CMS Implements Stricter Nursing Home Staffing Survey Rules for States

The Centers for Medicare & Medicaid Services (CMS) announced Friday that it will use payroll-based journal (PBJ) data to bolster state oversight of nursing homes, effective immediately.

Specifically, CMS will use PBJ data to identify and provide state survey agencies with a list of nursing homes that have several days in a quarter without a registered nurse (RN) on site, or have a significant decline in staff on the weekends. The survey agencies will then have to conduct surveys on additional weekends based on the federal list, according to a memo released to providers.

If surveyors find insufficient nurse staffing levels, the facility will be cited for noncompliance and have to implement a plan of correction.


The agency is specifically identifying facilities with the lowest levels of staffing, with no particular headcount decline that will trigger the extra inspections, a CMS spokesperson told Skilled Nursing News on Friday.

“We’re notifying states of the 20% of facilities in the state with the lowest levels of staffing on the weekends,” the spokesperson explained. “That’s not saying that we think the lowest 20% of facilities in a state are the only facilities with low staffing issues, or that all of them have low staffing issues. We’re not saying 20% is a threshold. We’re saying 20% to give [states] enough facilities to choose from to conduct these weekend surveys.”

CMS will be sending the lists to states in December, the spokesperson said.


Previously, the State Operations Manual required states to conduct at least 10% of standard health surveys on the weekend or during off-hours. But for facilities on the list provided by CMS, states are now required to conduct at least 50% of the required off-hours surveys on weekends.

And states could conduct more inspections if they choose, the spokesperson noted. State inspectors will receive the list of nursing facilities with low staffing levels each quarter, though if they need lists more frequently, CMS can provide them, the spokesperson told SNN.

“We’re deeply concerned about potential inadequacies in staffing, such as low weekend staffing levels or times when registered nurses are not onsite, and the impact that this can have on patient care,” CMS administrator Seema Verma said in a release announcing the new step. “The actions announced today strengthen our oversight of resident health and safety, and help ensure accurate public reporting.”

The move comes after CMS hinted to SNN that such a step was in the works.

“We also intend to use the data to support the health inspection process, by informing state inspectors of potential staffing issues,” a CMS spokesperson told SNN in response to questions about PBJ audits earlier last week.

For SNFs, the announcement means they must become even more aware of their staffing levels and how they report that data.

“It’s going to become even more imperative that they’ve got their information and their back-end systems up to reflect what’s going on in the building,” Don Feige, the founder and former owner of SNF-focused software firm ezPBJ, told SNN.

The American Health Care Association, the largest for-profit nursing home trade group, was not optimistic about the ramifications of the new step, though it did laud the effort to find uses for PBJ data.

“Unfortunately, today’s action by CMS will enforce policies that make it even more difficult to meet regulatory requirements and hire staff,” David Gifford, AHCA senior vice president of quality and regulatory affairs, said in a statement e-mailed to SNN. “Rather than taking proactive steps to address the national workforce shortage long-term care facilities are facing, CMS seems to be focusing on a punitive approach that will penalize providers and make it harder to hire staff to meet the shared goal of increasing staffing.”

LeadingAge president and CEO Katie Smith Sloan — whose organization represents non-profit aging services providers — stressed that any discussion of nursing home staffing has to be considered in the broader context of the labor force in a statement e-mailed to SNN, noting widespread workforce pressures in the skilled nursing field.

While expressing support for PBJ, she also expressed caution about some of the rules surrounding it.

“We believe that PBJ is an improvement because it standardizes data collection and holds the promise of more accurate data reporting,” she said. “However, PBJ policies regarding data collection submission are still relatively new, and our members tell us of issues with those policies. We’ve been voicing our concerns to CMS and will continue to do so.”

The staffing fluctuations came to national attention this summer after Kaiser Health News and the New York Times took a deep dive into the government’s numbers; the federal data strongly suggested that the Five-Star Quality Rating System exaggerated staffing levels across the country over the past decade. Soon after that report came out, CMS gave out almost 1,400 one-star reviews based on concerns about insufficient staffing levels in nursing homes.

The Friday memo also provided notice of updates to the PBJ Policy Manual and FAQ document, with guidance for deducting time related to meal breaks and a question-and-answer portion explaining the rationale for that policy.

The updates to the the policy manual and the FAQ reflect how CMS has operated around PBJ, Feige told SNN.

“It’s still very consistent,” he said. “They foreshadow it, and then they come out and they finally tell you what’s going on.”

Feige also believes there are some updates foreshadowed in the changes to the PBJ Policy Manual, which include a detailed breakdown of the meal break guidelines. Specifically, there are updates to the job descriptions associated with staff who have to be recorded in PBJ, such as administrators and medical directors. These moves provide more specific definitions, and they come after SNFs have been misreporting who serves in those roles, Feige said.

“To me, they’re clarifying the definitions because they’ve seen people not consistently reporting those roles,” he explained. “There’s very specific rules around those roles. This is probably their first step toward that next wave of: ‘Let’s get data for these things.'”

Written by Maggie Flynn

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