Skilled Nursing Facilities Targeted for Increased Government Oversight

May 27, 2021

Even as the pandemic recedes as a threat to older Americans, the pressure on senior care facilities to live up to government expectations is poised to intensify.

This means oversight is likely to be amped up as state and federal governments focus their attention on long-term and post-acute care facilities. Government inspections and reporting requirements are also set to increase. Although the federal government has not unveiled any changes to Payroll-Based Journal reporting requirements that skilled nursing operators submit, it has reinstated penalties for noncompliance and announced renewed regulatory enforcement.

Prepare for the unexpected by strengthening Payroll-Based Journal capabilities

As operators work to address concerns and brace for what’s coming, it’s a good time to prepare for surprise inspections and lock down your Payroll-Based Journal reporting.

If you haven’t already done so, consider automating every aspect of Payroll Based Journal reporting. The government will continue using Payroll-Based Journal reports as their primary method to evaluate staffing levels at skilled nursing facilities and a key factor in setting Five-Star Ratings.

Make sure your Payroll-Based Journal system is up to the task. Many standard Payroll-Based Journal systems collect staffing records at the end of the quarter to help you meeting federal Payroll-Based Journal reporting deadlines. This reactive approach to PBJ  reporting may have worked in the past but it carries a hefty risk now.  

State and federal regulators are stepping up their Payroll-Based Journal audits and onsite inspections. You may not receive any notice of inspection or audit. Regulators may perform some audits virtually.  Either way, inspectors will review your Payroll-Based Journal reports. They will demand you prove the Payroll-Based Journal reports you submitted are accurate by verifying the legitimacy of individual reports against other records, such as timecards.


Keeping up with Payroll-Based Journal demands means you should monitor staffing levels throughout the quarter, look for trends and correct issues before they jeopardize your Five-Star Rating. You can do this when your Payroll-Based Journal system is integrated with employee scheduling and time tracking applications. If it is, you can easily create Payroll-Based Journal reports throughout quarter, such as every month or pay period. Then you can quickly spot problems and work to resolve them. You will alleviate the tedious collection and processing efforts that operators face when they procrastinating their Payroll-Based Journal reporting and run up against the deadline.

You must also make sure your Payroll-Based Journal reports are auditable. When you integrate PBJ reporting software with your workforce management system, you can alleviate this compliance burden by creating clear auditable records that align time tracking and staffing. An integrated Payroll-Based Journal and workforce management system lets you search staffing records on demand and align them with the Payroll-Based Journal criteria, such as unique IDs, to prove their authenticity. Meanwhile standalone PBJ reporting systems will make you vulnerable to poor ratings.

Biden and Congress want skilled nursing facility reform

The current administration and multiple Congress members want to reverse the Trump administration’s regulation rollbacks and reductions in oversight of skilled nursing facilities – actions they maintain exacerbated the devastating impact of COVIC-19 on nursing home residents. The efforts are not exclusively partisan, as Republicans in Congress have joined Democrats in supporting in some these measures.

New CMS head pledges accountability for skilled nursing facilities

President Biden appointed Chiquita Brooks-LaSure as head of the Centers for Medicare and Medicaid Services, telling the Senate her top priority will be holding long-term care and post-acute care facilities “accountable for providing high quality care to their residents.”

The pledge from Chiquita Brooks-LaSure came in response to written questions submitted by Sen. Ron Wyden, D-OR, chairman of the finance committee, which subsequently split along party lines on her nomination, sending it to the full Senate without a recommendation.

In her written response, Brooks-LaSure also pledged “to work to address the disproportionate impact of COVID-19 on nursing home residents, especially those of color. I will also work to improve transparency, evaluation and accountability, including increasing the available data regarding vaccinations in nursing homes.”

Both the Biden administration and Congress are aiming for increased ongoing scrutiny of long-term care facilities, which were hit hard by the pandemic.

CMS proposes new regulations

CMS has updated its “Long Term Care Survey Process (LTCSP) Procedure Guide,” with the changes going into effect in early February. The guide outlines the processes for surveyors to inspect facilities and directs inspectors to determine if “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. Among those is a requirement to measure Medicare fee-for-services claims data to estimate the rates of infections acquired during care in skilled nursing facilities that result in hospitalization. The proposed rule included changes to the Skilled Nursing Facility Quality Reporting Program for FY 2022.

In addition, CMS is seeking to add new reporting requirements. A proposed regulation would require skilled nursing facilities to disclose COVID-19 vaccination rates among residents and staff as of Oct. 1, 2021. On that date, facilities would also be required to report healthcare-associated infections, including pneumonia and sepsis.

Federal law proposed to reform long-term care oversight

In the meantime, the two Pennsylvania senators, Bob Casey, a Democrat, and Pat Toomey, a Republican, have introduced legislation to reform senior care facilities’ oversight and enforcement. Then bill focuses on those facilities that consistently fail to meet health and safety standards.

The bill would also increase educational resources for underperforming facilities and create an independent advisory council to work with the Department of Health and Human Services on how to improve quality.

Second bill proposed to restore regulations on skilled nursing facilities

Democratic representatives Bill Pascrell and Mikie Sherrill have joined with Senator Bob Menendez introduce companion bills in the two chambers known as the Preparedness and Advancing Response to Epidemics in Long Term Care Act (PREPARE LTC Act) to restore regulations repealed by former President Trump, which they said disregarded safety and undermined accountability.

Among other things, the bill would prevent the secretary of Health and Human Services from waiving or suspending staffing reporting or critical inspections during a pandemic.

The bill would also increase reporting requirements related to infectious diseases, including COVID-19.

While Congress decides whether to enact these reforms, regulators have begun making changes.

Inspections eased during the pandemic, later reinstated

In March 2020, the Centers for Medicare and Medicaid Services (CMS) suspended standard surveys at long-term care and other medical facilities, to allow inspectors to concentrate their efforts on infection control.

Inspections for life safety code and emergency preparedness were scuttled between March and August, while surveyors concentrated on targeted infection-control surveys and surveys related to complaints and facility-reported incidents determined to be at the level of immediate jeopardy.

While the move was welcomed by providers, several members of Congress weren’t pleased. Two representatives from Pennsylvania, Conor Lamb and Mike Doyle, wrote a letter to CMS urging the agency to increase the frequency of inspections:

In normal times, visiting family members are the first line of defense against unsafe and unsanitary conditions. Now, if these conditions are allowed to develop for even a moment, and they are undetected because of the absence of visitors, the lives of our seniors will be at risk. With the new risks posed by COVID-19, and the absence of visiting family members, the current CMS inspection cycle of 9 -15 months is inadequate. COVID-19 spreads quickly through vulnerable communities such as long-term care residents and is unforgiving of mistakes or delayed responses. In Western Pennsylvania, Brighton Rehabilitation and Wellness Center is a concrete example of the risk to our seniors with over 400 presumed positive residents and over 60 COVID-19 related deaths.

Illinois considers revamping reimbursement model

Illinois legislators are contemplating ways to target understaffing at long-term care facilities. They considering revising the assessment fees that skilled nursing operators pay to subsidize proposals they believe can alleviate understaffing. The proposed law would increase reimbursements to operators that increase their staff of registered nurses, certified nursing assistants, and licensed practical nurses.

In addition, state lawmakers are also considering changing their reimbursement from services facilities provide to the Patient Driven Payment Model.  Meanwhile

Pennsylvania steps up onsite inspections

Pennsylvania resumed onsite inspections when the national suspension of routine inspections was lifted in August 2020. Numbers published monthly by the Pennsylvania Department of Health, which oversees 692 skilled nursing facilities, don’t show a significant change in the quantity of inspections conducted by that state for CMS at skilled nursing facilities. There were 450 inspections in February 2020, for example, 537 in March 2020 and 486 in April of that year.

The statistics include both CMS inspections and information on building inspections.

However, inspections dropped in May, June and July – 292, 269 and 330 – rising significantly in August to 635 and then 543 in September. The up and down numbers continued, with numbers ranging from 395 in November to 712 in January. The state began delineating in June 2020 how many of the monthly inspections were COVID-specific.  Those numbers ranged from 522 in August 2020 to 90 in April 2021.

Learn more about pressing compliance issues, download the free eBook, Long-term and Post-Acute Care Compliance in 2021.

See how you can simplify Payroll-Based Journal reporting, request a PBJ Reporting demo.  



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