-Policy-Manual-Final-V25-11-19-2018.pdf.  Accessed on  
May  22, 2020.  
63  Ibid.  
CMS Use  of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Findings  | 15   CMS  has  taken  an  important  step  by using  staffing data to 
inform  State inspections,  but  it  has  opportunities  to  better 
target  oversight  
CMS has taken an important step by  using staffing information to target  weekend  
inspections of nursing homes.   However, we identified  additional actions that  CMS  
can take  as it  helps  SSAs monitor nurse staffing requirements.   
CMS shares  some staffing information  with  SSAs to target their  
weekend inspections  
CMS has taken an important first step in using staffing data to help SSAs  target their 
oversight.  In January 2019, CMS began sharing  a list  with each  SSA  of nursing homes 
in that State  that reported lower weekend staffing  levels.64   In this report, we will refer 
to these as weekend lists for targeted inspections.  Eight of  the 10  SSAs we surveyed  
reported that this step helps improve the effectiveness of their efforts to oversee  
compliance with staffing requirements.65   Specifically, CMS  identifies the nursing  
homes in the bottom 20 percent within each State on the basis of  weekend  average 
nurse staffing per resident.  CMS instructs SSAs that 5 percent of standard inspections 
should occur on weekends, during which SSAs should consider citing these nursing  
homes for insufficient staffing.  CMS  allows  SSAs  discretion when selecting  nursing  
homes from these lists.   Exhibit  4  on the next page  summarizes how CMS uses the 
staffing data,  including to help monitor compliance with Federal staffing  
requirements.   Although Federal requirements require CMS only to provide  staffing  
information on  Care  Compare, CMS has made a  proactive  decision to  also use the 
staffing data to help target a portion of  State  inspections  of nursing homes.   
 
 
 
 
 
 
_____________________________________________________________________________________________________________________________  
64  OIG interview  with CMSs Director of the Division of Nursing Homes, July 2019, and CMS,  
QSO-19-02-NH Memorandum, https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/  
SurveyCertificationGenInfo/Downloads/QSO19-02-NH.pdf,  accessed on December 11, 2018.  
65  The remaining two SSAs did not indicate whether this step  has had a positive or negative  impact.    
CMS Use  of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Findings  | 16   Exhibit 4.  How CMS  uses nursing home staffing data to inform consumers 
and monitor compliance with staffing requirements  
 
However, CMS does not consider residents relative level of care 
needs when targeting nursing homes for weekend inspections  
CMS has taken an important step by sharing weekend lists with SSAs because doing  
so helps  SSAs conduct targeted inspections of nursing homes that report lower levels 
of nurse staffing on weekends.  However, CMS does not yet  use information about  
acuity (i.e., residents  relative level  of care needs)  when it creates the weekend lists for 
targeted inspections.    
When monitoring weekend staffing, CMS can use key information about  acuity to  
better identify nursing homes for heightened attention.  CMS  currently uses this 
acuity information  when calculating Staffing Star Ratings for  Care  Compare, but it  
does  not do so for  targeting potential weekend inspections.    
Because CMS does not  use information about  acuity when identifying nursing  homes 
for weekend lists, CMS  may miss nursing homes that  have  sicker residents who  
require more care.  If CMS  were to  use acuity information when  generating  each 
States  weekend  list, CMS would  likely identify different nursing homes to include.  For  
example, we found that  CMSs  method for creating  weekend  lists  would  miss,  on  
average, one in four  of the nursing homes with lowest nurse staffing  on weekends.   
These missing nursing homes have  residents with a relatively  greater level of need.   
For more information about  how  adjusting for acuity affects these  weekend  lists, see 
Appendix C.   
 
CMS Use  of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Findings  | 17   State survey agencies  are optimistic  that staffing information can  
help  them to  monitor nurse staffing requirements, but they  are 
concerned about  effects  on  their workload  
SSAs expressed interest in using staffing information from the PBJ to help them 
increase the  effectiveness of how they monitor nursing home  staffing.  Specifically,  
most SSAs  (9  of 10) reported that the use of staffing data  would  increase the 
effectiveness of their oversight for nurse staffing requirements.66   They also expressed  
interest in receiving  from CMS additional information about  nursing home staffing, 
including  the following: lists  of nursing homes that did not submit PBJ data  
(mentioned  by seven SSAs), results from CMSs analyses (mentioned by six SSAs), and  
training on how to conduct their own State-led  analysis (mentioned by four SSAs).   
No SSAs  stated  that the use of  more  staffing data would reduce the effectiveness of  
their efforts to oversee nurse staffing.67  
However, SSAs also expressed concern that using nurse staffing data  from the PBJ  
could  negatively affect  the efficiency of  inspections and limit  their ability to conduct  
other inspection tasks, such as monitoring for resident  neglect and abuse.  Some SSAs 
(2 of 10) reported  concern that using  CMSs staffing data would  cause inspectors to  
inefficiently spend  extra  time and resources in  monitoring staffing.   An additional 
four  SSAs  echoed these concerns  in open-ended comments.  They reported  that 
increased  use of staffing  data could  add burden to  existing tasks for inspectors (e.g., 
performing onsite observations and  interviews), thereby reducing  the time and  
resources available for other inspection tasks  such as monitoring for neglect and  
abuse of residents.  
CMS is aware of the need to consider the SSAs  workloads  when providing  staffing  
data.  CMS expressed  to OIG  the need to balance the amount of  inspection tasks that 
CMS requires  of SSAs because adding an inspection task can result in other inspection 
tasks receiving less attention.68   CMS  also indicated that it has a responsibility to  
analyze the staffing data  and provide inspectors with some of the resulting  
information in ways that  inspectors can easily use.   For example, CMS reported  that it  
would  like to integrate additional  information into a new inspection systemcurrently 
in developmentso that it can  more efficiently provide  useful  staffing information 
directly to  SSAs.   
 
_____________________________________________________________________________________________________________________________  
66  OIG surveyed the SSAs in April 2019, after CMS had introduced the  weekend inspection process.  Eight 
of 10 SSAs reported that use  of staffing data could increase the effectiveness of oversight for the  
requirement to have 8 RN hours every day and to have 24-hour licensed nursing.  In addition, 6 of  
10  SSAs reported that use of staffing data could increase the effectiveness  of oversight for the  
requirement to have sufficient staffing.     
67  The remaining SSAs said that use of staffing data would have neither a positive nor negative impact.  
68  OIG interview  with CMSs Director of the Division of Nursing Homes, July 2019.  
CMS Use  of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Findings  | 18   CMS can  take additional steps  to  strengthen  oversight  of  nursing 
home  staffing   
CMS helps oversee staffing in nursing homes in different ways, including using  
staffing data to help SSAs target weekend inspections.  However, CMS can take 
additional steps that will  help it ensure compliance with staffing requirements.    
CMS can inform SSAs  of the dates  on which the  lowest staffing occurred to better  
target how  SSAs  monitor nurse staffing requirements.   When providing weekend  
lists to help SSAs target  their inspections, CMS indicates whether  a nursing home 
frequently reported days with no  RN hours.  However, CMS  does not provide SSAs 
with  dates on which nursing homes reported  no hours for RNs.  CMS  told  OIG that 
part of the reason why CMS does  not  provide  inspectors with the specific dates  is that  
State inspectors are not  auditors and are generally unfamiliar with payroll  systems.69   
However, not sharing this information prevents State inspectors from targeting their 
documentation reviews to the most relevant dates when working to identify low  
staffing  from previous months.70     
CMS can inform SSAs  when reported staffing  was less than  8 RN hours or less than  
24  licensed-nurse hours.   CMS does not inform SSAs whether nursing homes report  
fewer hours for RNs and  licensed nurses than are federally  required.71   Specifically, 
that information would reveal whether nursing homes reported an RN  onsite for 
8  hours  and licensed nursing services on site for 24  hours, both of which are required  
every day.   From January through March 2019, 7  percent of nursing homes (1,100  of  
15,058)  reported fewer hours than required  more  than  twice per month  on average 
(i.e.,  on at least 7  occasions  in the 3-month  period).  CMS does not identify these 
nursing homes for SSAs, unless the  nursing home is included on CMSs weekend lists 
and the nursing home  reported no RN hours at least  four  times per quarter, which on 
average is more than one  time per month.    
Additionally,  CMSs  oversight efforts could better identify nursing homes at risk of  
staffing  below  Federal requirementsCMSs  current efforts do  not  target  the subset  
of nursing homes  that frequently  report staffing levels that are  below Federal  
requirements.  Among the subset of nursing homes that reported fewer RN or  
licensed-nurse  hours than required  at least  5  times per month on average  from  
January  through March 2019  (466 of 15,058  nursing homes), nearly 3 in 5  of these 
nursing homes would  be missing from CMSs weekend lists.  Further, among the  
subset of  these nursing  homes that received a standard health inspection in the same 
_____________________________________________________________________________________________________________________________  
69  OIG interview  with CMSs Director of the Division of Nursing Homes, July 2019.  
70  When reviewing the sufficiency of staffing, CMS suggests that inspectors may need to validate  
concerns by reviewing recordsincluding  the staffing schedule for the  past monthand says that  it  
may be necessary to expand [their] review.  CMS Form 20062, February 2017, Sufficient and Competent  
Nurse Staffing Review.  
71  CMS has a policy to downgrade the Staffing Star Rating of  a nursing home  to 1 star  if the nursing  
home  reported no RN hours at least 4 times  per quarter, which on average  is more than 1 time per  
month.   
CMS Use  of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Findings  | 19   quarter, less than one in six  received a deficiency citation for their nurse staffing  
levels.  For more  information,  see Appendix  D.  
CMS can better  leverage staffing data to help  SSAs more  easily identify nursing  
homes  that are at risk  of insufficient  nurse staffing.   In our survey, SSAs frequently 
reported  that it is  more  difficult  to determine that staffing levels were insufficient  than 
to  determine whether  nursing homes violated  other  parts of  the Federal requirements  
for nurse staffing levels.  Six  of the 10  SSAs in our review reported difficulty in  
determining when a nursing home violates the requirement  for sufficient staffing.  
Three of these six SSAs reported that using CMS  staffing data could improve the 
effectiveness of their monitoring  for sufficient staffing.72   In contrast, 8 of the 10  SSAs  
in our review reported  that  it  was straightforward to determine when to  cite nursing  
homes for not providing 8 RN hours and  around-the-clock licensed-nurse  services 
every day.   
CMS can help SSAs  more efficiently oversee staffing in nursing homes by identifying  
nursing homes that are at risk  of  insufficient staffing.  CMS currently does this in a  
limited capacity through its weekend lists for targeted inspections.  CMS  instructed  
SSAs to consider citing the nursing homes on those weekend lists if the nursing  
homes have insufficient  nurse staff.73   This is an important step to leverage the 
staffing data to help SSAs identify nursing homes that may not have sufficient  
staffing.  However, CMS  has not yet taken similar steps to  better leverage the staffing  
data to help SSAs to strengthen oversight of  insufficient nurse staffing during the 
95  percent  of standard  inspections that do not occur on weekends.   
CMS reports that Staffing Star Ratings can help SSAs  monitor for insufficient nurse 
staffing because nursing homes with low  Staffing Star Ratings might not provide 
sufficient staffing.74   However, Staffing  Star Ratings may be of limited use to help 
SSAs monitor for insufficient staffing because Care Compare does not  clearly 
distinguish  among the many potential causes for  any specific 1-star  Staffing Rating.   
For example, a  nursing home  may have a  1-star  Staffing Rating because  it  reported  
low staffing  throughout the quarter, because it reported no hours for RNs several  
days in a quarter, because it did not  report any staffing data, or because  an audit  
found that the nursing home had  inaccurate nurse staffing  information.   Additionally,  
while the Staffing  Star Rating and an RN  Star Rating are available on Care Compare, 
the website does not provide a star rating for total nurse staffing (which includes 
_____________________________________________________________________________________________________________________________  
72  Overall, 6 of 10 SSAs  said using CMS staffing data  could improve the effectiveness of their monitoring  
for sufficient staffing.  
73  CMS,  QSO-19-02-NH Memorandum,  https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationGenInfo/Downloads/QSO19-02-NH.pdf.  Accessed on December 11,  
2018.  
74  Documentation received from CMSs Director of the Division of Nursing Homes, October 2020.  CMS  
considers the  relationship between staffing and quality of care when establishing these cut points, but a  
1-star rating is  not an indication that staffing is insufficient.   CMS,  Nursing Home Compare Technical  
Users GuideOctober 2020, https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/CertificationandComplianc/downloads/usersguide.pdf.  Accessed on November 17, 2020.  
CMS Use  of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Findings  | 20   nurse aides).75   As a result, the Staffing Star Ratings may be of  limited use to help 
SSAs monitor for  insufficient staffing  with regard to  nurse aides.  
To target their inspection actions on  insufficient  staffing, SSAs may benefit from 
information that more clearly indicates the potential staffing  problem.  CMS publishes 
the underlying data used  to calculate the Staffing Star  Ratings on  Data.CMS.gov. 
These data may be more useful  than the Staffing Star  Ratings  to help SSAs monitor 
insufficient staffing because they clearly describe acuity-adjusted levels of RN staffing  
and total nurse staffing. 
_____________________________________________________________________________________________________________________________  
75  The Staffing Star Rating featured on Care Compare  is an average of two other measures that CMS  
calculates: the RN Star Rating and a staffing rating for total nursing (which  covers RNs, licensed practical  
nurses, and nurse aides).  If the average of these two measures is not a whole number, the overall  
Staffing Star Rating rounds towards the RN  staffing rating,  resulting in situations in which a staffing 
rating for total  nursing cannot be extrapolated from the information provided on Care Compare.  
CMS Use  of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Findings  | 21    
RECOMMENDATIONS  
 
 
 
 
This review focused on CMSs use of  staffing data from April 2018 through  
March  2019, before the COVID-19 pandemic.  We  also included  CMS actions  up until  
December 2020.  CMS has  long identified staffing as a vital component of a nursing  
homes ability to  provide quality care.  The  need  for reliable information about  
staffing  in nursing homes is  one of the reasons CMS built  the  PBJ.   
Using the PBJ, CMS has taken important  steps to provide consumers with more 
comprehensive and accurate information about staffing at nursing homes.  For  
example, CMS  provides  mostbut  not allrequired  information about  staffing to the  
public via  Care Compare.  This public website enables residents of nursing homes and  
their families to make informed choices based on reported staffing levels  and other 
information, such as results from SSA inspections and performance on  CMS  quality  
measures.  CMS has implemented a robust process for reviewing the nurse staffing  
data to ensure the datas  completeness and  accuracy.  Further, by targeting weekend  
inspections, CMS  has taken an important step in leveraging staffing data to protect  
residents of  nursing  homes.  
However, CMS has opportunities to further leverage the PBJ data to ensure that 
consumers have useful information to guide their decision-making.  For example,  
consumers do not yet have information about nurse staff turnover or tenure, even 
though CMS is required to provide this information by Federal law.  However, 
progress in 2020 on  sharing this information has been delayed by CMSs  focus on 
helping nursing homes combat COVID-19.  Further, CMS can take steps to ensure the  
accuracy of the reported  non-nurse  staff information  on Care Compare.  The 
information that CMS collects and publishes about  non-nurse staff  lacks a robust  
process to ensure  its  accuracy.  By taking steps to ensure the  accuracy of non-nurse 
staffing data, CMS can improve the staffing data that it provides the public.  
Finally, CMS has opportunities to better leverage nursing home  staffing  data to  more 
effectively monitor staffing.  For example, CMS  does not  factor in the relative care 
needs of residents when it identifies nursing homes with lower weekend staffing.  
Further, CMS does not  inform SSAs when nursing homes report staffing that is 
substantially below requirements, nor does it  inform SSAs  of the  dates on which 
reported staffing  was unusually low.  Addressing these issues would build  on what  
CMS has already done to oversee staffing  in nursing homes.  
OIG  acknowledges the  impact  that COVID-19 has had  on nursing home  oversight  and 
on  CMSs priority  of improving  the quality of care that nursing homes provide.   We  
also note  that  the pandemic  reinforces the importance of  having  adequate staffing  to 
respond to outbreaks of infectious diseases.  We offer CMS several recommendations 
as it continues to leverage nursing home staffing information from the PBJ.  
CMS Use  of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Recommendations  | 22   We recommend  that  CMS:  
Provide data  to  consumers  on nurse staff  turnover and  tenure, 
as  required  by Federal law  
To comply with Federal statute,  CMS  must publicly report  data  on  both nurse 
turnover and tenure on Care Compare.  CMS  is not currently reporting either of these 
measures to the public.   CMS has  made  progress toward  being able to report  
turnover  datait has  developed a definition for nurse turnover, a  critical  first step.  To 
ensure safety and quality of care for nursing home residents, CMS  should  take  similar  
steps to define nurse  tenure, and to report on both turnover and  tenure  as soon  as  
practicable  given the many urgent  needs that CMS  is facing.  
Ensure the accuracy of  non-nurse staffing data  used on  Care 
Compare  
CMS should  take  steps  to ensure the accuracy of PBJ data  for non-nurse staff  that it 
chooses to include in Care Compare.   These steps may be comparable to those that 
CMS  performs to ensure the accuracy of nurse staffing data.  For example, CMS may 
wish to  add  physical therapiststhe  only type of  non-nurse staff  with data  currently 
found on Care Compareto  its audits of PBJ data.  CMS may also  wish to explore 
other ways to improve the accuracy of non-nurse staffing data included  on Care 
Compare.  
Consider residents  level of  need  when identifying  nursing  
homes  for weekend  inspections   
CMS should  analyze and  use information about the relative acuity (or level of need)  of  
residents as it continues to compile lists of nursing homes with lower staffing to help 
SSAs target  nursing homes for weekend inspections.  CMS  calculates acuity-adjusted  
staffing  levels for the Staffing Star Ratings found in Care Compare.   Acuity-adjusting  
the weekend staffing levels for nursing homes before identifying those with lower 
staffing  will  improve the quality of the nursing-home lists that CMS  shares with SSAs  
for weekend inspections  
Take additional steps  to  strengthen oversight  of  nursing  home  
staffing  
CMS should  take additional steps to  oversee staffing in nursing homes by more fully 
leveraging  the staffing information  that  it collects and providing it to SSAs.  Doing so  
could  help SSAs more efficiently deploy their resources to target staffing reviews on 
those nursing homes at  higher risk for staffing problems during those dates when 
CMS Use of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Recommendations  | 23   nurse staffing appeared most problematic.  CMS  currently does this in a limited  
manner by providing SSAs with a list of nursing  homes that have potentially 
insufficient staffing on weekends.  CMS can build on this effort in several ways.  For 
example, CMS could inform SSAs which nursing homes reported  frequently  staffing  
below 8 RN  hours or 24 licensed-nurse  hours during a quarter and provide those 
dates to SSAs.  CMS could also  identify nursing homes at risk  of insufficient nurse 
staffing, which SSAs reported was relatively difficult to determine.  CMS  may wish to  
use the underlying data from  Staffing Star Ratings to strengthen oversight of nurse 
staffing.  If CMS uses  these  existing data,  it may  need to share information with SSAs 
and guide them on how to use  the data.  
Additionally, CMS is currently updating its inspection system.  OIG encourages CMS to  
ensure that  staffing  information is integrated into  the future  system so that SSA  
inspectors can easily access data about specific  nursing homes. 
CMS Use of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Recommendations  | 24    
AGENCY  COMMENTS AND OIG RESPONSE  
 
 
CMS concurred with all four of  our recommendations.   
In response to our first recommendationfor it to provide data to consumers on 
nurse staff turnover and tenure, as required by Federal lawCMS stated  that it will  
continue  working to publicly report  on  nurse staff turnover and tenure.  CMS  
described the actions that it has performed  to enable it to report  on  nurse turnover, 
which CMS  has prioritized over reporting on nurse tenure. CMS  also reported that the 
COVID-19 pandemic delayed its plans to introduce data on nurse turnover.    
In response to our second recommendationfor it to ensure the accuracy of  
non-nurse staffing data  used on Care CompareCMS stated that it  will  explore ways  
to improve the accuracy of  these data  by expanding its audits of Payroll-Based 
Journal data to include data submitted for non-nurse staff.  
In response to our third  recommendationfor it  to consider residents level of need  
when identifying nursing homes for weekend inspectionsCMS stated that it  will 
begin to use information about residents level of need when targeting weekend  
inspections to nursing homes that may have staffing problems.  
In response  to our fourth recommendationfor  it to take additional steps to 
strengthen oversight of  nursing home staffingCMS stated  that it  will  work to more  
efficiently provide useful staffing information directly to State survey agencies.  CMS  
reiterated that staffing is a vital component of  the quality of  care in nursing homes.   
CMS also emphasized its commitment to continually improve oversight of nursing  
homes.   
OIG appreciates the efforts that CMS has taken to use the staffing data reported by 
nursing homes.  We also acknowledge that CMS has faced a  serious challenge 
protecting  nursing home residents during the COVID-19 pandemicand  that CMS  
reprioritized its efforts in response.  OIG looks forward to collaborating with CMS as 
the agency continues  to leverage nursing home staffing information to improve the 
quality of care that nursing homes provide.  OIG will monitor CMSs progress in 
implementing these recommendations.  For the full text  of  CMSs comments, see  
Appendix E.  
CMS Use of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Agency Comments and OIG Response  | 25    
DETAILED METHODOLOGY  
 
 
We based this study on analysis of  interviews with subject-matter experts  at CMS;  
documentation from CMS;  publicly available data on staffing  and citations for nursing  
homes;  nonpublic  information about staffing  and inspection times for nursing homes;  
and a survey of  SSAs.  We reviewed information pertaining to staffing data from 
April  1, 2018, to  March 31, 2019, but  we also included updates on some of  CMSs 
subsequent actions through December  2020.  We collected  these data  between 
January 2019 and May 2020.   
Progress  Toward  Publicly Reporting  Required  Data  on  Staffing  
We  assessed  CMSs actions to provide the public with required  nurse staffing  
information and  to enable  effective  comparisons of this information on Care 
Compare.76   To do so, we reviewed publicly available information and analyzed  
interview responses.  During our interviews with CMS, we asked how it uses Care  
Compare to  inform consumers.  We also reviewed public communication about the 
importance of staffing  in nursing homes shared  from CMS  with nursing homes and  
State Survey Agencies.  
We also assessed  CMSs actions to introduce turnover and tenure data  on Care 
Compare by analyzing  interview responses and agency documentation.  We asked  
CMS  what it has done to introduce turnover and tenure data  in  Care Compare  and  
what sorts of challenges it has encountered in doing so.  Documentation that we  
collected and analyzed include  presentation slides and meeting minutes from the 
Technical Expert Panel Teleconferences on Care Compares Five-Star Quality  Rating  
System, which were  held  intermittently in  2017 and 2018.  Documentation  also 
includes  CMSs methods for calculating turnover and tenure and the agencys 
preliminary analysis of data on staffing turnover. 
Efforts To  Ensure the Quality Staffing  Data That  Nursing  Homes  
Report  
We determined the extent to which CMS took steps to ensure the completeness and  
accuracy of staffing  information  for  both nurse and non-nurse staff.  We  also  
performed  quantitative analysis of PBJ public use files (PUFs) to assess data  
completeness.   
_____________________________________________________________________________________________________________________________  
76  During the course of our review, we  collected and analyzed data from Nursing Home Compare, which 
was operational until December 1, 2020, when it was replaced by Care Compare.  Throughout the  
detailed  methodology, however, we refer only to Care Compare.  
CMS Use of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Detailed Methodology |  26   We conducted structured interviews and collected documentation from CMS  and  
analyzed  these data.  During our interviews with CMS, we asked the agency about  
steps it takes to ensure the quality of staffing data that nursing homes submit to the 
PBJ and how CMS ensures the quality of the PBJ-based staffing information on Care 
Compare.   We asked about CMSs ongoing and planned actions to  improve the 
accuracy and reliability of the staffing data.  We reviewed documentation of how  CMS  
monitors and ensures the completeness and accuracy of nurse data through various 
steps.  We reviewed 2018 and 2019 CMS policies and guidance documents, including  
SSA memorandums and technical user guides for the PBJ and  Care Compare.    
Additionally, we determined  how many  nursing homes did not  submit any  hours 
for specific  types of non-nurse staff.   We collected publicly available PBJ data directly 
from  Data.CMS.gov. We used CMSs PUF for non-nurse staff  from each quarter 
during the period of review, which included data  on over 95 percent of nursing  
homes, and determined the percentage of nursing homes in each quarter that did not  
report any hours for each type of non-nurse staff.  We focused our review upon non-
nurse staff that CMS prioritized for inclusion in Care Compare (physical therapists)  
and that  we categorized as other critical  staff,  including staff required for all nursing  
homes (administrators, medical directors, and dietitians)  and  workers who  provide 
required services (pharmacists).  
Efforts To  Coordinate with  SSAs  To  Monitor Staffing  
Requirements    
We determined the extent to which CMS uses PBJ data to help SSAs to  monitor 
Federal requirements for nursing home staffing.  To do so, we analyzed CMS  interview  
responses, documentation from CMS, staffing information found on HHS  websites, 
and SSA survey responses.  To provide context for the results of this analysis, we 
performed several quantitative analyses that compare the State-specific  weekend  lists  
of nursing homes that CMS  identifies with lower weekend staffing to other lists of  
nursing homes that report low staffing by different metrics.   
During our interviews with CMS, we asked how it currently uses and/or plans to use 
PBJ data to  help oversee and enforce Federal nursing home staffing requirements.  
We also  asked CMS about any roadblocks  for using the PBJ data to help oversee 
Federal  nursing home staffing requirements.  Additionally, we reviewed 2018 and  
2019 CMS policies and guidance documents, including SSA  memorandums.  
To discuss SSAs experiences with the current health inspection process and the PBJ, 
we surveyed 10 purposively selected SSAs in 2019.  We obtained their perspectives on 
the ways they use PBJ data to monitor staffing  levels and requirements of  
participation, challenges they encounter when determining sufficient nurse staffing  
levels, and any future actions they would like CMS to take to  improve their 
understanding and use of PBJ data.  We selected SSAs from States of assorted sizes, 
with various State-specific staffing  level standards, and that were in different parts of  
CMS Use of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Detailed Methodology |  27   the United States.  All 10 SSAsCalifornia, Colorado, Connecticut, Florida, Michigan, 
Missouri, New Mexico, New York, Utah, and Virginiaresponded to our survey.   
Quantitative Analysis  of  How CMS Uses Staffing Information  
To  Help Monitor Requirements  
To understand how CMS uses and shares key information to  help monitor staffing  
requirements, we conducted multiple quantitative analyses.  We used public and  
nonpublic  datasets on both nurse staffing  and the citations issued by SSA inspectors.   
We downloaded publicly available staffing  information directly from  Data.CMS.gov  
and  Data.Medicare.gov.  From Data.Medicare.gov, we also  downloaded publicly 
available information on SSA  inspections with deficiency citations.   Additionally, we 
collected  a  nonpublic  dataset from  CMS with information on the dates of SSA  
inspections at nursing homes.   
We determined how  many  nursing homes with  lower staffing  are  missing from  
CMS  weekend lists  by  comparing CMSs method  against  an alternative method that  
adjusts for  acuity  (i.e., relative level  of need).   To adjust nurse staffing according to  
resident  acuity, we used CMSs calculation of the case  mix HPRD values  for the 
applicable period, which CMS uses for Care Compare.77   To calculate its case  mix  
HPRD values, CMS relies on the Minimum Data  Set assessments and information from 
CMSs Staff  Time and Resource Intensity Verification (STRIVE) Project.  78   STRIVE 
assessed the average amount of nursing time provided in nursing homes according to  
residents needs and was published in 2006.79   We  first  determined a  list of the 
bottom 20 percent of nursing homes in each State  for weekend nurse staffing  in  
HPRDs,  while adjusting  for  acuity.  We determined how many of these nursing homes 
(in  our  acuity-adjusted State lists) would not be included in CMSs weekend  lists  
(CMSs lists contained  the bottom 20 percent of nursing homes  in each State  not  
adjusted  for resident  acuity.)80    
We determined how  many  nursing homes  reported staffing levels below  Federal  
requirements.   We  identified all RN  hours and licensed-nurse hours  on each day.  We 
determined which days nursing homes reported less RN hours than Federal  
_____________________________________________________________________________________________________________________________  
77  We obtained the case mix HPRDs from the corresponding Provider Information files (e.g., PBJ data 
from Q2 2018 corresponds to the Provider Information file for October 2018).  CMS makes this file  
publicly available at  Data.CMS.gov for the most recent data  on Care  Compare.  We  accessed the archived  
datasets at  https://data.cms.gov/provider-data/dataset/4pq5-n9py.  
78  CMS,  Nursing Home Compare Technical Users GuideOctober 2020, https://www.cms.gov/Medicare/  
Provider-Enrollment-and-Certification/CertificationandComplianc/downloads/usersguide.pdf.  Accessed  
on November  17, 2020.  
79  CMS funded a  national staff time measurement study on nursing homes (i.e., the STRIVE Project) to 
estimate daily  care  costs is nursing staff time.  CMS counted the number of  minutes that residents with 
similar needs received nurse  care.  CMS, STRIVE Project  Phase I Report,  https://www.cms.gov/Medicare/  
Medicare-Fee-for-Service-Payment/SNFPPS/TimeStudy.html.  Accessed on November 13,  2019.  
80  To avoid burdening CMS by requesting  additional nonpublic data, we opted to use the publicly  
available  data in the analysis presented in this report.    
CMS Use of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Detailed Methodology |  28   requirements stipulate (i.e., less than 8 RN  hours each day).81   We also determined  
which days  nursing homes reported having fewer licensed-nurse staff  than Federal  
requirements stipulate (i.e., anything  less than around-the-clock licensed-nurse  
staff).82   We counted the number of days in each quarter that nursing homes reported  
staffing  levels below either requirement.  
We determined how  many nursing  homes  that  frequently reported staffing  levels 
below Federal requirements  would  have been included  in  CMSs weekend  lists for  
weekend inspections.  First, we identified the nursing homes that reported  at least 
15  days  in the quarter  with staffing  levels below  Federal requirements.  We 
determined how many of these nursing homes would be included on CMSs weekend  
lists of the bottom 20 percent of nursing homes in each State in terms of  weekend  
nurse HPRDs.  
We determined  how many  nursing homes that frequently  reported  staffing  levels 
below Federal requirements  received deficiency citations for staffing.   First, we 
identified the nursing homes that reported  at least 15  days  in  the quarter  with staffing  
levels beneath Federal requirements.  Then we narrowed  this list to  only those nursing  
homes that received a standard health inspection in the same quarter.  We  used  
nonpublic  information from CMS to identify all nursing homes that received standard  
health inspections.  Next,  we determined how many of these nursing homes received  
deficiency citations for low staffing  levels.  We used public data on the SSA-issued  
deficiency citations  available from Data.Medicare.gov. We identified deficiencies for  
staffing  levels using F-tag 725 (sufficient nurse staffing, which includes 24-hour 
licensed nursing) and F-tag 727 (8 RN hours every day).   
_____________________________________________________________________________________________________________________________  
81  We categorized days when nursing homes staffed at least 7.5 RN hours as meeting this  Federal 
requirement because CMS guidance  indicates that an 8-hour RN shift should include a 0.5-hour meal  
break.  
82  We categorized days when nursing homes staffed at least  22.5 licensed-nurse hours as meeting this  
Federal requirement.   
CMS Use of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Detailed Methodology |  29    
APPENDIX A  
 
Information about  CMS  data  checks  and  audits  
Some nursing homes were not included in the  public staffing information.   These nursing  
homes either did not successfully submit their staffing information to the Payroll-Based Journal  
(PBJ),  orif  they submitted highly improbable dataCMS  excluded  them  from the public use file 
(PUF).83   
Exhibit A-1.  Few nursing homes did not successfully submit data  or had their data  
excluded by CMS from Q2 2018 through Q1 2019.   
Type  of Nursing  Home   2018 Q2   2018 Q3   2018 Q4   2019 Q1  
  Number   %   Number   %   Number   %   Number   %  
Active Nursing Homes   15,616     15,613     15,578     15,563    
Did  Not  Submit  to  PBJ    440   2.8   351   2.2   350   2.2   308   2.0  
Exclusions  From  PUF*   514   3.3   391   2.5   312   2.0   197   1.3  
Nursing  Homes  in PUF   14,662   93.9   14,871   95.2   14,916   95.8   15,058   96.8  
*For 2019 Q1,  CMS dropped  one of the exclusion criteria (5+ days with residents and no  nurse).  CMS excludes  
nursing homes that reported highly improbable data, which  CMS defines as a quarterly average of total nurse staffing 
less than 1.5 HPRDs, total nurse staffing greater than 12 HPRDs, or nurse aide staffing  greater than 5.25 HPRDs.   
Note:  Because  of rounding, subtotals  may not sum to 100 percent.   In addition, CMS does not include nursing homes  
in the public use file  if the nursing homes  did not report information on the number of residents to the Minimum  
Data Set.  
  
   
_____________________________________________________________________________________________________________________________  
83  CMS,  Nursing Home Compare Technical Users GuideOctober 2020, https://www.cms.gov/Medicare/  
Provider-Enrollment-and-Certification/CertificationandComplianc/downloads/usersguide.pdf.  Accessed 
on November  17, 2020.  
CMS Use of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Appendix A | 30   Summary of  the Audit  Process  and  Findings  for Data  Submitted  
to  the Payroll-Based  Journal  
Nursing homes could fail  a staffing audit if (a)  CMS found a significant  discrepancy 
between reported and verified hours or (b) nursing homes did not respond to an 
audit.  In January 2019, CMS began to automatically downgrade the Staffing Star 
Ratings to 1 star for nursing homes that failed a staffing  audit.   
The number of  audits conducted by CMS decreased during our period of  review, but  
the number of nursing homes reporting staffing that significantly varied from what  
they actually staffed remained the same (see Exhibit  A-2).  CMS  lowered the threshold  
for significant variance during Q4 2018 and Q1 2019.  That is  to say, CMS defined  
significant variance as errors of 3.59  percent  or greater change in HPRDs; previously 
(during Q2 and Q3) it  was 4  percent or greater.  
 
Exhibit A-2.  The number of audits decreased, andexcept in Q3 2018the  
number of nursing homes that failed audits (with a significant variance) did  
not vary substantially.   
Summary  of Audit  Q2 2018   Q3 2018   Q4 2018   Q1 2019  
Findings:   Count   %   Count   %   Count   %   Count   %  
Minimal  or  No 
201  46%   200  47%   165  48%   171  49%  
Variance  
Slight  Variance   155  36%   143  33%   113  33%   100  29%  
Significant  Variance1   67  15%   44  10%   67  19%   68  19%  
Other2   10  2%   43  10%   2  1%   11  3%  
Total  Audits   433    430    347    350   
1  When comparing the reported nurse  staff  hours to what auditors verified by reviewing  payment records,  
CMS  defined significant variance as errors  of 4  percent  or  greater in Q2 and Q3 2018 but modified this  
to 3.59  percent  or greater for  Q4 2018 and Q1 2019.  
2  The other category of audit findings captures instances  in which  audits were not completed for  
various reasons (nursing home in receivership, auditor unable to obtain all  documentation,  nonresponse, 
and the nursing homes having self-disclosed  significant errors).  
 
   
CMS Use of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Appendix A | 31   Additionally, CMS used information from audits to issue guidance to nursing homes.   
This guidance highlighted common types of errors found in data submitted by 
nursing homes that failed an audit.  For example, misreporting mealtimes was the 
most frequent error type found in data submitted by nursing homes that  failed  an 
audit (see Exhibit  A-3).  CMS published multiple memos and policy manuals to  
provide guidance to nursing homes  on how  to exclude time for meal breaks.84, 85   
Nursing homes can use this guidance to improve their reporting in submitted data to  
mitigate potential errors.    
Exhibit  A-3  provides a summary of the common types of errors found in data  
submitted by nursing homes  that failed an audit  during Q2 2018 through Q1 2019.  
 
Exhibit A-3.  Summary of Errors Found in Data Submitted by Nursing Homes  
That  Failed an Audit  With  a Significant Variance  
  Nursing  Homes      Nursing  Homes  With  
With  the  Error   This  as  Primary  Error  
Error Type   Count   %     Count   %  
Mealtime   193   78%     105   43%  
XML1  or  Manual  Entry2   56   23%     38   15%  
Non-SNF3  Hours   37   15%     33   13%  
Paid  Time  Off   59   24%     21   9%  
Unpaid  Hours  >  40   54   22%     5   2%  
Training   7   3%     2   1%  
Other   74   30%     31   13%  
1  XMLextensible markup languageis a  computer language that  helps transmit  data.  
2  Among nursing homes that received an audit finding of significant variance, one in four  nursing homes  
had errors  in their XML submissions or manual data submissions, and  only one in seven  nursing homes  
that failed audits  due to a  significant variance  had these types of errors as the most common error.   
3  SNF  stands for skilled nursing  facility.  
 
 
_____________________________________________________________________________________________________________________________  
84  CMS,  QSO-18-17-NH Memorandum.  
85  CMS,  PBJ Policy Manual, v2.4, September 2017,  and v2.5, October 2018.  
CMS Use of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Appendix A | 32   Appendix B 
Nursing  homes  reported  no  hours  for some  types of  non-nurse staff.  
Among non-nurse staff, CMS reports only physical therapists on Care Compare.  CMS requires 
nursing homes to submit all hours for therapy staff (i.e., physical, occupational, speech, and  
respiratory therapists) regardless of  payer.  For other staff, nursing  homes report hours that can be 
verified with payment records.    
Exhibit B-1.  Some nursing homes  did not report staff  hours for therapy  staff types.  
  Q2 2018   Q3 2018   Q4 2018   Q1 2019  
Total  Nursing Homes   14,662   14,871   14,916   15,058  
Staff Types   Count   %   Count   %   Count   %   Count   %  
Physical Therapists   1,068   7.3%   1,021   6.9%   945   6.3%   868   5.8%  
Occupational Therapists   1,188   8.1%   1,124   7.6%   1,051   7.0%   993   6.6%  
Speech Therapists   1,567   10.7%   1,532   10.3%   1,468   9.8%   1,386   9.2%  
Note:  OIG analysis of PBJ data available at  Data.CMS.gov.  This table  excludes  respiratory therapists  because 
approximately  86 percent of nursing homes did not report this category.  
 
We defined  other critical non-nurse staff  according to the criteria below:   
   Administrator Staff: Required under Federal regulation  (42 CFR   483.70(d))   
   Medical  Directors: Required under Federal regulation  (42 CFR   483.70(h))   
   Pharmacists: For residents on prescription medications, pharmacists are federally  required to  
perform monthly reviews of drug regimens  (42 CFR  483.45(c  ))  
   Dietitians: Required under Federal regulation  (42 CFR  483.60(a))   
Exhibit B-2.  Many nursing homes  did not report staff hours  for other  critical staff  types.  
  Q2 2018   Q3 2018   Q4 2018   Q1 2019  
Total  Nursing Homes   14,662   14,871   14,916   15,058  
Staff Types   Count   %   Count   %   Count   %   Count   %  
Other Critical*  staff types   7,182   49.0%   7,186   48.3%   7,233   48.5%   7,371   49.0%  
Pharmacists   4,511   30.8%   4,448   29.9%   4,536   30.4%   4,634   30.8%  
Medical Directors   4,198   28.6%   4,239   28.5%   4,309   28.9%   4,511   30.0%  
Dietitians   2,735   18.7%   2,713   18.2%   2,769   18.6%   2,841   18.9%  
Administrators   1,256   8.6%   1,229   8.3%   1,232   8.3%   1,170   7.8%  
Social Workers   1,265   8.6%   1,251   8.4%   1,239   8.3%   1,293   8.6%  
Activity Staff   1,066   7.3%   1,091   7.3%   1,116   7.5%   1,116   7.4%  
*We defined  other  critical non-nurse staff types  as including  administrators, medical directors, pharmacists, and dietitians.   
Note: We excluded  mental health staff, feeding assistants, and medical specialists  from this table.  Between 78  percent  and 
94  percent  of nursing homes did not report staff hours for these respective staff types, but not all nursing home residents  
may  need these non-nurse staff types.   In addition, some services provided by these specific types of non-nurse staff  may  
instead be performed by other types of non-nurse staff or by nurse staff.  
 
CMS Use of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Appendix  B | 33   Exhibit  B-3.  Nursing homes can  report up to 40 staff types to  the Payroll-Based Journal.   
  Mandatory  Job   Job Description   Description of Services  
Submission   Grouping   
1    Yes   Administration   Administrator   Administrative staff responsible for facility management as required under  
Services   483.70(d) such as the  administrator and the assistant administrator.  
2    Yes   Physician  Medical Director   A physician designated as  responsible for implementation of  resident  care  
Services   policies and  coordination of medical  care  in the facility in accordance with 
483.70(h).  
3    Yes   Physician  Other Physician   A salaried  physician, other than the medical director, who  supervises the  care  
Services   of residents  when the attending physician is unavailable, and/or a physician(s)  
available to provide emergency services 24  hours a  day.  
4    Yes   Physician  Physician Assistant   A physician assistant who  provides healthcare  services typically  performed by  
Services   a physician,  under the supervision of a physician.  
5    Yes   Nursing   Registered Nurse   Professional  registered nurse(s) administratively responsible for managing and  
Services   Director of Nursing   supervising nursing  services within the facility.   
6    Yes   Nursing   Registered Nurse with  Nurses (RN)  who perform the Resident Assessment Instrument function in the  
Services   Administrative Duties   facility and do not perform direct  care functions.   
7    Yes   Nursing   Registered Nurse   Those  persons licensed to  practice as  registered nurses.   Includes geriatric  
Services   nurse practitioners and clinical nurse  specialists who primarily  perform  
nursing, not physician-delegated tasks.   
8    Yes   Nursing   Licensed Practical   Those persons  licensed  to practice  as licensed practical/vocational nurses  and  
Services   Nurse with  do not perform direct  care  functions.   
Administrative Duties  
9    Yes   Nursing   Licensed Practical   Those persons  licensed  to practice  as licensed practical/vocational nurses.   
Services   Nurse  
10    Yes   Nursing   Certified Nurse Aide   Individuals who  have completed  a training and competency evaluation  
Services   program, or competency evaluation program, or have been determined  
competent as provided in 483.150 and who are providing nursing  or nursing-
related services to  residents.  
11    Yes   Nursing   Nurse Aide  in Training   Individuals in the first 4 months of employment and who are receiving  training  
Services   in an approved Nurse Aide training and  competency evaluation program and  
are providing nursing  related  services for which they have  been trained and  
are under the  supervision of a  licensed or registered nurse.   
12    Yes   Nursing   Medication  Individuals, other than a  licensed  professional, who fulfill the State  
Services   Aide/Technician   requirement for  approval to administer medications to residents.  
13    Yes   Physician  Nurse Practitioner   A registered nurse with specialized  graduate education who is  licensed  to  
Services   diagnose and treat illness, independently or as part of a  health care  team.  
14    Yes   Nursing   Clinical Nurse Specialist   A registered nurse with specialized  graduate education who provides  
Services   advanced nursing  care.  
15    Yes   Pharmacy   Pharmacist   The licensed  pharmacist(s)  whom  a facility is required to use for various  
Services   purposes, including  providing consultation on pharmacy  services;  establishing  
a system of records of  controlled  drugs;  overseeing records and reconciling  
controlled drugs;  and/or performing a monthly  drug-regimen  review for each  
resident.  
16    Yes   Dietary    Dietitian   A person(s) who is either registered by  the  Commission of  Dietetic  
services   Registration of the American Dietetic Association or is qualified to be a  
dietitian based on experience in identification of dietary  needs, planning and  
implementation of  dietary programs.  
17    Yes   Dietary    Paid Feeding Assistant   Person who meets the requirements  specified in  CFR    483.60(h)(1)(i) and  
services   483.60(h)(1)(ii) and who  is paid  to feed residents  by  a facility, or who  is  used  
under an arrangement with another agency or organization.  Paid feeding  
assistants can  feed only residents  who  do not have complicated feeding  
problems.  
18    Yes   Therapeutic   Occupational Therapist   Persons licensed/registered as  occupational  therapists.  
Services  
       
continued on the next page  
         
 
CMS Use of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Appendix  B | 34   Exhibit B-3  (continued).  Nursing homes can  report up to 40 staff types to the Payroll-Based 
Journal.   
  Mandatory  Job   Job Description   Description of Services  
Submission   Grouping   
19    Yes   Therapeutic   Occupational Therapy   Person(s)  who have licenses/certification and  specialized training to  assist a  
Services   Assistant   licensed/certified/registered  Occupational Therapist (OT) to carry out the OTs  
plan of care, without the  direct  supervision of the therapist.   
20    Yes   Therapeutic   Occupational Therapy   Person(s)  who have specialized training to assist an  OT to carry out the OTs  
Services   Aide   plan of care under the  direct supervision of the  therapist.  
21    Yes   Therapeutic   Physical Therapist   Persons licensed/registered as  physical therapists.  
Services  
22    Yes   Therapeutic   Physical Therapy   Person(s)  who have licenses/certification and  specialized training to  assist a  
Services   Assistant   licensed/certified/registered Physical Therapist  (PT) to  carry out the  PTs  plan  
of care,  without the direct  supervision of  the PT.  
23    Yes   Therapeutic   Physical Therapy  Aide   Person(s)  who have specialized training to assist a PT to  carry out the PTs plan 
Services   of care  under the direct supervision of  the therapist.  
24    Yes   Therapeutic   Respiratory Therapist   Persons(s) who are licensed as  respiratory therapists.  
Services  
25    Yes   Therapeutic   Respiratory Therapy   Person(s)  who provide respiratory care under the  direction of respiratory  
Services   Technician   therapists and physicians  
26    Yes   Therapeutic   Speech/Language  Persons licensed/registered  to  provide speech therapy and related services  
Services   Pathologist   (e.g., teaching a resident to swallow).  
27    Yes   Therapeutic   Therapeutic Recreation   Person(s)  who are licensed/registered and are eligible for  certification as a  
Services   Specialist   therapeutic recreation specialist by a  recognized accrediting  body.  
28    Yes   Therapeutic   Qualified Activities   Person(s)  who meet the  definition of an activities professional and  who are 
Services   Professional   providing an ongoing program of  activities  designed to meet residents  
interests and physical, mental, or  psychosocial needs.   
29    Yes   Therapeutic   Other Activities Staff   Persons providing an on-going  program of activities designed to meet  
Services   residents needs and interests.   
30    Yes   Therapeutic   Qualified Social  Worker   Person licensed to practice  social  work or persons  with a  bachelors degree in  
Services   social  work or a  bachelors  degree in a human services field and 1  year of 
supervised  social work experience in a  health care  setting  working  directly with  
elderly individuals.  
31    Yes   Therapeutic   Other Social  Worker   Person(s)  other than the  qualified social worker who are involved in  providing  
Services   medical social services to residents.   
32    Yes   Mental Health   Mental Health Service  Staff who  provide programs of services targeted  to residents mental,  
Services   Worker   emotional, psychological, or psychiatric  well-being.   
33   No   Dental Services   Dentist   Persons licensed  as dentists to provide routine and  emergency dental  care.  
34   No   Podiatry   Podiatrist    Persons licensed/registered as  podiatrists to  provide podiatric care.  
Services  
35   No   Vocational   Vocational Service  Evaluation and training aimed at assisting the resident to enter, re-enter, or 
Services   Worker    maintain employment in the labor  force, including  training  for jobs in 
integrated  settings (i.e., those which have both disabled and nondisabled  
workers) as  well  as in special settings  such as sheltered workshops.  
36   No   Clinical   Clinical Laboratory   Entities that provide laboratory services and are approved  by  Medicare as  
Laboratory   Service Worker    independent laboratories or hospitals.  
Services   
37   No   Diagnostic    Diagnostic X-ray  Radiology  services, ordered by a  physician, for diagnosis of a disease or other 
X-ray Services   Service Worker    medical condition.  
38   No   Administration   Blood Service Worker   Blood bank and transfusion services.  
& Storage of  
Blood Services  
39   No   Housekeeping   Housekeeping Service  Services,  including those of the maintenance  department, necessary  to  
Services   Worker    maintain the environment.   
40   No   Other Services   Other Service Worker   Record total hours  worked for all  personnel not already recorded (for example,  
librarian).  
Source:  CMS,  Electronic Staffing Data Submission  PBJ: Long-Term Care Facility Policy Manual,  https://www.cms.gov/Medicare/Quality-
Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/PBJ-Policy-Manual-Final-V25-11-19-2018.pdf.  Accessed on  
May  22, 2020. 
CMS Use of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Appendix  B | 35    
APPENDIX C  
 
State-by-State analysis to  identify lower staffed nursing homes  when 
adjusting  for the relative care  needs among  residents  
We identified the nursing homes in each State that would be in the bottom 20 percent of  weekend  
nurse staffing per resident, while adjusting for acuity  (i.e., the relative level of  care  needs).  We then 
determined how many of these nursing homes would be missing from  CMSs weekend  lists.  
 Exhibit C-1.  CMSs  weekend lists,  which do not adjust for residents care needs, miss 
some nursing homes that are identified by a method that adjusts for care needs.  
  Q2 2018   Q3 2018   Q4 2018   Q1 2019  
  %   Count  of  %   Count  of  %   Count  of  %   Count  of 
Missing  /  Missing  /  Missing  /  Missing  / 
State  
Total   Total   Total   Total  
AK   50%   1 / 2   33%   1 / 3   33%   1 / 3   50%   1 / 2  
AL   21%   9 / 43   23%   10 / 44   20%   9 / 44   20%   9 / 45  
AR   26%   11 / 42   20%   8 / 41   27%   12 / 44   20%   9 / 44  
AZ   17%   5 / 29   23%   7 / 30   21%   6 / 29   17%   5 / 29  
CA   48%   106 / 221   46%   102 / 224   44%   101 / 227   42%   95 / 228  
CO   25%   11 / 44   23%   10 / 44   20%   9 / 44   20%   9 / 44  
CT   44%   16 / 36   36%   15 / 42   31%   13 / 42   29%   12 / 42  
DC   0%   0 / 3   25%   1 / 4   25%   1 / 4   0%   0 / 4  
DE   67%   6 / 9   44%   4 / 9   44%   4 / 9   22%   2 / 9  
FL   50%   67 / 135   50%   68 / 136   49%   67 / 137   54%   74 / 137  
GA   23%   16 / 69   30%   21 / 70   22%   15 / 69   23%   16 / 71  
HI   22%   2 / 9   13%   1 / 8   13%   1 / 8   11%   1 / 9  
IA   22%   19 / 85   20%   17 / 85   20%   17 / 83   20%   17 / 86  
ID   31%   5 / 16   20%   3 / 15   25%   4  / 16   38%   6 / 16  
IL   16%   22 / 137   17%   23 / 138   16%   22 / 139   16%   22 / 138  
IN   26%   28 / 107   26%   28 / 107   25%   27 / 106   21%   23 / 108  
KS   15%   9 / 61   21%   13 / 62   17%   11 / 64   22%   14 / 64  
KY   27%   15 / 55   18%   9 / 51   25%   14 / 56   27%   15 / 56  
LA   32%   17 / 53   25%   13 /  53   30%   16 / 54   25%   13 / 53  
MA   20%   15 / 76   23%   17 / 75   26%   20 / 76   28%   21 / 76  
MD   31%   14 / 45   27%   12 / 44   20%   9 / 45   20%   9 / 44  
ME   5%   1 / 20   5%   1 / 19   22%   4 / 18   16%   3 / 19  
 continued on the next page  
CMS Use of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Appendix  C  | 36   Exhibit C-1 (continued).  CMSs weekend lists, which do not adjust for residents care 
needs, miss some nursing  homes that are identified by a method that adjusts for care  
needs.  
  Q2 2018   Q3 2018   Q4 2018   Q1 2019  
  %   Count  of  %   Count  of  %   Count  of  %   Count  of 
Missing  /  Missing  /  Missing  /  Missing  / 
STATE  
Total   Total   Total   Total  
MI   24%   20 / 84   19%   16 / 85   20%   17 / 86   23%   20 / 86  
MN   18%   13 / 72   11%   8 / 73   13%   9 / 72   12%   9 / 74  
MO   15%   14 / 96   16%   16 / 97   23%   23 / 99   14%   14 / 97  
MS   28%   11 / 40   40%   16 / 40   25%   10 / 40   27%   11 / 41  
MT   8%   1 / 13   15%   2 / 13   7%   1 / 14   13%   2 / 15  
NC   24%   20 / 82   22%   18 / 82   17%   14 / 81   20%   16 / 82  
ND   13%   2 / 16   19%   3 / 16   19%   3 / 16   13%   2 / 15  
NE   16%   6 / 38   13%   5 / 40   13%   5 / 39   13%   5 / 40  
NH   20%   3 / 15   27%   4 / 15   13%   2 / 15   20%   3 / 15  
NJ   31%   22 / 71   27%   19 / 71   26%   18 / 69   26%   19 / 72  
NM   14%   2 / 14   27%   4 / 15   7%   1 / 15   7%   1 / 15  
NV   25%   3 / 12   18%   2 / 11   17%   2 / 12   17%   2 / 12  
NY   28%   33 / 119   23%   28 / 121   23%   28 / 121   25%   30 / 120  
OH   27%   49 / 184   25%   47 / 187   22%   42 / 187   30%   56 / 189  
OK   30%   16 /  54   17%   9 / 53   11%   6 / 53   19%   10 / 52  
OR   31%   8 / 26   25%   6 / 24   33%   8 / 24   42%   11 / 26  
PA   28%   36 / 129   29%   40 / 136   34%   46 / 137   30%   41 / 136  
RI   13%   2 / 16   24%   4 / 17   13%   2 / 16   25%   4 / 16  
SC   16%   6 / 37   14%   5 / 37   25%   9 / 36   19%   7 / 37  
SD   20%   4 / 20   14%   3 / 21   29%   6 / 21   10%   2 / 21  
TN   28%   17 / 61   24%   15 / 62   21%   13 / 62   25%   16 / 63  
TX   19%   44 / 227   23%   54 / 234   20%   47 / 235   22%   52 / 235  
UT   10%   2 / 20   35%   7 / 20   15%   3 / 20   15%   3 / 20  
VA   20%   11 / 56   27%   15 / 56   30%   16 / 54   26%   15 / 57  
VT   43%   3 / 7   29%   2 / 7   25%   2 / 8   29%   2 / 7  
WA   28%   11 / 40   28%   11 / 40   30%   12 / 40   32%   13 / 41  
WI   18%   13 / 72   15%   11 / 73   13%   9 / 67   17%   12 / 70  
WV   26%   6 / 23   25%   6 / 24   13%   3 / 24   28%   7 / 25  
WY   29%   2 / 7   29%   2 / 7   38%   3 / 8   13%   1 / 8  
USA   26%   775 / 2,948   26%   762 /  2,981   25%   743 / 2,988   25%   762 / 3,011  
 
Note:   OIG analysis  of PBJ  data available on  Data.CMS.gov.   OIG combined  the CMS PUF data with CMS information on the  
differences in resident  care needs  available in the Provider Info File  accessed from  Data.Medicare.gov.   
   
CMS Use of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Appendix  C  | 37    
APPENDIX D  
 
Data  about  the current  oversight  of  nursing  homes  that  frequently 
reported  staffing  levels  lower than required  levels  
Exhibit D-1.  Some nursing homes frequently reported staffing data below requirements for  
RNs or licensed nurses.  
Number  of  days with   Q2 2018   Q3 2018   Q4 2018   Q1 2019  
either  less  than 8  RN  
14,662   14,871   14,916   15,058  
hours  or  24  licensed 
Count   %   Count   %   Count   %   Count   %  
nurse  hours:  
7 or more days   1,425   9.7%   1,403   9.4%   1,419   9.5%   1,100   7.3%  
15  or more days   565  3.9%   562  3.8%   609  4.1%   466  3.1%  
30  or more days   175  1.2%   170  1.1%   250  1.7%   175  1.2%  
Note: OIG analysis of  the Payroll-Based Journal Public Use Files, available at  Data.CMS.gov.  
Exhibit D-2.  Most nursing homes that frequently reported staffing data below requirements  
(at least 15  days in 3 months)  would not appear on CMS lists for potential weekend  
inspections.  
 
Q2 2018   Q3 2018   Q4 2018   Q1 2019  
 
Subtotal  of Nursing  Homes   565   562   609   466  
Count   %   Count   %   Count   %   Count   %  
Nursing  homes  that  CMS  would  
not  target  for  weekend  342  60.5%   335  59.6%   333  54.7%   268  57.5%  
inspections  
Note: OIG analysis of  the Payroll-Based Journal Public Use Files, available at  Data.CMS.gov.  
Exhibit D-3.  Among nursing homes that frequently reported staffing data below  Federal 
requirements (at least 15 days  in 3 months), few nursing homes received a deficiency  
citation for low staffing.  
 
Q2 2018   Q3 2018   Q4 2018   Q1 2019  
 
Subtotal  of Nursing  Homes  (with   151   135   143   111  
an  inspection  in  the quarter)  
Count   %   Count   %   Count   %   Count   %  
Nursing homes  that  received 
18  11.9%   15  11.1%   18  12.6%   17  15.3%  
citations  for  low  staffing   
Note: OIG analysis of  the Payroll-Based Journal Public Use Files, available at  Data.CMS.gov, and of CMS citation data  (F-tags 725 and 727)  
available at  Data.Medicare.gov  and obtained by  OIG from CMS.   
CMS Use of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Appendix  D  | 38   APPENDIX E: Agency Comments
DATE:  February 18, 2021 
TO:  Suzanne Murrin 
Deputy Inspector General 
FROM:  Elizabeth Richter 
Acting Administrator 
SUBJECT:  Office of Inspector General (OIG) Draft Report: CMS Use of Nursing Home 
Staffing Data: Progress and Opportunities to Do More OEI-04-18-00451 
The Centers for Medicare & Medicaid Services (CMS) appreciates the opportunity to review and 
comment on the Office of Inspector Generals (OIG) draft report.  
CMS is charged with developing and enforcing quality and safety standards across the nations 
health care system, a responsibility that the Agency takes seriously. This duty is especially 
important when it comes to the care provided for some of the most vulnerable in our society, 
beneficiaries residing in nursing homes, and is especially critical now as we respond to the 
coronavirus disease 2019 (COVID-19) pandemic. 
CMS has long identified staffing as a vital component of a nursing homes ability to provide 
quality care, and CMS has used staffing data to more accurately and effectively gauge its impact 
on quality of care in nursing homes. Through our Payroll Based Journal (PBJ) program, CMS 
began holding nursing homes accountable for their staffing levels through more precise staffing 
reporting. This monitoring system allows CMS to track nursing home staffing through auditable 
data, which nursing homes must submit on a quarterly basis. In response to the COVID-19 
pandemic, CMS temporarily suspended PBJ reporting requirements, which is retrospective data, 
to redirect resources to patient safety. However, due to the importance of staffing and its 
relationship to quality care, CMS resumed the requirement to submit staffing data on June 25, 
2020, and nursing homes had to submit staffing data for April  June 2020 through the PBJ 
system by August 14, 2020. Additionally, while CMS suspended updating the Staffing Star 
Rating due to the public health emergency; in October 2020, CMS resumed updating the PBJ 
staffing measures and staffing ratings. 
As OIG reported, CMS has a robust process to ensure the accuracy and completeness of reported 
nurse staffing information, including checks for data abnormalities, monitoring of data trends 
across quarters, downgrading of the Staffing Domain of the Five Star Quality Ratings System for 
nursing homes that do not successfully submit data, and audits of individual nursing homes 
staffing data. Additionally, when CMS identifies facilities with unreliable staffing data, neither 
staffing data nor a staffing rating are reported for these facilities on CMSs Care Compare 
website. These efforts have resulted in improved data reporting and accuracy rates. 
CMS works in partnership with State Survey Agencies (SSAs) to oversee nursing homes, as 
these agencies are responsible for surveying nursing homes for compliance with federal 
1 
CMS Use of Data on Nursing Home  Staffing: Progress and Opportunities To Do More 
OEI-04-18-00451                        Appendix E | 39  requirements, such as sufficient nurse staffing. CMS shares staffing data, including a list of 
nursing homes that have potentially insufficient staffing on weekends and after-hours, with SSAs 
so they know which nursing homes may have potential staffing problems in order to target their 
surveys appropriately. Prior to the COVID-19 pandemic, SSAs were conducting a portion of 
their unannounced surveys after-hours and on weekends using lists provided by CMS to focus on 
possible staffing problems during those times. In addition, when conducting standard or 
complaint surveys, the SSAs would also investigate compliance with the nursing services 
staffing requirements. Appropriate enforcement actions would be taken against those facilities 
that failed to provide the required nurse staffing. By targeting these surveys, CMS has been able 
to engage in better, stronger enforcement of staffing requirements. 
CMS is dedicated to empowering consumers, their families, and their caregivers by giving them 
the resources they need to make informed decisions, and key to this effort is the Care Compare 
website, which replaced Nursing Home Compare on December 1, 2020. Care Compare offers a 
wide variety of data related to nursing home quality, including nurse and non-nurse staffing data 
for individual nursing homes presented in a format that allows consumers to meaningfully 
compare differences between nursing homes. Care Compare was designed based on research and 
stakeholder feedback, and offers the features and functions that most appeal to consumers. It is 
also optimized for both mobile and tablet use. A facilitys quality rating for staffing levels is one 
of three performance measures that make up a facilitys overall rating under CMS Nursing 
Home Five-Star Quality Rating System, which is posted on Care Compare. 
The Five-Star Quality Rating System helps consumers make meaningful distinctions among high 
and low-performing nursing homes, compare nursing homes more easily, and identify areas that 
they may want to ask the nursing home about. It also helps nursing homes identify areas for 
improvement. CMS announced in April 2018 that it would automatically downgrade a nursing 
homes Staffing Star Rating to the lowest one-star if it reported no registered nurse hours for at 
least seven days within a quarter. In April 2019, CMS strengthened its criteria, and now 
downgrades the Staffing Star Rating if no registered nurse hours are reported for at least four 
days within a quarter, and increased the threshold a facility must exceed to obtain a five-star 
staffing rating.1  
CMS thanks the OIG for its efforts on this issue and looks forward to working collaboratively on 
this and other issues in the future. OIGs recommendations and CMS responses are below. 
OIG Recommendation 
Provide information to consumers on nurse staff turnover and tenure, as required by Federal law. 
CMS Response 
CMS concurs with the OIGs recommendation. As CMS began to collect direct care staffing data 
through the PBJ system, CMS was able to start analyzing the data to determine how to accurately 
report nurse staff turnover and tenure. CMS first focused on nurse staff turnover, which measures 
staff retention over a shorter amount of time than tenure, given the limited amount of initial PBJ 
data. Specifically, CMS updated the data reporting process in November 2017, allowing CMS to 
1 CMS Center for Clinical Standards and Quality/Quality, Safety & Oversight Group, Memo to State Survey Agency 
Directors, Ref: QSO-19-08-NH, April 2019 Improvements to Nursing Home Compare and the Five Star Rating 
System (March 5, 2019) 
2 
CMS Use of Data on Nursing Home  Staffing: Progress and Opportunities To Do More 
OEI-04-18-00451                        Appendix E | 40  track when an individual employee worked at a nursing home. The new reporting system enabled 
CMS to overcome prior technical challenges and begin developing both turnover and tenure 
measures.  CMS has made significant progress in defining a measure on nurse staff turnover. 
Originally, CMS had taken steps to introduce a turnover measure on Care Compare in late-2020, 
including consulting with outside experts to define and refine a potential measure; however, due to 
the COVID-19 pandemic, this timeline has been delayed. CMS will continue to make progress 
towards reporting both nurse staff turnover and tenure publically.  
OIG Recommendation 
Ensure the accuracy of staffing data for non-nurse staff used on Care Compare. 
CMS Response 
CMS concurs with the OIGs recommendation. As OIG reported, CMS has a robust process to 
ensure the accuracy and completeness of nurse staffing information, including checks for data 
abnormalities, monitoring of data trends across quarters, downgrading of Staffing Star Ratings 
for nursing homes that do not successfully submit data, and audits of individual nursing homes 
staffing data. CMS will explore ways to improve the accuracy of non-nurse staffing data reported 
by facilities by expanding our process for auditing the data submitted for these staff.  
OIG Recommendation 
Consider resident level of need when identifying nursing homes for weekend inspections. 
CMS Response 
CMS concurs with the OIGs recommendation. CMS shares staffing data, including a list of 
nursing homes that have potentially insufficient staffing on weekends, with SSAs so they know 
which nursing homes may have potential staffing problems in order to target their surveys 
appropriately. Prior to the COVID-19 pandemic, SSAs were conducting a portion of their 
unannounced surveys after-hours and on weekends using lists provided by CMS to focus on 
staffing problems during those times. CMS will analyze and use information about residents 
level of need as the Agency continues to compile lists of nursing homes with lower reported 
staffing to help SSAs further target nursing homes for weekend inspections.  
OIG Recommendation 
Take additional steps to strengthen oversight of nursing home staffing. 
CMS Response 
CMS concurs with the OIGs recommendation. As stated above, CMS has long identified 
staffing as a vital component of a nursing homes ability to provide quality care. CMS approach 
to oversight of nursing homes, including their staffing levels, is constantly evolving as reflected 
by our commitment to enhancing enforcement through reporting requirements. CMS is 
committed to increasing accountability, which the Agency demonstrated first through the 
weekend staffing lists for SSAs, and will work to more efficiently provide useful staffing 
information directly to SSAs. 
3 
CMS Use of Data on Nursing Home  Staffing: Progress and Opportunities To Do More 
OEI-04-18-00451        Appendix E | 41  
ACKNOWLEDGMENTS AND CONTACT  
 
Acknowledgments  
Lucio Verani  served as the lead analyst  for this study.  Others in the Office of  
Evaluation and Inspections who conducted the study include  Victoria Coxon,  
Rebekah  Schwartz, and Brianna Weldon.  Office of Evaluation and Inspections staff  
who provided support include Joe Chiarenzelli, Althea Hosein,  and  Christine Moritz.  
This report was prepared under the direction of  Dwayne Grant, Regional  Inspector 
General for Evaluation and Inspections in the Atlanta  regional office;  Evan Godfrey, 
Deputy Regional Inspector General;  and Jaime Stewart, Assistant Regional Inspector 
General.  
Contact  
To obtain additional information concerning this report, contact the Office of Public 
Affairs at  Public.Affairs@oig.hhs.gov.  OIG reports and  other information can be found  
on  the OIG website at  oig.hhs.gov.  
Office of Inspector General  
U.S. Department of Health and Human Services  
330 Independence Avenue, SW  
Washington, DC 20201  
CMS Use of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   Acknowledgments and Contact | 42    
ABOUT THE OFFICE OF  INSPECTOR GENERAL  
 
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-
452, as amended, is to protect the integrity of the Department of Health and Human 
Services (HHS) programs, as well as the health and welfare of  beneficiaries served by 
those programs.  This statutory mission is carried out through a nationwide network  
of audits, investigations, and inspections conducted by the following operating  
components:  
The Office of  Audit Services (OAS)  provides auditing services for HHS, 
either by conducting audits with its own audit resources or by overseeing audit work  
done by others.  Audits examine the performance of HHS programs and/or its 
grantees and contractors in carrying out their respective responsibilities and are 
intended to  provide independent assessments of HHS programs and operations.   
These audits  help reduce waste, abuse, and mismanagement and promote economy 
and efficiency throughout HHS.  
The Office of Evaluation and Inspections  (OEI)  conducts national  
evaluations to provide HHS, Congress, and the public with timely, useful, and  reliable  
information on significant issues.  These evaluations focus on preventing fraud, waste, 
or abuse and promoting economy, efficiency, and effectiveness of departmental  
programs.  To promote impact, OEI reports also  present practical recommendations 
for improving program operations.  
The Office of Investigations  (OI)  conducts criminal, civil, and administrative 
investigations of fraud and misconduct related to HHS programs, operations, and  
beneficiaries.  With investigators working in all 50 States and  the District of Columbia, 
OI utilizes its resources by actively coordinating  with the Department of  Justice and  
other Federal, State, and local law enforcement authorities.  The investigative efforts 
of OI often lead to criminal convictions, administrative sanctions, and/or civil  
monetary penalties.  
The Office of Counsel to the Inspector General (OCIG)  provides 
general legal services to  OIG, rendering advice and opinions on HHS programs and  
operations and providing all  legal support for OIGs internal operations.  OCIG 
represents OIG in all civil and administrative fraud and abuse cases involving HHS  
programs, including False Claims Act, program exclusion, and civil monetary  penalty 
cases.  In connection with these cases, OCIG also  negotiates and monitors corporate 
integrity agreements.  OCIG renders advisory opinions, issues compliance program 
guidance, publishes fraud alerts, and provides other guidance to the health care 
industry concerning the anti-kickback statute and other OIG enforcement authorities.  
CMS Use of Data on Nursing  Home Staffing: Progress and  Opportunities  To Do More  
OEI-04-18-00451   About OIG | 43