A report released Monday by the Office of the Inspector General (OIG) is recommending that the Centers for Medicare and Medicaid Services (CMS) strengthen its oversight of nursing home staffing by enhancing how it uses Payroll-Based Journal (PBJ) data.
The OIG is urging the federal agency to flag all nursing homes that provide fewer than the federally required 8 hours of registered nurse (RN) care per day and to supply states with more detailed staffing data.
If followed, OIG’s directive will result in even more citations over and above ones that the sector is anticipating from the revised guidance to surveyors issued early this year, according to nursing home industry advocates, who say that government investment in staffing rather than scrutiny is the better solution to address staffing concerns.
“[CMS] released additional guidance to surveyors in the January 2025 update of Appendix PP of the State Operations Manual for utilizing PBJ data to focus survey efforts; we expect to see more citations arrive from these clarified investigational directives,” Jodi Eyigor, senior director of nursing home quality and health regulation, told Skilled Nursing News in an emailed statement.
OIG is calling for more detailed staffing data, and it is also suggesting that CMS include information related to resident needs and certified nurse aide (CNA) levels in order to better identify facilities at risk of noncompliance.
CMS pushes back
However, CMS is not fully embracing all of OIG recommendations.
CMS did not agree with OIG’s recommendation to inform states of nursing homes that appear from PBJ data to violate the required number of RN hours, arguing in its response that this move would place an undue burden on state survey agencies (SAs) without a corresponding increase in inspection resources.
Due to “limited resources,” CMS has had to make choices – and currently flags the most at-risk nursing homes for survey agencies, which include nursing homes that report zero hours of RN staffing for four or more days in a quarter, the agency said in its response to OIG that was shared in the report.
“[R]esidents living in nursing homes without an RN onsite for four days per quarter are at a greater risk for harm than residents living in nursing homes without an RN onsite for one day per quarter,” Stephanie Carlton, Acting CMS Administrator said in a letter dated April 14 to OIG.
Moreover, CMS said that it already issued stricter guidance to states via various updates, including the revised version of the LTC surveyor guidance issued in January 2025.
Despite acknowledging CMS’ concerns about limited resources and recognizing its ongoing efforts, OIG still maintained that its recommendations were reasonable, although it does eventually plan to revise these.
“OIG is committed to improving oversight of and, in turn, ensuring the safe care for residents in nursing homes, and we will continue to work with CMS on these issues. We look forward to CMS’s response to the adjusted recommendation in its Final Management Decision,” OIG’s report said.
Over the years, PBJ data reporting and CMS guidance have played an important role in helping states target nursing homes with staffing issues.
For example, the expanded PBJ staffing data reports, which flag facilities for issues like zero RN hours, fewer than 24 hours of licensed nursing, and low weekend staffing, have enabled states to flag high-risk homes via surveys. This approach has led to a modest increase in citations for staffing deficiencies, though the OIG report suggests that the overall citation rate remains lower than expected, raising concerns about potentially missed deficiencies.
Meanwhile, critics of this use of PBJ data say that it is not designed to serve as a real-time or comprehensive tool for depicting staffing in nursing homes.
Holly Harmon, senior vice president of quality, regulatory and clinical services at the American Health Care Association and National Center for Assisted Living (AHCA/NCAL), echoed Eyigor’s views.
“We support the federal government sharing data with states, and at the same time, we believe there are opportunities to enhance PBJ reporting,” she said. “However, strengthening the long-term care workforce requires more than data and inspections. Without meaningful government investment in recruitment, retention, and support for caregivers, enforcement alone will only deepen existing workforce challenges and restrict access to care for millions of seniors.”
The findings of the latest OIG report show states expressed a need for more detailed staffing data to help them assess potential deficiencies more accurately. States requested information on nurse aide staffing and staffing levels relative to residents’ care needs, and in a more timely manner.
In OIG’s investigation, many states reported receiving outdated staffing data, often covering periods that were 2 to 5 months old, which prevented them from addressing current staffing issues. Some states also expressed the need for more data on nighttime staffing and staffing relative to residents’ care needs.
“CMS should consider using PBJ Staffing Data Report to inform States about potentially insufficient staffing in relation to the number of residents in the nursing home and their care needs. States we reviewed reported wanting more information about staffing,” the OIG report states.
For its part, CMS has taken steps to strengthen oversight and has introduced changes to Care Compare to incentivize nursing homes to submit accurate staffing data, the report acknowledges.
As of April 2024, nursing homes that failed to submit or submit inaccurate data faced more severe penalties, with the potential for a one to two-star reduction in their overall staffing rating for up to 15 months, up from the previous three-month penalty. This change was aimed at encouraging more accurate and timely data submission, ultimately improving the reliability of staffing information available to surveyors.
And yet, the report points to gaps in CMS’ oversight.
Gaps in CMS oversight
For starters, while CMS flags homes with zero RN hours, it does not flag facilities that report fewer than 8 RN hours, which violates current staffing requirements, OIG said. This gap means that hundreds of nursing homes that report insufficient RN hours go unflagged, despite posing a risk to compliance, the report notes. The OIG recommends that CMS expand its flags to include all nursing homes with fewer than 8 RN hours, potentially identifying an additional 5% of facilities that need further investigation.
Another issue the OIG’s report raises is that of one-star staffing rating, which is meant to alert surveyors to potential staffing problems. This rating, however, encompasses multiple components, including turnover rates and the failure to submit PBJ data. And yet, states found this flag to be less useful, as it does not clearly identify the specific staffing issues that require attention. And so, OIG suggests that CMS refine the one-star flag to provide more insights for state surveyors.
“CMS could provide state surveyors with greater detail about staffing levels in each nursing home to compare to the facility-wide assessment. This information about staffing levels per resident per day is already provided within the Care Compare website,” OIG’s report recommends.
Calls for stricter long-term oversight
Aside from providing information about staffing levels to surveyors as part of the PBJ Staffing Data Report on a quarterly basis, OIG is suggesting long-term measures for appropriately staffing nursing homes.
Over the longer term, CMS revisions could include a breakdown on RN staffing and nurse staffing that it uses as components of the star rating.
“Currently, the staffing star rating is calculated by using multiple staffing types. But, state surveyors can benefit from knowing which specific staff types appear insufficient,” OIG stated in the report.
And secondly, “CMS could calculate other metrics not based on the one-star staffing rating. For example, CMS could consider using specific staffing levels (in terms of hours per resident day) that appear insufficient and may wish to consider the results from its Nursing Home Staffing Study published in 2023,” the report recommends.
But more scrutiny doesn’t always mean efficiency, said Eyigor.
Even though the Star ratings for nonprofit providers that are members of LeadingAge tend to be higher, staffing challenges are universal to the sector, she said.
“[A]ll providers navigate the same struggles in recruiting and retaining qualified workers in a highly competitive labor market in which demand for staff far outweighs supply. It is our hope that as the realities of this struggle are discussed more and more among government agencies, we will see investment in the programs that can help us address staffing issues across the aging services continuum,” she said.
