Steven Littlehale

As the Biden administration marches toward some type of minimum staffing requirement for nursing homes, it’s easy for providers to feel like helpless, angry victims. Even as a proponent of acuity-based staffing standards in some form, I too am annoyed. 

How can we authentically work toward nursing home reform if our efforts are based upon decades-old staffing studies that don’t acknowledge the diversity of residents, specialization of providers and caregivers, and technologies in nursing homes today? 

But rather than feeling hopeless, now is the time to look inward. We must address the inefficiencies and redundancies that we have created in our nursing homes, improve our care delivery systems, and maximize the time our caregivers can spend at the bedside. 

Despite the continuous refrain of “too much paperwork” and “too many meetings,” many facilities’ first response to a challenge is to perpetuate the very things that keep staff from the bedside — more paperwork and additional meetings. This is so common that when we are providing clinical consultation, we never introduce a new time commitment to a nursing home unless we first remove twice as much in equivalent burden. In doing so, we’ve often found that we can “give back” 30 minutes to CNAs per shift and similar to licensed staff. 

Here are some highlights from recent client engagements, with insights from our staff. Note that we follow Donabedian’s model to ensure we capture the entire environment. This is essential for our efforts, as we believe, and I paraphrase, that every nursing home’s system will deliver precisely what it is designed to deliver. 


Take a look at your policies and procedures, the structure or “rules governing your practice.” Are they customized, current, or over the top? In particular, have past plans of correction (PoC) become needlessly integrated into ongoing practice?

PoCs are put in place to deal with a specific situation identified during survey. They tend to address a single issue yet go well beyond what is required by regulation. It’s too common for these PoCs to unnecessarily become integrated into ongoing policies and procedures, or just unwritten folklore of the nursing home. 

“One of our clients was cited for not following MD orders. Oxygen was to be titrated based upon pulse oximetry. The nursing home’s PoC indicated that all residents would have pulse oximetry every shift. While it satisfied surveyors in the moment, it was a setup for the facility,” shared Melanie Tribe-Scott, director of quality initiatives. It would be hard to justify this clinical practice or the authenticity of the assessments. Regardless, the nursing home had kept the PoC in place for five years. 

Upon review of another system’s policy and procedures, we identified a policy that required a skilled note to be written on every shift, though the federal requirement only requires a daily note. 

“It’s common for nursing homes to want skilled documentation on every single shift, then to consolidate into one complete daily note that meets requirements. But this particular multisite provider required a complete skilled note three times a day. Subsequently, most of these notes were incomplete, and not supporting the requirement for skilled care, or nonexistent, demonstrating noncompliance with the nursing home’s policy and procedures,” added Amy Greer, clinical consultant for quality initiatives. 

Melanie added that she’s seen nursing home policies require CNA documentation to support section GG every shift. The rationale is to capture documentation in the event that an optional Interim Payment Assessment (IPA) is deemed necessary. A more realistic and meaningful guideline would be to start documenting when an IPA is identified or to use other existing therapy and nursing documentation to determine the usual function of the resident 


“Copy and Paste” features within documentation systems are not your friend. While they can seemingly offer excellent efficiencies, they often perpetuate errors and create a sea of meaningless data that obliterates information about the resident. We’ve all seen impossible vital signs that carry on for days, even after the resident is no longer there. These errors are problematic during survey, and in my experience, they often end up lowering resident acuity.

“I recently worked with a nursing home that had 26 tasks per resident per shift that required documentation. For a resident assignment list of 10, it’s impossible to contemplate 260 documentation elements being accurate,” noted Melanie. “Information about the resident doesn’t require CNA signoff. For example, TED hose, pureed diet, and hearing aids shouldn’t be on CNA signoff flow sheets, TAR, or MAR. There are exceptions to the rule, but documenting these should not be the rule.” 

Amy added, “Be aware of what tasks you send to the CNA via the care plan. Pages and pages of generic care plans don’t necessarily benefit the resident, but create a daunting and needless burden for all nursing staff.”


As said, upon completion of these engagements, it’s common to give back 30 minutes per day to each CNA and sometimes even more. As well, when reviewing the effectiveness of our interventions, we find less redundant documentation, fewer episodes of missing data, and more accurate assessment and measurement of resident outcomes.

“Staff were grateful to have streamlined meetings and documentation and proactively identified other barriers to time with residents and documentation inefficiencies,” Amy shared regarding one client. “We learned of documentation kiosks that were frequently offline and computer screens that were not properly scrolling.” 

These barriers existed for some time, but staff wrongly assumed that leadership knew of the problems. 

In summary

  • Determine whether policy and procedures are evidence-based and in line with current science or regulation
  • Ensure PoCs are scoped appropriately and not perpetuated indefinitely
  • Identify and consolidate duplicative assessments
  • Examine whether add-on technology is helping or hindering best practices and time with residents
  • Determine whether every meeting has a rationale that links to resident care or regulation
  • Creatively meet multiple goals with fewer, better-defined meetings
  • Never conduct a meeting without a delineated agenda and follow-up plan

Sometimes the staffing debates feel like our industry is headed to “external stakeholder-centered care” rather than resident-centered care. While the federal government hashes out policy, take steps now to make your work environment as efficient and successful as possible. Minimize duplication, both in documentation and in meetings, and give the newfound time back to resident care. It’s always a winning strategy. 

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.