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Nursing Home Compliance: Prepare for Focused Inspections

To align with the latest federal guidance on state nursing home surveys, consider what policies and practices you need to update to better ensure regulatory compliance.

New requirements from the Centers for Medicare and Medicaid Services (CMS) announced in November 2021 and a new time-limited enforcement effort by the Occupational Safety and Health Administration (OSHA) announced in March call for focused inspections and put a higher level of scrutiny on nursing home compliance and the quality of care provided.

In a recent presentation on compliance, Trish Richardson, MSN, BSBA, RN, NE-BC, CMSRN, Director of Post-Acute Care Solutions at Relias, acknowledged that preparing for these state surveys can be stressful for nursing home directors and staff. Richardson also shared some motivational insights: “I see it as an incredible opportunity to position yourselves to achieve successful surveys and improve care quality and resident experiences.”

To position your nursing home for optimal outcomes, it is important to examine the CMS changes concerning surveys, the OSHA inspection initiative, and what steps you can take to better prepare for these surveys.

Enhanced Nursing Home Oversight

Post-acute care facilities have long been the subject of reforms targeting quality of care and staffing issues. The COVID-19 pandemic, the biggest public health crisis most of us have witnessed, shook the nation to its core and had a tragic impact on our nursing homes. It’s no surprise that governing agencies took notice and called for change.

In March, an OSHA memo announced a focused, short-term initiative involving inspections of skilled nursing facilities and hospitals that have prior citations or complaints and treat COVID-19 patients. OSHA is “focusing on follow-up and monitoring inspections of hospitals and skilled nursing care facilities that OSHA had previously inspected or investigated,” the memo said. The agency intends to magnify its presence in those facilities with the goal of protecting the health and safety of healthcare workers at higher risk of contracting the coronavirus.

Other calls for reform have come from inside the healthcare industry. In early 2021, the American Health Care Association and LeadingAge proposed the Care for Our Seniors Act. This act calls for enhanced clinical oversight and infection control requirements, more robust staff development, accountability for poor-performing facilities, and changing accommodations to single-resident rooms to assist in infection control efforts, according to a LeadingAge press release.

CMS Guidance to State Survey Agencies

A November 2021 CMS memo shared concerns that the lack of traditional nursing home oversight during the pandemic may have had detrimental effects on seniors’ health and safety. CMS outlined steps that state survey agencies should follow to manage the backlog of complaint and recertification surveys.

According to CMS, its Focused Infection Control survey timing will be adjusted back to a rate of 20% of nursing homes surveyed annually, and recertification surveys will return to a scheduled routine. To efficiently move through the backlog, CMS has offered additional guidance and is allowing some flexibility in investigating complaints.

While it may seem like the guidelines are returning to pre-pandemic levels, nursing homes will actually come under greater scrutiny in 2022. CMS has instructed state survey agencies to prioritize surveys of nursing homes that:

  • Report new COVID-19 cases and have low vaccination rates
  • Are special-focus facilities
  • Have a history of:
    • Complaints of abuse or neglect
    • Infection control issues
    • Failures to follow transfer or discharge requirements
    • Insufficient staffing or nurse competency levels
    • Care quality issues

In addition to detailing those priorities, CMS asked surveyors to investigate other problem areas. Staffing and nurse competency concerns, overuse of antipsychotics, and quality of care issues — such as pressure wounds, unexplained decline in function, or weight loss — will trigger a deeper look into the facility’s practices.

White House Reform Initiatives

During the 2022 State of the Union (SOTU) address, President Biden referenced reforms targeting nursing homes and their owners/operators, saying that Medicare will provide stricter oversight of nursing homes. In addition, the purchase of nursing homes by private-equity firms has been shown to contribute to declining care quality and higher costs, Biden said, and those entities will face intense scrutiny and reform in the future.

A White House briefing released prior to the SOTU address detailed four initiatives to ensure that nursing homes provide care to residents that is safe, of the highest quality, and transparent to families and the public. These initiatives will:

  • Set minimum guidelines for staffing numbers, as well as for types of staff employed
  • Support better infection control by changing nursing home accommodations to a one-resident-per-room model
  • Update the value-based purchasing program payments, making payments dependent on facility ratings by residents, whether the staffing requirements are met, and staff turnover rates
  • Further reduce the use of antipsychotic medications

CMS will be tasked with holding nursing homes accountable for the care they provide their residents and terminating underperforming facilities from Medicare or Medicaid programs. Financial penalties will be higher than in the past, and CMS will broaden what constitutes an out-of-compliance situation.

According to the briefing, CMS will be given the authority to investigate owners of nursing homes to uncover past compliance issues. Biden is asking CMS to create a public database to increase transparency of nursing homes’ history. The database will include a history of compliance issues and violations, as well as a history of the owner’s present and past nursing home holdings in other states.

Assessing Your Compliance Strategy

Understanding how these initiatives impact your business is a crucial step as you update your compliance plans at the facility level. An important step is to review your education management policies and systems to ensure they are adequate for your compliance needs.

A compliance and education management system that saves time and keeps you on track for future surveys can help ease the burden that educators and HR personnel face in this year of changing compliance regulations.

In her presentation, Richardson encouraged an honest evaluation of your current compliance management practices and the systems that support them by asking:

  • How is your compliance information recorded? Can the information be recorded efficiently and pulled for data reporting? Is it up to date?
  • How often are training modules updated? How often are state and federal regulations reviewed and updated?
  • Can your compliance data be accessed easily when surveyors come knocking?

“Surveyors will be placing your organization’s compliance program and practices under a microscope,” said Richardson. A single missing piece can have a financial impact on your business, as you well know. Having an efficient compliance management system can provide peace of mind for your educators and HR personnel as they work to navigate the changing regulatory landscape.

Your Compliance Management Program

Richardson reviewed some of the benefits of using a robust compliance management program:

  • Targeted education modules based on system-identified knowledge gaps, resulting in safer care for residents
  • Improved quality care scores
  • An improved reputation built on high-care-quality standards that positions you for referrals from hospitals and other acute care facilities
  • A survey-ready facility and staff
  • Educators focused on educating and retaining staff instead of manually keeping up with new regulations and updating training

A robust compliance management program can “increase staff preparedness, which increases safety of the care environment, which increases care quality and outcomes and improves overall survey readiness,“ said Richardson.

Increasing care quality involves a partnership with your staff as you hire, educate, mentor, and evaluate. If instead you are spending time manually keeping track of evolving regulations, monitoring licensure and education requirements, and updating compliance training, you have less time to focus on your quality goals.

Again, consider what strategies and policies you can put in place or enhance to better manage your alignment with these new expectations. Make sure you have systems that support your ability to adapt along with the compliance regulations and successfully emerge from regulatory scrutiny.


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