On June 18, 2024, the Centers for Medicare & Medicaid Services (CMS) released QSO-24-13-NH, which contained the interpretative guidelines for surveyors reviewing compliance with updated rules regarding facility assessments. These new rules go into effect on August 8, 2024, and are the first step in implementation of the Minimum Staffing Standards for Long-Term Care (LTC) Facilities and Medicaid Institutional Payment Transparency Reporting final rule (CMS 3442-F), published on April 22, 2024.
Here is a 10-point checklist on what you need to be doing right now to prepare for the impending changes to the facility assessment requirements.
1. Set Policies for When Your Assessment Is to Be Updated
The timelines for completing and updating the facility assessment are not new. The previously existing rules state, “The facility must review and update that [facility] assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment” (§483.71).
What is new, however, is the scope of the facility assessment. It now includes other items related to staffing, as described in the memo. As noted, the rule takes effect on August 8, 2024. Therefore:
- All existing facility assessments should be reviewed by nursing homes to be compliant with the new rules, with any updated policies being reviewed as part of the Quality Assurance and Performance Improvement (QAPI) process in the community.
- Policies should also be developed to address new situations that might trigger updating the facility assessment during the year. These might include changes in resident mix that are material enough to drive revisions in the staffing plan. For instance, adding a new clinical service line for medically complex residents.
2. Implement Process for Evidence-Based, Data-Driven Staffing Decisions
This is perhaps the most interesting of the new requirements. The memo does not add much interpretative guidance around this new requirement for “evidence-based, data-driven” staffing except to make clear that the data-driven part refers to data derived from the resident assessments (e.g., the minimum data set or MDS).
The term “evidence-based” in this context seems to refer to a systematic process of taking the resident assessment data and using it to inform how staffing might change as resident acuity changes, often referred to as acuity-based staffing. It seems that CMS is leaving some latitude as to exactly what the facility assessment will need to contain on this topic, but it is important to keep some things in mind: Staffing must be “sufficient” to meet the needs of the residents, and there must be some form of a relationship to resident acuity.
It is likely that this area will evolve over time, particularly as technology vendors increasingly develop software to take MDS data and link it to staffing levels and outcomes. In the meantime, there are spreadsheet-based tools and data from sources like Nursing Home Care Compare that can help correlate staffing and resident acuity. Ask for help from outside sources such as Health Dimensions Group® (HDG®) if you need assistance with developing a process for acuity-driven staffing.
3. Ensure Facility Assessment Addresses Behavioral Needs
According to the training requirements for F-Tag 949, community staff must be trained to address behavioral health concerns, including the provision of person-centered care, which is inclusive of pharmacological approaches, and ensure the environment is conducive to mental and psychosocial well-being. Considerations include:
- Trauma-informed care and an understanding of mental, psychosocial, or substance abuse disorders upon admission will assist in providing individualized care, but also will ensure you can provide the appropriate education to your team to ensure you can support each individual who lives in your community.
- Ensuring you have an accurate history upon admission, a thorough list of diagnoses and conditions captured on the MDS, an accurate PHQ-2 and 9 interview score, a person-centered care plan, and the ability to partner with additional care providers to support each resident is crucial to address the needs of the resident.
- Including the details of how you will handle the training and provision of care to meet behavioral needs will be important for meeting the updated requirements of the facility assessment.
4. Inventory Nurse Staffing Competencies and Skill Sets
The memo and the State Operations Manual updates mention “competencies” and “skill sets” in the same sentence, but it is sometimes hard to discern the difference. Typically, a nurse demonstrates competency of a specific task, such as changing a catheter. A skill set is the ability of the nurse to not only change the catheter but also to provide catheter care, identify a breakdown in skin integrity, and determine cause of infection, all to ensure the needs of the resident are met based on the provision of person-centered care, which must be reflected in your facility assessment.
Ensure your nursing staff can clinically manage and care for residents with the conditions outlined on your updated facility assessment. For example, if you use a process such as “Red, Yellow, Green” for admissions and bring in a resident who requires suctioning, yet the one nurse who was able to perform that procedure is no longer employed at your community. In that case, you are setting yourself up for regulatory risk and the resident for substandard care. Ensure your assessment is updated to match the competencies and skill sets of your clinical team to the changing needs of your residents.
5. Address “Other Direct Care Staff” in Addition to Nursing Staff
The memo states that the facility assessment should address “other direct care staff,” which includes those who provide direct care under service agreements. Therefore, it is important to ensure that the facility assessment incorporates other direct care providers, whether employed by the facility or not, to ensure the care and services provided are person-centered, meet the needs of residents, and comply with the facility assessment.
6. Involve a Wider Range of People in Developing Your Assessment
The new rules call for a wider range of people to be involved in the drafting and review of the facility assessment, including those listed below. Their participation should be documented and ideally it should be substantive. This will help to ensure that the facility assessment becomes a meaningful process and will help to promote compliance.
The persons to be involved in drafting and reviewing the facility assessment should include[1]:
(i) Nursing home leadership and management, including but not limited to, a member of the governing body, the medical director, an administrator, and the director of nursing; and
(ii) Direct care staff, including but not limited to, RNs, LPNs/LVNs, NAs, and representatives of the direct care staff, if applicable.
(iii) The facility must also solicit and consider input received from residents, resident representatives, and family members.
“Representative of direct care employees” is defined in the memo as “an employee of the facility or a third party authorized by direct care employees at the facility to provide expertise and input on behalf of the employees for the purposes of informing a facility assessment.”
7. Use Your Assessment to Inform Staffing Decisions
The conditions and diagnoses listed on your facility assessment for which you are capable of providing care and services should help to drive staffing decisions within your community, including the awareness of census data with the percentage of residents in your community who receive long-term or short-term care services.
Conditions higher in acuity will likely require the care and oversight of more RN/LPN hours, whereas short-term residents with lower acuity may only need additional CNA hours. In completing the facility assessment, it would be helpful to review the nursing case mix data from your MDS to identify current complexity while comparing the information with your current staffing patterns. Is staffing sufficient or is more labor required to meet the needs of your population? If you currently use an MDS scrubbing technology, the provider will likely be able to assist you in pulling this data efficiently.
8. Consider How Staffing Varies by Shift and Acuity
As your resident population changes, so will this portion of your facility assessment. Knowing the functional ability of your resident population is key for planning the staffing needs of your community based on shifts.
- Do you have more residents who need assistance with a.m. and p.m. activities of daily living, but who are more independent with eating, toileting, and toileting hygiene?
- Perhaps you have heavier staffing in the morning and in the evening, and less mid-day and overnight, when residents are typically sleeping. This will change if you begin to provide care for residents who have more acute needs, such as IVs or ventilators, who require services more frequently at night as well as during the day.
9. Formalize a Recruitment and Retention Plan
The pandemic exacerbated longstanding workforce shortages, particularly for certain types of team members. This can vary from market to market, though long-run demographic projections clearly show that the supply and demand for labor will be imbalanced for the next five years at least. These realities make having a solid recruitment and retention plan more important than ever.
When it comes to workforce retention, the use of a recognition program, career advancement, and creating a positive organizational culture will keep employees empowered to stay, learn, and grow with your company.
The use of centralized recruitment to attract and build a continuous pipeline of candidate interest for open vacancies is a critical recruitment strategy. If you are having difficulty maintaining appropriate staffing levels, HDG’s Workforce Solutions can help.
Learn how HDG’s centralized recruitment services helped a portfolio of 11 communities significantly increase hires and engagement, while reducing agency and overtime expenses.
10. Have Proactive Staffing Contingency Plans for Non-Emergent Situations
Nursing homes should already have emergency plans in place. What is new is that these updated facility assessment rules make clear that there should be proactive plans in place for day-to-day variations in staffing that do not necessarily rise to the level of emergency situations. This includes developing a plan for coverage with a shortage in direct care staffing, such as cross-training your team to assist with basic resident care needs. Cross-training may also include providing additional behavioral health training to all team members in your community to ensure more team members are able to provide care beyond just the physical and functional needs of the residents.
Delegation of nursing tasks is another method of planning for potential staffing shortages. Keep in mind that this may vary from state to state depending on practice acts. However, if nurse-delegated tasks have been taught, trained, and observed for competency, additional community staff can step in to assist when non-emergent staffing shortages arise.
Similar to planning for staffing during the pandemic, we must have a written contingency plan for staff in the event there are sudden staffing shortages. This includes staffing agencies who may be able to help in emergency situations. Work with outside vendors to determine if they are able to assist with additional resources and supplies when needed.
Health Dimensions Group Can Help You Prepare
Health Dimensions Group® (HDG®) has nearly 25 years of experience providing management and consulting services to senior living, post-acute, and long-term care providers across the nation. If you need assistance ensuring you’re prepared to meet the requirements of the staffing rule, don’t hesitate to contact us at info@hdgi1.com or 763.537.5700.
[1] CMS, QSO-24-13-NH, https://www.cms.gov/files/document/qso-24-13-nh.pdf
