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The Centers for Medicare & Medicaid Services (CMS) recently introduced a proposal for minimum staffing standards in long-term care (LTC) facilities. It is part of the broader Nursing Home Reform initiative by the Biden-Harris Administration, which is focused on ensuring safe and high-quality care. The main goal is to establish CMS minimum staffing requirements for LTC facilities. 

The proposed rule sets new staffing standards based on the case mix, revising the requirements for registered nurses (RNs), and reevaluating facility assessments. Also under this proposal, nursing facilities will have to provide residents with a minimum of 0.55 hours of registered nurse (RN) care and 2.45 hours of nurse aide care daily. It’s worth noting that this new rule does not cover licensed practical nurses.

The CMS guidelines for long-term care facility requirements were initially published in 2016. These guidelines were implemented in three distinct phases: 

Phase 1 in 2016, Phase 2 in 2017, and Phase 3 in 2019. The rationale behind this phased approach was to allow facilities sufficient time to acquaint themselves with new regulations and participate in surveys designed to assess their compliance.

Team that is stronger because of the CMS minimum staffing requirements.
Ensuring adequate staffing levels for quality care – CMS minimum staffing requirements matter.

During Phase 1, a key focus was placed on the qualifications of key personnel, including registered dietitians, dietary managers, and staff members, and the CMS expanded the scope of Dietary Services (483.85) to encompass Food and Nutrition Services (483.60). As a result, facilities are now mandated to employ a full-time, licensed registered dietitian or a certified dietary manager along with a consulting dietitian. 

Another important addition was the inclusion of support staff to ensure that facilities have an adequate workforce capable of efficiently managing the responsibilities of the Food and Nutrition Services department.

In Phase 2, the CMS made revisions to the f-tags specific to nursing facilities. In some instances, tags were consolidated or subdivided into multiple subsections. Concurrently, there was a transition from traditional paper-based surveys to a computer-based process. This new f-tags approach integrated both the conventional survey and the Quality Indicator Survey (QIS) to enhance efficiency and effectiveness in the survey process.

A shift happened on February 28, 2022, when the White House released a fact sheet that underscored the imperative for substantial improvements in nursing home care. This call to action centered on enhancing the quality of care afforded to seniors, individuals with disabilities, and other residents of nursing homes. Consequently, a comprehensive suite of reforms, diligently formulated and implemented under the purview of the Department of Health and Human Services (HHS), has been set in motion.

These reforms are designed to usher in a new era of nursing home care, marked by heightened safety and quality standards. Nursing homes are expected to be more accountable for the care they provide. And greater transparency is expected from owners so that potential residents and their families can receive the requisite information to make informed choices regarding care facilities. Here we’ll clarify what these requirements entail and what they mean for nursing homes in the US.

CMS Phase 3 Requirements

CMS Phase 3 requirements are part of a comprehensive framework for ensuring the quality and safety of care provided in nursing homes. Phase 3 of CMS minimum staffing requirements includes various elements, such as:

Visual representation of CMS phase 3 requirements.
CMS Phase 3 requirements have emerged as a pivotal progression towards elevating standards.
  • Emergency Preparedness: Nursing homes must have comprehensive emergency preparedness plans in place to effectively address natural disasters, pandemics, and other emergencies.
  • Behavioral Health: Phase 3 emphasizes the importance of addressing the behavioral health needs of residents, including psychological and emotional well-being, through person-centered care.
  • Trauma-Informed Care: Nursing homes must adopt a trauma-informed care approach that considers the potential trauma history of residents and seeks to create a safe and supportive environment.
  • Infection Control: Strict infection control protocols are mandated to prevent the spread of infections within the facility.
  • Pharmacy Services: CMS Phase 3 also focuses on improving medication management and oversight, ensuring residents receive appropriate medications and minimizing adverse drug events.
  • Quality Assurance and Performance Improvement (QAPI): Nursing homes are required to have a QAPI program in place to continuously assess and improve the quality of care and resident outcomes.

It should be noted that Phase 3 provides for timeframes of three and five years in both urban and rural contexts to achieve the 0.55 hours for resident nurses and 2.45 hours for nurse aides per resident day requirements mentioned above.

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Standard Staffing

The proposed staffing rule requires certain standard staffing levels in long-term care facilities. Here’s a concise summary of the key CMS minimum staffing requirements:

Visual representation of standard staffing.
Standard staffing underpins the delivery of quality care.
  • Minimum Staffing Levels: The proposed rule mandates specific staffing levels in terms of hours per resident day (HPRD) for two roles: registered nurses (RNs) at 0.55 HPRD and nurse aides (NAs) at 2.45 HPRD. It does not specify minimum staffing requirements for licensed practical nurses. Higher staffing may be necessary based on patient populations and acuity.
  • The CMS’ Basis: The proposed minimums are based on a new 2023 staffing report by the CMS, which found a “statistically significant difference in safety and quality care” at certain minimum levels. The CMS aims for these minimums to exceed state minimum staffing requirements to improve quality and safety while considering cost-effectiveness.
  • RN Availability: The rule also requires a registered nurse (RN) to be present on-site 24/7 and available to provide care. This is in addition to the 0.55 HPRD RN requirement.
  • Facility Assessments: The rule includes additional requirements for facility assessments, such as using evidence-based methods for care planning, assessing specific resident needs, involving staff in care planning, and developing staffing plans to recruit and retain staff effectively.
  • Exemption Process: The CMS proposes an exemption/hardship process for the RN and NA HPRD minimums. Facilities that fail to submit Payroll-Based Journal data or are facing staffing-related issues resulting in harm may be ineligible for this exemption. To qualify for an exemption, facilities must be:
    • In an area with an insufficient nursing workforce
    • Located at least 20 miles from another nursing home
    • Making efforts to hire and retain staff
    • Showing a financial commitment to staffing may qualify for an exemption

Staffing requirements can vary significantly from state to state. Today, each state has developed its own distinct regulations governing staffing levels within nursing homes. These regulations take various factors into account, including the size of the facility and the specific needs of its residents. Make sure to check nursing home staffing requirements by state to get a better understanding of local specifics. 

The introduction of CMS Phase 3 requirements marks a significant milestone in the advancement of nursing home quality. For example, starting in summer 2023, there have been significant changes in how nursing homes and their staff manage information using the Payroll-Based Journal (PBJ) system. 

The PBJ system is a tool employed by nursing homes to meticulously monitor the working hours of their staff. This includes collecting data on various staff categories, such as nurses, aides, therapists, and more. The crucial point is that nursing homes are required to submit this data on a quarterly basis.

The primary purpose of gathering this data is to gain insights into the number of hours worked by different staff types within each nursing home. Furthermore, it plays a vital role in determining the daily population of residents living in these nursing homes.

As for CMS phase 3 requirements, there has been a change in where the PBJ data is now stored. Since the summer of 2023, this valuable information has been housed in a new location. Importantly, the dataset has grown significantly in size, making it necessary to use specialized software to handle it effectively. These adjustments signify a shift in how nursing homes manage staff and resident data for improved efficiency and accuracy.

As you can see, the CMS staffing requirements for nursing homes encompass multiple facets of care, spanning from registered nurses and licensed practical nurses to nursing assistants. They are important, as they help ensure that nursing homes meet and adhere to these requirements directly correlate with the creation of a safe, comfortable environment for residents.

CMS Minimum Staffing Requirements

The constantly shifting terrain of nursing home regulations, while sometimes difficult to navigate, is designed to promote the safety and well-being of residents. The introduction of CMS minimum staffing requirements raises the bar for care standards. To meet its standards, caregivers must stay informed, embrace evolving regulations, and make staffing a priority. By doing so, we can create a nurturing and secure environment for those under our care. 

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