CMS Issues PBJ Updates, 2 New MDS Reports and Notifications to State/Regional Offices

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare®

All of the information below was released on Friday, November 30th via QSO 19-02-NH and CMS Strengthens Nursing Home Oversight and Safety to Ensure Adequate Staffing – Press Release.


Notification to States and CMS Regional Offices

While CMS is encouraged by facilities’ efforts to improve staffing, we are also concerned about some of the findings from the new PBJ data. For example, some facilities are reporting several days in a quarter without a registered nurse (RN) onsite and/or significantly low nurse staffing levels on weekends (see QSO-18-17-NH). Since nurse staffing is directly related to the quality of care that residents’ experience, CMS is very concerned about the risk to resident health and safety that these situations may present. Therefore, CMS will begin informing state survey agencies of facilities with potential staffing issues: facilities with significantly low nurse staffing levels on weekends; and facilities with several days in a quarter without an RN onsite.

Facilities identified as having low staffing on weekends:

The State Operations Manual, Chapter 7, section 7207.2.2, requires states to conduct at least 10 percent of the standard health surveys on the weekend or before 8:00 a.m. or after 6:00 p.m. (i.e., “off-hours”). States shall [now be required to] conduct at least fifty percent of the required off-hours surveys on weekends using the list of facilities provided by CMS.

Facilities identified as having reported days with no RN onsite:

We are aiding surveyors’ investigations by identifying facilities who have higher risk of noncompliance with the RN staffing requirement. When conducting a scheduled standard or complaint survey (regardless of the type of complaint), surveyors should investigate compliance with 42 CFR 483. 35(b)(1), which is the requirement for a facility to provide the services of an RN seven days a week, eight hours a day. If a surveyor confirms that this requirement has not been met, the facility shall be cited for noncompliance under deficiency F-tag 727.

CMS Administrator Seema Verma is quoted in that press release.   “Today CMS is taking important steps to protect nursing home residents based on potential risks revealed by new payroll-based staffing data that our Administration released. We’re deeply concerned about potential inadequacies in staffing, such as low weekend staffing levels or times when registered nurses are not onsite, and the impact that this can have on patient care. The actions announced today strengthen our oversight of resident health and safety, and help ensure accurate public reporting.”

“CMS will use frequently-updated payroll-based data to identify and provide state survey agencies with a list of nursing homes that have a significant drop in staffing levels on weekends, or that have several days in a quarter without a registered nurse onsite.  State survey agencies will then be required to conduct surveys on some weekends based on this list.  If surveyors identify insufficient nurse staffing levels, the facility will be cited for noncompliance and required to implement a plan of correction.”


PBJ Policy Manual and FAQ Updates

Meal Break Policy:

We are expanding the guidance in the PBJ Policy Manual related to deducting time for meal breaks. Note: This is not a change in policy, but that we are only providing additional details. The guidance includes information for deducting meal times for specific shifts (e.g., eight-hour shifts, twelve-hour shifts, etc.). We have also added a Q&A to the PBJ Policy FAQs that explains the rationale for the meal break policy.

Universal Care Workers:

Some facilities employ “Universal Care Workers,” who are typically certified nurse aides (CNAs) who perform additional duties outside of the nurse aide role, such as food preparation or light housekeeping services. CMS has added language to both the PBJ Policy Manual and the PBJ Policy FAQ to instruct facilities that they must use a reasonable methodology to allocate the hours that these employees are providing CNA services and report these hours accordingly. Hours spent on other duties (i.e. housekeeping, cooking etc.) must not be reported as CNA hours.  These hours can be reported under housekeeping or other services; however, reporting of these hours is not required.


MDS Census Reports

CMS has created two reports for providers to help ensure data is submitted accurately and in a timely manner. These reports use the same methodology CMS uses to calculate each facility’s census, which is then used to calculate the number of staff hours per resident per day posted on the Nursing Home Compare website. The reports are:

The MDS Census Summary Report:

Allows users to retrieve the daily MDS-based resident census (i.e., count of residents) for each day in a quarter.

MDS Census Detail Report:

Allows users to retrieve a list of the residents that the MDS-based census is comprised of on a given date or dates.

Please reference the QSO 19-02-NH (hyperlink provided in 1st paragraph) for additional website links to supporting information.  All of this information is critical to your daily work.