Massive New Regulation Aims to Modernize Skilled Nursing

Big changes have swept the whole senior care industry since 1991, with leading providers innovating in nearly every aspect of operations. But one thing that has remained constant in the last 24 years now appears set to change: The requirements that skilled nursing facilities must meet to participate in Medicare and Medicaid.

The Centers for Medicare & Medicaid Services (CMS) announced the proposed update Monday, in conjunction with the White House Conference on Aging. This is a once-a-decade meeting to discuss ways to improve the well-being of seniors in the United States.

Of course, providers already have had to adapt to changes in technology, new clinical best practices, and the demands of the marketplace. So while the 403-page proposed rule is a comprehensive update, skilled nursing providers already should be well-positioned to meet some of the most important new requirements, CMS noted in its official announcement.


“Many of the proposals build on improvements that nursing homes have already made since 1991, the last time these conditions of participation were comprehensively updated,” the announcement states. “This rule would bring these best practices for resident care to all facilities that participate in Medicare or Medicaid and implement a number of important safeguards that have been identified by patient advocates and other stakeholders, and include additional protections required by the Affordable Care Act.”

Standards for dining, discharge planning, staff training in dementia care, and medication management are among the new changes.

The dining-related changes reflect a growing trend in senior living generally, to provide a greater variety of foods made with higher-quality ingredients. For example, the proposed rule clarifies that facilities “may procure food items obtained directly from local producers and are not prohibited from using produce grown in facility gardens.” 


The proposed rule also calls for facilities to provide greater choice in available foods and to be more flexible in dining times for residents. In general, care plans under the new rule would have to take into account resident goals and preferences.

In conjunction with long-term care provider associations, CMS already has launched a program to reduce the number of residents who are taking antipsychotic medications to control dementia symptoms. The new rule would codify certain best practices for achieving this, such as requiring more vigilance and action on the part of consultant pharmacists.

Changes in technology have been among the most dramatic since these rules were last updated, and the proposed rule includes references to how SNFs may use electronic health records.

The proposal explicitly states that use of EHRs can help providers cut costs, such as by reducing the amount of time it takes to furnish a clinical record. However, skilled nursing facilities have been excluded from some of the government programs to increase electronic health record adoption, including through subsidizing their cost. 

LeadingAge, which represents more than 6,000 organizations in aging services, zeroed in on this aspect of the new rule in comments on Monday.

While the organization supports the goals of improved cross-setting coordination, more action is needed to ensure providers have the necessary tools, according to Majd Alwan, Ph.D., executive director of LeadingAge’s Center for Aging Services Technologies (CAST). 

“From a technology perspective, we will be advocating for CMS to identify incentives to ensure that all providers, including smaller and rural providers, have the right health IT tools in place, as well as the opportunity to actively participate in meaningful exchange of health information,” Alwan said in a prepared statement.

Some advocates were pushing for a federally established minimum nurse-to-resident staffing ratio, but this was not included in the CMS proposal. However, nursing homes will be required to report staffing levels. 

Staffing levels are particularly important when it comes to having enough manpower to provide high-quality dementia care rather than resorting to antipsychotic medication, consumer advocates told Kaiser Health News.

Written by Tim Mullaney

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