The Centers for Medicare & Medicaid Services (CMS) on Wednesday issued updated guidance for nursing home surveyors under the requirements of participation for Medicare and Medicaid, and in support of nursing home reform initiatives first unveiled in February.
As providers and industry associations digested the updates, one familiar theme emerged: concern over new requirements and regulatory pressures at a time when the sector is still facing Covid-related challenges and a labor crisis.
Staffing and infection control are among the main areas of focus in the CMS guidance.
For example, CMS aims to bolster staffing levels by adding use of the Payroll Based Journal staffing data for inspections, the agency said in a memo.
CMS said this would help identify potential noncompliance with the agency’s staffing requirements, including the lack of a registered nurse for eight hours each day, or lack of licensed nursing 24 hours.
Such measures dovetail with nursing home reform efforts already launched by the Biden administration.
“In announcing this [update], CMS connects this with the President’s initiative to promote safety and quality and notes that it is putting this requirement into place while minimum nurse staffing requirement ‘rulemaking is underway,’” Cynthia Morton, executive vice president of the National Association for the Support of Long Term Care (NASL), noted to Skilled Nursing News.
CMS has said little publicly about the status of its regulatory plan to study staffing ratios, other than a desire to finish the study in a year – what Morton considers to be a very rapid timetable. And operators such as Vivage Senior Living echo her concerns.
“I don’t think CMS gets what we’re going through right now,” said Jay Moskowitz, CEO of Vivage Senior Living. “We can’t afford to get the amount of nurses that we need. It’s like they made us a target and continue to make us a target.”
Vivage operates facilities across Colorado, Missouri and Nevada.
Nate Schema, president and CEO of The Evangelical Lutheran Good Samaritan Society, said said in a statement that the organization would love to hire more caregivers, but they cannot find enough applicants to fill their current needs.
“Seventy percent of our nursing home residents live in rural communities across the country. The workforce crisis we are experiencing right now cannot be overstated,” added Schema. “Recruitment is even more challenging in rural areas.”
The American Health Care Association (AHCA) is still reviewing updated CMS guidance, the association’s chief medical officer, Dr. David Gifford, told Skilled Nursing News in a prepared statement.
“We appreciate CMS providing an extended effective date for these changes to allow surveyors and providers time to prepare. We will continue to advocate for resources to help providers make meaningful changes that benefit the safety and wellbeing of our residents,” added Gifford.
Gifford refers to a timeframe provided by CMS – surveyors and providers have until Oct. 24 before the guidelines go into effect.
LeadingAge, which represents more than 5,000 nonprofits in the long-term care space, said it shares the Biden Administration’s goal of access to quality nursing home care – but CMS’ “additional pile-on” of regulations will strain already-stretched providers.
“The sector is finding its footing after years of COVID-induced financial stress and workforce challenges,” Katie Smith Sloan, president and CEO of LeadingAge, said in a statement. “We all know that staffing goes hand-in-hand with quality care, and our mission-driven members are working valiantly to stay compliant. But we continue to urge the administration to back its words of commitment to ensuring older adults’ access to care with meaningful action and funding.”
The CMS guidance was expected; they are the third phase in implementing requirements of participation that were updated in 2016. But while this timing might not be ideal for many operators, organizations are ready to tap into their “resiliency” to manage through these changes.
“We look forward to more information from AHCA and from CMS regarding the topic,” said Wanda Prince, chief strategy officer for Brickyard Healthcare in Indiana. “Like so many others in our industry, we’re resilient, we’re strong, we care about our patients and residents in this industry that we’re blessed to serve.”
Prince added that her team will take advantage of updates to CMS’ surveyor training and education website, due to come through in September, working through education sessions offered by CMS as the operator anticipates more information coming from different resources.
Infection control in the spotlight
The agency is doubling down on its call to reduce room crowding at this point in the pandemic as well, with all the lessons learned in the last three years – a maximum of double occupancy in each room, while encouraging operators to find a way to allow for more single occupancy rooms.
While there is no new regulation related to resident room capacity, the update highlights infection prevention benefits of reducing the number of residents in each room, along with making sure residents have access to a private, homelike environment.
In the same vein, CMS is also requiring facilities to have an infection preventionist (IP) to oversee its infection prevention and control program. This is in accordance with Biden’s campaign commitment to have sufficient on-site IPs.
Behavioral health elements
CMS aims to improve its guidance for mental health and substance abuse disorders using its Behavioral Health Strategy in order to meet the “unique needs of LTC facility residents,” according to the memo.
Updated mental health guidance will address situations where practitioners or operators inaccurately diagnose a resident with schizophrenia, CMS noted. Coupled with misdiagnoses, new guidance aims to tackle unnecessary use of non-psychotropic drugs and antipsychotics while promoting gradual dose reduction.
“As the COVID-19 pandemic highlighted, we have a pressing moral responsibility to ensure that residents of long-term care facilities are treated with the respect and dignity they deserve,” said CMS Administrator Chiquita Brooks-LaSure. “CMS is proud to be leading President Biden’s initiative to improve the safety and quality of care in the nation’s nursing homes, and this set of improvements is our next step toward that goal.”
A wide-ranging update
The Phase 3 requirements are wide-ranging, and in addition to the elements described above, include a variety of measures that providers will have to review in the coming weeks and months. Among the “significant changes” flagged by CMS:
- Clarifies requirement related to facility-initiated discharges
- Clarification on compliance requirements tied to arbitration agreements
- Clarifies the “reasonable person concept,” severity levels for deficiencies within the psychosocial outcome severity guide
- Timeliness of state investigations and communication of complainants to improve across state lines
- Guidance related to Covid-19-related visitation from CMS memos all in one place, with changes for clarity and technical corrections
The agency will also ensure timely investigations into abuse and neglect reports, as the Government Accountability Office (GAO) found tracking and processing such reports was slow.
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