James M. Berklan
James M. Berklan

When a government watchdog decides it wants to investigate you, it’s usually not going to be content with a “No fire here, folks!” conclusion. Nobody knows that better than nursing home operators.

And so we unfold the latest Office of Inspector General investigation into skilled nursing staff levels, which came out Monday.

In brief, nearly 1,000 operators (7%) were found to have had more than 30 days without the required amounts of nurse staffing in 2018. Also, 900 had 16 to 29 days that weren’t up to snuff. Those are pre-pandemic days, of course. But still not too early to set the stage for a little “You always were slack” blame-gaming over coronavirus carnage, if we know how this game works. And we all do.

It already has happened with regard to infection control citations. Regulators haven’t minded pointing out that you never washed your hands enough as an industry before the pandemic, so it would naturally follow that such slovenly habits wouldn’t help matters come the public health story of the century. The nerve.

Backing up a little, let’s remind all players that the Centers for Medicare & Medicaid Services requires a minimum number of hours per day for nursing types. Among them, a registered nurse must be on duty at least eight hours per day and there must be at least one licensed nurse around 24/7.

The OIG, however, took issue with the fact that regulators do not use Payroll-Based Journal data to enforce the staffing requirements. PBJ data helps form staffing star ratings for the consumer-facing Nursing Home Compare website. Just about two-thirds of the days without enough nurse staffing occurred on weekend days, by the way.

“This raises concerns that some nursing homes may not have fully met their residents’ needs in 2018,” wrote OIG report authors, who also electronically surveyed 20 local long-term care ombudsmen.

This stuff is important because you’ll remember that two years ago, CMS started a policy that knocks provider’s Staffing rating down to 1 star automatically if it has seven or more days in a quarter with no reported RN time.

With the new policy in place, some 27% fewer nursing homes reported days with no RN time, and 7% more reported at least some RN time. This could have meant less than the required eight hours per day, but as the OIG noted, it indicated overall progress with regard to staffing levels.

There’s a problem identified by the OIG, however (they do call it a “watchdog” for a reason). Investigators said staffing star ratings on Nursing Home Compare didn’t match what providers were reporting day-to-day. Not all facilities had widely varying staffing levels on a day-to-day basis, but some did.

That’s why OIG recommends (wait, here it comes … ) that CMS “enhance” its oversight of providers’ daily staffing levels. (“Enhance” is a less genteel “bust your chops” in more common vernacular.) This is to work in coordination with exploring “ways to provide consumers with additional information on nursing homes’ daily staffing levels and variability.” [Emphasis added.] The push, you see, is to find a way to reflect day-to-day staffing fluctuations and not just quarterly averages. This will naturally make some providers flinch while others will shrug it off.

CMS did not “explicitly” agree or disagree with the OIG’s recommendations, but the agency said it was working on achieving them all the same. To providers, that means a hunch not to expect bouquets of flowers and air kisses. (And remember that a week from today is a deadline that marks the resumption of regular PBJ data gathering.)

The even stronger hunch? Expect tougher surveillance of staffing levels in the future.

Follow Executive Editor James M. Berklan @JimBerklan.