‘A Very Large Task’: CMS’ Facility Assessment Arduous For Some Nursing Homes Amid Cost Pressures, Staffing Shortages

The new facility assessment requirements that federal agencies are expecting will guide decisions on staffing levels are also garnering concerns about potential administrative and financial burdens, particularly for smaller-sized nursing home chains.

The Centers for Medicare & Medicaid Services (CMS) modified the existing requirements in late June, issuing expanded guidance to include metrics that are collected through “evidenced-based and data-driven approaches” and that also mandate additional information on the behavioral health of residents at facilities, among other changes. 

These guidelines have been a cause for worry for some — mostly small- to mid-sized chains — in the sector. But now, one thing that both larger and smaller operators agree upon with the latest changes is the evolving nature of the guidelines for which they will need to be on their toes.


Leah Klusch, executive director of The Alliance Training Center, who advises nursing home operators across the country, said that while there is no rush nor panic attached to fulfilling the facility assessment requirements come August 8, when these kick in, the requirements are, nevertheless, an added burden at a time when nursing home operators are still reeling from staffing shortages, high operating costs and inflationary pressures.

Meanwhile, the level of specificity and detail being required by CMS will certainly add to administrative and financial burdens, she said.

“This is building specific, so you can’t just go online and find a good facility assessment template and say, ‘Well, we’re very similar to the platform that this template was written on, and so we’re just going to download that,’” Klusch told Skilled Nursing News. It simply is not that easy, she said.


Given the detail and specificity based on each facility’s shifting demographics, working with a set template might work for larger corporate-owned nursing home chains, but it’s not an optimal approach for all operators.

“The requirements are just really, really shifting,” she said. “Every building has its own demographic.”

For larger operators, however, the transition to completing the more expanded requirements for facility assessments hasn’t been too bad, partly due to the use of existing technologies – and the ability to devote extra resources to the task.

Steve LaForte, director of corporate affairs and general counsel at Cascadia Healthcare, told SNN that at his organization, such a technology-based program has been updated to incorporate CMS’ new guidance.

“We have been, and are adapting, to the new guidance,” said LaForte, adding that Cascadia uses an online quality management program designed for long-term care facilities and rehabilitation centers.

“All in all, until we get actual feedback on some of the open areas from surveyors, this has not been a huge lift for us,” he said.

Based in Eagle, Idaho, Cascadia provides care for over 1,800 residents in more than 35 skilled nursing facilities, 2 assisted living facilities and multiple home health & hospice agencies across 6 states.

Technology-based solutions

Use of such technology can come at quite a cost, which smaller operators are unable to afford, Klusch explained.

Moreover, the assessment is a time consuming job to establish and maintain, she noted, because it requires collaboration from across a spectrum of clinical specialities and roles at a facility. At smaller operators, this is causing tremendous hardship amid ongoing staffing shortages and other operational pressures, she said.

“You have a significant increase in the sophistication of the data that should be looked at. So that’s taken us to a higher level of analytics. And then, there’s a rather lengthy list of [involvement from] different people, practically everybody on your resident care side, admissions, MDS people, nurse managers, ADL needs and rehab staff, nurses and nutritional aides, and families. And now they have behavioral needs added,” she said.

To top that, the data has to be analyzed and correlated to staffing needs, she said.

Facilities must now use the assessments to inform staffing decisions, while considering specific needs for each shift. They must develop, maintain and maximize recruitment and retention, and use the information for contingency planning.

“[Now] a surveyor could ask a director of nursing [DON], ‘How did you use the facility assessment information from your immediate facility assessment to make staffing decisions?’” she said.

And so, the rigorous analytical evaluation the new guidelines require may necessitate specialized software, which many facilities struggle to afford, she said.

And aside from technical support through vendors of such technology, dedicated in-house roles can prove helpful, Klusch said. However, the staffing shortages make assigning someone that task is yet another impossible feat, especially at smaller operators, she said.

And LaForte agrees.

“We are lucky in that we have a dedicated director of quality and integrity … who is leading the oversight of this compliance for our facilities.”

But whether all nursing homes are generally clear and up to speed on how to conduct the facility assessments, is another matter.

“There are certain tools that can assist and allow all facilities access to guidance, including the Critical Element Pathways, which are available to all facilities. However, to some extent this is another example of paperwork over people, and will likely place a heavier burden on smaller operators with less resources, whether financial or staff,” LaForte said.

‘A very large task’

And while larger operators are able to use external vendors to put together the facility assessment and even correlate staffing needs based on the inputs, for smaller, more financially-strained operators, it’s an added expense that they simply cannot afford at this time, Klusch said.

“The facility assessment document has become a very detailed, data-based document that is rather time consuming to not only establish, but also to maintain, because [each facility’s] level of service, the level of acuity, the types of treatment protocols that they have, their demographics of their patients, [CMS] is expecting all of that to be in the facility assessment. And that is a very large task,” Klusch said.

CMS timing for these “extra” requirements comes at a challenging time for the nursing home industry, which has been grappling with a range of challenges besides financial constraints to include new regulation, and the ongoing impact of the COVID-19 pandemic, Klusch said. Many facilities are already stretched thin, and the added burden of compiling and analyzing such extensive data threatens to divert critical resources away from direct resident care.

Recent regulations, such as the 5-claims audits, further complicate compliance efforts, making it increasingly difficult for facilities to meet these new requirements without additional support.

“Now we have the 5-claim audits out there, and so the percentage of buildings that are having to pay some of the funding back to Medicare and Medicaid programs [has grown],” she said. “We have the economy, the cost of food, the cost of personnel, the cost of utilities in some areas of the country has changed dramatically. So you can’t pay your electric bill. Your electric bill is 30% higher than it was, and so the economic stress also is very real.”

Larger operators also have lingering concerns

And while the larger operators may find it easier to complete the facility assessments with the help of vendors or dedicated staff, even for these operators the CMS guidelines are vague, and these operators feel that they have to be ready to evolve in the future.

“The lack of clarity and open-endedness is not encouraging, but for now we feel that we are employing the best practices that we can,” LaForte said. “Our data is comprehensive and with the use of our quality management platform we feel ready. Of course, depending on CMS’ subjective application of the standards and regional differences, we expect to have to adjust course as we move forward.”

All said, there remains a need for continued dialogue between federal agencies and industry stakeholders to refine these requirements in a way that promotes both compliance and sustainable operations, Klusch and LaForte said.

“As always, it would be nice to have CMS seek collaboration with operators on implementing quality enhancement. And of course, none of this touches on what this is precedent to, i.e. the staffing rule, which still remains an impossible mandate,” LaForte said.

And while CMS’ intent behind these new facility assessment requirements is a good one, stemming from a desire to improve transparency and quality of care, the implementation must consider the feasibility for facilities of all sizes, Klusch said.

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