The Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting Final Rule (CMS 3442-F) was released on April 22, 2024, and is expected to be officially published in the Federal Register on May 10, 2024.[1] The proposed rule generated over 46,000 comments and plenty of controversy. There are some important details to be fleshed out and there will certainly be further advocacy efforts. The unfunded cost of this final rule is between $4 and $8 billion annually, depending on who is doing the estimating. Here are ten items that skilled nursing providers need to be working on right now to prepare for these major changes.
What You Need to Know and 10 Steps to Take to Prepare
Taking a proactive approach to the changes coming in the staffing mandate, given the phases in implementation, will help to ensure you are prepared when the deadlines roll around.
1. Assess Your Current Facility Assessment and Review the Rules
The finalized changes to the Facility Assessment will take effect August 8, 2024, 90 days from publication. The shortness of this timeframe means that these changes demand immediate focus.
- When was the last time the Facility Assessment was updated?
- Does it meet all the current regulations?
- Do you have buy-in from your staff?
- Is your current resident population identified?
With CMS not requiring one specific format, look at the option from your QIO partners to review the current format, thinking about how you will include the changes outlined in the final rule.
Access summary of facility assessment changes
2. Use Data-Driven Methods to Inform Staffing Levels
Among other things, the changes to the Facility Assessment require an evidence-based approach to personnel coverage on units and by shift. At a minimum, review the acuity of your residents to know where each of them fall into the nursing classifications of the Patient Driven Payment Model (PDPM). Not only will this provide insight on how to staff for the acuity in your community, but you will be set up for success with the staffing changes to the five-star ratings related to the staffing measure. This can be a complicated process. Seek assistance if you are unsure how to proceed.
3. Ensure Success Now
Focus on excellent survey results, especially if your community is in an area where there is not an abundance of nurses or direct care staff to guarantee you are able to meet the expectations of the hardship exemptions (ratios of nurses per capita being 20 percent higher than national average). With the criteria for the exemptions having to be met and the need to have a positive survey history, this is the time to consider a Positive Review and Evaluation Process (PREP) or Mock survey.
Discover how HDG recently led a SNF to regulatory compliance through our PREP survey services.
4. Include Input from Your Entire Team
Your Quality Assurance and Performance Improvement (QAPI) process should be inclusive of all levels of staff, from the front-liners to the administrators, as you begin to update your Facility Assessment. Making sure your team understands the changes and how you are working to be prepared for the increasing acuity of the population coming into your community will help fortify long-term success.
5. Review Your Current Staffing Options
Think differently when staffing registered nurses.
- Could your MDS coordinator work on the floor in the evening to complete assessments for new admissions while helping to provide eight hours of RN coverage on second shift?
- Can your DON work overnight a couple times a week to assist with providing care while also completing administrative tasks, such as audits and documentation reviews to assist with 24-hour coverage?
If you are having difficulty maintaining appropriate staffing levels, HDG’s Workforce Solutions could 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.
6. Determine Your Geographic Classification
Knowing if your community is considered urban or rural (non-urban) will assist with meeting the definitive timelines you are working toward. For now, if you are in a rural area for purposes of SNF PPS, you can assume you are in a rural area for purposes of this rule. We will send out further clarification on urban/rural definitions and hardship exemptions at a later date.
7. Review Your Payroll-Based Journal (PBJ) Reporting Data for Accuracy
We are still awaiting clarification on how some job codes will be treated (e.g., nurse administrators) and exactly what the look-back periods will be for the staffing minimums, but it is a very good idea to dive in on the data and make sure it accurately reflects all staff.
8. Open Your Pipeline of Nurses
Build relationships with colleges and universities to bring nursing students into your community. Bringing students into the community exposes them to the wonderful population we serve in skilled nursing and helps the students experience a sense of helping someone’s life be more meaningful. Remember, on average about one-third of the working age population is not considered to be a labor force participant. Pulling some of these folks off the sidelines is essential to long-term success, given the imbalance of supply and demand for workers over the next five years.
9. Assess Your Operating Culture and Turnover Rates
One of the most important factors in retaining staff and reducing turnover is an intangible—your operating culture. Conduct a top-to-bottom assessment of your retention practices, including compensation strategy, team member engagement, and recognition.
10. Consider Strategic Alternatives
Assess your market. It is not too early to begin serious, long-term strategic planning. In some communities, there are years-long trends that have been exacerbated by the pandemic that have fundamentally changed how nursing homes fit into the continuum. You need to understand those changes, what your competitors are doing, and what the future holds. This begins with a solid market assessment and a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis. If need be, you can get external help for the analysis.
Health Dimensions Group Can Help You Prepare
Health Dimensions Group® (HDG®) has nearly 25 years of experience owning, operating, and providing third-party consulting services and workforce solutions for a vast array of partners. 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] See CMS Fact Sheets for more details.
