New Government Action Puts Pressure on Long-Term Care

April 28, 2021

Get the Latest on Payroll-Based Journal and Five-Star Ratings

Empowered primarily by Payroll-Based Journal Reports, Five-Star Ratings have defined success for long-term care and post-acute care facilities for the past five years. Those with the highest Five-Star Ratings enjoy higher per patient Medicare reimbursements, more physician referrals, better financial rates, and an overall stellar reputation.

Many skilled nursing facilities watched their reputation sour during the COVID-19 pandemic regardless of their Five-Star Rating.

Rising media attention as well as state and federal government scrutiny have put long-term care operators under a microscope as journalists and authorities strive to quantify the reason behind for COVID-19’s devastating effects on resident populations.

Evolving Federal Oversight on Long-Term Care

During his election campaign, President Joseph Biden pledged to make long-term care facilities safe from COVID-19 and other threats while criticizing the previous administration for rolling back regulations designed to protect senior care and post-acute care residents.

The previous administration claimed it valued “people over paperwork” when it sought to reduce compliance requirements during the pandemic. Seema Verma, administrator of Centers for Medicare & Medicaid Services (CMS), chose to reduce survey frequency for skilled nursing facilities with high Five-Star Ratings, stating higher ranked facilities needed less attention.

As part of the Regulatory Relief Act, the Trump administration delayed finalizing a rule requiring  long-term care facilities maintain a compliance and ethics program. But Biden’s new leader of the Department of Health and Human Services, Xavier Becerra  is expected to finalize and enforce these efforts.

Currently, most long-term care facilities have a formal compliance program. Those that don’t should step up their compliance efforts and develop a program that carefully adheres to government guidelines.

New Policy Reinstates Safety and Infection Control Rules

Critics condemned this lack of oversight during the healthcare crisis that slammed long-term and post-acute care facilities and left more than 130,000 dead. After the former administration was accused of allowing COVID-19 to fester in skilled nursing facilities due to weak oversight, the new president released an official policy statement vowing to reinstate key safety rules first established under President Barak Obama.

And now, the burgeoning administration is expected to follow through on promises to improve senior care. What they consider the relaxed of oversight of skilled nursing facilities will likely become history.

President Biden committed to increasing the frequency and scope of surveys for skilled nursing facilities and “restore levels of penalties needed to obtain compliance with quality standards.”  The Biden-Harris proposal features:

  • Mandate requiring an  “infection disease specialist” at every facility
  • Protection guaranteeing workers the right to form and join unions
  • Direction for Occupational Safety and Health Administration (OSHA) to create an emergency temporary standard for nursing home workplace safety
  • A requirement for the Department of Health and Human Services (HHS) Office of the Inspector General (OIG) to audit nursing home cost reports and ownership data, specifically by using the Provider Enrollment Chain and Ownership System (PECOS)

With the spotlight shining brightly on regulation, skilled nursing operators must stay abreast of changes to enforcement and penalties when creating their Payroll-Based Journal action plan. It’s in their best interest to find technology solutions, like integrated Payroll-Based Journal and workforce management systems, that automate compliance monitoring and reporting.

In addition, long-term care operators must prepare for the unexpected —surprise inspections from federal and state regulators, who will look to prove or refute their Payroll Based Journal reports. Not only must they comply to stringent CMS staffing, operators also must stand ready to use their Payroll-Based Journal software to demonstrate compliance at any time. Passing a surprise inspection requires proving compliance for any date or time within a few minutes.

Despite rigorously collecting and creating Payroll-Based Journal reports, operators will struggle to pass a surprise inspection unless their Payroll-Based Journal system is fully integrated with the employee scheduling and time tracking systems.

When it’s integrated with the workforce management applications, the Payroll-Based Journal system can immediately generate compliance reports for any time or date without require administrators manually research and create the PBJ reports.

Infection Control Deficiency

Infection control issues were prevalent before the pandemic but lacked strong consequences for deficiencies. According to a Government Accountability Office report issued in May, 82 percent of more than 13,000 nursing homes surveyed had an infection prevention and control deficiency cited in one or more years from 2013 to 2017. But the Office’s review of federal data shows that “implemented enforcement actions for these deficiencies were typically rare.”

Stricter Oversight of Payroll-Based Journal Reports Coming

Another Biden campaign promise focused on providing staffing and training adequate to meet the needs long-term care residents’ needs. In fact, the President’s team cited a study that drew a correlation between levels of nursing staff and the prevalence of COVID-19 cases in senior care facilities.

Researchers determined the better staffed a facility was, the fewer residents died from COVID-19. More caretakers meant senior care residents received better care and were more closely monitored. The pandemic compounded staffing challenges as the nursing staff and employees fell ill.

The Biden campaign pledged to increase the frequency and scope of surveys and data collection and “restore levels of penalties needed to obtain compliance with quality standards.”

Staffing Ratios Face Widespread Scrutiny

Rumor has it, the government may revise the staffing ratios at skilled nursing facilities, specifically the per patient ratio for caretakers, especially certified nursing assistants (CNAs). CNAs generally care for approximately 15 patients per shift while staff nurses supervise two to three CNAs, according to  Christopher E. Laxton, executive director of AMDA—The Society for Post-Acute and Long-Term Care Medicine. Staff nurses are also tasked with administering medication and other key caregiving tasks for those 30 to 45 patients. Laxton believes this staff-to-patient ratio is insufficient especially when compared to staffing requirements at hospitals.

Meanwhile, studies continue to confirm the connection between levels of nursing care, especially RNs, and better resident outcomes. One study of Connecticut skilled nursing facilities discovered facilities with more RNs experienced fewer COVID-19 cases and deaths. Another study of California facilities found that facilities where RN staffing levels did not meet the recommended minimum standard of 0.75 hours per resident day experienced twice the probability of COVID-19 infections among residents. It also found that  80 percent of the state’s nursing homes didn’t meet that standard.

Growing media attention will undoubtedly pressure the government to review staffing requirements and more carefully inspect staffing data in Payroll-Based Journal reports, which could prompt tougher requirements and mandatory penalties.

New CMS Long-Term Care Guide Hits the Presses

Within a few weeks of Biden taking office, CMS published an updated “Long Term Care Survey Process (LTCSP) Procedure Guide,” which went into effect Feb. 6. The CMS guide describes inspection processes for skilled nursing facilities and directs inspectors to evaluate whether “concerns with staffing can be linked to resident complaints, or quality of life and care concerns.”

In April, CMS proposed a rule that included several regulatory changes, including measuring Medicare fee-for-services claims data to estimate the rates of infections acquired in skilled nursing facilities that resulted in hospitalization. The proposed rule included changes to the Skilled Nursing Facility Quality Reporting Program for FY 2022.

In its rule proposal, CMS aligned infection rates to characteristics in the facility’s operation, such as staffing levels. For example, CMS noted the infections can be related to high turnover rates and low ratios of staff to residents.

While the administration is looking at tightening oversight, Congress, too, is considering changes. Legislators have held hearings looking into long-term care facilities and COVID-19, as well as ways to improve quality of care.

With such renewed focus on skilled nursing facilities, it’s safe to expect there will be increased penalties for falling out of compliance and more surprise audits to support tougher enforcement of regulations. Now, more than ever, it’s crucial to stay abreast of changing regulations and expectations to keep facilities in compliance.

Don’t be surprised to see the government crackdown more on staffing and enact serious repercussions for any facility that violates these regulations.

Find Technology that Promotes Compliance

Technology can make a big difference in satisfying CMS requirements. Workforce management systems can help automate hiring and enhance employee engagement to help stem employee turnover and promote the required level of staffing. Learn the secrets to PBJ success.

Payroll-Based Journal software helps operators prove compliance by automatically collecting staffing data and comparing staffing levels to the resident population, also known as PPD census values.

During the pandemic, CMS waived several quarterly Payroll-Based Journal reports. The demand for quarterly reports resumed later in 2020 despite the Trump administration’s relaxed approach to skilled nursing facility oversight and penalty enforcement.

Not all Payroll-Based Journal systems are the same.  Many systems simply collect historical records and require a great deal of manual intervention. These PBJ reports may help operators meet the quarterly Payroll-Based Journal submission requirements. But they cannot help operators achieve compliance or pass a surprise inspection.

Proactive Payroll-Based Journal reporting can ensure your compliance reports meet CMS standards. When it’s integrated with workforce management applications, such as scheduling and attendance tracking, operators can automatically create schedules that adjust to PPD census values and customize them to also support state staffing requirements.

Looking forward, it’s best to be prepared for enhanced oversight and ready to anticipate the demands of regulators.

This will take some work. But technology can smooth the way and enable facility operators to meet the challenges ahead.

Get started optimizing your Payroll-Based Journal reporting with a personalized demo to ensure all data captured is auditable and verifiable.

For additional tips on how to meet the demands of today's compliance regulations, download our recent webinar "Common Compliance Pitfalls and How to Avoid Penalties". 


Report: 2021 Long-Term Care and Post-Acute Compliance 

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