After three months of preparation, skilled nursing providers across the country were required late last week to complete their first enhanced facility assessment.
The broader look at resident and staffing needs will be used to support the federal staffing mandate, whose more specific hourly staffing requirements begin to come into play in 2026.
Some providers say the new, expanded process led to valuable insights into staffing needs or improved documentation. But while they feel they’ve complied with the spirit of the rule, they also remain in the dark about just how surveyors will weigh some critical elements — and what any unintentional misinterpretations might cost them.
“Generally, our concern is that the guidance is open enough and not specific enough that surveyors will have a lot of leeway in their survey process,” said Steve LaForte, executive vice president of corporate affairs and chief legal officer for Cascadia Healthcare. “And the impression we have of the mandate generally is that it is another punitive regulation that there won’t be a lot of forgiveness on.”
The Centers for Medicare & Medicaid Services finalized components of the facility assessment in its final staffing rule April 22. Questions then around the rule’s dependence on evidence-based standards — standards that were not explicitly defined — persisted after surveyor guidance was issued in June.
One provider organization told McKnight’s Long-Term Care News that a CMS triage email told employees that the evidence to be used should come from the facility’s Minimum Data Set. Why something that basic wouldn’t be included in the formal guidance perplexed multiple leaders involved in the assessment process.
“There were a few vague areas in the guidance provided by CMS, such as what was considered to be ‘evidenced-based and data driven,’” Heather Haberhern, senior vice president for quality at Health Dimensions Group, told McKnight’s. “Some clarifying examples from CMS would’ve been useful to our communities. With CMS not providing a desired format, some communities have struggled with how to convey the retention and contingency staffing plans.”
Size and strategy
Larger providers have been able to share their approach between sites, hoping that they’ve struck on the elements and presented them in a way that will be helpful to surveyors. Yet providers have little doubt some modifications may be required by inspectors or by CMS in future rule-making.
“We know that the surveyors are learning along with us, and it will be interesting to see their evaluation of the updated assessment,” Haberhern said. “As with any new regulation, it will be a learning process to ensure we are on the same page as the surveyors. Again, with there not being a specific format for how the information is conveyed … the interpretation of the surveyors may be different than how we’ve documented the information.”
Because nursing homes were previously required to have facility assessments, several nursing home operators contacted by McKnight’s said the new exercise wasn’t a huge burden.
The broader assessment requires more parties to be involved in the process, including residents, frontline staff and staff representatives including unions. It also demands more information about weekend and emergency staffing plans, as well as details on the behavioral or otherwise complex health needs of residents.
“When we began to dig into the updated regulation, we identified most of the changes were requirements from other federal regulations,” Haberhern said. “We are meeting the regulation and just had to identify ways to document our approaches. It was also helpful to have a written plan for staffing nights and weekends to ensure resident needs are being met.”
Health Dimensions and Cascadia each own or operate dozens of nursing homes. LaForte said the assessment requirements would likely be more onerous and costly for smaller operators who can divide the spend across multiple locations.
Cascadia, for instance, relied upon its corporate clinical and quality resource teams to support individual facilities during the assessment process, and the company added additional technology tools specific to the task.
At Florida-based Mission Health Communities, each facility needed about 4 to 6 hours to complete its assessment draft, which was then reviewed by frontline staff, department heads, medical directors and the corporate team.
Leaders put the initial process in the hands of administrators and directors of nursing. The company also used a question in its EHR to solicit stakeholder feedback on staffing, a move that was seen to save time and will be used again when they repeat the process annually.
“Assessment is always a good exercise, and I think the most valuable was having the DON and NHA go away together quietly to really dive in and see where they are and where they want to be now, and in 2-3 years,” said Karen McDonald, BSN, vice president and chief clinical officer for Mission Health.
“The bright spot was the results of the question out to our stakeholders about our staffing. Most of the respondents spoke highly of our staff and how we do try to meet their loved ones’ needs on an ongoing basis. Generally, our stakeholders know how difficult it is for us to recruit staff in very rural areas and the competition we have in the urban areas.”
What’s next
CMS on Monday did not respond to McKnight’s specific questions about the possibility of additional guidance, or how providers might be cited for missing or incorrectly completed facility assessments.
Instead, a spokesman said “the final minimum staffing requirements represent a critical step in the Biden-Harris Administration’s commitment to building a long-term care system where older Americans can age with dignity, people with disabilities can receive high-quality services and supports in the setting of their choice.”
“CMS believes the facility assessment is a foundational element to ensuring nursing homes have the staffing and resources needed to provide safe, quality care that meets the specific needs of their residents,” he added.
Providers, of course, know the assessments’ long-term role is to create a baseline for staffing needs that could ultimately be ratcheted up beyond the 3.48 per patient per day nursing hours that CMS formalized in April.
“Using the resident assessment for making informed staffing decisions to provide an individualized approach to care and services outlined in the care plan may result in the need for more than the minimum staffing mandate,” Haberhern said. “If there’s high acuity in your community or you serve a larger behavioral health population, the surveyors may identify the need for more staff to meet the needs of the residents.”
Another question is whether surveyors will stay within the scope of work they’ve been assigned for now.
McDonald noted the QSO memo said surveyors should “determine whether a facility assessment contains the required components under the regulation. However, they should not evaluate the quality of the assessment.” But she said a list of “investigative procedures” directly following that statement gives surveyors a roadmap by which to judge quality.
“I am always worried at survey time how individual surveyors will interpret the Facility Assessment but with utilizing their own checklist from the Interpretive Guidelines, we are hoping it meets to their satisfaction,” McDonald told McKnight’s.
Yet another issue: how to know exactly when and why to conduct a fresh assessment, beyond the annual requirement.
“Staffing is not static,” McDonald said. “The grey area is what happens if we have behaviors which require 1:1, or God held us, another pandemic. Do we have to redo the FA each time? Does one admission of a resident wishing a vegan diet or a Kosher diet require an entire review? Even though the [guidance] states ‘several,’ who is defining several? I think that could lead to interpretation issues.”
LaForte remains more concerned about long-term implications as the assessment intersects with hourly mandates.
“The place where the one-size fits all staffing ratios — regardless of acuity within a facility, specialization and rural vs. urban markets — meets the resident-specific aspects of the assessments seems like an area where the latter will continue to drive up requirements,” he said. “This seems to drive home the point that we need more collaboration with CMS to solve workforce issues, rather than a tone-deaf mandate without shared input form the people providing the care.”
