As the long-term care industry comes to terms with the nursing home staffing mandate, there are many factors for operators to consider as they plan for the coming years.

The final rule on staffing, which has been received with harsh criticism from the industry, establishes updates to facility assessment standards on top of the minimum staffing requirement of 3.48 hours per resident per day (HPRD), including 0.55 HPRD of direct RN care and 2.45 HPRD of direct nurse aide care.

Changes to facility assessments – unlike the other requirements in the final rule that are years away from implementation – will go into effect on August 9th, 90 days from official publication date, which is scheduled for May 10th. These changes will need to be implemented on this timeline regardless of whether a facility is rural or urban.

“That means that SNFs have just a few short months to revise their policies and procedures to incorporate the new facility assessment requirements, which include how the assessment is used to inform staffing decisions, requirements for active participation by certain individuals and use of acuity-based process for staffing,” Brian Ellsworth, VP of Public Policy & Payment Transformation at Health Dimensions Group, told Skilled Nursing News (SNN).

CMS already mandates skilled nursing facilities conduct and document an annual facility-wide assessment, considering factors such as resident acuity and care needs. The updated policy adds to this requirement by stipulating that facilities must use evidence-based methods when planning care for their residents, including consideration for those residents with behavioral health needs — and linking that data to staffing.

What the changes mean

According to CMS, operators must use the facility assessment to assess the specific needs of each resident in the facility and to adjust staffing as necessary based on any significant changes in the resident population. And they need to include the larger parts of the nursing home staff and community into the process.

“Facilities must include the input of the nursing home leadership, including but not limited to, a member of the governing body and the medical director; management, including but not limited to, an administrator and the director of nursing; and direct care staff, including but not limited to, RNs, LPNs/LVNs, and NAs, and representatives of direct care staff as applicable,” CMS wrote in the rule. “The LTC facility must also solicit and consider input received from residents, resident representatives, and family members.”

By early August, facilities are also required to develop a staffing plan to maximize recruitment and retention of staff. Yet some operators say the mandate and added requirements will be untenable for facilities.

“Delivering quality care is not a numbers game,” Nate Schema, president and CEO, Good Samaritan Society told SNN, adding that Good Samaritan Society already uses a team-based approach to determine staffing levels based on caregiver experience, training and resident health needs.

There are simply not enough caregivers in rural America to meet the final minimum staffing requirements, Schema said.

“[The mandate] will force rural nursing homes to close their doors when they can’t meet the minimum staffing requirements, taking our nation’s seniors away from their loved ones, and the lives they know,” he said.

Adam Berman, CEO of Legacy Lifecare, which provides administrative and operational support to nonprofit facilities across New England, said the facility assessment rules won’t impact the operator he works with much – since they already have a very hands-on approach to staffing. But he is worried that without substantial investment in training new RNs, the RN requirements of the mandate may be infeasible.

“We anxiously await further clarification about the roll-out,” he said.

Acuity-based staffing

Some of the new requirements, such as developing and maintaining a recruitment and retention plan for direct care staff, are simply good business practices that should already be underway but now will need to be documented, Ellsworth said.

“SNFs will need to understand all of the new requirements and make sure that the annual facility assessment is compliant,” he said.

Yet acuity-based staffing will require management of information flowing from resident assessments – and turning that into actionable staffing levels could add to burdens, he added.

“Depending on how CMS chooses to enforce this new requirement, it could be a compliance challenge for those providers that have been preoccupied with simply finding any staff, let alone benchmarking staffing to acuity levels,” he said. “Fortunately, there are solutions out there and facilities will need to consider those in coming weeks and months.”

During CMS’ stakeholder call this week, Jean Moody-Williams, deputy center director at CMS’ Center for Clinical Standards and Quality, said a template on how to do the facility assessment will be published soon.

“Additional information will be coming out as we work with our quality safety and oversight group and our survey and oversight group on that matter,” Moody-Williams said.

Effective implementation of the new CMS staffing standards hinges on the agency’s enforcement approach and the yet-to-be-determined penalties, Ellsworth said.

Regardless, facilities will need to assess their current staffing practices, particularly in terms of evidence-based decision-making and resident acuity considerations. This includes evaluating access to electronic medical record (EMR) systems, manual acuity-based staffing methods, and revisiting policies and procedures to align with the new requirements.

“Some facilities have a stable population, while others have highly variable acuity levels, so they’ll need to decide how often to update their staffing,” Ellsworth said. “The new rules imply that the facility assessment must include a plan for how staffing needs are assessed at the unit level and by shift.”

Challenges greatest for mid-size chains

While technology solutions exist to help operators collect more resident data, mid-sized facilities face challenges in determining suitable solutions, Ellsworth said.

“Larger chain facilities may have a technology solution, while smaller facilities may do it by hand,” Ellsworth said. “The real issue is for facilities in the middle—what solution will they choose, and how will they adjust their policies and procedures to ensure they’re getting input from various sources? The meaningfulness of this process depends on where CMS lands on this.”

Leah Klusch, executive director of the Alliance Training Center, said that now that the facility assessment is more specifically tied to staffing, it further complicates the process for facilities.

“Along with everything else that is changing, if you’re sitting in an operational leadership role or clinical leadership role in a facility, and you’re dealing with the regulatory process, now you’re also dealing with staffing parameters that are next to impossible in many areas,” she said.

Enhanced data on facility assessments, coupled with updated compliance guidelines put out by the Office of the Inspector General, creates a litany of expanded requirements for operators to prepare for beyond the regulatory tags in State Operations Manual.

“We’re also looking at the payment rule, changes in quality measures, and significant data changes on the MDS,” she said. “Any one of those things is enough to dominate the thought process of facility management.”