​	​Center for Health Care Quality (CHCQ) Meeting Minutes for: 3.5 SNF Staffing Requirements
​	​Participants
​Date/Time	The following persons were present: Teresa Calvert (DOF),  Chelsea Driscoll (CHCQ), Adam Dorsey (DOF), Cassie Dunham (CHCQ), Lisa Hall (CAHF), CJ Howard (CHCQ), Jean Iacino (CHCQ), Roseliz Kondo (CDPH SAS), Phuong La (DOF), Ben Menzies (DOF), Janne Olson-Morgan (CHHS), Holly Pearson (CDPH OLS), Matt Robinson (CAHF), Sharon Simms (CDPH OLS), Jeff Sandman (CAHF), Scott Vivona (CHCQ) and Matt Yarwood (St. Francis Extended Care) The following persons were present via teleconference: Sergio Aguilar (CHCQ), Tim Frazier (St. Paul's Senior Services) Sandra Haskins (Gold Country Retirement Center), Brenda Klütz (LeadingAge), Muree Larson-Bright (CHCQ) and Ben McBean (St. Paul's Senior Services)
​Friday August 11, 2017
​Location
​73.425

I. Introductions

Scott Vivona opened the meeting at 1:00 pm on August 11, 2017.

II.Overview of Staffing Requirements

Chelsea Driscoll provided an overview of the 3.5 staffing requirement as amended by SB 97 (Chapter 52, Statutes of 2017).

• Effective July 1, 2018, SB 97 requires SNFs, except those that are a distinct part of a general acute care hospital or a state-owned hospital or developmental center, to have a minimum of 3.5 direct care hours
• The 3.5 staffing requirement is only operative upon appropriation in the annual budget act and on continued approval of the Skilled Nursing Facility Quality Assurance Fee.
• CDPH must develop emergency regulations in consultation with stakeholders to implement the 3.5 direct care services of per patient day with a minimum of 2.4 hours performed by CNAs
• Must provide notice to stakeholders at least 90 days prior to adopting regulations – by April 1, 2018
• The bill authorizes two types of waivers:
• A waiver to meet individual patient needs while maintaining the 3.5 direct care service hours
• A waiver process due a shortage of appropriate health care personnel and direct caregivers

Penalties

• Authorizes the department to develop a schedule to issue penalties for violations of the staffing requirements resulting in harm or has the potential to cause harm
• Prohibits CDPH from issuing penalties for failure to comply with the staffing requirements until FY 2019-20.
  

QASP Impact

• Allows a SNF that receives a waiver from the California Department of Public Health for meeting staffing requirements pursuant to HSC section 1276.65 to remain eligible for a supplemental payment if the facility meets the 3.2 minimum staffing, to the extent the Department of Health Care Services determines federal financial participation is available and not otherwise jeopardized.
• Prohibits the use of the 3.5 staffing standard to determine eligibility for a supplemental payment until fiscal year (FY) 2019-20.
  

Evaluation

• Requires the department to evaluate the impact of the staffing changes on quality of care, the workforce, and the effectiveness of the 2.4 CNA staffing minimum, and authorizes the department to contract for the evaluation. 

III. STAFFING REQUIREMENT DISCUSSION QUESTIONS:

QUESTION:

Do you envision converting direct care hours into a staffing ratio?

• Leading Age stated a ratio was not practical because facilities have different shifts, conversion to a ratio would be difficult because patient acuity can change hourly and facilities need flexibility.
• CAHF stated staffing should be based on the facility wide needs. Having a ratio limits the availability to admit residents who come in late at night. If the Department adds the ratio, the facility may not be able to accept the patient.
• The representative from Gold Country Retirement Center/St. Francis Extended Care stated, it would be challenging to convert hours per patient day to a ratio. Providers stated smaller facilities would have a larger challenge using ratios. Shift ratios are dynamic and can depend on shift length. Having a ratio takes away flexibility.

QUESTION:

What issues with a staffing ratio are unique to the smaller facilities? (CHHS)

• There are facilities with different methods of staffing. For example, a facility may have two 12-hour shifts or three eight-hour shifts for 24 hour monitoring. Facilities need flexibility to shuffle staff to meet the nursing hours per patient day requirements.(CAHF/Gold Country Retirement Center)

QUESTION:

Is it possible to call someone in to meet the ratio if new patients come in to the facility?

• CAHF commented that there is a limit of resources when it comes to CNAs. There is not always on-call staff.

QUESTION:

Considering the requirement to maintain 3.5 direct care hours with a minimum of 2.4 performed by CNAs, what are the minimum standards to ensure safe patient care?

• CAHF stated CMS requires facilities to staff based on patient acuity as determined by patient assessments that take into account the needs of residents.
• CAHF commented that based on the needs of the residents in the building there may be a need to adjust the nursing staff between RN, LVN and CNA.

QUESTION:

Regarding MDS nurses, would it be reasonable to only count the hours the MDS coordinator is doing assessments? Should a percentage of the hours be discounted for administrative hours?

• CAHF commented that there is not a way to breakout the hours that are not direct care service hours. The need for coordinators changes based on the needs of the facility. CAHF stated the administrative work of the MDS coordinators should not be discounted. Their time is similar to direct care staff that has a certain amount of their time allotted to charting and handling other administrative tasks. Many facilities may not make the 3.5 requirement.

QUESTION:

Are there enough training resources to provide the CNAs needed to meet the staffing requirements?

• CAHF anticipates the need for 1400-2000 new CNAs requiring training to meet the staffing requirements.
• A provider stated there is a wide variety in training program availability. Some programs are closing and others have waiting lists. Rural areas such as Chico may only have one training program.

QUESTION:

Are there CNAs interested, but waiting to get in the program?

• LeadingAge commented that some of the programs affiliated with colleges have large waiting lists and a lack of available staff that meet the experience criteria to be instructors.

QUESTION:

Are the training programs diminishing due to a lack of interest?

• Leading Age stated finding staff will be difficult if there are no training programs in rural areas
• CAHF mentioned a previous effort to increase training opportunities that is no longer funded called, the Caregiver Training Initiative; however, the program is no longer funded. .

QUESTION:

What are your thoughts on the allowance of CNA trainees counting toward the 3.5 hours? Should there be any limits on counting trainee hours?

• One Provider commented that currently trainee time is only counted if the facility operates a training program. Providers would like CDPH to consider allowing trainee time to count for facility direct care hours whether the training program is facility based or not.
• Gold Country Retirement Center has the only CNA training program in Placerville. They have about 20 nurse assistant trainees complete the program each year and only have 25 staff. If nurse assistants cannot be counted, certain facilities cannot meet the 3.2 nursing hour requirement. The pay difference is what keeps CNAs uninterested in staying in SNFs versus higher paying facility types. Once trained CNAs often leave for higher paying jobs at other facility types such as hospitals

QUESTION:

How many skilled nursing facilities have training facilities for CNAs?

• CAHF stated that there are about 40 skilled nursing facilities operating training programs.

QUESTION:

How long are Nursing Assistant Trainees on the floor?

• Gold Country Retirement Center stated that nursing assistants are in class two days a week. Once they receive a sign-off on their skills, they go out to the floor so the facility can meet hours. Outside of the classroom time, nursing assistants are there to provide direct patient care.

QUESTION:

If a CNA is at a facility five days/40 hours a week, how much is working time and how much is in the classroom?

• Gold Country Retirement Center stated that the trainee may spend two days in class and three on the floor providing direct patient care.
• CAHF stated that there are set classroom hours and a certain amount of clinical hours. When a nursing assistant trainee is not in class or on clinical time, the hours providing direct care count towards the 3.2 hrs.

IV. WAIVER AUTHORITY

DISCUSSION QUESTIONS:

Waiver to meet patient needs while meeting the 3.5 overall staffing

• CAHF commented that they are unhappy with the language in the bill, but understand the law. CAHF expressed the need for an appropriate waiver process.
• CAHF stated most facilities currently meet 3.7 direct care hours with up to 2.2 -2.43 CNA time. Meeting the CNA requirement is difficult. Facilities hire CNAs; once trained CNAs often leave for higher paying jobs at other facility types such as hospitals.
• CAHF stated that when the economy is good, like it is now, it is harder to get CNAs, because they can find work elsewhere.
• Facilities that staff above the requirement and have high quality outcomes of care should have a waiver developed for them.
• A provider suggested eligibility for Quality Assurance Supplemental Payments as a justification for a waiver

QUESTION:

Do you have the same challenges attracting LVNs and RNs as CNAs?

• CAHF stated it is easier to attract RNs and licensed vocation nurses (LVN) because they can pay them more. CAHF also stated there is a larger cost benefit from hiring RNs and LVNs because their scope of practice allows licensed nurses to do more.
• Some areas of the state do not have the training resources for new CNAs. Thus facilities focus more on higher level nurses.(CAHF/St. Francis Extended Care)
• LeadingAge asked if the Department had data on the number of CNAs that have active certificates and if the number is consistent, increase, or decreasing.
• CDPH committed to providing this information.

QUESTION:

Regarding the staff shortage waiver, are there issues you want to point out?

• CAHF commented that the language used in the regulations should be consistent with that of CMS. If patient care is not compromised and a facility is making sure that the recruitment effort is there to meet the staffing minimum, a waiver for the facility should be considered.
• CAHF stated that there are issues with staffing in rural areas or smaller bed facilities that advertise for CNAs but are not able to attract them.

QUESTION:

Regarding the waiver of 3.5 if there is a shortage of health care workers and direct care workers, the providers made the following comments:

• Gold Country Retirement Center commented that there are certain times in communities where you cannot pay CNAs prevailing wage, thus it should not be a deciding factor.
• Leading Age indicated the possibility of looking at OSHPD data for 2-year compliance with 3.5 requirements, and show advertising efforts and evidence of a competitive wage.
• One provider noted there might be challenges with paying competitive wages for facilities that have a high percentage of Medi-Cal patients. The provider would not want to see a facility denied a waiver because the facility is unable to pay competitive wages due to Medi-Cal rates. 

QUESTION:

If facility A can pay the prevailing wage for nursing assistants, but facility B cannot, how do we determine why facility B needs a waiver if they are both in the same community?

• CAHF asked why the 2.4 requirement is a part of the regulations if there are facilities that meet and exceed the ratio.
• St. Francis Extended Care commented that just because a facility applies for a waiver does not mean that they will not put in the effort to meet the staffing ratio.
• Gold Country Retirement Center commented that smaller facilities may have a couple days where they may not be able to get staff in. Funds that are being used to recruit new CNAs could be used towards greater patient care.
• CAHF commented that the waiver will not allow for compromised patient care. If there is a building with higher-level staff, they should receive consideration.

QUESTION:

Are there other comments about waivers?

• LeadingAge commented that a quality of care ratio must be different. Facilities should propose their own ratios that would meet the 3.5 or 2.4 requirements based on their own staffing shifts. This would be a part of their ability to obtain a waiver.
• CAHF commented that right now facilities have the flexibility staff to meet the needs of the patients.
• St. Francis Extended Care commented that some facilities have time tracking systems that break staff time out by departments and classification, and others do not. To verify staffing for a waiver, some facilities may need an IT update. In addition, those facilities meeting tiers 2 and 3 in the QASP should be able to apply for the waiver. A facility demonstrating compliance with California recognized quality measures should receive waiver.

Additional Comments

• CAHF asked if the Department would push back the enforcement of penalties beyond the effective date of the regulations.
• The bill delays implementation of the penalties until fiscal year 2019-20.
• CAHF proposed counting therapy (occupational and physical), and social service time as part of the direct care hours.
• CDPH provided a two-week timeframe for stakeholders to submit written comments.
• CAHF asked what other groups the Department met with.
• CDPH responded that the Department has met with various members from labor unions, patient advocates, and provider associations. CDPH plans to host a combined meeting including all interested stakeholders. CDPH will send notice to all stakeholders once the meeting is scheduled.
• LeadingAge asked if the Department considered meeting with CNA training program advisory groups.
• CDPH plans on meeting with the training program representatives within the next few weeks.
• Providers asked for clarification of the intent of Welfare and Institutions Code section 14126.022 (s) regarding eligibility for QASP payments if they meet the 3.2.
• CDPH committed to researching and responding to the request.
• Providers stated they cannot hire all the necessary CNAs immediately on July 1, 2018 and will not hire new staff prior to the effective date of the mandate. Providers indicated they met with Department of Health Care Services and Department of Finance staff to discuss the need to increase funding to allow facilities to hire staff in anticipation of meeting the requirements and to discuss reimbursement rates
  

V. Adjournment

• Scott Vivona adjourned the meeting.