CMS Updates LTC Surveyor Guidance (Again) and Extends Implementation Date

(Jan. 21, 2025) On Jan. 16^th, the Centers for Medicare and Medicaid Services (CMS) issued memorandum QSO-25-12-NH, which is a revision to the earlier QSO-25-07-NH released in November updating Appendix PP of the State Operations Manual (SOM). Providers should be aware that the effective date of these new revisions to the Long-Term Care Surveyor Guidance, originally Feb. 24, 2025, has been extended to March 24, 2025.

The latest updates are related to nurse staffing and Payroll-Based Journal (PBJ). CMS instructs surveyors in how to use PBJ data in reviewing for sufficient nurse staffing and Director of Nursing (DON) requirements. The new guidance instructs surveyors in interviewing all types of staff and residents/representatives to determine sufficient staffing.

The details of the additions to the SOM in F725, F727, and F851 are described in detail below.

Sufficient Nursing Staff, RN 8 Hrs./7days/Wk., Full Time DON, & Payroll Based Journal

Guidance for investigations using the Payroll Based Journal Staffing Data Report has been added. This report will be used as one of the sources of information indicative of potential noncompliance. Instructions specific to staff interviews, observations, key elements of noncompliance, and deficiency categorization are also added to the guidance. Instructions to surveyors based on whether or not the report identified concerns were added to the guidance. Investigative probes for the Director of Nursing requirements and deficiency categorization examples, as well as investigative procedures for evaluating compliance with the submission of direct care staffing information and payroll using the Payroll Based Journal Staffing Data Report were added to the guidance.

F725 – Nursing Services

“Licensed Nurse” means any nurse that requires the successful completion of a National Council Licensure Examination (NCLEX-PN or NCLEX-RN). At a minimum this would include a Licensed Practical Nurse (LPN) or a Registered Nurse (RN). Licenses and titles are defined and protected by the Nurse Practice Act (NPA) for usage in the public. They are privileged and granted by the Board of Nursing (BON) after meeting the requirements of graduating from accredited nursing educational programs, passing professional board examinations, background checks, and paying applicable fees.

“Charge Nurse” is a licensed nurse with specific responsibilities designated by the facility that may include staff supervision, emergency coordinator, physician liaison, as well as direct resident care.

“Scope of Practice” describes the services that a qualified health professional is deemed competent to perform and permitted to undertake – in keeping with the terms of their professional license.

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The facility is required to provide licensed nursing staff 24-hours a day, along with other nursing personnel, including but not limited to nurse aides. The facility must also designate a licensed nurse to serve as a charge nurse on each tour of duty.

Concerns such as falls, weight loss, dehydration, pressure ulcers, elopement and resident altercations can also offer insight into potential insufficient numbers of staff available in the facility. Surveyors must discuss these concerns during team meetings and investigate how or if these adverse outcomes are related to sufficient staffing.

Compliance with State staffing standards does not necessarily determine compliance with Federal staffing standards that require a sufficient number of staff to meet all of the residents’ basic and individualized care needs. If a facility does not meet state regulations for staffing, do NOT cite that as a deficiency here, but refer to Administration, F836, §483.70(b).

Cite this F-Tag only if there is non-compliance related to a facility not providing services by sufficient number of nursing personnel (licensed and non-licensed), not providing licensed nursing staff 24-hours a day, and/or does not have a licensed charge nurse on each tour of duty.

NOTE: The actual or potential physical, mental, or psychosocial resident outcomes related to noncompliance cited at F725 should be investigated at the relevant tags, such as Abuse at §483.12, Quality of Life at §483.24, and/or Quality of Care at §483.25.

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While many factors may need to be considered when determining if a facility has sufficient nursing staff to care for residents’ needs, as identified through the facility assessment, resident assessments, and as described in their plan of care, the PBJ Staffing Data Report provides very clear and distinct areas that could identify deficient practices. The steps below must be followed to determine the facility’s compliance with F725, using the PBJ Staffing Data Report as a starting point.

The PBJ Staffing Data Report identifies if the facility:

Reported no RN hours (F727);
Failed to have Licensed Nursing Coverage 24-hours/day (F725);
Reported excessively low weekend staffing (F725);
Has a one-star Staffing Rating (F725); and
Failed to submit PBJ data for the quarter (F851).

The staffing domain of the Five Star Quality Rating system is based on six specific measurements that are derived from the PBJ data submitted by the facility.

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1. Identify if the facility is triggered for reporting NO licensed nursing coverage 24-hours/day. If this metric is triggered on the PBJ Staffing Data Report:
  1. During the entrance conference, the TC must inform the facility of these infraction dates and that a citation at F725 will be issued unless evidence is provided that shows the facility had licensed nursing coverage 24- hours/day on those infraction dates. Acceptable evidence is timecards, timesheets, or payroll information that clearly shows licensed nurse coverage on the dates in question. A schedule of who was supposed to work is NOT acceptable.
  2. If the facility does not provide acceptable evidence, a citation at F725 must be cited at a minimum of scope and severity of “F”. The scope and severity may be increased based on further investigation throughout the survey. If the facility does provide the evidence that there was 24-hour licensed nursing coverage, surveyors must continue to conduct investigations as described below to assess compliance with the requirements for facilities to have sufficient nurse staffing.

Note: If the facility failed to have licensed nursing coverage 24-hours/day, (e.g., four or more days as indicated by the PBJ Staffing Data Report or for even just one day as indicated through general investigations), F725 must be cited.

If the surveyor is aware of the absence of licensed nurse (LN) coverage on one or more days use the following questions to provide insight into severity that may have already been identified, such as incidents that caused harm or placed residents in immediate jeopardy (IJ) for serious harm when a licensed nurse was not available.

Director of Nursing or Administrator

How often are there days with no LN onsite available to provide care for residents?
What types of services or care are not provided when there is no LN staff in a 24-hour period?

Front line staff (e.g., nurse aides, LPN/LVN, RN)

Are you aware when there isn’t a LN available to provide services to the residents?
Are you aware of any residents who needed LN services (i.e., medications or treatments) and did not receive it due to no available licensed nurse? If so, please explain.
Who do you notify in the event of an emergency when there is no licensed nurse available?
- If the staff member is not aware of who to notify, ask if they’ve ever experienced this situation and what actions did they take? Was any resident harmed?
- If the staff member is aware of who to notify, what direction were they given? Was any resident harmed?

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Staff Interviews for triggered PBJ Staffing Data Report areas

If the facility triggered for One Star Staffing Rating, surveyors must interview at least two additional front-line staff (e.g., housekeeping, dietary, and/or maintenance) with focused questions such as:

Have you noticed the facility not having enough staff, especially during the last six months?
Have you observed the facility not having enough staff to meet residents’ needs, such as residents waiting a long time for someone to help them? How often does this happen?
Do you ever smell bad odors when you are walking through the facility, for example, when a resident did not receive toileting or incontinence assistance in a timely manner
Do you ever hear residents or their friends and family complain about not enough staff to provide the care needed?

If the facility triggered for Excessively Low Weekend Staffing, surveyors must interview at least two additional front-line staff (housekeeping, dietary, and/or maintenance) with focused questions such as:

Are there ever times when there are not enough staff to take care of the residents on the weekends? For example, are any residents calling for assistance for extended periods of time? If so, can you describe what happened to any residents affected
- If there have not been enough staff during those times, do you know who you can alert to ensure that the residents needs are met?
- If you have ever notified that person, what was their response?
Have weekend activities ever been canceled due to lack of staffing to get residents up and dressed to attend (e.g., church services or day trips)?
Are beds left unmade and rooms messy on the weekend?

Additionally, if the facility triggered for Excessively Low Weekend Staffing, then review the Facility Assessment to evaluate if the facility assessed resident needs and acuity to determine the number of qualified staff needed to meet each resident’s needs (see §483.71)

Interview questions for use whether or not the facility triggered any of the PBJ areas

Facility Residents and/or Resident Representatives

Has the facility informed you that care could not be provided because there wasn’t a LN available?

Nursing Staff

During interactions with staff, ask if they feel they have enough staff to meet resident needs and the training/skills needed to provide the care required. If no, additionally interview staff using the probes below to further evaluate staff sufficiency.

Do you have enough time to complete your required assignments each day? If not, why, and what assignments are you not able to complete? Who do you report this to?
Are you able to participate in care planning, attend team meetings and trainings, take meal breaks and provide the care residents need?
How often are you asked to stay late, come in early, or work overtime? Tip: this assists in determining the frequency of open shifts, which provides insight into the extent of any staffing issues in the facility.
Are you aware of who is the designated charge nurse on each shift?

Dietary/Kitchen/Dining Staff

Interview staff if concerns related to resident food, weight loss, or nutrition are identified and are potentially related to nurse staffing.

Do you hear residents complain about their food getting cold while they wait to be assisted by nursing staff?
Do you see food trays come back untouched that might indicate insufficient nursing staff?
Are you aware of any residents that might be absent because nursing staff was not available to assist them to the dining room?

F727 – Required Nursing Care

Per Facility Assessment requirements at F838, §483.71, facilities are expected to identify when they may require the services of an RN for more than 8 hours a day based on the acuity level of the resident population. For example, the facility may serve a population of residents that require more frequent assessment, as well as care plan development and evaluation of interventions that may not be delegated to the LPN or other healthcare professional.

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The requirement for 8 consecutive hours of RN services can be met by any RN or multiples of RNs. The hours worked by the DON would be considered applicable towards the requirement.

F851 – Mandatory Submission of PBJ Data

When completing the offsite preparation for all recertification surveys, the team coordinator must obtain the most recent quarter data from the PBJ Staffing Data Report and evaluate PBJ data submitted by the facility.

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The team coordinator must follow the steps below:

Obtain the PBJ Staffing Data Report.
Identify if the facility triggered for “Failed to Submit Data for the Quarter.”
1. If the facility failed to submit the required PBJ Staffing Data, F851 must be cited as a Severity and Scope of “F”.

Training Resources

CMS has posted guidance training for nursing home surveyors and providers publicly in the Quality, Safety, and Education Portal (QSEP). This specific training can be found on the QSEP page by going to Long Term Care Appendix PP Regulatory and Interpretive Guidance Updates – Effective February 2025 (LTCAPP_PP) within the Training Catalog page. This training will explain the revisions made to the guidance. Note: training for nurse staffing and PBJ has been added to the existing training in the QSEP.

The critical element pathway for Sufficient and Competent Nurse Staffing is a helpful tool in preparation for these updates. More information on CMS's updated surveyor guidelines can be found here and here.

Contact: Carrie Mosley, cmosley@leadingageny.org, 518-867-8383 ext. 147