The Centers for Medicare & Medicaid Services (CMS) is proposing to expand the Skilled Nursing Facility Quality Reporting Program (SNF QRP) so that reporting requirements would apply to all payer types, not just Medicare residents. Extending this will create substantial administrative, staffing and financial burdens for nursing homes, leaders said.
CMS’s proposal to require admission and discharge assessments for all residents, rather than only traditional Medicare Part A stays, would force facilities to evaluate every resident to determine whether they meet the criteria for skilled care. This includes assessing whether the resident’s daily services are medically necessary and can only be provided in a skilled nursing facility (SNF). This would add substantial responsibilities related to clinical monitoring, documentation, scheduling and care planning beyond simply completing the forms themselves.
“The CMS proposals are not only a compliance burden, but also an extensive administrative burden, that will take hours away from direct resident care,” Jessie McGill, senior curriculum development specialist at the American Association of Post-Acute Care Nursing (AAPACN) told Skilled Nursing News.
The financial footprint of this change will likely also be substantially more than CMS’ estimated cost, she said.
“It’s really important at this early stage to really let CMS know some of the concerns we have regarding the burden,” she said. “For example, in the proposal, CMS actually estimates the cost of the burden per year at just over $88 million. Based on our initial analysis of that number, we think that is a very low estimate.”
The proposal is included in the FY 2027 rule, but CMS does not plan to implement it until FY 2031, giving providers time to prepare and provide feedback before the changes take effect, and nursing homes along with related parties are encouraged to submit comments to CMS by June 1.
McGill said that in a separate “mock-up” document, CMS is proposing to add two new assessment types under the PPS assessment names: the “Other Skilled Care Admission Assessment” and the “Other Skilled Care Discharge Assessment.”
The added requirements pertain to the nursing home PPS, or NP item set as they are termed, which is a subset of minimum data set (MDS) items.
“We still have a lot of unanswered questions about how this will work,” she said. “[I]f there’s a way that we can do it with less burden, we want to help suggest alternative ways to collect this data so facilities don’t have to take nurse hours away from patient care.”
‘More and more items’
One focus for AAPACN is ensuring that the burden of increased administrative paperwork is limited.
To that end, AAPACN commissioned a study to determine the additional time CMS’ proposed assessments will require. The study concluded that increased compliance requirements would pull nursing staff away from direct resident care by more an hour per resident on a daily basis.
AAPACN’s “NAC Work Study Time Report” for nurse assessment coordinators (NACs) conducted in 2025 found that completing a stand-alone PPS 5-Day assessment would take an average of 56.92 minutes, while a PPS Discharge assessment would take 32.93 minutes. This would multiply the workload across facilities, she said.
The clinical team would need to review residents daily to determine whether they continue to meet the skilled level of care, McGill explained. This responsibility would likely involve unit managers, directors of nursing (DONs), bedside nurses, direct care nurses and therapists, all of whom typically participate in monitoring residents’ daily skilled care needs.
In addition, nursing staff would need to document the skilled care being provided each day because, in nursing practice, if it is not documented, it is considered not done, she said. Direct care nurses would therefore need to maintain daily documentation to support that residents continue to meet the requirements for skilled level of care.
CMS would require nursing homes to evaluate all residents, regardless of payer type, to determine whether they meet four skilled care criteria: need for skilled services, daily necessity, inpatient-only SNF appropriateness and medical need. McGill notes this expands skilled coverage determinations beyond current practice. The proposal could apply to residents covered by Medicare Advantage, Veterans Affairs, commercial insurance, Medicaid, managed Medicaid, workers’ compensation as well as private pay.
And while CMS has suggested to providers that the added burden is minimal, citing that many facilities already complete 5-Day assessments for some Medicare Advantage plans, McGill counters that most MA plans do not require PPS Discharge assessments right now, and current requirements vary widely across payers.
“While the assessment can be combined with other assessments if it happens to be required at the same time, there’s some other nuances on these assessments that are only required during the skilled stay, so that adds in more and more items,” McGill said.
Moreover, CMS is underestimating the cumulative burden of applying skilled determinations at every admission and readmission, particularly after short hospital stays, she said.
CMS further argues that burden may be offset because SNFs would no longer need to determine which residents require MDS submission. However, McGill argues that this overlooks current workflows, where skilled determinations are only required for certain payer types, whereas the new rule would require universal screening and ongoing daily monitoring for all qualifying residents until they are discharged from skilled services.
Removing redundancies from oversight
CMS’ future expansion of SNF QRP reporting requirements to all payer populations through new admission and discharge assessments for other skilled care residents needs to be mindful of staff not repeating tasks.
The newly released CMS “mockups” reveal the added complications, McGill said. These show changes to the MDS structure, including a new classification under item set field A0310B for “SCA – Other Skilled Care Admission Assessment,” alongside the existing PPS 5-Day and Interim Payment Assessment categories. A new discharge field – A0310I – would also capture “SCD – Other Skilled Care Discharge Assessment” for non-Medicare skilled residents, using the same PPS discharge item set for end-of-stay at the nursing home termed NPE.
These changes effectively create a parallel assessment system for non-Medicare skilled residents, expanding documentation requirements and reinforcing concerns that staffing time will shift further from resident care toward administrative compliance, McGill said.
While AAPACN is still working on offering final recommendations to minimize added burden, the organization has shared some initial ideas, primarily based on preventing nurses from repeating data collection efforts, she said, referring to the OBRA (Omnibus Budget Reconciliation Act) requirements for facilities to conduct comprehensive, regular assessments of each resident’s functional capacity using the MDS.
“We already submit OBRA assessments on all payer types, and we would like to explore if there are ways to collect this data without adding additional assessments and the additional monitoring that would be required,” McGill said.
More recommendations from AAPACN will be forthcoming, she said.
“We have just started to have our conversations, collaboration calls [with our expert advisory panel], so we’ll be working towards recommendations, but it’s really too early to speak on what our final recommendations will be,” she said.
