Maryland Nursing Home Staffing Regulations 


People living in nursing homes and their friends and families deserve to know whether the minimum required number of staff is on duty on every wing, unit, or floor and on every shift without the need to collect the staffing numbers for all shifts for the entire building and most importantly without the need for an advanced math degree. This can most easily be done by setting minimum staffing levels in the following manner:

  • Ratios of aides and nurses to residents on each unit, wing, or floor for each shift — this allows residents to know that the minimum number of aides and nurses are indeed working in each unit
  • Clearly stating that the required minimum staffing levels be posted on each wing, unit, or floor along with the names of the aides and nurses on duty and their room assignments
  • Remembering always that these are the minimum staffing levels that everyone is entitled to. There will be people who require higher levels of care, and staffing on units where they reside will need to be increased.


Originally written in 2003–still relevant today.

Are They Adequate? The Report to Congress: Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes Phase II Final Report done by the Centers for Medicare & Medicaid Services and released to the public in 2002 found that harm can occur in a nursing home if direct nursing care falls below 2.75 hours per resident per day. The same study found that, for quality care, at least 4.13 hours of direct nursing care are needed. Many nursing homes often have staffing levels at or a small percentage above the minimum required hours.

In the Legal Code of Maryland (COMAR), the minimum staffing requirements changed from 2.0 hours of care per resident per day to 3.0 hours of care per resident per day. Current minimum staffing requirements in Delaware as provided for in the Legal Code of Delaware, are 3.28 hours per resident per day.* (

There’s another critical difference between the two states and that’s the way these hours are calculated. Delaware, along with a number of other states, is ‘user friendly’. Delaware uses The Ratio. This is stated as 1:10 which means that there must be one caregiver for every 10 residents. In Delaware, it’s even better. They specify The Ratio by shifts. For the day shift, for instance, the nurse’s aide ratio must be 1:8* or one aide for every 8 residents.

When you go in to visit Mom in Delaware, you count the number of aides working on her unit and ask how many residents are in that unit at that time. Divide the number of aides by the number of residents and you get The Ratio stating the number of residents each caregiver is responsible for.

Maryland is not a ‘user friendly” state. In Maryland, you must calculate the hours per resident per day and you must do it for the entire facility. . Count the entire direct care staff (nurses and nurse’s aides) working on every unit for the entire facility, not for one shift but for all three shifts in a 24-hour period. Add them together to get the total. Then, divide the total number of care givers, by the total number of residents, you to get The Ratio.  Assuming each caregiver works 8 hours, you must then divide the number of residents each caregiver is responsible for into the 8 hours each caregiver works to get the hours of care per day for each resident.

So, if you’re trying to calculate staffing in Delaware, your math skills don’t have to be nearly as sharp as they do if you’re trying it in Maryland. And, you only need to do it for Mom’s unit, not for the entire facility. Delaware, by the way, also has a separate ratio for nurses. They don’t lump all the caregivers together. You can follow the same procedure to get the ratio of nurses to residents.

Another feature of the Maryland staffing laws is that if there is a rehabilitation or a skilled nursing unit in the facility, the staffing numbers for that unit are included in the total count. Rehabilitation and skilled nursing units, by definition, have a much higher staffing ratio than your regular long-term care units. Including them in the long-term care count significantly raises the staffing levels even though that staff does not care for residents on the long-term care units. In Delaware, calculations are made for each shift and for each unit. Staffing levels in skilled nursing or rehabilitation units do not have any impact on staffing levels in long-term care units.

Consider a facility with three units, one of them is a rehabilitation unit, the other two are long-term care units. In that facility, in Maryland, the long-term care units could usually or always fall below the 3.0 minimum and that facility would still be in compliance with the Maryland staffing laws. In Delaware, each unit in a long-term care facility must meet the minimum staffing ratios.

To ensure quality care in Maryland and to give family members a reasonable chance of checking it, changes are needed. Voices for Quality Care (LTC) is studying this issue. We haven’t reached a conclusion yet but here are a few ideas we are considering.

1. Maryland needs to become a ‘user friendly’ state. Minimum staffing levels need to be stated using The Ratio rather than or in addition to hours per day. They need to be stated for each shift.

2. Staffing ratios need to be stated separately for nurses and nurse’s aides

3. The minimum staffing levels need to be raised again to reach at least 4.0 hours of care per resident per day.

4. Rehabilitation and skilled nursing units need to be counted separately and not included in long-term care unit staffing totals.


*The Delaware law provides for a phase-in on May 1, 2003 that raises these levels to 3.67 hours of nursing care per resident per day and a ratio of 1:7 for nurses’ aides on the day shift. Medicaid funding in the state was not sufficient to implement this phase-in. The minimum hours and nurses’ aide ratio given above are currently being implemented in Delaware. They hope to increase those numbers as soon as Medicaid funding is available. This information was provided by Robert Smith, Licensing and Certification Administrator of Delaware.


Possible Staffing Minimums 

CLICK HERE to view possible nurse and aide ratios in 4 incremental increases from 2.00 hours of care per resident per day to 4.01 hours of care per resident per day.  


Update November, 2019

Maryland minimum nursing home staffing levels:  

 Maryland’s minimum staffing in nursing homes changed from 2.0 hours of care per resident to 3.0 hours of care on July 1, 2019.  Staffing is still calculated for the entire building for a full 24 hours (3 shifts).   Below is a chart that offers one way to correct staffing and take the state from 3.0 ours of care through a series of steps that bring the minimum level of care to a reasonable 4.01 hours of care per day for everyone in the nursing home.  These ratios are intended to be applied individually to each unit, wing, or floor.  Remember, minimum staffing is the least that can be given.  Naturally, those people living in the home in need of additional care should be provided with additional staffing.

Voices for Quality Care believes that staff count requirements must allow anyone — residents, families of residents, staff, ombudsmen, and surveyors — a way to quickly determine whether any individual unit, wing, or floor in a nursing home is in compliance with minimum staffing requirements at any specific time.  We believe this is the only way that such staffing requirements can actually be regulated and monitored.  In a full building, 24-hour staff count situation, it is impossible for even the surveyors to determine whether a nursing home is in compliance at any given time.