An ongoing depletion of knowledgeable nursing staff at nursing homes, such as the Minimum Data Set (MDS) coordinators, is leading to errors and confusion with facility surveys and ratings. This, in turn, is impacting operations and the ability to acquire and improve distressed facilities.
A high turnover among those close to the survey process is causing a process breakdown among nursing home operators, as newly hired MDS coordinators, for example, struggle to keep up while learning the RAI manual at the same time. Given this situation, as large operators seek to save and revamp nursing homes on the Special Focus Facility (SFF) list, they are urging the Centers for Medicare & Medicaid Services (CMS) to provide some concessions through changes to the survey process, which has proven to be a stumbling block for such acquisitions.
If a leader is brought in but has no actual building experience, there’s “tremendous liability” there, said Leah Klusch, executive director of the Alliance Training Center. This person might have graduated to become an MDS coordinator or administrator but haven’t been managing claims and audits every day, she explained.
“Auditors and surveyors are walking into buildings where somebody says the MDS manager quit last week and they are brand new, they don’t even have a manual yet,” said Klusch.
Turnover is so pervasive in the industry that it has impacted every facet of operations, including survey processes, Cascadia Healthcare Chief Legal Officer and Executive VP of Corporate Affairs Steve LaForte told Skilled Nursing News. Recovery is still happening from a mass exodus of seasoned staff during the pandemic.
Cascadia operates 45 skilled nursing facilities across five states.
“In the last four years, and especially in 2021 and 2022 we saw a huge exodus generally. Turnover was just awful,” he said. “Not having a sustainable workforce and not having retention creates imperfect milieus which take away from quality. The team is not as strong, the culture is not as strong, and you can’t be on your game.”
For Cascadia, finally reducing or eliminating agency staff at its facilities has been an effective way to help address survey inconsistencies. Less agency staff has led to a stronger company culture, allowing the Cascadia team to have lower-than-average turnover rates.
Reluctance to acquire SFFs
However, problems stemming from the survey process have made larger operators like Cascadia reluctant to acquire SFFs and turn them around, and CMS needs to make some changes to the survey process, LaForte said. After all, given issues with access, it’s in the interest of all to keep facilities open and their quality up.
And yet, the “unforgiving nature” of the survey process doesn’t take into account acquisitions for distressed properties, Laforte said. In fact, the survey process could be a disincentive to taking on an SFF property, he said, if it comes on the heels of an acquisition. At the very least, there could be a time period baked into the SFF program, he said, where the new operator has some time to turn things around before a survey is done.
“You get no dispensation from surveys,” said LaForte.
Cascadia has taken on SFF properties in the past as well as generally distressed properties.
“There definitely should be something because this is a public-private partnership, where surveys look at these things. If you have new people in place, or you’re taking over a facility and you’re trying to turn it, it makes it tougher on the [survey] process. It unfairly and inaccurately skews the process.”
This is especially true since the survey process affects the Five-Star Quality Care rating, which is used as an indicator of overall quality for residents and families. It’s a domino effect, he said. When staff turnover is ramping up it’s difficult to maintain culture and tight-knit teams. The quality and survey performance suffer and Five-Star rating is impacted, he said.
An operator can get into a cycle where admissions are impacted because of a drop in the Five-Star ratings, and a provider may be several years away from increasing their score again, because of the way Five-Star was designed, he noted.
It’s a cycle that’s difficult to break, made even more difficult by the CMS focus on a staffing mandate rather than workforce development, he said.
“You have these anomalous circumstances where they give you no dispensation,” LaForte said of CMS. “I think that there’s more dispensation that could go into the system without sacrificing quality and probably enhancing quality overall. It allows facilities to adjust and perform at the higher level that they can be in a more forgiving environment.”
Still, LaForte understands it’s a huge undertaking, with survey agencies being too disparate, divided up by regions.
Where are we headed?
Out of the roughly 15,000 facilities in the country, there are some that still don’t have formalized policies and procedures for the assessment process, Klusch said. These facilities can’t show that the people who are actually documenting the assessment have been trained to do so.
It’s going to be difficult for operators to be fairly represented with quality reporting program data as well, given CMS is collecting information from the MDS for measures due to be implemented in 2025 and 2026, Klusch added. Having a seasoned MDS team means that the data is more likely to pass surveyor muster.
“The surveyors are going to come in and just slice and dice the data [facilities] have sent in. If it’s not substantiated, or it’s not accurate, they have so many ways to interfere with operations,” said Klusch. “[CMS] can fight all kinds of different issues. That’s what we’re looking at in 2025, 2026 – the refinement of the functional outcome data, and then also the application.”
In terms of the actual formalized facility assessments, Klusch said she’s concerned about the direction CMS is going, a worrisome level of scrutiny the industry hasn’t seen before. A big topic CMS is focused on with facility assessments is finding a way to measure what’s happening to the resident when they’re in a facility, if they’re getting better, worse or staying the same.
“CMS can hang their hat on that. They find mistakes, and then they start taking money [away]. That’s the very slippery slope that no facility wants to be in,” said Klusch.
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