Ftag of the Week – F725 Sufficient Nursing Staff

This week on the CMSCG Blog, we are reviewing F725 Sufficient Nursing Staff for our “Ftag of the Week.” We held off on reviewing this tag over the past few years in anticipation that it could be expanded once the revisions to the State Operations Manual were released, but thankfully it’s not chock-full of surprise revisions.

The Nursing Services regulation requires that providers need to have sufficient staff with the appropriate competencies and skillsets to provide nursing care and services for all residents, as determined by their care plans, to assure resident safety and ensure each resident achieves or maintains his/her highest well-being. Determining sufficiency of staff should also be based on the Facility Assessment so the census, acuity, and diagnoses of the residents in the building are considered. This overall requirement is split into two separate tags, F725 Sufficient Nursing Staff and F726 Competent Nursing Staff.

 Let’s look at what’s required under F725.

The Regulatory Requirement

Facilities must provide services by sufficient numbers of each licensed nurses and (RNs and LPNs) other nursing personnel, including nurse aides, on a 24-hour basis to provide nursing care to all residents in accordance with their plans of care. Exceptions noted based on F731 (Waiver – Licensed Nurses 24 Hr/Day and RN Coverage) are included in the regulatory language. At the crux of this requirement is ensuring that you have sufficient numbers and types of nursing staff to provide for each resident’s basic needs, as well as their individual needs, in order to provide the care required based on the resident’s medical conditions, diagnoses and plan of care.

For example, what does this mean for all those residents who are currently on 1:1 or “close” supervision? That’s likely not going to be a feasible plan given the staffing crisis being encountered throughout the industry and the need to have “hands” to provide care. The interventions that may have previously worked/been available may have gone out the door with a lot of your staff, so, unfortunately, many providers have had to restrict admissions to ensure staff sufficiency. There does not seem to be any relief coming related to this widely acknowledged issue, so you need to think smarter about what you can do with, in many cases, “less” to try to be more efficient while preventing additional staff burnout and still achieve good resident outcomes. Hopefully, many of you will have figured out the best way to utilize your current nursing staff to meet your individual facility’s resident population needs.

Determining Sufficiency

The Interpretive Guidance (IG) lists a number of areas where information about the overall resident population can be gleaned to help determine the level of staff needed. Most importantly for you to be aware of is the Facility Assessment and how it plays into your staffing plan. The guidance under F725 states that all of the following should be in your Facility Assessment and then you can review that and figure out your staffing. The Centers for Medicare and Medicaid Services (CMS) provided a Facility Assessment template when the requirement first came out which includes this information, but the key is using those details to develop a staffing plan, including:

  • Diseases
  • Conditions
  • Physical limitations of residents
  • Cognitive limitations of residents
  • Acuity

The regulation also references promoting each resident’s rights and physical, mental and psychosocial well-being. If you read our last blog series on F740 Behavioral Health Services, you’ll see that there is a tremendous emphasis in the revised guidance as it relates to mental and psychosocial well-being – not just providing “traditional” clinical-based care. Have you updated your Facility Assessment to reflect your resident population’s mental and psychosocial needs in additional to their physical needs – and staffed accordingly? Looking at competencies for those needs has its own regulation, which CMSCG will review in a future “Ftag of the Week” post.

State Staffing Ratios

Here’s another bit of bad news. The updated guidance states that compliance with State staffing requirements does not necessarily mean that you’re compliant with the Federal requirement for sufficient staffing. Specifically, “A facility may meet a state’s minimum staffing ratio requirement, and still need more staff to meet the needs of its residents. Additionally, the facility is required to provide licensed nursing staff 24 hours a day, 7 days a week.”

Payroll-Based Journal

F851 Payroll-Based Journal (PBJ) is still where issues related to submitting staffing information will be cited, but it is also referenced under this requirement. That is because CMS will be making key staffing data and potential problems available to surveyors to review during offsite prep ahead of your next survey. This data, which is available in CASPER, including information about overall direct care staff levels. The Long-Term Care Survey Process (LTCSP) software is being updated to alert surveyors of specific dates where potential staffing issues were identified through the PBJ.

On Survey

In addition to any offsite prep tidbits provided from the PBJ, surveyors have many opportunities to identify issues with staffing sufficiency. These include:

  • Reviewing the Facility Assessment to determine if it includes the type and level of staff required to meet each resident’s needs, and if this is reflected in what they see while they are at the facility
  • While interviewing staff, residents/ representatives or other stakeholders, seeing if any concerns are raised about the number of staff or time staff have to provide care and services
  • While interviewing residents/ representatives, surveyors may learn that staff are not responsive to residents’ requests for assistance, or the surveyors may see call bells going unanswered for long periods of time
  • Seeing a high number of potentially inappropriate use of practices or devices to manage residents’ behaviors that could indicate insufficient staff
  • Identifying issues in a number of other areas reviewed during survey – falls, weight loss, pressure ulcers, resident-resident altercations – which could indicate there is not a sufficient number of staff to provide care and supervision

A note in the guidance at F725 states that actual or potential resident outcomes related to identified staffing concerns should also be investigated for abuse, quality of life and/or quality of care. There are a lot of areas to consider related to staffing – and surveyors will likely be using all that new guidance to look at them on your next survey.  How would your weekend staffing sheets look to a surveyor who is at your door following up an elopement?


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