Research on nursing staff ratios and quality of care in nursing homes prompted Florida to implement minimum nursing staff ratios for certified nursing assistants (CNAs) in 2001. Using the contingency theory, the authors investigated the response to this mandate and its potential effects on indirect-care staff. This study used the Online Survey, Certification, and Reporting (OSCAR) staffing data for freestanding Florida nursing homes between the years 1999 and 2004. Piecewise regression growth curve models were investigated to test whether the percentage of Medicaid residents is associated with change in indirect-care staffing levels. The number of indirect-care staff hours per 100 residents declined significantly following the mandated increase in nursing staff, particularly among facilities with a low percentage of Medicaid residents. This may have stemmed from a partial transfer of indirect-care to CNAs and was exacerbated in facilities that received less additional reimbursement to pay for CNA increases.
Bergmann, J. ( 1999). Legislative developments: California enacts nurse-to-patient ratio law. Journal of Law and Medical Ethics, 27, 387.
2.
Bolton, L.B., Jones, D., Aydin, C.E., Donaldson, N., Brown, D.S., Lowe, M., et al. (2001). A response to California’s mandated nursing ratios. Journal of Nursing Scholarship, 33, 179-184.
3.
Conway, P.H., Konetzka, T.R., Zhu, J., Volpp, K.G., & Sochalski, J. ( 2008). Nurse staffing ratios: Trends and policy implications for hospitalists and the safety net. Journal of Hospital Medicine , 3, 193-199.
4.
Cowles, C.M. ( 2002). Nursing home statistical yearbook. Montgomery Village, MD: Cowles Research Group.
5.
Cox, K.S., Anderson, S.C., Teasley, S.L., Sexton, K.A., & Carroll, C.A. ( 2005). Nurses’ work environment perceptions when employed in states with and without mandatory staffing ratios and/or mandatory staffing plans. Policy, Politics, and Nursing Practice, 6, 191-197.
6.
Dalton, K., Van Houtven, C.H., Slifkin, R., Poley, S., & Howard, A. ( 2002). Background paper: Rural and urban differences in nursing home and skilled nursing supply (No. 74). Chapel Hill: North Carolina Rural Health Research and Policy Analysis Center.
7.
Degenholtz, H.B., Kane, R.A., Kane, R.L., Bershadsky, B., & Kling, K.C. ( 2006). Predicting nursing facility residents’ quality of life using external indicators. Health Services Research , 41, 339-396.
8.
Donaldson, N., Bolton, L.B., Aydin, C., Brown, D., Elashoff, J.D., & Sandhu, M. ( 2005). Impact of California’s licensed nurse-patient ratios on unit-level nurse staffing and patient outcomes. Policy, Politics, and Nursing Practice, 6, 198-210.
9.
Feng, Z., Grabowski, D.C., Intrator, O., Zinn, J., & Mor, V. ( 2008). Medicaid payment rates, case-mix reimbursement, and nursing home staffing: 1996-2004. Medical Care, 46, 33-40.
10.
Feng, Z., & Mor, V. ( 2008, June). Quality of life deficiencies in U.S. nursing homes: Prevalence, trends and organizational correlates. Poster presented at the Academy Health Annual Research Meeting, Washington, DC.
11.
Florida’s 2001 Legislative Session. ( 2001). Wrap up, 1-4. Retrieved October 29, 2009 , from http://www.leg.state.fl.us/data/legislators/House/008/Newsletter/2001.PDF
12.
Grabowski, D.C., Feng, Z., Intrator, O., & Mor, V. ( 2004, June 16). Recent trends in states’ nursing home payment policies. Health Affairs (Suppl. Web Exclusive) , W4-363-W4-373.
13.
Gregory, S. ( 2001). The nursing home workforce: Certified nurse assistants (Fact Sheet). Washington, DC: AARP Public Policy Institute.
14.
Harrington, C., Carrillo, H., & LaCava, C. (2005). Nursing facilities, staffing, residents and facility deficiencies, 1998-2004. San Francisco : University of California, Department of Social and Behavioral Sciences.
15.
Harrington, C., Zimmerman, D., Karon, S.L., Robinson, J., & Beutel, P. ( 2000). Nursing home staffing and its relationship to deficiencies. Journals of Gerontology, B: Psychological and Social Science , 55, S278-S287.
16.
Health Care Financing Administration. (1989 ). Rules and regulations. Federal Register, 54, 5316-5373.
17.
Health Care Financing Administration. (2000 ). Report to Congress: Appropriateness of minimum staffing ratios in nursing homes. Washington, DC: Author.
18.
Hyer, K., Temple, A., & Johnson, C.E. ( 2009). Florida’s efforts to improve quality of nursing home care through nurse staffing mandates, regulation, and Medicaid reimbursement . Journal of Aging and Social Policy, 21, 318-337.
19.
Kasper, J., & O’Malley, M. (2007). Changes in characteristics, needs, and payment for care of elderly nursing home residents: 1999-2004 (No. 7663). Washington, DC: Henry J. Kaiser Family Foundation.
20.
Konetzka, R.T., Stearns, S.C., & Park, J. ( 2008). The staffing-outcomes relationship in nursing homes. Health Services Research, 43, 1025-1042.
21.
Lawrence, P., & Lorsch, J. ( 1967). Organization and environment. Cambridge, MA: Harvard University Press.
22.
Martin, S., & Smith, R. ( 1993). OBRA legislation and recreation activities: Enhancing personal control in nursing homes. Activities, Adaptation and Aging, 17, 1-14.
23.
Medicaid Reform Meeting. (2004, June 11). Summary of issues raised. Meeting of the Florida Agency for Health Care Administration, Subcommittee on Medicaid Reform. Retrieved June 20, 2008, from http://www.fdhc.state.fl.us/Medicaid/medicaid_reform/2004meetings.shtml
24.
Mueller, C., Arling, G., Kane, R., Bershadsky, J., Holland, D., & Joy, A. ( 2006). Nursing home staffing standards: Their relationship to nurse staffing levels. The Gerontologist, 46, 74-80.
25.
Office of the Inspector General. (2008). Trends in nursing home deficiencies and complaints (OEI Rep. No. OEI-02-08-00140) . Washington, DC: Department of Health and Human Services.
26.
Polivka, L., Salmon, J.R., Hyer, K., Johnson, C., & Hedgecock, D. ( 2003). The nursing home problem in Florida. The Gerontologist, 43, 7-18.
27.
Raudenbush, S.W., & Bryk, A.S. ( 2002). Hierarchical linear models: Applications and data analysis methods (2nd ed.). Thousand Oaks, CA: Sage.
28.
Ryan, J., Stone, R.I., & Raynor, C.R. ( 2004). Using large data sets in long-term care to measure and improve quality. Nursing Outlook, 52, 38-44.
29.
S. 1202, Long Term Care Facilities, Florida, Senate. ( 2001). Retrieved October 28, 2009, from http://www.fdhc.state.fl.us/MCHQ/Long_Term_Care/LTC/FAHA_FHCA_Sept_Presentation.ppt
30.
SAS Institute. (2004). SAS system for Microsoft Windows, Version 9.1 [Computer software]. Cary, NC: Author.
31.
Schnelle, J.F., Simmons, S.F., Harrington, C., Cadogan, M., Garcia, E.M., & Bates-Jensen, B. (2004). Relationship of nursing home staffing to quality of care. Health Services Research , 39, 225-250.
32.
Spector, W.D., & Takada, H.A. ( 1991). Characteristics of nursing homes that affect resident outcomes. Journal of Aging and Health, 3, 427-454.
Tucker, D. ( 2001, March). Bringing housekeeping up to state survey standards . Nursing Homes. Retrieved November 11, 2008 , from http://www.thefreelibrary.com/Bringing+Housekeeping+Up+to+State+Survey+Standards.-a073750605
U.S. Congress. (1987). Omnibus Budget Reconciliation Act of 1987. Washington, DC: 100th Congress, 151 Session Pub. Law 100-203.
37.
Weech-Maldonado, R., Neff, G., & Mor, V. ( 2003). Does quality of care lead to better financial performance? The case of the nursing home industry. Health Care Management Review, 28, 201-216.
