Amy Stewart, RNSuzie is a registered nurse (RN) with 15 years of experience. She has worked at a dialysis clinic for the past seven years. During her interview for a second-shift RN position on the post-acute unit of a skilled nursing facility (SNF), she appears confident and knowledgeable about caring for older adults with multiple chronic conditions. She demonstrates good communication skills and has supervisory experience that seems to make her a perfect fit.
Suzie is hired for the position, but how does any hiring manager know with confidence that a new hire has the specific competencies and skill sets necessary to care for residents’ needs, as identified through resident assessments and described in the plan of care?

Required Competence

Just this past September, the Centers for Medicare & Medicaid Services (CMS) released the much-anticipated reform Requirements of Participation for Skilled Nursing Facilities, the first major update in regulations since 1991.

Although implementation of the requirements will be phased in over a three-year period, one notable update with an implementation date of Nov. 28, 2016, is the language that has been added regarding sufficient staffing, specifically related to competency. While competency is now required and should seem like common sense, it is not defined in the regulation by credentials or experience.

So how do facility leaders know whether a new or current staff member is competent to perform the required duties, and how can they prevent deficiencies for competency under F-Tag 353?

The Revised Staffing Requirements

The revised staffing requirements in §483.35 Nursing Services include new and strengthened language with regard to not only how many staff are providing care at any given time, but also the quality of each staff member’s care.

According to the final rule (bold type indicates newly inserted language), “the facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility’s resident population” (81 Fed. Reg. 68861). This applies to all nursing personnel, including but not limited to nurse assistants.

In addition to this, as part of Phase 2 of the Final Rule implementation (scheduled for Nov. 28, 2017), SNFs will need to use the newly required facility assessment to ensure staffing is adequate based on the number of residents and the acuity and diagnoses of the resident population.

As competency is not defined in the final rule, it falls on SNF leadership to identify the specific competencies and skills germane to the facility’s needs and to provide appropriate continuing education and training.

According to new language in the Final Rule published in the Federal Register, “providing care includes but is not limited to assessing, evaluating, planning, and implementing resident care plans and responding to residents’ needs” (81 Fed. Reg. 68862). With this wording, CMS is encouraging providers to be aware of the specific needs of their residents and to thoughtfully staff their facilities according to those specific needs.

Competency-Based Training

Although competency-based training is not a new concept, it is new for many long term care leaders. When nursing facilities hire licensed staff, leadership tends to assume competency because the candidates have specific education or credentials. But this is not always the case, which is why continuous, competency-based training is key in any facility.

Competency-based training requires staff to demonstrate that they have the knowledge to complete a specific task. Training could include case studies, online learning with return demonstration, or even a “skills day” during which all staff attend various skills stations to learn specific skills and demonstrate them to the director of nursing services or others.

Determining Competency-Based Education Needs

Competency-based education is particularly important, and the need for it is brought sharply into focus when a new resident is admitted who requires a treatment that staff members either aren’t familiar with or haven’t worked with in some time. Training needs can be discovered more proactively, however; facility leaders can use a variety of metrics to determine the need for ongoing staff training.

To start, nurse leaders need to consider the staff members’ skills, the resident population, and any special services the facility offers (for example, a ventilator unit, a post-acute unit, a pediatric unit, or a dementia unit). Specialty units may demand specialized training for staff who work in them.

Next, to identify any potential gaps in care delivery, nurse leaders need to examine resident acuity, diagnoses, and the intensity of services required for care. Some examples might include:
  • Reviewing readmission rates and common trends for residents who are discharged and return, which may require continuing education and competency checks to address knowledge deficits in staff;
  • Analyzing an increased number of infections, which may require additional training and competency reviews to ensure proper infection-control measures are being used by all staff;
  • Reviewing an increased number of resident admissions requiring intravenous (IV) medications, which may indicate that it is time to assess the competency and skills of the nurses administering the IV meds; and
  • Reviewing resident assessments (such as the minimum data set) to identify common diagnoses and offering additional training specific to the resident population.

Understanding Staffing Patterns

In addition to ensuring competency of the staff, it is wise for facility leaders to consider how staff orientation could be enhanced by adding competency/skill-set checklists specific to the unit the staff member will be working on.

For example, if a new nurse assistant will be assigned to a unit that specializes in behavioral health-related issues, orientation material should include how to address resident behaviors that the nurse assistant may be exposed to. A one-size-fits-all approach to orientation is no longer enough, if it ever was.

Although some facilities may provide specific unit orientation information informally, now is a good time to formalize this process.

In addition to enhancing orientation material, it is also important to keep competency in mind when scheduling staff. What would be the impact of having a unit shift filled with all new staff members? It could lead to confusion and errors, since no one staff member is familiar with the residents on the unit, including their specific tendencies or ailments.

For example, new staff might misinterpret a change in behavior of a resident with dementia, when in fact the perceived change is not abnormal for that individual. Not knowing this, the new staff member might send the resident to the emergency room, an unfamiliar environment that can be frightening and stressful. The resident’s stress and confusion may lead to increased behaviors and decline.

Unanswered F-Tag Questions

Because competency is not clearly defined, how F-Tag 353 will be applied to address lack of competency is also unclear. For example, three residents fall during one shift and the facility is cited for F-Tag 323 Accidents.

At the time of the falls, four staff members were attending to 20 residents, with each staff member assigned to five residents. Would the facility also be cited under F-Tag 353 Sufficient Staffing, because despite the appropriate number for sufficiency, those staff members were not competent enough to prevent the falls, per the care plan, according to their assigned residents’ needs?

Although sometimes the newly released final rule can read better than a favorite mystery novel, full of unknowns until further clarification is received, the best path forward is to use the new requirements, however murky, as a tool to improve quality of care. This is definitely true of the new staff competency requirements. Facility leaders should know their residents, know their staff, and not assume competency when hiring. Rather, they should focus on continuing education and ensuring and improving competencies for all involved in resident care.
Amy Stewart, RN, DNS-MT, QCP-MT, RAC-MT, is a curriculum development specialist at the American Association of Directors of Nursing Services. She can be reached at