Beyond minimum staffing requirements, operators may need to prepare for updated assessment requirements, which leaders say will be a “core” aspect of the mandate, along with the 24-hour registered nurse (RN) requirement.
And these assessment requirements have increased, resulting in criticism from industry experts on both their value and the added burdens that these might create.
“While we propose to require all LTC facilities (subject to exemptions) to comply with the minimum nursing staffing requirements, … those minimum standards are only the beginning,” the Centers for Medicare & Medicaid Services (CMS) wrote in the mandate proposal.
CMS wants nursing homes to go beyond meeting the minimum staffing thresholds, to appropriately staffing for the needs of their resident population, including their acuity levels, cultural and clinical needs.
In the proposal, CMS writes that facilities need to use “evidence-based, data-driven methods” that consider the types of diseases, conditions, physical and behavioral health issues, cognitive disabilities, overall acuity, and other pertinent facts that are present within the resident population that they serve, with an increased focus on behavioral health needs.
There is also a call for more involvement from direct-care staff and other stakeholders for the assessments. Moreover, the federal agency wants to see more transparency into how particular shifts or units are staffed.
Lastly, there is a push for nursing homes to use their facility assessment to develop and maintain a staffing plan to maximize recruitment and retention of staff.
“We believe that our staffing proposals are balanced and achievable,” CMS’ chief medical officer Dora Hughes said. “They would help advance safe quality care for residents, while also striking an appropriate balance that considers the current challenges some nursing homes are experiencing particularly in rural areas.”
CMS’ proposed staffing mandate calls for Medicare and Medicaid-certified nursing homes to provide a staffing equivalent of 3 hours per resident per day (PRPD), with 0.55 hours of care from registered nurses (RNs) and 2.45 hours of care from certified nursing assistants (CNAs).
LeadingAge, the largest advocacy group for nonprofits, expressed concerns about the assessment criteria.
“Ultimately, CMS proposes that the Facility Assessment will be used to determine additional staffing that may be required beyond the minimum HPRD standards to satisfy requirements for sufficient staffing,” LeadingAge told SNN in an email.
In particular, LeadingAge is critical of the input from labor unions. “LeadingAge does not support inclusion of external third parties such as labor union representatives in development of the Facility Assessment. We recognize the rights of workers to have third party representation and the importance of being able to communicate directly about facility conditions. Concerns such as these should be heeded and addressed by the nursing home. However, the Facility Assessment is an operational document and inclusion of outside parties in the development of such a document is neither appropriate nor efficient.”
The advocacy group added that conversations between the nursing home and third party representatives may have appropriate influence over aspects of the Facility Assessment such as a staffing plan, but these conversations should be separate from the nursing home’s procedures for developing staffing plans.
Historical context of the assessment
Sara Deiter, VP of Consulting with Health Dimensions Group, said the roots of the facility assessment can be traced back to the imperative need for emergency preparedness.
The original concept aimed to ensure that every nursing home had a well-defined plan for handling emergencies, a vital aspect of resident care. However, the scope expanded significantly during the Covid-19 pandemic, where the focus shifted to preparing for emergency staffing needs during infectious outbreaks.
Experts emphasized that the facility assessment, now proposed with enhancements, had gradually transformed from a periodic, annual process into a dynamic, day-to-day evaluation of residents and staffing needs. This evolution became particularly pronounced during events like the Covid-19 pandemic, where the industry needed to respond swiftly to ensure adequate care for residents in the face of rapidly changing circumstances.
The facility assessment, initially conceived as a strategic emergency preparedness measure, had evolved into a tool for daily decision-making, reflecting the industry’s adaptability in addressing unforeseen challenges.
“The idea was, every building needs to have a plan for being emergency prepared,” she said. “During Covid, it got to be that we needed to have plans and preparations for emergency staffing around infections. And there was a time when [operators had to get] everybody out, because everybody’s sick, [and had to ask the questions of] how are you going to still manage residents who are in the building?”
Deiter noted that the long-term care workforce had been drained over the past few years, with burnout and wage competition reaching critical levels.
The industry is struggling to meet existing staffing requirements, Deiter said. And so, coupled with CMS’s call for an increase in standards, and the estimated need for 60,000 new nurses, the situation poses a significant hurdle, especially with challenges in nursing school admissions.
In terms of the increased focus on assessments included in the mandate, operators need to be checking on how many staff are needed in each of their facilities and what their competencies need to be, Deiter said.
“I’ve been advising clients about this,” she said. “I’ve said, ‘Did you have your morning meeting? Who did we admit yesterday? Are there any additional needs that having that person in the building might expose? Does it change what’s needed in terms of staffing? And how does it affect the competency level of our staff?’”
Administrative burdens on facilities
Leah Klusch, executive director of the Alliance Training Center, raised concerns about the administrative burden on facilities seeking exemptions from the enhanced assessments proposed by CMS, especially in rural settings with limited resources.
“Whether it’s rural or urban, we have more nurses per square foot in urban areas,” she said. “That’s very true. But we still don’t have enough nurses in total, to fill all these positions. And one of the things that’s happening in nursing education is that they’re having trouble filling their classes, because nursing is such hard work. There are various dynamics in nursing education right now that are working against some of these issues that they’re proposing.”
Having been involved in the industry since the 1960s, Klusch highlighted the evolving nature of nursing tiers, including RNs with collegiate degrees and the increasing demand for advanced skills due to rising acuity levels. She discussed the challenges faced by RNs who may lack specific geriatric training, emphasizing the valuable contributions of licensed practical nurses (LPNs) with years of experience in post-acute care.
Klusch criticized the focus of CMS on RNs and nurse aides in the proposed policy, neglecting the diverse roles and skills within the interdisciplinary team. She contested CMS’ assertion that the presence of LPNs did not lead to improved care, citing her extensive experience witnessing proficient LPNs working under RN supervision.
“I am offended by the fact that they don’t want to identify the LPN as an important part of this,” she said. “Post-acute care is getting higher acuity in a lot of our facilities, but we still have that group of elders who are in the facilities who do not need high acuity care, they need good, basic care and they need support, and many of them need dietary support and social service support.”
Klusch emphasized the need for clarity in communication between oversight and survey processes, expressing apprehension about potential distractions caused by increased scrutiny.
“I don’t see a very clear description of the communication that is going to occur between oversight and survey, and exactly how that’s going to feed into the outcomes,” she said. “Additional oversight [could create] additional burdens for facilities that are already having issues keeping everything compliant and keeping everything moving, so that’s going to be another distraction.”
Klusch also discussed the importance of evidence-based data-driven methods in facility assessments, noting the lack of specificity in CMS’s requirements. She praised good nursing homes for already implementing practices such as customer satisfaction surveys and emphasized the need for CMS to recognize existing systems that contribute to evidence-based information.
In response to potential operational changes, Klusch highlighted the proactive approach of quality-focused facilities in monitoring and improving their outcomes.
“[Effective operators] are looking at their quality measures, and they’re constantly monitoring their MDS data, to make sure that they aren’t making any mistakes,” she said.
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