Skilled nursing facilities (SNFs) have long been an integral part of the health care continuum, but never before have they proven to serve in such an integral capacity as during the current COVID-19 public health emergency (PHE). While frontline providers spent countless hours dealing with the most critically ill, SNFs provided an undeniable support to the entire healthcare community and continue to do so as the public health crisis continues.

PHE and the Impact on Skilled Nursing Facilities
During the PHE, the Centers for Medicare & Medicaid Services (CMS) used emergency powers to implement waivers to allow flexibilities related to the care and treatment of patients within all venues of care.1 These waivers have allowed the use of SNFs to serve as a critical resource for hospitals and health systems across the country. Being able to move patients into SNFs without awaiting the three-day acute care stay requirement freed up desperately needed acute care beds to serve those most acutely ill.

Issues continued, however, when SNFs were required to implement processes that decreased the number of beds available to serve as a pop-off valve for overcrowded acute care hospitals dedicated units to accommodate those with known or suspected COVID-19, as well as staff availability to accommodate the needs to screen, treat, and test the resident and/or staff population.

This is not to say that the government was incorrect in imposing requirements; it was necessary to maintain the health and safety of the residents and staff. However, the restrictions did not come without a great cost to a venue of care that already operates with thin margins.

Many waivers were put into place to ease burdens during the PHE which provided relief not only for SNFs, but also their acute care referrals sources. Some were short term to allow for adjustment to the numerous operational changes needed and some lasted more than two years to relieve the burden.

There are currently a number of waivers are still in place, but the following have already been terminated, requiring facilities to return to routine regulatory requirements:

  • Staffing data submission for payroll-based journal (PBJ) – reinstated 6/25/2020
  • Timeframe requirements for submitting minimum data sets (MDS) – reinstated 5/10/2021
  • Notice and rationale for resident room changes – terminated 5/10/2021
  • Resident transfer and discharge – expired 5/10/2021 with some noted exceptions
  • Restriction for in-person resident groups – terminated 5/7/2022
  • Allowance for limited Quality Assessment and Performance Improvement (QAPI) activities – terminated 5/7/2022
  • Limited discharge planning data sharing requirements – terminated 5/7/2022
  • Extension of time to provide clinical records – terminated 5/7/2022
  • Delegation of physician tasks to nurse practitioners, physician assistants, and clinical nurse specialists – terminated 5/7/2022
  • Physical environment waivers such as inspection, testing and preventative maintenance scheduling, outdoor window requirements for all resident rooms – terminated 6/6/2022
  • Life safety requirements such as fire drills and temporary construction of walls and barriers – terminated 6/6/2022
  • Timeframe for training of paid feeding assistants – terminated 6/6/2022
  • Allowance to create additional SNF/NF in nontraditional spaces – terminated 6/6/2022
  • Nursing aide in-service training requirements – terminated 6/6/2022
  • Provider enrollment related waivers have mostly been terminated related to facility providers. A small number of waivers remain in place.

While the above waivers have been terminated or expired, the following waivers still remain in place to allow for latitude during the ongoing PHE:

  • Three-day acute care hospitalization prior to SNF stay
  • Preadmission screening and annual resident review (PASSR) 30-day suspension of assessment
  • Data related to PHE extended until 12/31/2024
  • Timeliness for submission of Medicare appeals with good cause
  • Resident rooms and grouping for cohorting for illnesses
  • Placement of alcohol-based hand rub dispensers
  • Testing of staff and residents for SARS-CoV-2

Despite these ongoing concessions, it will be critical for skilled nursing facility operators to begin preparations to operate without the waivers allowed under the PHE.

Operational Changes Needed During the PHE
During the PHE, skilled nursing facilities were required to implement a number of operational changes to ensure the health and safety of residents. While these requirements were in the best interest of residents and staff, they did not come without significant impact to the operations of the skilled nursing facility.

The requirement to develop a designated area for those with known or suspected COVID-19 meant that a number of normally operating beds were decreased by those that became part of a unit, which, if lucky to not incur an outbreak, remained unused. Should residents be admitted that require observation and or COVID-19 placement, this required additional dedicated staff that were unavailable to care for other residents in the facility. Again, while best for resident health and safety, this created an operational and administrative burden on the SNFs.

In addition, staff and resident testing was required which brought the need for additional manpower with already scarce resources available. Ensuring that residents were able to maintain visitation, either in-person or virtually, brought additional resource needs and very clever operational changes to meet the rights of this population. Again, while these efforts were necessary for the health and safety of the resident population, pressures mounted on the venue to ensure adequate staffing to meet not only routine care needs. What we have seen is a workforce whose continued dedication to this unique patient population growing stronger as the pandemic continued.

Skilled Nursing Facility Closures under the PHE
If we have learned anything over the past (almost) three years, it is how valuable this venue of care is within the health care continuum. However, COVID-19 placed such extreme pressures among the leadership and staff of SNFs while they still remain dedicated to ensuring that the residents rights are protected while balancing routine care needs and the the mandates pertaining to staff testing, visitation, and management of staff and visitor screening during the PHE.

Despite all efforts of providers across the nation, there have been substantial closures of skilled nursing facilities. According to an article written by AHCA/NCAL in April 2022, there had already been 327 nursing home closures throughout the pandemic with another 400 anticipated to close in 2022.2 This has resulted in the displacement of thousands of residents and also reduces the number of beds available to acute care facilities looking to free up much needed beds for those critically ill.

Susan Maupin, J.D.With the mounting pressures to retain staff, meeting increased infection prevention, and quality requirements to ensure resident safety, and maintain financial viability, the SNF operators will need to well prepare for what occurs once the PHE ends. The healthcare system with need this post-acute champion to continue to meet the needs as the PHE continues.

Susan Maupin, J.D., is a vice president at Advis. Prior to Advis, she served as a registered nurse at St. Anthony Medical Center, Crown Point, Indiana.
1.     Centers for Medicare and Medicaid Services, Long Term Care Facilities (Skilled Nursing Facilities and/or Nursing Facilities): CMS Flexibilities to Fight COVID-19.
2.     American Health Care Association National Center for Assisted Living, Nursing Home Closures: By the Numbers, April 2022.​