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As providers focus on nurse hour and RN coverage requirements in the federally proposed staffing mandate, experts warn it’s critical they not overlook the first change in the rule’s planned implementation.

It is a significant overhaul of the existing skilled nursing facility assessment, one that would put it higher on a surveyor’s dashboard and underpin efforts to enforce new staffing requirements.

The facility assessment was initiated as part of the 2016 Requirements of Participation. Clarifications the Centers for Medicare & Medicaid Services outlined in its proposed staffing mandate would strengthen certain assessment components, involve more staff in the assessment process and, possibly, trigger more frequent updates.

“CMS is looking to enhance the existing FA (facility assessment),” Janine Finck-Boyle, LeadingAge vice president of health policy, told members on a call Wednesday. “It is going to be a big roadmap if this rule becomes final.”

The new assessment standards would be in play 60 days after the rule is finalized.

Currently, facilities determine “sufficient” staffing needs for their resident populations based on census, acuity, diagnoses, as well as the competencies staff need to care for those residents, explained Linda Elizaitis, president of CMS Compliance Group. But some providers have leaned too heavily on templates made available when the assessments were first implemented. They will have some major work to do to catch up to the potential new considerations and ensure their plans fit their population.

“However, much of what is being clarified — or even added — in the proposed rule related to the facility assessment are likely practices many facilities committed to quality already have in place,” Elizaitis said. “For example, if finalized, the facility assessment would be used to assess the specific needs of each resident unit in a building and then adjusted as necessary based on shifts in the resident population. This type of staffing plan should already be in place in all buildings, as it is really a good nursing management practice.”

Yet there are already questions emerging as to how often providers would have to adjust their assessments to stay in compliance. Currently, noted AAPACN Chief Nursing Officer Amy Stewart, RN, RAC-MT, DNS-CT, the assessment only has to be updated annually or if there are specific changes in the facility. But final CMS guidance might be more stringent.

“To be honest with you, with staffing, looking at acuity is a day-to-day thing,” she told McKnight’s. “So clearly, the requirement to review the facility assessment, I would assume, will have to change, at least for the staffing portion. … Acuity can change within one hour from either one admission coming in, multiple admissions coming in, or even an outbreak of something as common as the flu.”

Situational staffing

The rule proposed Sept. 1 also calls on nursing homes to involve more staff in the assessment itself. Typically, it may only be department heads involved in writing the analysis and determining what resources are needed, said Elizaitis.

But the updates would require including the input of more facility staff, which according to CMS includes but is not limited to “nursing home leadership, management, direct care staff (i.e., nurse staff), representatives of direct care staff, and staff who provide other services.” In its full proposal published in the Federal Register, CMS also noted that a union representative could be included as a direct care voice. 

“You really need to make sure that your core groups are part of creating this facility assessment,” Finck-Boyle said, adding that housekeeping and other departments might need to be consulted too.

In addition, the entire assessment must be based on evidence-based standards, experts noted. Those should be used to determine what competencies are needed, specific skills for each shift and day of the week, and whether the admission of patients with behavioral health concerns of higher medical needs would trigger additional coverage.

Providers may tend to pull much of the planning data they need from Payroll-Based Journal reporting or state staffing minimums in many states, Elizaitis said. But Finck-Boyle noted that input from the MDS, PDPM, care plans, quality measures and even satisfaction surveys could help inform and provide a basis for a facility’s staffing decisions.

While the staffing rule imposes specific hourly requirements for certified nurse aides and registered nurses, as well as full-time RN coverage, CMS has said that those are only minimums. 

“When assessing the sufficiency of a facility’s staffing it is important to note that any numeric minimum staffing requirement is not a target and facilities must assess the needs of their resident population and make comprehensive staffing decisions based on those needs,” the agency wrote. “The additional requirements proposed in this rule to bolster facility assessments are intended to address this need and guard against any attempts by LTC facilities to treat the minimum staffing standards included here as a ceiling, rather than a floor.”

During on-site inspections, surveyors will use the facility assessments and the evidence included in it to determine whether facilities are truly in compliance with providing sufficient staff for their residents’ needs.

“We have been advising our clients for the past few years that the Facility Assessment is meant to be a key document that requires thoughtful review and update when a provider changes its scope of services or begins admitting residents with differing acuity and diagnoses than the current population,” Elizaitis said. “One of the areas where we routinely see vulnerability is the master staffing plan, and the proposed rule reflects the need for providers to pay more attention to that plan and to make the overall assessment facility-specific.”