Total Nursing Hours per Resident Day (Total Nurse Staffing Measure) is a structural measure. This measure began impacting the Value Based Purchasing program this Fiscal Year, 2026. It further impacts Five-Star and Care Compare. Data for this measure is sourced from CMS’ Payroll Based Journal (PBJ) system.
The numerator for this measure is the total nursing hours, consisting of Registered Nurse (RN), Licensed Practical/Licensed Vocational (LPN), and nurse aide hours. The specific hours used to calculate this measure are:
- RN hours: RN Director of Nursing + RN with administrative duties + RN
- LPN hours: LPN with administrative duties + LPN
- Nurse Aide hours: Certified Nurse Aides + Aides in training + Medication Aides/Technician
The hours further include full-time and part-time employees of the facility and contracted staff, both organizational and individual contracts. “Private duty” nursing staff are not included in the PBJ data. Hours are reported quarterly and are summed across all days in the quarter, including weekdays and weekends.
The denominator for this measure is a count of daily MDS census. This is taken from resident assessments and is summed across all days in the quarter. It is calculated by:
- Identifying the reporting period, or quarter
- Extracting MDS assessment data for all residents beginning 1 year prior to the reporting quarter to determine all residents that may reside in the facility
- Identifying residents who were discharged or deceased through either an MDS Discharge Assessment or Death in Facility Tracking Record OR there is no assessment for an interval of 150 days from the last assessment as assessments are to be completed quarterly.
There are denominator exclusions forthis measure as follows:
- Total nurse staffing summed over all days in quarter is excessively low (< 1.5hours per resident day)
- Total nurse staffing summed over all days in quarter is excessively high (> 12hours per resident day)
- Nurse aide staffing summed over all days in quarter is excessively high (> 5.25hours per resident day)
For this measure staffing ratios are adjusted by CMS. The 25 nursing Case-mix Groups (CMGs) and corresponding Case-mix Indexes (CMIs) from the Patient Driven Payment Model (PDPM) are used. Case-mix hours are based on the distribution of nursing CMGs within each facility, PDPM nursing CMIs, and the reported national average staffing level.
Case-Mix Adjusted Hours = Reported Hours/Case-Mix Nurse Staffing Hours X National Average Case-Mix Hours
The Reported Hours are those submitted via the PBJ system. The National Average Case-mix Hours for each staff type represents the national mean of case-mix hours across all active facilities on the last day of the quarter and submitted valid data for the quarter via PBJ. This is updated quarterly. This information is available in the State US Averages table within CMS’ Provider Data Catalog at https://data.cms.gov/provider-data/.
Case-mix nurse staffing hours per resident day for each facility is calculated by the following method:
- Use MDS’ to assign a PDPM nursing CMG to each resident for each day in quarter. This is calculated similar to the method used for calculating the daily MDS census as described above. It simply looks at PDPM nursing CMGs versus resident count.
- Aggregate information to generate resident count for each of the 25 PDPM nursing CMGs foreach day in the quarter. If a CMG is not represented on a given day, it is counted as zero. If there is insufficient MDS information to assign a CMG, do not include
- Determine the average nursing CMI for the quarter by dividing the aggregate nursing CMIs across nursing CMGs by the number of resident-days in the quarter. This is calculated on a facility level and a national level.
- Calculatethe relative nursing CMI ratio as the ratio of its weighted-average nursing CMIto the national weighted-average nursing CMI
The case-mix total nursing per resident day is then calculated:
Case-mix hours per resident day = Facility Nursing CMI ratio x National Mean of Reported Hours per Resident Day
Providers need to ensure they are submitting accurate and timely PBJ data as well as MDS data to ensure they eceive optimal credit for this structural measure for the Value BasedPurchasing Program, Five-Star, and Care Compare.
To learn more go to https://www.cms.gov/files/document/specifications-skilled-nursing-facility-value-based-purchasing-snf-vbp-program-total-nursing-hours.pdf.