Section 300.1230  Direct Care Staffing

a)         For purposes of the minimum staffing ratios in Section 3-202.05 of the Act and this Section, all residents shall be classified as requiring either skilled care or intermediate care.  (Section 3-202.05(b-5) of the Act)

b)         For the purposes of this Section, the following definitions shall apply:

1)         "Direct care" − the provision of nursing care or personal care as defined in Section 300.330, therapies, and care provided by staff listed in subsection (i).  Direct care staff are those individuals who, through interpersonal contact with residents or resident care management, provide care and services to allow residents to attain or maintain the highest practicable physical, mental and psychosocial well-being. Direct care staff does not include individuals whose primary duty is maintaining the physical environment of the facility (e.g., housekeeping).

2)         "Skilled care" – skilled nursing care, continuous skilled nursing observations, restorative nursing, and other services under professional direction with frequent medical supervision.  (Section 3-202.05(b-5) of the Act)  Skilled nursing services are either nursing or therapy care services, furnished pursuant to physician orders, that require the skills of a licensed nurse to treat, manage, and observe a resident's condition and evaluate a resident's care. The skilled nursing services may be provided by a CNA, under the supervision of a licensed nurse to ensure the safety of the patient and to achieve the medically desired result. A resident in a skilled nursing facility is classified as receiving skilled care if:

A)        The resident is receiving care covered by Medicare under any arrangement allowed by Title XVIII of the Social Security Act;

B)        The resident is receiving care that would be covered by Medicare, but the resident has exhausted his or her Medicare benefits; or

C)        The resident is not Medicare eligible, but is receiving care that would be covered by Medicare if the resident were eligible.

3)         "Intermediate care" – basic nursing care and other restorative services under periodic medical direction.  (Section 3-202.05(b-5) of the Act)  Services not classified as skilled care will be classified as intermediate care.

c)         A minimum of 25% of nursing and personal care time shall be provided by licensed nurses, with at least 10% of nursing and personal care time provided by registered nurses. Registered nurses and licensed practical nurses employed by a facility in excess of these requirements may be used to satisfy the remaining 75% of the nursing and personal care time requirements. (Section 3-202.05(e) of the Act)

d)         The minimum staffing ratios shall be 3.8 hours of nursing and personal care each day for a resident needing skilled care and 2.5 hours of nursing and personal care each day for a resident needing intermediate care.  (Section 3-202.05(d) of the Act)  For the purpose of this subsection, "nursing care" and "personal care" mean direct care provided by staff listed in subsection (i).

e)         The facility shall schedule nursing personnel so that the nursing needs of all residents are met.

f)         The number of staff who provide direct care who are needed at any time in the facility shall be based on the needs of the residents, and shall be determined by figuring the number of hours of direct care each resident needs per day. 

g)         Each facility shall provide minimum direct care staff by complying with subsection (f) and meeting the minimum direct care staffing ratios set forth in this Section.

h)         The direct care staffing calculations in this Section shall include only the number of staff actually on duty on site.  The following shall not be included in direct care staffing calculations:

1)         Meal and break times (paid or unpaid);

2)         Scheduled training; and

3)         When a facility is utilized as a clinical site for nurse aide training, if the facility is not paying the employee for the services provided.

i)          For the purpose of computing staff to resident ratios, direct care staff shall include the following:

1)         Registered professional nurses;

2)         Licensed practical nurses;

3)         Certified nurse assistants;

4)         Psychiatric services rehabilitation aides;

5)         Rehabilitation and therapy aides;

6)         Psychiatric services rehabilitation coordinators;

7)         Assistant directors of nursing;

8)         50% of the Director of Nurses' time;

9)         30% of the Social Services Directors' time (Section 3-202.05 of the Act); and

10)         Licensed physical, occupational, speech and respiratory therapists.

j)          Facilities subject to Subpart S may utilize specialized clinical staff, as defined in Section 300.4090(c) and (f), to count towards the staffing ratios. (Section 3-202.05(a) of the Act)

k)         To determine the direct care staffing required to meet daily minimum staffing ratios for skilled care and intermediate care, the following staffing formula shall be used:

1)         Determine the number of residents requiring skilled care and the number of residents requiring intermediate care.

2)         Calculate the total daily required nursing and personal care hours for each level of care:

A)        The number of residents requiring skilled care shall be multiplied by the required number of hours (3.8) per resident.

B)        The number of residents requiring intermediate care shall be multiplied by the required number of hours (2.5) per resident.

3)         Add the total number of hours of direct care required for each level of care to determine the total number of hours required to provide direct care for all residents in the facility.

4)         Multiplying the total minimum hours of direct care hours required for all residents, determined under subsection (k)(3), by 25% results in the minimum amount of licensed nurse hours that shall be provided during a 24-hour period.

5)         Multiplying the total minimum hours of direct care time required for all residents, determined under subsection (k)(3), by 10% results in the minimum amount of registered nurse hours that shall be provided during a 24-hour period.

6)         The remaining 75% of the minimum required direct care hours may also be fulfilled by other staff identified in subsection (i) as long as it can be documented that those staff provide direct care, and that nursing care and nursing delegation is in accordance with the Nurse Practice Act.

7)         The amount of time determined in subsections (k)(4), (5) and (6) is expressed in hours.

8)         See Appendix A for an example of staffing calculations. 

l)          A written work schedule shall be posted at least 10 days prior to the first day on the schedule. The work schedule shall be posted in a location conspicuous and accessible only to employees.

1)         This work schedule shall contain the employee's name, job title, (identifying the job title or titles listed in subsection (i), if applicable), shift assignment, hours of work, and days off.

2)         If an employee works in more than one job during the same week, specifically including those job duties listed in subsection (i), if applicable, the facility shall separately state the hours of work for each job duty.

3)         The work schedule, whether a hard copy or in an electronic format, shall be kept on file in the facility in the administrator's office for a minimum of three years after the week for which the schedule was used.

m)        Time spent in scheduled breaks and mealtimes, and scheduled training, when staff are not providing direct care shall be documented.

n)         A facility operating under a waiver from the minimum registered professional nurse staffing requirements (see Section 300.1232) shall provide written documentation of the waiver to the Department upon request.

(Source:  Amended at 45 Ill. Reg. 1134, effective January 8, 2021)