CMS’s Regulatory Delay: What’s In, What’s Out, and Why Nursing Homes Could ‘Substantially’ Reduce Costs

Skilled nursing facilities could see relief from regulatory burdens if a proposed rule from the Centers for Medicare & Medicaid Services (CMS) takes effect, and according to the agency, it could lead to millions in savings.

Specifically, the rule would overhaul multiple requirements and delay the implementation of regulations related to the Quality Assurance and Performance Improvement (QAPI) program, as well as compliance and ethics program requirements — both parts of Phase 3 of the Requirements of Participation (RoPs), which were initially slated to take effect in November of this year.

“The immediate effects of these proposed reforms will benefit nursing facilities by reducing their costs, in some cases quite substantially,” the agency said in the proposed rule.


CMS estimated in the proposed rule that the changes would lead to savings of almost $644 million a year over the first five years the rule was in effect, in part because of certain Life Safety Code savings that would only be achieved in those first five years. The LSC is a set of fire protection requirements that covers construction, protection and operational features aimed at fire safety.

Under the proposed rule, CMS floated a range of revisions to the LTC RoPs, designed to streamline the current requirements and increase provider flexibility. Because of the changes, the agency would partially postpone their implementation, citing the desire to avoid making providers implement provisions that are potentially destined for revision.

“We understand potential concerns regarding further delaying the implementation of the QAPI and compliance and ethics requirements, as these provisions were required to be implemented by statute in 2012 and 2013 respectively,” CMS wrote in the rule. “However, we believe that moving forward with implementing these provisions in November 2019, only to implement significant revisions to the provisions proposed in this rule, would create significant additional work and confusion for the nursing home community.”


The changes in the proposed rule affect provisions in three primary areas: the designation and training of the infection preventionist (IP), the QAPI program, and the compliance and ethics program; CMS does not propose delays related to the infection preventionist.

The Glendale, Wis.-based North Shore Healthcare, which has more than 40 SNFs in the states of Wisconsin, Minnesota, and North Dakota, is still reviewing the ins and outs of the 110-page proposed rule. But on a first look, the provider sees the changes as a chance to spend more time on direct resident care, chief clinical officer Dee McCarthy told Skilled Nursing News.

“The things they seem to have targeted actually allow us to spend more time on resident care, and less time on completing paperwork that really doesn’t do anything to keep our residents safer or healthier or actually improve quality in the long run,” she said.

Some of the revisions that will help reduce administrative burden include requiring operators to only send “facility-initiated involuntary transfers and discharges” to state long-term care ombudsmen, the reduction of the timeframe that facilities have to retain posted daily nurse staffing data, and revision of the informal dispute resolution process to be more timely, McCarthy told SNN.

The IP, by contrast, is an example of an RoP that needs to be implemented, as “having that in a facility is very important,” she explained. But CMS did propose a change that will be a help to providers amid the country-wide labor crunch, McCarthy noted: that position no longer has to work “part-time” at a facility or have frequent contact with the facility’s infection prevention and control program staff.

Instead, CMS is going to require that facilities “ensure that the IP has sufficient time at the facility to meet the objectives of its infection prevention and control program.”

That’s a help, particularly for smaller facilities, where someone such as a director of nursing (DON) might also serve as an IP, McCarthy said. While the requirements for infection control still have to be met by November of this year, under the proposed rule, facilities wouldn’t have to dedicate an entire staffer to the role of IP.

In another boost to small facilities, CMS proposed eliminating a requirement that all chains with five or more buildings designate a compliance officer and compliance liaison.

“Instead, we would propose that such organizations develop a compliance and ethics program that is appropriate for the complexity of the organization and its facilities, and that each facility assign a specific individual within the high-level personnel of the operating organization with the overall responsibility to oversee compliance,” the agency said in the rule.

CMS also proposed removing the annual review requirement and instead would require that each organization conduct a periodic assessment of its compliance program to identify necessary changes.

When it comes to the QAPI program, CMS’s proposed revisions are intended to give facilities more flexibility, though SNFs will still have to document and demonstrate evidence of their QAPI programs, present the initial and subsequent plans as required in surveys and to CMS, and document the program’s implementation.

But the agency is proposing to streamline the rules for the QAPI program’s design and scope to include only the text requiring that the program “be ongoing, comprehensive, and address the full range of care and services provided by the facility” — while more detailed requirements would be removed.

Other proposed revisions to the QAPI requirements include trimming the regulations related to program feedback, data systems, and monitoring, and the requirements for program systematic analysis and systematic action.

“We believe that these proposed revisions recognize the diversity throughout LTC facilities and would reduce burden on facilities by allowing facilities greater flexibility in tailoring their QAPI programs to the specific needs of the facility,” CMS said in the proposed rule.

Provider groups representing nursing homes were optimistic about the proposed rule’s reduction of paperwork and administrative burdens.

“We have pointed out to CMS that requiring nursing homes to designate specific staff as compliance officers, compliance liaisons, and grievance officers would take valuable staff time away from caring for residents, and we appreciate CMS’s agreement on this point,” LeadingAge president and CEO Katie Smith Sloan said in a statement on the proposed rule issued on Wednesday.

The American Health Care Association, another nursing home trade group, agreed.

“More regulations are not the way to incentivize quality improvement,” David Gifford, senior vice president of quality and regulatory affairs and chief medical officer at AHCA said in a statement. “This rule recognizes that more paperwork and administrative requirements takes time away from nurses who want to spend more time at the bedside.”

For McCarthy, the proposed changes are encouraging for providers.

“It really does reflect that they’re trying to give us a break on some of this stuff,” she told SNN. “And this stuff is not common sense. Some of it is just paperwork.”

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