This week’s Ftag of the Week on the CMSCG Blog is F732 Posted Nurse Staffing Information, which is part of the Nursing Services regulatory group. Facilities are required to post specific information regarding nurse staffing as well as have if available upon request and retain it per regulatory requirements. The nurse staffing data needs to be posted on a daily basis at the beginning of each shift. This is an easy observation for surveyors, and now that survey and certification activities are back, it’s something to make sure responsible staff are posting.
What Needs to Be Posted
The required information that needs to be posted includes:
- Facility name
- Current date
- Resident census
- Total number of staff and actual hours worked per shift for:
- Registered Nurses
- Licensed Nurses
- Certified Nurse Aides
The facility needs to post nurse staffing information in a prominent place where it is accessible to residents and visitors. The data should be clear, readable, up to date and current. When listing the total number of staff and actual hours worked, the facility is required to reflect staff absences on each shift that occur due to call-outs or illness. This data needs to be retained for a minimum of 18 months to satisfy the federal requirement, or, if the State’s law requires a longer retention period, then that must be adhered to. Additionally, if the information is requested by the public, the facility has to make this data available.
How It’s Cited
This information needs to be visibly posted, so if a surveyor can’t find it or the data is not current, then the facility is likely looking at a citation. However, in reviewing many actual citations under F732, there are several things to be aware of:
- Responsible staff need to be aware of all data that has to be posted, including posting call-outs. Many facilities have been cited for not providing all required information or not providing it by the beginning of each shift.
- The staffing data needs to be retained. Facilities have been cited for not being able to provide staffing data for surveyors review, and generally have told the surveyors that they were not aware of the data retention requirement.
- When there is a personnel change and the staff responsible for posting this information changes, it is important to ensure that the newly assigned staff member is aware of this responsibility and the data the needs to be provided.
Citation Example – F732 S/S: D
At one facility, the surveyor could not find any posted staffing information during a January survey. When he inquired about this with the Staffing Coordinator, she stated that she did not know the information needed to be posted and that she had started in August. The surveyor then confirmed that not only was the staffing data missing from the current date, but had not been posted since August of the prior year.
Issues that CMSCG consultants frequently identify during quality reviews include staffing information posted for the entire day in advance and not updated to reflect actual staffing when data is rechecked the next day or Friday’s 7-3 staff data is the last data posted when checked on Monday morning. Who is responsible for educating the weekend and off-shift staff on this regulatory requirement? Hate to say it, but it is one of those gotcha deficiencies!