As healthcare providers adapt to the third and final phase of the Centers for Medicare and Medicaid (CMS) Final Rule: Medicare and Medicaid Programs: Reform of Requirements for Long-Term Care Facilities, much attention is being placed on implementation and compliance. As part of that Stage 3 rollout process, a heightened awareness also should be placed on staff competency vs. simply enhancing staff training, says Ellen Kuebrich, Senior Director of Business Development at HealthStream.
“What we've seen with competency is that some overcomplicate it, while others under-complicate it,” says Kuebrich, who has more than 12 years of expertise in advising government regulated medical industries, including the medical device, issue transplant, biologic, pharmaceutical, and long-term care industries. “CMS is defining competency as a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully.”
To untangle all that, she says, pay attention to a couple of key elements:
Measurable benchmarks. Organizations need to have defined characteristics that will measure staff as being competent or not.
Knowledge, skills, abilities, behaviors, and other characteristics. Staff training often goes into test mode and regurgitation-of-knowledge mode, which is useful in some cases, but not in all—especially in skilled nursing. Also test behaviors, critical thinking, the culture, and the way that staff is participating in that culture, all of which will roll into competency.
Long-term care facilities no strangers to training, but less so to competency plans
The concept of employee competency is nothing new in the long-term care arena. So why is the new rule creating a potential for headaches? It could be because often competency and training are seen interchangeably, explains Patrick Campbell, RN, BSN, a master trainer and surveyor, and Senior National Account Services Director with HealthStream.
“Competency is verifying that [staff] actually have training and that they're ready to go,” says Campbell, who spent more than six years as a state surveyor in North Carolina, serving as a team leader and as a frequent member of the state's informal dispute resolution committee. “When we look at phase three, this is going to equate to surveyors marking multiple deficiencies for a single incident where you didn't really have that before.”
As an example, he describes a case where a single staff member uses a mechanical lift that's designed for two staff members to transfer a resident. An incident results in an injury, or the potential for one.
“As we investigate, we're going to pull the care plan,” he says. “If they're not following the care plan that says use a two-person lift technique, then you're going to get an F656 for your care plan. If the care plan isn't accurate and didn't say to use two people, then you've got that second deficiency. That is going to lead us into the next section, staff competency. The new F tag is F726. The surveyor is going to talk to the staff and ask where they trained and was there any sort of check-off or return demonstration. They’ll need to see documentation of that. The surveyors are going want the details: not just a signed paper that the staff were in a training, but what were they shown and how did you verify that they were competent? We may have an issue with competency if you can't show that those things were done.”
And from there, further penalties around sufficient staffing and related facility operations can come into play. To avoid the potential of all these, it will be essential for facilities to have established and implemented a QAPI (Quality Assurance and Performance Improvement) plan and facility assessment as outlined in Phase 2, Campbell notes.
“A facility assessment that's going to identify issues like this,” he points out. “Do you have enough staff, enough equipment, and are the staff competent in this case to provide these transfers? If the surveyor finds an issue there and you have not addressed that on the facility assessment, there’s another deficiency. A QAPI program should be identifying issues and providing corrective action as things are found. In this case, you can see that one incident with that one staff member transferring incorrectly could lead to seven different deficiencies.”
To avoid this situation, long-term care facility operators need to ensure that their competency assessments and plans dovetail with training and development processes. This can take some time up-front, but will pay dividends down the road, Campbell says.
The providers and organizations across the continuum of care that will continue to excel are those that treat residents as people worthy of respect, regardless of medical condition or funding source—and regardless of the pressures felt by staff. HealthStream works with the care continuum, to address these challenges, from keeping pace with regulatory requirements like QAPI and other issues related to Conditions of Participation (CoPs) to engaging and developing competent staff who can satisfy the demands of increased patient complexity. Learn about HealthStream’s Workforce Development Solutions for the Continuum of Care.