CMS Use of Staffing Data To Inform State Oversight of Nursing Homes

Why OIG Did This Review

• Nursing home residents and families depend on nursing homes to maintain sufficient staffing to meet their needs. To that end, the Centers for Medicare & Medicaid Services (CMS) has long required nursing homes to meet minimum staffing requirements, which include at least 8 hours of registered nurse (RN) services each day.
• This evaluation assesses the early experiences of States in leveraging new data and guidance provided by CMS to identify staffing deficiencies.
• Previously, CMS implemented the Payroll Based Journal (PBJ) to provide consumers with more accurate information about nursing home staffing. The PBJ is a system where nursing homes submit auditable information about the hours worked each day by different types of staff. Then in response to OIG recommendations, CMS began providing certain PBJ data to State survey agencies (States) along with guidance for using the data during nursing home inspections.

What OIG Found

Although States reported that the PBJ data have been useful, CMS did not provide States with all the information they need to effectively oversee the minimum requirement to provide 8 RN hours every day, as well as the broader requirement to provide sufficient staffing to meet residents’ needs.

• CMS does not identify all nursing homes with fewer than 8 RN hours. Instead, CMS targets nursing homes with zero RN hours. States could better target their oversight if CMS identified all nursing homes that had more than zero but fewer than 8 hours of RN coverage.
• CMS does not explain to States which aspect(s) of staffing pose a risk for insufficient staffing, when it identifies nursing homes with a one-star staffing rating (the lowest rating on Care Compare, the public website for consumers). For example, States we reviewed wanted to know specifically whether low staffing of nurse aides contributed to the potential insufficient staffing in nursing homes identified by CMS.

What OIG Recommends

1. CMS should inform States of nursing homes that appear from PBJ data to violate the required number of daily RN staffing hours.
2. CMS should provide States additional nursing home staffing analysis and guidance to identify potential insufficient staffing.

CMS nonconcurred with the first recommendation. For the second recommendation, CMS neither concurred nor nonconcurred but stated that it has already implemented it.