For the past 15 years, I have worked as a Certified Nurse Assistant (CNA), and I've witnessed firsthand the daily challenges faced by my colleagues and me on every shift. With no existing federal regulations to govern CNA-to-resident ratios, CNAs are overburdened, residents do not receive the optimal care they deserve, and facilities are left vulnerable to lawsuits and high turnover rates. The absence of these crucial regulations has resulted in numerous negative consequences that could be easily mitigated.

Imagine a day at work where you are responsible for the care of so many residents that it becomes nearly impossible to give each the attention they need. This is the reality for CNAs across the nation. The lack of mandated staffing ratios means that we are often overstretched, leading to burnout and diminishing the quality of care for our residents. Without CNAs, millions of geriatric and disabled individuals would be without the necessary medical care needed to ensure their quality of life.

We propose the following CNA-to-resident ratios, which are essential for maintaining quality care:
- Day Shift: 1 CNA to 6 residents
- Evening Shift: 1 CNA to 8 residents
- Night Shift: 1 CNA to 12 residents
- 12-hour Day Shift: 1 CNA to 8 residents
- 12-hour Night Shift: 1 CNA to 10 residents

For acuity adjustments one would subtract 1 resident from each CNA workload for each category below:

·         Total assistance with ADLs

·         Two-person transfer

·         Severe dementia/behavioral needs

·         High fall risk

·         Wounds requiring frequent repositioning 

 

For example: If a CNA has 8 residents on evening shift but 2 are high acuity, the load must be reduced to 6.

 

The equation for a facility to know how many CNAs to have on shift would be census divided by ratio. Example: If the facility has a census of 100 residents on day shift they would divide 100 by 6 making the required number of CNAs 16-17 for the shift.  

These ratios are not arbitrary but rather reflect the intense labor and dedication required for each resident's care.

To become a CNA, one must complete a state-approved training program. In the state of Missouri, an individual is required “to complete 75 hours of classroom training, 100 hours of on-the-job training, and successfully complete a two-part final examination. The two-part final examination includes a written (or oral) and practicum examination” (Missouri Department of Health & Senior Services, n.d.). A majority of states require similar training to obtain a Nurse Assistant Certification. Throughout their time in the profession, CNAs are also required to complete continuing education with no compensation.  The U.S. Bureau of Labor Statistics shows that in 2024, the U.S. average hourly rate for a Certified Nurse Assistant is $18.96. That is only four dollars over the U.S. average for fast food workers. Poor compensation lowers workplace morale as well as enables short staffing. We are recommending that the U.S. median wage be raised to $22 an hour. 

Once implemented into the national average, the regional adjustments will be made using the Consumer Price Index (CPI). The formula being:

Adjusted Wage= Base Wage x State Cost of Living Adjustment

This prevents underpayment in the states with a higher cost of living while also preventing overpayment in the states with a lower cost of living. 

To increase retention and reduce turnover Certified Nurse Assistants should receive:

·         $1-$2/hour extra for 5+ years experience

·         $1-$3/hour extra for dementia care certification

·         $1/hour night shift differential

·         $1/hour weekend differential

Every year, wages should increase by +1% to account for inflation. 

The funds would come from the reallocation of Medicare/Medicaid reimbursement. Since nursing homes already receive payments from Centers for Medicare & Medicaid Services (CMS) I propose that facilities would have to show that they use a fixed percentage of reimbursement for direct care wages. “Quality is defined by the National Academy of Medicine as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (Centers for Medicare & Medicaid Services [CMS], 2024). Utilizing the CMS Quality Measurement and Quality Improvement (QI) grants could support:

·         Wage increases

·         Training programs

·         Sign-on Bonuses

·         Retention Incentives

Another resource that could be used to fund fair compensation for CNAs would be the Federal Medical Assistance Percentage (FMAP). “The FMAP is based on a formula that provides higher reimbursement to states with lower per capita incomes relative to the national average. The formula is intended to reflect states’ differing abilities to fund Medicaid from their own revenues” (MACPAC, 2020). Using FMAP the federal government could offer enhanced matching funds for states that increase CNA wages. This would help the states cover a large percentage of the wage increase. 

A final recommendation to federally increase the wages for Certified Nurse Assistants is to give the facilities that meet the staffing standards tax credits. Facilities that comply with the federal CNA ratio and wage regulations could receive:

·         Annual Tax credits

·         Priority CMS reimbursement

·         Reduce liability insurance premiums

This not only will benefit the CNAs by incentivizing the facilities to comply with the federal regulations, but compliance also benefits the facilities. 

Through the utilization of these recommendations there would be no large tax increase required. This system uses programs that are already set in place as well as ensuring that the money gets to the direct care staff instead of being funneled to the administrators. 

By implementing these guidelines, we can ensure all CNAs operate in a safe and supportive working environment, reducing burnout and turnover, while improving the quality of life for those in our care.

It's not just about protecting CNAs and the residents; it's about ensuring the entire healthcare system functions effectively without the crippling effects of overworked staff. Proper staffing levels will also decrease legal risks for healthcare facilities and ensure compliance with quality standards.

We call upon policymakers to take immediate action to develop and enforce federal regulations concerning CNA-to-resident ratios and fair compensation. Join us in advocating for a healthcare environment that values its workers and provides optimal care for all residents. Sign this petition to demonstrate to lawmakers the importance of these necessary changes to protect both caregivers and those they serve.