Staffing: A Survey Survival Issue.

It has become quite clear that successfully passing a survey, whether an annual, revisit or complaint survey, depends a great deal on how well staffed your facility is. This does not mean merely adequate numbers of staff, but also the right types of staff--staff who are properly deployed to meet residents' needs, who are well trained, responsive to and genuinely care about residents. It has also become clear that successfully delivering high-quality care all year long depends on effective staffing levels.

Increasingly these days, surveys are scattered throughout the calendar year. There are variations in the intervals between annual surveys, changes in the timing of revisit surveys and a dramatic increase in the number and frequency of complaint surveys. True, there is still some predictability in the timing of certain surveys. For example, if a resident suffers an injury, you will almost certainly experience a complaint survey between 2 and 10 days following a report of the event to your state's health department. And, if you are awaiting a revisit survey, you know that the survey team must return within a specified time period to evaluate your corrective actions. However, if you are expecting surveyors to arrive for your annual survey at the 12th month, on a Tuesday morning at 8:30 a.m., following a scheduled office work day, you might be caught off guard.

In the past, some facilities temporarily increased staffing levels during the month or two leading up to the expected annual survey date. Some facilities even rescheduled certain staff from the first shift to second or third shift, hoping that surveyors wouldn't catch a glimpse of a poorly trained nursing assistant or LPN. Some facilities even temporarily restricted the duties of certain staff members who were known to have poor skills in such areas as treatments or medication passes. Sometimes those strategies worked. More often than not, however, a conscientious staff member confided to surveyors about such practices, and surveyors detected the unusual staffing patterns.

The new survey process, implemented July 1, 1999, requires facilities to provide a copy of the nursing department's "actual working schedule" at the entrance conference. Throughout the survey process, of course, surveyors examine facility compliance with quality-of-care and quality-of-life requirements, including preventing pressure sores, weight loss, dehydration, unavoidable declines in important activities of daily living, such as eating, toileting, transferring and ambulating; responding to residents' requests for help; interacting with residents in a dignified manner; accommodating residents' individual needs; and providing the necessary care and services to help each resident "attain and maintain the highest practicable physical, mental and psychosocial wellbeing." What is new now is that if surveyors detect problems with the quality of care provided to residents, they will utilize one of the new investigative protocols entitled, "Nursing Services; Sufficient Staffing."

The procedures for this protocol require that surveyors review the "actual working schedule" to determine whether inadequate staffing has contributed to quality-of-care problems. They will also interview staff, including licensed nurses and certified nursing assistants, to find out if staffing is a chronic problem. In addition to deficiencies related to quality of care, you can expect surveyors to also cite F353 Nursing Services; Sufficient Staffing if they conclude that inadequate staffing has contributed to quality-of-care problems. You can also expect that the scope and severity assigned will be at least as high as the most severe quality-of-care deficiency cited, and maybe even higher if surveyors conclude that staffing problems are widespread.

With even a single deficiency rated at G or H, you could be vulnerable to an H or I staffing deficiency. I have already reviewed deficiency statements with F353 cited at level L, where other quality-of-care deficiencies were deemed to constitute "immediate jeopardy."

In today's survey and enforcement environment, most facilities would be thrilled to maintain a stable staffing level on any shift, using any type of staff, all year long. Frequently, facilities have budgeted and are prepared to pay for more staff than they can usually recruit and retain. Often, facilities feel pressured to advertise constantly for staff to fill a variety of positions, knowing that another employer down the street might soon raise starting wages, offer signing bonuses or increase employee benefits to attract staff. Since effective staffing clearly contributes to achieving good surveys and, most importantly, to delivering high-quality care all year long, let's examine the factors that pose obstacles to successful staffing.

First, general economic conditions, especially a growing economy in virtually all employment sectors, have contributed to sustained low unemployment rates throughout the nation. Most recent figures peg the national unemployment rate at 4.2%, and even lower in some geographic regions. Government economists generally believe that such low rates constitute virtually full employment for most Americans who want to work. That is very good news for employees and very bad news for employers. It means that the nursing home industry does not have a crowd of candidates in the lobby waiting to be offered jobs.

Second, the implementation of the Medicare Prospective Payment System (PPS) has tightened the purse strings of many nursing homes that must try to generate enough reimbursement to cover the actual costs of caring for residents. Cutting back expenses, such as staffing costs, can be one method of making sure that a facility survives in the face of lower revenues. Traditionally, although Medicare has paid for only about 9% of all nursing home days in the United States, its reimbursement rates were relatively high and helped to support the cost of providing care to other residents for whom reimbursement was lower, such as Medicaid residents. Some industry experts believe that Medicare contributed nearly 40% of the overall nursing home profits, even though the number of resident days was a much lower percentage of total bed days. Certainly, many nursing homes today are feeling the twin pinches of lower reimbursement and higher regulatory expectations.

Third, nursing home work is not generally perceived as attractive. For licensed nurses, employment in acute care hospitals is more highly regarded and often more highly paid. Even working in a doctor's office is perceived as higher-status employment. Many other healthcare settings that employ nurses offer better working conditions--e.g., less cumbersome documentation requirements, weekends off, on-site childcare and flexible shifts.

For certified nursing assistants, who are generally entry-level workers without formal education beyond high school and who might have language or literacy barriers, nursing home work is perceived as even less attractive. After all, these caregivers perform much of the hard work of hands-on resident care, including lifting and turning, bathing and toileting, feeding and cleaning, and talking and touching. Unfortunately, most nursing home staff experience negative reactions when they tell family and friends about their chosen occupations: "I could never do that for a living!" "How can you stand to work there?" "Why don't you work at Burger King? They pay just as much, and you wouldn't have to do all that work!"

Fourth, some nursing home workers have personal and family issues that pose obstacles to steady, reliable work habits. I think most of us would find it difficult, if not impossible, to come to work on time every day if we faced daily challenges such as not having a car that starts every morning, not having enough money to put gas in the car, having young children who are sick and can't go to school, having a babysitter who doesn't show up, not having a washer and dryer in the basement to wash clothes, having to walk a mile to a bus stop when the temperature is 10 degrees, having an aging parent to take care of at home, not having a spouse with whom to share household responsibilities, living in a neighborhood far from work and worrying about paying the rent each month. Sure, each of us must deal with life's daily logistics, but I suspect that without the support of a spouse, extended family, neighbors and child care centers, many of us might have unreliable work habits, too.

Fifth, some nursing home managers do not treat staff respectfully. In my role as a consultant, I have personally visited nearly 1,000 nursing homes in more than 30 states, and I have witnessed heartbreaking scenes. I watched a Michigan nursing assistant struggle to come to work every day, bald, nauseated and weak after each chemotherapy treatment, only to be lectured by the DON about coming to work late. I saw an Illinois corporate nurse grab a nursing assistant by the shoulders, shake her and say, "You better put a smile on that face right now." I listened to a regional operations manager tell Maryland nurses, "I could find trained zoo animals to do your jobs tomorrow." I witnessed a Pennsylvania administrator scream at department heads after a survey exit conference, "This is all your fault, and I will make you pay." Does this sound like respect? I think it is the ultimate hypocrisy to demand that nursing home workers show respect for residents, when they are often not treated respectfully themselves.

Sixth, many nursing home managers might not know how to schedule staff effectively throughout the facility and across shifts. They do not offer innovative, effective education programs to improve staff skills. Nor do they understand how to retain workers by accommodating their needs. Finally, they do not hear the very solutions presented by the staff themselves that could solve at least part of the critical staffing problem.

What to do? In my next column, I will write about specific, realistic strategies to attract, schedule and retain nursing home staff. If we are to improve the quality of care that is delivered at survey time and all year long, then we must solve this fundamental problem. If not, then our chances at providing quality care, much less passing a survey, are slim.

Beth A. Klitch, FACHCA, is president of Survey Solutions, Inc., Columbus, Ohio.