Recent findings published in the American Health Care Association's 2023 State of Industry report demonstrate the impact staffing challenges are having on nursing homes across the country. Specifically, 84 percent of nursing home respondents rate the current staffing shortages in their respective centers as moderate to high. In response, 78 percent of nursing home respondents have incorporated the use of temporary agency staffing to ensure the delivery of care to facility residents.

During the COVID-19 pandemic, staffing agencies contracted with health care organizations in supporting direct care to COVID-19 patients or in assisting organizations to cover openings due to staff quarantine and position vacancies. Multiple stories exist of dedicated health care professionals contracting with agencies for temporary and travel work, becoming essential front-line support in several hot spot communities around the country.

Locally, staffing agency professionals have been reliable collaborators in the provision of services in high-need markets. During times of staffing crisis, it can be difficult for organizations to implement strong temporary agency staff programs compliant with operational guidelines, further supporting the need for quality assurance review. Organizations should conduct a quality assurance review of the temporary agency staffing program to ensure continued compliance and safe delivery of care practices are maintained.

The Need for Quality Review of Temporary Staff

Nursing homes must maintain the responsibility of ensuring a strong program is in place to support these temporary professionals working onsite at the facility. This becomes increasingly relevant following the October 2022 updates to the State Operations Manual (SOM) by the Centers for Medicare & Medicaid Services (CMS). Several updates are in the areas of staffing and staff competency. The SOM directs organizations to ensure the availability of trained and competency verified staff to provide services aligning with the needs and care levels of current residents. Nursing home organizations must consider staffing needs as well as competency level for those residents that are being accepted for services, as documented within the Facility Assessment reviews.

Accordingly, organizations utilizing temporary agency professionals should conduct routine quality assurance reviews to ensure continued compliance is maintained. The quality assurance reviews should include a review of the Facility Assessment; review of the SOM guidance on staffing, training, and staff competency; as well as review of the Sufficient and Competent Nurse Staffing Review for survey pathway compliance. To assist in this review, a summary of considerations is provided in Table 1: Temporary Agency Professional Quality Assurance Review.​ However, these considerations are not all inclusive and should include supplementary guidance from state licensing and regulatory standards.

How to Conduct a Quality Review

To prepare, the organization should assemble a Process Improvement Project (PIP) team, consisting of the internal stakeholders. Organizations that engage internal stakeholders in performance improvement projects increase regulatory knowledge within their team, determine potential barriers with system implementation, and create stronger outcomes.

Prior to initiating the PIP, the center should verify what temporary staffing agency (or agencies) internal staffing coordinators are contacting for assistance in filling open shifts. This is a good opportunity to validate active, signed contracts are on file for the currently used staffing agencies. While doing the contract review, ensure the activated contracts include language documenting the expectation the temporary agency professionals immediately report any allegations of abuse, neglect, misappropriation, or exploitation to the Administrator consistent with center policies.

Organizations should also ensure there is a process in place to verify the skill, licensing, and competency level of the temporary agency professionals. According to the Sufficient and Competency Nurse Staffing pathway (CMS-20062), organizations are directed “to ensure the work assigned contract staff is within their skill set." Organizations should determine which position(s) is responsible for review of the onboarding packet and determining appropriate assignment within the center.

Equally important as validating the onboarding packet is being reviewed for completeness prior to the first shift worked. These documents should be assembled into a temporary agency staff file, maintained on site. The files should contain the temporary agency professional's resume', license or certification, documented training completed by the temporary staffing agency, completed competency skill assessment, copy of TB, required vaccination(s), and background check information.

Complementing the staffing agency documents should be the center's validation of license or certification, background check, and enrollment in the State's fingerprinting system for notice of findings. This is an opportunity for the organization to identify if the temporary agency professional has had prior actions on their license and ensure corresponding education on center policy is provided before starting a shift. For ongoing compliance, the organization should ensure a process is in place to monitor the state's disciplinary board notices, mitigating the opportunity for a licensed health care professional to continue working on an inactive license.

Orientation and Continued Training

Organization-specific orientation is an important investment in the temporary staff relationship. Temporary agency professionals represent the organization and are responsible to provide care aligned with the organization's customer service expectations. Providing training and review at the onset of the relationship helps to support the professional in this role. Furthermore, professionals who are provided with training and guidance report higher levels of satisfaction, increasing the potential to assist the organization in future staffing needs.

The training needs extend beyond the condensed orientation period. Organizations need to ensure temporary agency professionals are included in identified training opportunities on an ongoing basis.

A key principle in quality assurance programs includes involving “the people directly working in a process to improve the process." Organizations should validate there is a check-in process with the temporary agency professionals and the temporary agency management on a routine basis. The flow of communication improves outcomes, identifies training opportunities, as well as identifies opportunity for continued process improvement resulting in improved resident outcomes, staff satisfaction, and operational efficiencies.

Alyssa PischelTemporary agency staff programs have served an important purpose in the changing health care environment and remain a viable temporary solution for the current staffing challenges. It is important for organizations to conduct ongoing quality assurance reviews on these programs. This ensures that regardless of staff crisis level operations, organizational standards are being met in the delivery of patient care.

Alyssa Pischel is a licensed nursing home administrator with over 20 years' experience in the health care industry. She is currently a Quality Improvement Specialist, supporting nursing homes in the pursuit of quality initiative adoption.

1.     American Health Care Association (2023). More than Half of Nursing Homes are Limiting New Patients Due to Staffing Shortages. Press Release, January 10, 2023.
2.     American Health Care Association. (2023). State of the Nursing Home Industry: Survey of 524 nursing home providers highlights [persistent staffing and economic crisis. January 2023.
3.     United States Centers for Medicare & Medicaid (ND). QAPI at a Glance manual.
4.     United States Centers for Medicare & Medicaid. (2022). State Operations Manual. Appendix PP – Guidance to Surveyors for Long Term Care Facilities. (Rev. 208, 10-21-2022).
5.     United States Department of Health & Human Services (2022). Sufficient and Competent Nurse Staffing Review. Centers for Medicare and Medicaid. Form CMS-20062 (10/2022).