Steven Littlehale

On a recent flight, I sat next to an attorney whose principal focus was compliance. It turned out that we were both on our way to speak at events in the same popular Florida conference destination. She was not in healthcare, but when she heard that I worked with nursing homes, she made a comment that caught my attention.

“There are often significant compliance issues in highly regulated industries,” she said. Intrigued, I asked her to elaborate.

She went on to share that in such industries, especially ones with low margins, staff must be creative and resourceful to meet regulatory requirements and still achieve business goals.

“It’s the perfect Catch-22,” she said. “You have little flexibility, yet you’re always working to find ways to play within the rules and win.” But, she explained, that quest to play within the rules is where nursing homes likely misstep and create compliance issues. 

What a fascinating conversation! This stranger, by her own admission, had never stepped foot in a nursing home — yet she would have been perfectly suited to deliver the keynote address at the nursing home conference I attended during that trip. 

When the Centers for Medicare & Medicaid Services changes the rules, we relearn the game and hope not to misstep. In saying this, I mean no disrespect to anyone who has devoted their careers to improving elder care, either at CMS or in nursing homes. The recurring learning process is just part of our reality. Thirty-three years working in our heavily regulated industry affords me this insight. 

And so here we are: In the last few weeks, CMS has introduced additional staffing metrics to Five-Star and ramped up surveyor enforcement of staffing. The rules have changed. We now have six staffing metrics, and we no longer have the opportunity to pick up an additional star for achieving a “4-star” in staffing. 

The six staffing measures included within the Five-Star system are:

  1. Case mix–adjusted total nurse (RN, LPN/LVN, aide) staffing levels (hours per resident per day)
  2. Case mix–adjusted RN staffing levels (hours per resident per day)
  3. Case mix–adjusted total nurse (RN, LPN/LVN, aide) staffing levels (hours per resident per day) on the weekend
  4. Total nurse turnover, defined as the percentage of nursing staff who left the nursing home over a 12-month period
  5. RN turnover, defined as the percentage of RNs who left the nursing home over a 12-month period
  6. Administrator turnover, defined as the number of administrators who left the nursing home over a 12-month period

A few comments for nursing home providers:

  • Without exception, whenever I review PBJ submissions in the support of nursing home legal defense, I discover staff hours that were paid and worked but never submitted. So:
    • Do not delegate PBJ submissions without providing the appropriate context, education and support. And routinely audit prior to submission.
    • Include corporate staff who are in the building fulfilling PBJ job codes 5, 6, 7, 8, 9, 10, 11 and 12.
    • If you use agency staff for PBJ submissions of their staff, audit their work as well.
    • Determine how to pay overtime to salaried staff and count their time.
  • Take a careful look at your weekend staffing in comparison to Monday-Friday staffing. Can you justify the differences, particularly related to skilled care? Significant differences do impact your future stability in ways aside from a potential black eye on Five-Star.
  • The recent focus on turnover is not without merit. Creating a workplace that attracts and retains the best people will have a significant positive impact on your outcomes.

A few comments for CMS:

  • When it comes to case mix adjustment of our staffing metrics, we simply cannot rely on the decade-old STRIVE study that utilized RUG-53. This is because:
    • Many nursing homes utilize technology/analytics to leverage greater efficiencies compared to 2011.
    • As nursing homes specialize in specific types of residents, they often fall out of “average expectations” for staffing, as reported in STRIVE.
    • These specialized nursing homes are penalized by the staffing metrics and an inflexible survey process. We are a heterogeneous industry. RUG-53, RUG-66, and PDPM have all failed to adequately capture this fact.
  • You have removed the bonus star at the 4-star staffing level, implying that quality outcomes change between 4- and 5-star ratings in staffing. Please share the evidence to support this assertion. 

Ultimately, there is good in these new staffing measures. We should embrace them and learn from them. They are delivering a greater ROI than we may realize. Nursing homes that “staff to the stars” or “enough to avoid a penalty” rather than to staff to their residents’ needs, will continue to miss the mark. 

Ultimately, I’m afraid that we’ll see some overall slippage with the removal of the additional bonus star. This troubles me, as it feels like an unnecessary punishment for above-average operators who are challenged by a staffing shortage.

Steven Littlehale is a gerontological clinical nurse specialist and chief innovation officer at Zimmet Healthcare Services Group.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.