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HealthStream Executive Briefing: CMS Minimum Staffing Standards: What You Need to Know

July 11th, 2024
July 11th, 2024

Beginning in August, long-term care facilities will be required to demonstrate an increase in RNs and nurse aides to the Centers for Medicare and Medicaid Services (CMS). The rule also contains a provision requiring state Medicaid agencies to report on the percentage of payments for Medicaid-covered services that are spent on compensation for direct care workers. In addition, there are updated requirements for Facility Assessments. It is a daunting challenge and a recent HealthStream webinar provided insight and recommendations into the new rule for long term care leaders.

The webinar was led by HealthStream’s Caroline Acree, Director of Marketing for Quality and Compliance and featured presenter, Tracy Cooley, RN, BSN, Senior Success Manager, HealthStream.

New Requirements – Minimum Staffing Requirements

CMS recently released the final rule (CMS 3442-F) on minimum staffing standards and it requires a significant increase in RN hours. “The new rule requires a registered nurse to be on-site 24 hours per day, seven days a week to provide skilled nursing care to all residents per their care plans. This exceeds the current requirement of 8 hours per day, seven days a week,” said Cooley.

Cooley went on to explain that the standards were developed using case mix adjusted data sources and facilities are required to meet the staffing standard regardless of the case mix of their own facility.

CMS has proposed a staggered implementation for the new rule. Rural facilities will have three to five years to implement the requirement and non-rural facilities will have 2-3 years from the publication of the final rule.

Further, CMS has indicated that these are minimum standards which are subject to re-evaluation and are expected to increase over time.

Medicaid Reporting – Compensation for Direct Care Workers

The final rule also contains a provision requiring state Medicaid agencies to report on the percentage of Medicaid payments covering compensation paid to direct care workers. This provision will not be implemented until June 21, 2028. States will then be required to make this payment information available on public-facing websites. Furthermore, CMS has stated that the information needs to be clear, easy to understand, and verified quarterly. CMS will also report this data on their website.

Financing the New Rule

If this sounds expensive, that is because it is. CMS estimates that implementation will cost long term care facilities 43 billion dollars over a ten-year period. They further expect that facilities will have three approaches to funding the new rule.

  • Reduce margin of profit
  • Reduce other operational costs
  • Increase the costs charged to payors such as Medicare, Medicaid, private insurers, and private pay patients

There will be waivers and exceptions, but CMS will be deciding whether or not to grant them on a case-by-case basis.

Workforce Development

Workforce development will likely be a key strategy of long term care facilities as they plan to implement the new rule. CMS supports the implementation of workforce development programs and is launching a comprehensive workforce development initiative. They are also exploring the possibility of providing technical assistance through existing Quality Improvement Organizations (QIOs). In addition, CMS is launching a campaign to help workers pursue careers in nursing homes. The campaign will support recruiting, training and retention of long term care staff.

Facilities will also need to use their Facility Assessments to develop and maintain a staffing plan to maximize recruitment and retention of direct care staff. The staffing plan must be documented and is considered to be a demonstration of a good faith effort to hire staff.

Updated Facility Assessment

CMS has also finalized several updates to the Facility Assessment requirements. Facilities must now demonstrate that they use evidence-based methods when creating care plans for residents, including those with behavioral health issues. This assessment must be used to determine the specific needs of residents on each unit. Facilities will also be required to consider input from nursing home leadership, management and direct care workers. They have also added that facilities consider input from residents, family members, resident representatives, and representatives of direct care staff.

Solutions for Leaders

The requirements of the new rule are likely to feel overwhelming for long term care leaders, but HealthStream has solutions that can greatly simplify the implementation of the new rule. HealthStream's Quality Manager has an interactive Facility Assessment template which includes a comprehensive staffing plan template.

In addition, Quality Manager's MDS Resident Population Profile includes MDS resident-based data to address the regulation requiring the use of evidence-based methods to inform care planning decisions. The MDS Resident Population Profile is based on a year's worth of stays and provides a quantitative picture of the types of care being provided. Users can see this profile within the Facility Assessment Workflow in the Quality Manager system and is also available as a standalone report.

Cooley encouraged leaders to begin preparing to address the new rule and suggested that leaders: 


  • Take a proactive stance
  • Have sufficient competent nursing staff
  • Consider resident preferences when determining staffing
  • Review and update your Facility Assessment

Reach out to HealthStream today to learn more about how Quality Manager can help your facility meet these updated requirements.

 

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