Top Tips for Skilled Nursing Providers to Win Under the New CMS Rules

The Patient-Driven Payment Model (PDPM) has gobbled up most of the recent headlines in the skilled nursing industry regarding new regulations, but there’s another set of rules that providers shouldn’t forget about.

The industry remains in the thick of the new Requirements of Participation, which the Centers for Medicare & Medicaid Services (CMS) will finish rolling out in November of next year. Operators scored a major victory last year when the agency announced an 18-month moratorium on penalties for failing to meet new standards set under the second round of new RoPs, which formally hit the books in November 2017. Still, that doesn’t mean operators should simply ignore their new responsibilities — or stop looking forward to next fall.

“You’ll still be tagged for it. You just won’t be penalized for it,” Gwen Dayton, executive vice president and general counsel for the Oregon Health Care Association, said during the American Health Care Association’s annual conference and expo in San Diego earlier this month. “You’re still going to be surveyed for it. You’re still going to be found in violation, at least for now.”


During a wide-ranging talk on compliance strategies, Dayton repeatedly emphasized the importance of the facility assessment, one of the new RoPs introduced under the delayed-enforcement set last year.

“This assessment is at the hub of so many other compliance efforts,” Dayton said, adding that CMS mentions it more than 150 times in its final rule on RoPs. “If you don’t get the facility assessment done right, you’re going to be subject to other tags and other enforcement problems.”

This document serves as a blueprint for each SNF’s capabilities and day-to-day makeup, including average daily census, common diseases that its residents have, and detailed staffing information.


As Dayton pointed out, compliant providers should have already conducted a facility assessment, even without the threat of penalties — but the burden doesn’t end once the initial report is drafted. Providers must routinely update their facility assessments every time there’s a triggering event that substantially changes the kind of care that an individual skilled nursing facility providers. For instance, an influx of stroke patients might require different staffing needs, while an increase in overall census could necessitate the purchase of new equipment — all of which would need to be reflected in the assessment.

“This needs to be a living and breathing document that not only says this is what you are, but says what you need to be,” Dayton said.

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Dayton suggested using the types of documentation that each SNF already must maintain to compile the all-important facility assessment: business plan, staff training materials, payroll-based journal (PBJ) documents, and even a SNF’s long-term strategic plans. And while it isn’t legally necessary, she recommended talking with residents to ensure that their needs are being met and documented as well; CMS requires providers to note any specific ethnic, cultural, or religious factors that might play into a SNF’s care plans.

With all that said, Dayton said that the violation tag associated with facility assessments — F838 — hasn’t ranked among the most common citations from CMS, with infection control topping the list. Still, she warned of “companion” citations that could arise if a separate violation eventually leads back to the assessment.

“Know that these things tend to walk in hand-in-hand with other tags,” Dayton said. “Somebody walks in and argues insufficient staffing. What does your facility assessment say about staffing? And then your FA doesn’t say very much about staffing. You’ll get tagged for the staffing. You’ll get tagged for the facility assessment.”

As for industry hopes that CMS might roll back some of the new requirements of participation — which Dayton described as the biggest overhaul to nursing home regulations since the early 1990s – providers will probably have to wait until after the midterm elections to see which way the wind might blow from Washington. That said, Dayton noted that implementing the second round of requirements hasn’t necessarily been prohibitive for providers thus far.

“When I look at this opportunity to roll back, I’m grateful to some extent, because if there’s something that we’re doing that isn’t really useful … then probably, you ought to roll it back,” Dayton said. “But most people are in compliance with phase II.”

Written by Alex Spanko

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