PBJ Data Use in Surveys Serves as ‘Breadcrumbs’ to Looming Federal Staffing Mandate

The Biden administration, and its federal agencies, appear to be in lockstep in how they have been thinking and talking about nursing homes, industry leaders say, further evidenced by the latest release on the rules of participation for Medicare and Medicaid.

Specifically concerning the administration’s efforts to establish a minimum staffing ratio among facilities, the recently released guidance gives operators and advocacy groups a glimpse into agency efforts toward that end.

The Centers for Medicare & Medicaid Services (CMS) as part of its June 29 updates said Payroll-Based Journal staffing data will be used for inspections effective on Oct. 24.

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PBJ usage will help surveyors identify potential noncompliance with agency staffing requirements, CMS said, including the lack of a registered nurse for eight hours each day or a lack of licensed nursing for 24 hours.

“For the first time ever, surveyors have objective staffing data in front of them, and they’re going to use it to probe and ask staff very poignant questions about specific days when they were working and frankly, I think that’s a game changer,” said Steven Littlehale, chief innovation officer for Zimmet Healthcare Services Group.

CMS will have a lot of staffing data, a lot of ammunition to ask very specific, directed questions about day-to-day operations, he said. As a result, nursing homes aren’t going to fare too well in terms of avoiding existing citations tied to sufficient staffing.

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“How sufficient staffing was interpreted in the past is being reinterpreted – it’s data-driven. It’s not quite minimum staffing [ratios] yet but it feels like it’s one step before,” added Littlehale.

Cynthia Morton, executive vice president of the National Association for the Support of Long Term Care (NASL) sees the PBJ updates as “breadcrumbs,” indications of what CMS is working toward in terms of minimum staffing requirements.

Little is known about what the staffing requirement might look like in its final form. CMS is expected to conduct a study to determine the level and type of staffing needed and propose a new standard within one year.

“We should be hearing about where the administration is going to go … this memo shows at least one piece. They’re going to use tools that they already have, like the PBJ data,” Morton said. “This is just one of our first tangibles about how they’re going to use tools that are available to them.”

The change also runs in tandem with five-star staffing measures announced in January that are due to be implemented this month.

CMS is adding three staffing turnover measures as part of its rating system – the percentage of registered nurses that have left over a year’s time frame; the total number of nurses that have left over the year, including RNs, licensed practical nurses (LPNs) and nursing assistants; and the percentage of administrator turnover.

Weekend staffing data will also be part of the five-star system updates, per updates published late last week.

“We’ve gotten no ramp at all, no headway on this, which is in and of itself portraying a picture about how CMS really thinks about providers,” Littlehale said. “Yes, this is supposed to be for consumers, but it’s firing directly at providers and not giving them a heads up.”

Littlehale believes the data will allow for more consistent and predictable assessments of staff sufficiency, although it’s hard to imagine that surveyors weren’t already accessing PBJ data as the system was introduced five years ago.

Data during a staffing crisis

PBJ staffing data reporting, surveyor updates and five-star implementations are all contending with the “elephant in the room,” Littlehale said, referring to the labor shortage.

The timing, he said, was “just awful” and the administration could do better in more directly acknowledging the staffing crisis and approaching this challenge to the industry more realistically.

“It’s CMS’ role to make the rules, enforce the rules and it’s the administration’s prerogative, of course, to focus on staffing,” said Morton. “But, if we’re going to have success in this area … there’s going to have to be a little give because we can’t force people to come into the sector.”

Morton isn’t sure when that give might be, or if the administration and CMS will continue to put pressure on the industry for the foreseeable future.

A lot of “thoughtful recommendations” which acknowledge the staffing crisis while helping solve the present issues can be found in the National Academies of Sciences, Engineering and Medicine (NASEM) report on nursing homes, according to Morton.

Financial support too will take more than just “finding coins in the sofa,” Morton said. It will take an initiative by Congress, however, the opposite seems to be happening with CMS poised to take more money away from the industry in the form of a 4.6% cut related to the Patient Driven Payment Model (PDPM).

“The agency is really in a posture of taking funds away from the industry. I think the good thing here is, [staffing] is a high priority of [the Department of Health and Human Services (HHS)], you know, the president mentioned it in the State of the Union. When you’re a high priority, that’s a good thing,” added Morton.

Existing staffing data

About 14% of nursing homes already receive citations for insufficient staffing, according to Littlehale, what is known as an F-725 tag.

Still, that doesn’t mean nursing homes are missing the mark, he added. There’s a “tremendous” amount of inconsistency in how surveyors use that F-tag, according to Littlehale.

“Though the national average is 14%, not every state is 14%. Some are much much higher, some are much much less,” noted Littlehale. “That makes me think that it’s not that facilities are consistently meeting the standard; surveyors are not consistent with how they apply the standards.”

The F-851 tag, also tied to the guidance update, will be added. Such a citation would be given if a facility fails to submit staffing data through the PBJ.

Updated CMS guidance outlines exactly how surveyors will be instructed and educated to assess staffing moving forward; it’s a path toward more consistency and common ground between operators and surveyors, according to Littlehale.

Surveyors will be prompted to ask questions of direct care staff and the director of nursing (DON) or administrator, if the surveyor is made aware of absences in licensed nursing staff in a 24-hour period.

Based on surveyor questions, there’s an expectation on the part of CMS that the DON assist and monitor all certified nursing assistants (CNAs) in the building – in reality, this role is oftentimes bogged down with corporate meetings.

The DONs could be in another part of the building, or in care planning meetings, not necessarily supervising aides at all times, he said. Pointed surveyor questions will expose an inconvenient truth – that the DON cannot possibly supervise care and be in and out of meetings all day.

“When you push a little bit, facilities will often say that they staff based on their budget, and not on their casemix and that’s a significant problem,” added Littlehale. “You’ve got a tool that tells you who you need and if there’s a disconnect between what this document says you are to provide and what you’re actually providing … that’s a very distinct problem, and you will most certainly be cited for that.”

Echoing Littlehale’s thoughts, Morton expects PBJ data utilization to result in more F-tags. It’s also an indication of how important sufficient staffing is to the Biden administration – CMS is adding these duties to surveyor requirements.

“It’s another breadcrumb, you know, the administration is definitely telling us operators, staffing matters significantly to us and so we’re going to measure you on that any way we can,” Morton said.

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