4 Nursing Home Compliance Issues to Watch in 2022 and Beyond

While the nursing home industry has been struck with headlining reforms and looming mandates set to shake the whole sector, some compliance issues have largely flown under the radar for operators.

Compliance surrounding trauma-informed care and care quality metrics, such as unplanned weight loss, loss of mobility and pressure injuries, are all still important areas that the Centers for Medicare & Medicaid Services (CMS) and the Biden administration are looking into, experts caution. What’s more, government watchdogs are acting with a new, targeted approach to assessing such areas.

When day-to-day issues aren’t acted upon early or addressed in small but consistent ways, they snowball into bigger problems. That could mean abuse and neglect complaints, according to Trish Richardson, director of post-acute care solutions at Relias.

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But it’s hard to keep up with the day-to-day when major reform initiatives and changes to quality reporting are unveiled by the Biden administration and CMS, she said.

“Industry executives, clients and prospects that I talk to every day are saying … they feel this intense pressure to perform, when they have been stressed with all of these concerns that have been coming out,” Richardson told Skilled Nursing News.

A new, targeted approach to assessing compliance was issued in a CMS bulletin back in November. The agency sought to get caught up on a backlog of complaint and recertification surveys, along with reopening visitation as the industry was battling the delta variant of Covid-19.

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“They want to get back to business as usual, get back to the standard recertification and the surveys that they’re used to doing, but it is a blend,” added Richardson. “They are also looking for those that historically have not performed well.”

Coupled with day-to-day compliance issues are seemingly small regulatory updates; these are actually far more wide-ranging for operators. One such update detailed in CMS’ rules of participation – trauma-informed, culturally competent care – needs to be incorporated into policies and procedures complete with education programs for staff.

“You really need a team to work on this. It’s going to involve your facility assessment. It’s going to involve looking at your policies. It’s going to be looking at your environment as well,” Amy Stewart, vice president of education and certification strategy for the American Association of Post-Acute Care Nursing (AAPACN), told SNN. “Trauma-informed care is really unique and probably one of the regulations that might require the most work for people because it might require the most changes.”

Such care updates may have flown under the radar compared to other rules of participation updates involving infection prevention, incorporating Payroll Based Journal (PBJ) staffing data into surveys and updating behavioral health protocols. Rules updates largely dovetailed with nursing home reform efforts launched by the Biden administration in February.

Drilling down to quality

Care quality focus revolves around areas CMS feels it hasn’t had the proper insight into or oversight of during the pandemic, Richardson said.

Three of the biggest care quality areas are all issues that often go under the radar because they worsen slowly: unplanned weight loss, loss of mobility and pressure injuries, for example.

Behind infection control cited 23% of the time, 18.6% of nursing homes are receiving F-tags for accidents, according to Sara Deiter, vice president of consulting services for Health Dimensions Group.

About 10.2% of nursing homes are getting cited for pressure ulcers and 11.5% for quality of care in general, she added.

General quality of care citations also include activities of daily living (ADL) care, Deiter said. That term is used to collectively describe skills needed to independently take care of oneself, like eating, bathing and mobility.

“We are really pushing our SNFs to know where they are challenged, have a plan and work it,” Deiter continued. “The surveyors know about our staffing challenges and are showing no mercy in that regard.”

Sustaining quality of care in an agency-heavy environment is just one of a few “nonstop” compliance challenges faced by nursing homes, added Deiter.

Such issues aren’t going unnoticed by administrators or directors of nursing (DONs), per se, but may not be top of mind when a facility is simply trying to stay open, or leaders are trying to keep staff engaged.

At this point in the pandemic and despite staffing woes, Richardson said, it’s a good idea for facility leadership to get back to basics. That means reassessing current compliance practices to pinpoint vulnerabilities and strengths.

“You’ve got a situation that is just ripe for a moment of pause,” she said. “When you don’t have the time, you don’t have the bandwidth to address [day-to-day issues], those are the things that get missed – unintentionally missed. We’ve got to take a moment … just a moment of self reflection.”

Rolled up in care quality is paying attention to administrator and DON turnover, she added, as longer tenured leadership does support a more stable workforce and in turn improves care quality and staff engagement.

Trauma-informed, culturally competent care

As part of updated rules of participation in Medicare and Medicaid, a relatively small change could have huge implications for the industry because of its widespread implementation: trauma-informed care.

The rules update defines trauma-informed care as an approach for delivering care that involves an understanding, recognizing and responding to the effects of all types of trauma, according to CMS.

A trauma-informed approach to care delivery in the nursing home recognizes a “widespread impact” on day-to-day operations, and the incorporation of the trauma-informed lens into care plans, policies, procedures and practices to avoid retraumatization.

Culturally competent care means caregivers can interact with residents whose culture differs from their own, CMS said in its update. A resident’s care plan must reflect the needs and preferences of the resident, and align with that resident’s cultural identity.

“It is policies, yes, but also process and education and then monitoring for the effectiveness of … a trauma-informed organization. You also have to monitor it, and that’s true for a lot of other regulation,” Stewart said.

Direct caregivers need to know if residents are trauma survivors and what their triggers are, so that they can adequately care plan to avoid those triggers in the future, she explained.

Stewart isn’t sure leadership has really thought about trauma-informed care and how much it affects operations, with attention being pulled in so many other directions.

While the industry knew such changes were coming in the Phase 3 rules update, Stewart said many organizations had to put a pin in trauma-informed care incorporation when the pandemic hit.

But it’s also a reason why nursing homes must focus on it now.

“The social isolation could be so significant that they could have long-lasting effects from this. It’s even more important now to ensure that you have this culture and that you have a method of screening people not just at admission, but when something happens in their life or at regular intervals,” added Stewart.

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