When the Centers for Medicare & Medicaid Services (CMS) began basing its rating of nursing home staffing levels on payroll records in April of this year, many skilled nursing facilities were found to be underreporting their nursing and caretaking personnel levels.
Soon after the New York Times published an analysis of the records by Kaiser Health News — which showed serious fluctuations in skilled nursing facility staffing – CMS hit almost 1,400 facilities with one-star ratings for staffing coverage.
The results came as a surprise to some facilities, according to Don Feige, the founder and former owner of SNF-focused software firm ezPBJ, which was recently acquired by Des Moines, Iowa-based Briggs Healthcare. And it’s sparked some soul-searching among the SNFs who were hit hard by the change to the payroll-based journal (PBJ) system.
“People are like, ‘Wait, what happened? What did I do to go down? What did I do to go up?'” Feige told Skilled Nursing News. “I think that’s triggered a lot of people now to start to analyze and figure out what’s in their data … I think we’re in the first few months of that awareness and that seeking to understand what’s really going on with their staffing data.”
Verifiable data required — for everyone
Under the PBJ system, SNFs must send in a quarterly electronic, auditable file with data for every employee in 35 key positions. Those employees have a unique identifier, and providers have to identify the number of hours each person works for those positions on a daily basis, Peter Corless, executive vice president of enterprise development at the Cleveland-based software company OnShift, explained to SNN.
With this quarterly data and the daily facility census information obtained from the Minimum Data Set (MDS), CMS can calculate hours-per-day coverage at a facility.
But there are some hiccups, Corless noted. For one thing, agency workers are on the rise in the SNF world, as the labor market tightens and certain areas of the country near full employment. These workers’ hours aren’t captured the same way as full-time employees, but the nursing home is still responsible for making sure they record that time.
“An agency person is not an employee, so they’re not on the payroll of the facility,” Corless explained. “So the facility has to have a methodology in place to be able to capture those hours, report those hours, and have an auditable paper trail if CMS comes in and audits them, to substantiate the hours they reported. If you have an employee who’s punching a time clock, that’s a really easy way to capture hours, but an agency person is not an employee, and a facility has to have a way to capture those agency hours.”
There are multiple ways for SNFs to achieve that goal. OnShift, for instance, has a check-in tool in its app that lets a facility receptionist record the worker in the company’s PBJ software with a unique identifier as required by the system, Corless said.
Agencies can also provide an XML file that the SNF can upload to its PBJ software, whatever that may be. Manual entry is another option, which is cumbersome but might be an option for mom-and-pop SNFs, according to Corless.
Navigating multiple information streams
One of the major hurdles of navigating PBJ is the fact that it incorporates data from multiple sources, Feige told SNN. These can include numbers from the payroll, the therapy file, nursing agency staffing data, and information from other outside vendors whose contractors provide direct care.
Feige expected that the usual compliance workers would be handling the PBJ data, and was surprised to see that payroll departments have increasingly ended up taking over, he said. He’s also starting to see an evolution in how providers approach PBJ.
“In the beginning, it was just checking a box,” he said. “People were looking for ‘What can I buy to say that I’m compliant?’ and just be done with it. I think that’s evolving now.”
One of the unpleasant surprises for facilities stemmed from CMS’s definition of a single day as “midnight to midnight,” while facilities have overnight workers who start before midnight and end sometime the following morning, Feige said. The second issue was the audits surrounding meal breaks.
“In facilities, a lot of times you have nursing staff working through lunch, CNAs working through lunch,” Feige explained. “If they’re working through lunch, you’re paying them for it.”
But CMS requires that meal breaks be removed, even if the nurse or CNA worked through that time — which has hit quite a few facilities, he said. With hours being reported to PBJ that are less than what is reported on the payroll, nursing homes have been “scrambling” to adjust, according to Feige.
Another issue came with RN staffing, as some RNs report for duty on days when they aren’t officially given hours. Since facilities automatically receive a one-star staffing rating if they have seven or more days per quarter with zero RN hours, the question becomes whether they actually don’t have an RN — or whether the data are incorrectly being entered, Feige said. He estimated about 1,000 facilities were caught off-guard by this problem.
Briggs Healthcare works with about 12,000 long-term care facilities in some capacity, and for general manager Jeff Kane, being able to help facilities properly assemble their data will provide value beyond Briggs’ original focus on compliance.
“We’re trying to take things beyond simple regulatory and clinical compliance, structuring things so that we can provide solutions that will help their facilities use their data proactively to help improve the quality of care they provide,” he said. “Going beyond checking the box by helping folks unlock the value that’s hidden in their data.”
Written by Maggie Flynn
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