As the nursing home industry grapples with federal audits related to changes in survey requirements – seen as compounding burdens on staff – the sector lags behind other health care areas in filling openings for nurses.

Signature HealthCARE’s Chief Nursing Officer Barbara Revelette shared her thoughts on the fallout from ramped-up CMS scrutiny related to inappropriate diagnoses and psychotropic drug prescriptions and the federal agency’s delays in reporting nursing home deficiency citations as well as her company’s program for foreign nurses, noting that the recruitment of international nurses is key to easing some of these challenges.

The Centers for Medicare and Medicaid Services (CMS) unveiled a series of major revisions to its long-term care survey guidelines, now scheduled to take effect on March 24, after being previously scheduled to begin in February.

“I would love [to see] the state annual surveys go back to more training and development versus penalties,” Revelette told SNN. “They’re so far behind, and it’s so important that the role of these surveys should be on where are your opportunities and where you can enhance your care, versus penalizing something that could have occurred years ago.”

Revelette sat down with Skilled Nursing News recently for a wide-ranging interview.

Headquartered in Kentucky, Signature is a provider of long-term care, offering services across the health care continuum, including skilled nursing, home health, assisted living, and in-home care, with more than 60 locations across Indiana, North Carolina, Virginia, Kentucky, and Tennessee.

The following conversation has been edited for length and clarity.

SNN: As you are well aware, CMS is running behind in reporting nursing home deficiencies in Care Compare. We’ve reported that this disrupts the Star ratings, along with other problems. Is it concerning to you that consumers don’t have access to or visibility into what nursing homes are being cited for? And generally speaking, what are your thoughts on this issue?

Revelette: Yes, it is concerning. Consumers rely on up-to-date information to make informed decisions, and the lack of timely updates could potentially limit their access to important information and other data driven measures when comparing facilities to other health care providers. It also affects facilities that may have corrected deficiencies, but still appear unfavorable due to [outdated survey results]. Timely reporting is essential for transparency and accountability in the health care sector.

SNN: CMS has been conducting audits related to inappropriate diagnoses and psychotropic drug prescriptions. How are these audits proceeding for Signature and the sector at large, and do you think that in 2025, CMS is going to be increasingly focused on how well nursing homes are serving the behavioral health needs of residents.

Revelette: These audits often reveal documentation gaps despite good faith efforts by the facilities, rather than misuse. CMS will likely increase the scrutiny of how nursing homes handle the behavioral health issues in the [nursing home] population. Given the rising importance of mental health, I think they’ll focus on ensuring accurate diagnosis, proper medication use, alternative therapies and staff training to meet the behavioral health needs of our communities.

SNN: Does it impact Signature in any way? Operators have said that delays have influenced their decisions on whether to make acquisitions because the outdated data means that the acquiring entity is presented with extra financial and legal challenges.

Revelette: From our experience, I will tell you that most organizations in the health care sector have transparency. And that public data, even though it’s not on Care Compare, is available from a survey standpoint … I feel like as long as everyone’s transparent, you should know what you’re acquiring or divesting.

SNN: At Signature, are you feeling the pinch of the discrepancies between the cost of nursing home care versus what is reimbursed to nursing homes.

Revelette: I would say the actual cost of providing care to residents is significantly higher than what Medicaid reimburses. We have to look at inflation and the cost of living, that the direct care costs, the wages for staff, medical supplies, medications, all of that is increasing, and that has to be taken into consideration.

SNN: Which states are generally difficult to operate in from the regulatory standpoint?

Revelette: I would say Kentucky. It is currently behind in conducting annual surveys for long-term care. It’s causing facilities to enter into catch up [mode]. They may be three to five years without a survey and then being evaluated for the entire period at once. That increases the pressure on staff and resources, making it harder to focus solely on delivering quality of care.

SNN: What are your views on the immigrant nurses and easing of immigration policy related to health care workers?

Revelette: We recognize the critical role that international nurses play in addressing the national shortage of health care professionals. You know, with an increasing demand for skilled nursing care, especially in long-term care settings, the recruitment of international nurses has become essential to maintaining high quality of care. We’re proud to have several international nurses on our team. Their dedication and expertise has been outstanding. They not only deliver exceptional patient care, but they also contribute to the richness of our communities. They foster an inclusive environment that enhances the overall quality of health care.

We are continuing to explore options to expand the international nurse program at Signature, and we are committed to ensuring that we meet the growing needs of our population.

SNN: Do you have any sense for how many immigrant nurses have come on board at Signature?

Revelette: I don’t have the exact number, but I can tell you that we have at least a dozen or so, and across several of our states. And they really are impactful. They’ve fit right into our culture and our diverse workforce. We’re definitely embracing their presence, and they’re definitely adding, you know, to our workforce in a positive way.

SNN: One set of requirements related to the federal minimum staffing mandate that went into effect were enhanced facility assessments in August of 2024. Did these facility assessments yield any kind of insights for Signature in terms of how much staffing you would need, or anything valuable or challenging?

Revelette: We, like every other provider, have updated our facility assessments based on the regulatory requirements. I don’t feel that those have yielded any insights on whether a building is meeting or exceeding those expectations. I think that, you know, information will be more readily available in the next year or so based on the outcomes of those.

SNN: Anything from your expertise in the clinical arena that would like to see changed?

Revelette: Besides a seat at the table with policy makers, the only other thing I would love to see is the state annual surveys go back to more training and development versus penalties. They’re so far behind, and it’s so important that the role of these surveys should be on where are your opportunities and where you can enhance your care, versus penalizing something that could have occurred years ago.