The OIG’s 2008 Supplemental Compliance Guidance for Nursing Facilities identifies the issue of sufficient staffing as a risk area which should be addressed in an effective nursing facility compliance program. Unlike many of the other risk areas identified by the OIG, sufficient staffing cannot be reduced to or even measured by a set of consistent objective criteria. Rather, how much staffing is “sufficient” will depend on a variety of factors potentially unique to each facility.
The Federal OBRA statute and regulations issued under it require nursing facilities to provide sufficient staff so their residents attain or maintain their highest practicable physical, mental and psychosocial well-being. The OIG states in the Supplemental Guidance that some facilities have systematically failed to provide staff in sufficient numbers and with appropriate clinical expertise to adequately serve their residents. The OIG urges facilities, as part of their compliance programs, to regularly evaluate their staffing levels and patterns to determine whether they have sufficient staff, with appropriate competencies, based on the acuity levels of their residents.
The OIG recommends a list of “information sources” which facilities should include in this evaluation. They include
- Resident case-mix scores
- Staff skill levels
- Staff-to-resident ratios
- Staff turnover levels
- Staffing schedules
- Staff disciplinary records
- Payroll records
- Adverse events reports (such as falls, adverse drug event)
- Interview with staff, residents (or their legal representatives) and families
OIG suggests that examining records of time actually worked by staff (i.e., “on the floor” staff), such as payroll records or timesheets, is more instructive than staffing schedules which may or may not reflect time actually worked.
Auditing and Monitoring for Sufficient Staffing
The following auditing and monitoring sample suggests one way facilities may approach the task of monitoring their staffing levels and ensuring compliance with the Federal requirement for adequate staffing.