Several years ago the U.S. Centers for Medicare and Medicaid Services (CMS) required skilled nursing facilities (SNFs) to report nurse staffing levels using the SNF’s payroll records, in an effort to obtain more accurate information about actual daily nurse presence in SNFs. CMS has collected this Payroll Based Journal (PBJ) information for a few quarters now. CMS uses this data to publically report each SNF’s nurse staffing level on its Nursing Home Compare website and to calculate each SNF’s Five Star Rating. Publication of this PBJ data is part of CMS’ initiatives to keep consumers informed about SNF quality, so that market pressure will incentivize SNFs to improve their performance. But the PBJ data is now going to bite some SNFs through survey enforcement.

On November 30, 2018, CMS announced its concern with the most recent PBJ data (see QSO 19-02 NH). The data revealed that some SNFs have markedly decreased nurse staffing levels on weekends, and some do not have a Registered Nurse (RN) at the facility every day as required by the Requirements for Participation for Long-term Care Facilities (ROPs). Consumer advocates and CMS have long contended that inadequate nurse staffing contributes to poor resident outcomes such as increased hospitalizations. Indeed, in its 2016 overhaul of the ROPs, CMS made it clear that SNFs must tailor both the number and qualifications of nursing staff to meet the needs and acuity level of the SNF’s particular resident population. Adherence to state minimum staffing numbers is just the beginning of staffing compliance; the ROPs impose a higher standard that can vary from unit to unit within a single facility.

The November 30, 2018, announcement states that CMS will notify state Survey Agencies of SNFs that have markedly lower nurse staffing levels on weekends and/or an absence of an RN for several days during a quarter. The Survey Agency will be required to conduct an on-site survey of the offending SNFs—on a weekend if appropriate—and consider issuing deficiency citations if the nurse staffing levels are deemed to be inadequate. Cited SNFs will at a minimum be required to submit and implement a Plan of Correction and may face enforcement penalties like civil money penalties or denial of payment. In extreme cases, lack of an RN may raise questions of professional licensure compliance for individuals that need RN supervision, and/or possible Medicare/Medicaid overpayment.

To avoid being on CMS’ new Wall of Shame, SNFs should consider several actions:

• Verify that they are correctly submitting their PBJ data to CMS. The PBJ system is complex and there are many opportunities to both under and over report staffing levels. CMS offers assistance to SNFs on its website.
• Review their mandatory Facility Assessment to verify that they have identified and analyzed all factors appropriate to determine proper staffing levels for RNs, Licensed Practical Nurses (LPNs) and Certified Nurse Aides (CNAs). Be sure to include resident acuity and cognitive impairments in the analysis.
• Be sure that staff scheduling reflects the assessed need, and that appropriate procedures are in place to quickly fill temporary staffing vacancies. All SNFs face the frustration of a staff no-show or last-minute call in. Survey Agencies may not be forgiving if the SNF does not have an actionable plan to cover these contingencies.
• Take advantage of CMS’ online tools to assist in staff retention and morale. The newly announced Civil Money Penalty Reinvestment Initiative (CMPRI) will produce toolkits in 2019 to assist with these staffing concerns.

By taking charge of PBJ reporting and nurse staff scheduling, SNFs can avoid being bitten by the PBJ sandwich.