Assessing the Impact of Minimum Nurse Staffing Standards Enforcement on the Quality of Care in Nursing Homes : Evidence from the Centers for Medicare and Medicaid Service’s Staff Star Rating Downgrade Policy Announcements

Policymakers have historically attempted to influence quality in nursing homes through the imposition of minimum staffing standards (MSS) and through the public dissemination of quality on websites like Care Compare. Current Federal MSS require a registered nurse (RN) on duty for at least eight hours each day. In 2018, the Centers for Medicare and Medicaid Services (CMS) announced that they would incentivize compliance with Federal MSS by downgrading nursing homes by one star on their Care Compare quality ratings if they had 7 or more days without an RN present during the quarter. CMS subsequently revised the threshold to 4 or more days in 2019. This study exploits the timing these announcements using intent-to-treat samples of nursing homes at risk for downgrade using difference-in-differences and event study models and finds that the announcements significantly increased RN staffing, skill mix, and produced clinically meaningful improvements in quality across several dimensions