The Centers for Medicare & Medicaid Services (CMS) has issued new guidance for Long-Term Care (LTC) facilities addressing staffing requirements based on resident assessments.
The new requirements, which come into effect on August 8, 2024, mandate LTCs to ensure that all future staffing decisions are driven by “data-based resident assessments” of diseases, conditions, physical or cognitive limitations of the resident population; the severity level of those limitations; and “any other pertinent information” that may affect the facility’s services.
These resident assessments must include input from all staff and informed consent-driven residents. These requirements are designed to ensure that LTCs have sufficient nursing staff to meet residents’ needs, as determined by the CMS guidelines. If surveyors find that residents’ needs are not being met due to insufficient staffing, the facility will be cited for noncompliance at §483.35 and required to implement a plan of correction.
Appendix PP of the State Operations Manual (SOM) has been updated to include the revised regulatory requirements and updated guidance for F838 – Facility Assessment. This version of Appendix PP is effective August 8, 2024.
The complete CMS memorandum can be accessed here.
Compliance Perspective
Issue
Facilities must conduct a comprehensive assessment to determine the resources necessary for competent care of residents during regular operations (including nights and weekends) and emergencies. This assessment must be documented and updated annually, or as needed, especially when planning for significant changes that would affect its components. Additionally, facilities must ensure adequate nursing staff with appropriate competencies and skills to deliver necessary services for resident safety and well-being, aligning with resident assessments, individual care plans, and the facility’s resident population characteristics per F838 requirements.
Discussion Points
- Review your policies, procedures, and staffing guidelines to ensure they are designed to result in provision of quality care for all. Review your facility assessment as required by F838 to ensure it addresses the needs of all residents. Update your policies and facility assessment as necessary.
- Train staff who are responsible for hiring to develop innovative and effective ways to recruit and retain staff. Train staff responsible for scheduling and distribution of available staff per unit to ensure that the facility’s staffing levels meet the needs of the residents, that this information is posted as required by regulation, and that staffing is secured on all shifts for this purpose. Train staff on their responsibility to provide safe, high quality nursing care or to provide support services that help meet resident needs.
- Periodically audit to determine if the numbers of staff needed to meet the levels of acuity of all residents in the facility are being posted, and that those staffing requirements are actually being met on all shifts on a day-by-day basis. Also periodically audit to ensure staff are following policies for delivering safe, quality nursing care and support services. Ensure your facility assessment is current, thoroughly assesses the needs of all residents, and determines the resources required to provide high quality resident care and services.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
