Nurses are at the heart of every Skilled Nursing Facility (SNF). Ensuring that your Facility is appropriately staffed should be a top priority to enable you to provide the best quality of care to your residents.
Certifications and Licenses
Facilities must verify that all nursing staff are appropriately licensed and certified to perform their job duties. Upon hire, the Facility should obtain original copies of any required licenses or certifications and make copies of the original document to keep on file. Accepting photocopies of licenses or certifications leaves the Facility at risk for documentation falsifications, which can lead to improper staffing and quality of care liability. A Facility should also ensure that it has proper tracking mechanisms in place to determine when licenses are nearing expiration, or have expired, so that the nursing staff is always in compliance.
Meeting the 3.2 Nursing Hours Per Patient Day (NHPPD) Standard
The state of California requires that SNFs employ sufficient staff to provide a minimum daily average of 3.2 nursing hours per patient day.  While most Facilities are familiar with the requirement, not all Facilities understand how to properly assess their compliance with this standard. In 2011, the California Department of Public Health released information regarding its process for auditing SNFs’ NHPPD compliance.  Outlined below are some of the commonly overlooked aspects of accurately calculating the NHPPD:
Only direct caregivers should be counted toward the NHPPD calculation. A direct caregiver means a registered nurse, a licensed vocational nurse, a psychiatric technician, or a certified nursing assistant that directly provides care for a resident. For example, if the Director of Nursing Services (DON) is working an eight hour day, but only directly provides care for residents for two of those hours, the Facility may only attribute two of the DON’s hours to its NHPPD calculations.
The actual nursing hours and NHPPD may only be calculated at the end of each 24-hour patient day. This means that a Facility may estimate its resident census and nursing hours for the day, but the DON should only sign and confirm the average census and NHPPD calculations at the end of each 24-hour patient day.
To consider employees not captured in payroll records for NHPPD purposes and those who are hired to perform duties other than nursing services, documentation must show the time spent on actual nursing services. The Facility should create an assignment sheet or use CDPH’s “Nursing Staffing Assignment and Sign-In Sheet”  to record daily staffing assignments for these employees.
Staffing for Acuity
Another important thing to keep in mind is whether or not your Facility is appropriately staffed for the acuity of its resident population. When determining nursing assignments, be sure to consider the following:
Number of residents who need 1:1 supervision;
Number of residents that are on safety checks (and frequency of checks);
Incident Log for the last 90 days;
Most recent ADL scores for all residents; and
Admission, Discharge, Transfer information for the last 90 days.
Appropriate staffing for acuity is crucial to providing quality care to residents; reducing employee stress and burnout; and reducing the likelihood of falls, abuse and neglect, and other resident safety issues.
In addition to implementing the aforementioned best practices for keeping your nursing staff in compliance, your Facility should solicit feedback from its nurses regarding areas for improvement. No one knows your Facility’s operations better than your nursing staff and keeping up with your nursing staff’s opinions is a great tool for improving your overall quality of care.
22 Cal. Code Regs. §72329(f)
California Department of Public Health All Facilities Letter 11-19
California Department of Public Health Form 530