Regulatory requirements are meant to improve patient care; however, many post-acute care providers struggle to meet them considering post-pandemic challenges.
By Jenna Hughes
Long-term care (LTC) providers such as skilled nursing facilities, inpatient rehabilitation centers, and home health providers face the daily task of maintaining compliance with a growing number of healthcare regulatory requirements. Federal regulations on healthcare facilities have historically been implemented to ensure that patients receive high-quality access to care. However, the post-acute care sector is subject not only to federal compliance requirements but also state, local, and agency requirements. Increasingly, physicians are having to delay care or spend less time on patient care overall to focus on administrative tasks related to compliance.
Health systems, hospitals, and post-acute care providers must adhere to over 629 discrete regulatory requirements across nine domains, according to the American Hospital Association’s “Regulatory Overload Report,” published in 2018. This includes 341 hospital-related requirements and 288 post-acute care specific requirements, with the number of regulatory requirements having significantly increased for post-acute care providers since the pandemic.
The primary drivers of federal regulation include the Centers for Medicare & Medicaid Services (CMS), the Office of Inspector General (OIG), the Office for Civil Rights (OCR) and the Office of the National Coordinator for Health Information Technology (ONC), according to AHA. However, providers must also keep up with their specific state and local requirements simultaneously.
Impact on long-term patient care
Hospitals and post-acute care providers spend nearly $39 billion a year on administrative activities related to regulatory compliance annually. An average sized hospital spent nearly $7.6 million annually on administrative activities related to compliance in 2018, and the figure raises to $9 million for hospitals with post-acute care facilities. In 2018, regulatory burden cost more than $1,200 every time a patient was admitted to the hospital, according to the AHA.
Post-acute care facilities have their own specifically designated regulatory requirements that differ from general hospitals. One such requirement is the recently proposed ‘Minimum Staffing Standards for Long-Term Care Facilities’ from CMS, which was updated in April 2024.
The minimum staffing requirement final rule aims to reduce the risk of residents receiving unsafe care by finalizing a total nurse staffing standard of 3.48 hours per resident day (HPRD), which must include at least 0.55 HPRD of direct registered nurse (RN) care and 2.45 HPRD of direct nurse aide care, according to CMS. Facilities may use any combination of nurse staff to meet the requirement (such as an RN, licensed practical nurse (LPN) and licensed vocational nurse (LVN), or nurse aide) to account for the additional 0.48 HPRD. Before the minimum staffing requirement, nursing homes were only required to have an RN on-site for eight hours per day.
While the new rule aims to provide improved patient care, it has resulted in negative impacts for hundreds of already stretched-thin nursing facilities, many post-acute care providers have said. For facilities that were already struggling to retain staff and care for a growing number of patients, the staffing requirement rule has led to higher healthcare costs and the potential for any nursing homes that don’t meet staffing requirements to not be able to legally operate and they must close entirely, according to NPR.
Impact on patient care
Patients, too, are significantly impacted by regulatory requirements, receiving less time with their caregivers, unnecessary hurdles to receiving care, long wait times to be discharged from the hospital to post-acute and hospice care, and a growing number of regulatory requirements leading to increasing healthcare costs.
Nearly 54% of nursing home providers are now having to limit new admissions due to staffing shortages, according to the American Health Care Association/National Center for Assisted Living (ACHA/NCAL). Nursing homes are down more than 240,000 employees since the start of the pandemic, according to NPR and the Labor Department. Facilities across the country are facing numerous unfilled staff positions because of staff departures during the pandemic.
Often, spending time focusing on complying with regulations means that already overwhelmed physicians are taken away from patient bedsides to focus on administrative tasks. For many post-acute care facilities, this results in less time spent with patients and reduced care quality. Many post-acute patients have experienced long waits for care or inadequate care altogether, according to NPR.
An average-sized hospital dedicates almost 59 full-time equivalents (FTEs) to regulatory compliance, over one quarter of which are doctors and nurses, according to the AHA report. Physicians, nurses and healthcare staff make up more than one-quarter of the full-time equivalents (FTEs) dedicated to regulatory compliance, which also takes clinicians away from patient care responsibilities. While an average size community hospital dedicates 59 FTEs overall, PAC regulations require an additional 8.1 FTEs.
The timing and pace of regulatory change can additionally make compliance very challenging to keep up with for LTC providers. Regulations change often, which can result in the duplication of compliance efforts and substantial time away from patient care. According to the AHA, as new or updated regulations are issued, facilities must quickly mobilize clinical and nonclinical resources to understand the regulations and communicate new processes throughout a facility.
Complying with federal regulations
The post-acute care workforce continues to face significant regulatory burdens, exacerbated by post-pandemic staffing shortages. The industry is in critical need of practical considerations to improve patient care and safety in LTC facilities while meeting regulatory requirements.
The Nursing Facility Industry Compliance Program Guidance (ICPG) is a source of compliance program guidance for nursing facilities from the U.S. Department of Health and Human Services (HHS) and the Office of Inspector General (OIG). In the Nursing Facility ICPG, OIG has paid special attention to four risk areas. Within each risk area, the OIG explains the relevance of the topic, cites the requirements of participation (RoP) or other applicable laws that relate, and provides recommendations for mitigating those risks.
The four risk areas are Quality of Care and Quality of Life, Medicare and Medicaid Billing Requirements, Federal Anti-Kickback Statute, and Other Risk Areas. The resource identifies methods that nursing facilities can use to reduce fraud, waste, substandard care, etc.
The purpose of the ICPG compliance guidelines is to help nursing facilities identify their risks and implement an effective compliance and quality program to reduce those risks. The guidelines are voluntary and non-binding, meaning they do not represent a regulatory requirement but instead are intended as a reference for building better compliance programs across the nation, according to the OIG. The guidelines are not one-size fits all and must be tailored to each post-acute care facility’s unique needs.
The AHCA/NCAL recommends that long-term care facilities review the Nursing Facility ICPG with attention to risk areas that are relevant to their operations. AHCA is also working on additional educational training to support LTC facilities’ understanding and application of these guidelines.