CMS Strengthens Nursing Home Oversight and Safety to Ensure Adequate Staffing
PBJ Outcomes start to Settle in
Following the April 2018 launch of PBJ-based Five Star ratings, a November 2018 QSO memo and updated Policy Manual cleaned up data issues with MDS census and meal breaks.
Critically, CMS began using PBJ data for state survey and went so far as to send states PBJ data highlighting facilities not meeting core nurse staffing level rules. A new era of compliance enforcement using PBJ data begins.
CMS Strengthens Nursing Home Oversight and Safety to Ensure Adequate Staffing
The Centers for Medicare & Medicaid Services (CMS) announced actions that will bolster nursing home oversight and improve transparency in order to ensure that facilities are staffed adequately to provide high-quality care. These actions include sharing data with states when potential issues arise regarding staffing levels and the availability of onsite registered nurses; clarifying how facilities should report hours and deduct time for staff meal breaks; and providing facilities with new tools to help ensure their resident census is accurate.
“CMS takes very seriously our responsibility to protect the safety and quality of care for our beneficiaries,” said CMS Administrator Seema Verma.
“Today CMS is taking important steps to protect nursing home residents based on potential risks revealed by new payroll-based staffing data that our Administration released. We’re deeply concerned about potential inadequacies in staffing, such as low weekend staffing levels or times when registered nurses are not onsite, and the impact that this can have on patient care.”
Centers for Medicare & Medicaid Services. “CMS Strengthens Nursing Home Oversight and Safety to Ensure Adequate Staffing | CMS.” CMS News and Media Group, 30 Nov. 2018, www.cms.gov/newsroom/press-releases/cms-strengthens-nursing-home-oversight-and-safety-ensure-adequate-staffing.
CMS directive orders state agencies to increase weekend surveys of skilled nursing facilities
Staffing in long-term care facilities significantly affects the care delivered to residents. Since July 2016, nursing homes have been reporting staffing data electronically through the payroll-based journals (PBJ) system. Data submitted provides the number of hours that direct care staff is paid to work each day. In April 2018, the Centers for Medicare & Medicaid Services (CMS) began using PBJ data to calculate staffing levels and star ratings for the Nursing Home Compare website.
Based on audits of the PBJ data, CMS became concerned that some nursing homes are reporting several days in a quarter without a registered nurse (RN) onsite and/or significantly low nurse staffing levels on weekends, potentially impacting risk to resident health and safety.
“CMS Directive Orders State Agencies to Increase Weekend Surveys of Skilled Nursing Facilities.” Bricker & Eckler Attorneys At Law, www.bricker.com/insights-resources/publications/cms-directive-orders-state-agencies-to-increase-weekend-surveys-of-skilled-nursing-facilities.
Will state surveyors be knocking on your door Saturday night?
As early as April 2018, the Centers for Medicare & Medicaid Services was planning to use Payroll Based Journal (PBJ) data in ways other than calculating and reporting a staffing rating on the Five-Star Quality Rating System. In memo QSO 18-17-NH, CMS reported its intention to use PBJ data to inform the survey process to help surveyors identify if a facility’s staffing is an underlying root cause for quality issues.
Little details were given regarding definition of terms or the methodology CMS would use to analyze and then report the PBJ data. Seven months later, in a subsequent memo (QSO 19-02-NH), CMS notified state survey agencies that CMS would be providing them a list of facilities with potential staffing issues. CMS defines facilities with potential staffing issues as those facilities with low nurse staffing levels on weekends.
But what does low nurse staffing levels mean, and how will PBJ data be used to create the list? After posing these questions, CMS clarified how facilities with low nurse staffing levels on weekends will be identified.
Chenail, Susan. “Will State Surveyors Be Knocking on Your Door Saturday Night?” McKnight’s Long-Term Care News, 11 Feb. 2019, www.mcknights.com/marketplace/marketplace-experts/will-state-surveyors-be-knocking-on-your-door-saturday-night.
CMS to take Active Role in Ensuring Adequate RN Staffing in Nursing Facilities
In Quality, Safety and Oversight (QSO) Group Memorandum QSO 19-02-NH, dated November 30, 2018 (the “November Memorandum”), the Centers for Medicare & Medicaid Services (CMS) stated that it would begin providing CMS Regional Offices and State Survey Agencies (SSAs) with a list of nursing facilities for which data submitted as part of the Payroll Based Journal (PBJ) reporting system indicated potential nurse staffing issues, particularly on the weekends.
Previously, the State Operations Manual required states to conduct at least ten percent (10%) of standard health surveys during such times.
“CMS to Take Active Role in Ensuring Adequate RN Staffing in Nursing Facilities.” Arnall Golden Gregory LLP, 12 Dec. 2018, www.agg.com/news-insights/publications/cms-to-take-active-role-in-ensuring-adequate-rn-staffing-in-nursing-facilities-12-12-2018.
How Would Your Nursing Facility Fare on a Weekend Survey?
According to a new QSO memo from the Centers for Medicare & Medicaid Services (CMS), some nursing homes are going to find out just how they would do with surveyors in their building over the weekend. CMS has identified concerns in nursing home staffing levels using the Payroll-Based Journal (PBJ) data, including multiple days with no RN on site as well as significant decreases in staffing levels over the weekend.
As a result, CMS will be providing the Regional Offices and State Agencies (SAs) with a list of facilities that may have potential staffing issues to aid their investigations on survey to see if there is sufficient staffing.
Elizaitis, Brandie M. “How Would Your Nursing Facility Fare on a Weekend Survey?” CMS Compliance Group, 5 Dec. 2018, cmscompliancegroup.com/2018/12/05/weekend-surveys-coming
CMS intensifying nursing home staffing oversight; providers say it won’t help
Following recent national furor over nursing home staffing levels, the federal government declared Friday it is stepping up oversight measures, including more focused surveys. Industry advocates say the announced changes won’t help.
The Centers for Medicare & Medicaid Services announced that it will be turning up the heat, particularly on weekends. The changes come after a Kaiser Health News analysis in July uncovered an average of 11% percent fewer direct-care nurses and 8% fewer aides on duty on weekends.
Stempniak, Marty. “CMS Intensifying Nursing Home Staffing Oversight; Providers Say It Won’t Help.” McKnight’s Long-Term Care News, 3 Dec. 2018, www.mcknights.com/news/cms-intensifying-nursing-home-staffing-oversight-providers-say-it-wont-help
Meal breaks eating away at Star ratings
With the latest update to the PBJ Policy Manual, CMS makes very clear its rules on removing meal breaks from Payroll-Based Journal reports.
Take note: ALWAYS remove 30 minutes for lunch in your PBJ reports. Even when your staff works through lunch, those 30 minutes CANNOT be reported.
With confusion and inconsistent reporting by facilities, CMS updated its PBJ Policy Manual with detailed guidance on applying Meal Breaks.
“Meal Breaks Eating Away at Star Ratings.” SimpleLTC, 1 Dec. 2018, www.simpleltc.com/meal-breaks-eating-away-at-star-ratings
CMS Implements Stricter Nursing Home Staffing Survey Rules for States
The Centers for Medicare & Medicaid Services (CMS) announced Friday that it will use payroll-based journal (PBJ) data to bolster state oversight of nursing homes, effective immediately.
Specifically, CMS will use PBJ data to identify and provide state survey agencies with a list of nursing homes that have several days in a quarter without a registered nurse (RN) on site, or have a significant decline in staff on the weekends. The survey agencies will then have to conduct surveys on additional weekends based on the federal list, according to a memo released to providers.
Flynn, Maggie. “CMS Implements Stricter Nursing Home Staffing Survey Rules for States.” Skilled Nursing News, 30 Nov. 2018, skillednursingnews.com/2018/11/cms-implements-stricter-nursing-home-staffing-survey-rules-states.
States now required to conduct at least 50% of off-hour surveys on weekends for facilities with potential staffing issues
A list of facilities with potential staffing issues is being provided to CMS regional offices and state survey agencies to support survey activities for evaluating sufficient staffing, according to a memo released by CMS back in November, 2018. The memo states that “while CMS is encouraged by facilities’ efforts to improve staffing,” payroll based journal (PBJ) data has raised a few concerns, prompting them to inform state survey agencies of facilities with potential staffing issues.
These issues include facilities with significantly low nurse staffing levels on weekends and facilities with several days in a quarter without an RN onsite.
Hurlburt, Amanda. “States Now Required to Conduct at Least 50% of Off-Hour Surveys on Weekends for Facilities with Potential Staffing Issues.” The Post-Acute Advisor, 10 May 2019. No longer available.
Related CMS and PBJ Resources
To learn more about the details, policies and information in these articles, please review these CMS and PBJ publications.
QSO Memo 19-02-NH
PBJ Policy Manual
