How many times following the department of health survey have you sat down to write your facility's plan of correction and noticed yourself writing that all too familiar phase “facility staff will be [or have been] in-serviced on…”? The frequency with which this phrase appears in the responses to deficiencies reported on the CMS-2567 implies that most deficiencies received during the annual survey resulted from a lack of staff knowledge. If we are to assume that this is true, one should ask the logical question: Why wasn’t education provided to staff in the first place? And that question should immediately give rise to another question: Why weren’t these educational needs identified and addressed before the department of health survey?
It has been said that philosophy and staff development share the commonality that neither discipline “bakes any bread,” that is, neither contribute directly to the bottom line. According to some nursing home administrators (NHAs), not only does staff development not “bake bread,” it “costs bread.” It is sometimes hard for the NHA to see the tangible results of the staff development department because staff education is not a directly billable service, like therapy. Nor is staff education able to be “captured” on the Minimum Data Set (MDS) for increased rates of reimbursement.
Having a full-time staff development professional in long-term care is often viewed as a “luxury” or something that's “nice but not necessary.” In an attempt to save money in the years following the implementation of the Medicare Prospective Payment System (PPS), many skilled nursing facilities eliminated the staff development role, or reduced it to a “part-time” position. Those facilities that eliminated the role completely added the responsibility for staff development to the already long list of duties assigned to the Director of Nursing. While this idea appeared to save facilities money in the short term, it may be resulting in additional costs in the long run.
This article will explore how lack of a staff development department has the potential to negatively affect skilled nursing facilities (SNFs) in a multiplicity of ways—and what to do about it.
Federal Regulations Specific to Staff Development
Two federal regulations are immediately applicable to staff development: F-tag 497 and F-tag 498 (see sidebar, p. 34). Other regulations deal with requirements for nurse aide training and still others are indirectly related to staff development, but for the purpose of this discussion we will focus only on these two regulations. Most skilled nursing facility administrators are aware of the existence of these regulations, but many are not aware of their complete content and consequences.
When a surveyor has concerns specific to nurse aide performance, the regulations provide specific guidance to the surveyor to assist him or her in evaluating the facility's training and development programming. In the “guidance to surveyors” section of F497, it is pointed out that educational activities should be conducted to address areas of weakness, as determined in the nurse aide's annual performance review.
The facility administrator should be aware of both of these regulations and be certain that a mechanism exists within the organization that translates identified areas of nurse aide performance “weakness” into educational activities and subsequent competency evaluation. Who in your facility is doing this?
Impact on Staff Turnover
One study estimated that the cost of employee turnover can climb to 150% of the employee's annual total compensation.1 Bales et al, as cited in Parsons et al, concluded that poor job orientation and training influence nursing assistants’ desire to leave skilled nursing facilities.2 Perhaps some of the problems associated with nursing assistant turnover can be addressed through the efforts of an effective staff development program.
Impact on Clinical Reimbursement
In addition to regulatory compliance and employee retention, appropriately conducted staff education can translate into higher reimbursement through proper coding of the MDS 2.0. Section G of the MDS includes items termed “late-loss” activities of daily living (ADLs), including bed mobility, transfer, eating, and toileting. These items account for 30% of items used to calculate the RUG-III score. Appropriate initial and ongoing education is needed for all staff members responsible for completing the supporting documentation specific to these MDS items. Still other areas, such as mood, skin assessment, time awake, nutrition, and special treatments and procedures, are responsible for determining RUG-III classification. Those staff members responsible for completing these MDS items require ongoing education, competency validation, and support to ensure that these items are accurately documented in the resident's clinical record and subsequently captured on the MDS 2.0. Training in these areas is essential to provide the interdisciplinary team with a true picture of resident care needs and maximize reimbursement.