CMS Strengthens Nursing Home Oversight and Safety to Ensure Adequate Staffing

PUBLISHED: Dec 11, 2018
Relevant to: Long Term Care

The Centers for Medicare & Medicaid Services (CMS) recently announced actions intended to strengthen nursing home oversight and improve transparency in order to ensure that facilities are staffed adequately to provide high-quality care.

According to CMS, research shows the ratio of nurses to residents impacts quality of care and health outcomes. For example, facilities with higher nurse staffing levels tend to have fewer resident hospitalizations. According to CMS, new payroll-based staffing data shows that most facilities have somewhat fewer staff on weekends, but some facilities are reporting significantly lower weekend staffing. In fact, some facilities have reported days with no registered nurse onsite, although nursing homes are generally required by law to have a registered nurse onsite eight hours a day, seven days a week.

To help address and hopefully mitigate these risks, CMS intends, effective immediately, to use the new, frequently-updated payroll-based data to identify and provide state survey agencies with a list of nursing homes that have a significant drop in staffing levels on weekends, or that have several days in a quarter without a registered nurse onsite. Additionally,

  • The CMS State Operations Manual, Chapter 7, section 7207.2.2, previously required states to conduct at least 10 percent of the standard health surveys on the weekend or before 8:00 a.m. or after 6:00 p.m. (i.e., “off-hours”). States shall now be required to conduct at least fifty percent of the required off-hours surveys on weekends using the list of facilities provided by CMS. If surveyors identify insufficient nurse staffing levels, the facility will be cited for noncompliance and required to implement a plan of correction.
  • When conducting a scheduled standard or complaint survey (regardless of the type of complaint), state surveyors are now instructed to investigate compliance with 42 CFR 483. 35(b)(1), which is the requirement for a facility to provide the services of an RN seven days a week, eight hours a day. If a surveyor confirms that this requirement has not been met, the facility shall be cited for noncompliance under deficiency F-tag 727.
  • CMS has also expanded guidance related to deducting time for meal breaks. Note: This is not a change in policy, simply additional detail from CMS. The guidance includes information for deducting meal times for specific shifts (e.g., eight-hour shifts, twelve-hour shifts, etc.). Additionally, CMS has added a Q&A to the Payroll Based Journal Policy that explains the rationale for the meal break policy.
  • CMS has also provided clarifying language for facilities employing “Universal Care Workers,” who are typically certified nurse aides (CNAs) who perform additional duties outside of the nurse aide role, such as food preparation or light housekeeping services. CMS has added language to both the PBJ Policy Manual and the PBJ Policy FAQ to instruct facilities that they must use a reasonable methodology to allocate the hours that these employees are providing CNA services and report these hours accordingly. Hours spent on other duties (i.e. housekeeping, cooking etc.) must not be reported as CNA hours. These hours can be reported under housekeeping or other services; however, reporting of these hours is not required.

Included with today’s notice is an example policy regarding staffing. Also included is the link to the CMS memorandum to states addressing the updates to the Payroll Based Journal (PBJ) Policy Manual, Notification to States and New Minimum Data Set (MDS) Census Reports.

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