Rural Nursing Homes Discuss Regulation With CMS

Members | June 14, 2016

On June 9, 2016, LeadingAge Kansas and public policy staff from LeadingAge facilitated a rural issues forum that focused on the particular challenges rural nursing homes face in caring for residents and serving their communities.  

The forum included a conference call with top officials of the Centers for Medicare and Medicaid Services (CMS). CMS participants included Evan Shulman, Deputy Director, Division of Nursing Homes; and representatives from CMS’s MDS, Nursing Home Compare and PBJ teams.

Provider participants included representatives of 28 nursing homes located in Indiana, Kansas, Minnesota, and South Dakota; and representatives of LeadingAge, LeadingAge Kansas, LeadingAge Nebraska, LeadingAge Minnesota, LeadingAge Oklahoma, LeadingAge Iowa, and the South Dakota Association of Health Care organizations (SDAHO).

Dr. Cheryl Phillips, LeadingAge’s Senior Vice President for Public Policy and Health Services, described the nursing homes participating in the call in terms of their size and their place in their communities. She emphasized that the purpose of the call was not to discuss payment issues or pending regulations, but simply to enable the rural nursing homes to raise some of the particular challenges they face in caring for residents. She and Even Shulman agreed that CMS and providers have a common goal of high-quality care for nursing home residents, even if they may see different ways to meet the goals.

Workforce Issues 

Deb Barnes from Lakeview Methodist in Fairmont, Minnesota noted that in Minnesota there are 0.9 applications for every nursing home job vacancy. Her nursing home sometimes is unable to admit people who need care because there are not enough staff members. She described the staffing situation as uniquely dire and close to collapse. She questioned whether there could be more flexibility or a reduction in the paperwork necessary to meet survey requirements, noting that some nursing staff have to be devoted solely to documentation rather than being available to provide care.

Holly Noble from Attica Long-Term Care in Attica, Kansas discussed the difficulty rural nursing homes have in complying with physician visit requirements. As rural physicians retire and no new doctors move in to take their places, both staff and residents have to travel several hours to doctor appointments for no reason other than to comply with survey requirements. She questioned whether medical necessity could be taken into consideration, with a requirement for a physician visit only if the resident has a change in medication or an MDS condition, or other triggering factor. She also questioned whether appointments with a nurse practitioner or physician assistant could substitute for physician appointments or whether a longer period could be allowed between physician visits, beyond the current 60-day requirement.

Neil Ostlie from Prescott Country View in Prescott, Kansas, the only nursing home in the county, described how a staff member has to spend three hours driving a resident to a regulatory-required physician appointment when the resident is not sick, nor had any change in condition.

Nate Glendening from Philips County Retirement Center in Phillipsburg, Kansas brought up the difficulty his organization has in finding clinical staff like directors of nursing, infection control specialists, etc. He questioned whether some of these clinical staff positions could be shared among nursing homes.

Evan Shulman emphasized that the requirements of participation set minimum standards to ensure that nursing home residents receive the services they need and questioned whether standards should be lowered. Cheryl Phillips asked whether there might be different ways to meet needs in rural communities. She noted that nursing homes in rural areas are closing because they can’t meet staffing requirements and pointed out that current requirements do not take into account the size of a nursing home or its geographic location.

Behavioral Health 

Mike Smith from Wheat State Manor in Whitewater, Kansas, described the pressure his nursing home often feels to admit someone with mental illness to the home’s Alzheimer’s unit. Wheat State Manor prescreens all applicants to determine whether their needs can be met, but Smith questioned whether younger people diagnosed with severe mental illness or PTSD should be mixed in with a population of elders with Alzheimer’s disease. If the home admits someone with mental illness, problems can develop, but if the person is not admitted, they will not get the care and services they need because there is nowhere else for them to go.

Patricia Raasch from Mission Village in Horton, Kansas described the related problem of rural communities’ lack of psychiatric specialists and trained staff to treat people with serious mental illness. She said that her nursing home wants to care for community residents so that they can remain close to home, but the human resources just aren’t there.

Evan Shulman responded that CMS wants to work on these problems beyond today’s call, that we need to figure out how people with mental health issues can be served, especially given the potential for injury to themselves or other residents. Cheryl Phillips noted that surveyors may cite nursing homes for deficiencies if the surveyors can’t distinguish between dementia and mental illness.


Erica Peterson from Sanford Chamberlain Care Center in Chamberlain, South Dakota noted that her nursing home is the only long-term care provider in a three-county area. She questioned how CMS sees the role of information technology and telemedicine in the long-term care field.

Evan Shulman responded that there is a greater and greater role for telemedicine in connecting providers to each other and to their communities. He cautioned that it can’t be a substitute or an easy way out.

Returning Nursing Home Residents to the Community 

Jen Porter, SDAHO's Vice President for Post-Acute Care, brought up the letter the South Dakota government received from the U.S. Department of Justice about the state’s slowness in making home- and community-based services more available under its Medicaid program. Jen said that SDAHO is working with the state to expand HCBS options, but in rural areas it is hard to discharge residents from nursing homes because services and caregivers are not available in the community. She mentioned one SDAHO member that created a traumatic brain injury unit so that South Dakotans who needed this kind of treatment would not have to leave the state. Now the member is being criticized for not discharging residents from the unit even though they would have no support system in their communities.

Cheryl Phillips brought up the rules on home- and community-based services for Medicaid beneficiaries in residential settings, noting that in rural areas the only affordable housing for seniors and people with disabilities often is located on the campus of an assisted living facility or nursing home.

Evan Shulman responded that there needs to be continued discussion, but that solutions may depend on what the state is willing to do.

New  Regulations 

Liz Davidson from LeadingAge Iowa questioned where various regulations stand.

Eric Shulman discussed the new 5-star measures that will roll out in July. He said that in developing them, CMS examined both the traditional survey system and the QIS system to establish one unified system for the whole country, which he hopes will roll out next year. He said that there will be no expansion of QIS surveys.

With regard to PBJ, he said that it will become mandatory in July. From what CMS has heard so far from nursing homes that have voluntarily submitted data, a frequency of every two weeks in accordance with a nursing home’s payroll schedule seems to work best.


Judy Kregar from Hill Top House in Bucklin, Kansas discussed the role of small nursing homes in rural communities. They frequently are the area’s primary employer; in Bucklin, one third of the town’s residents either live or work in Hill Top House. The survival of small rural nursing homes is essential to residents’ quality of life, since their friends and families are close by and can visit regularly.

Cheryl Phillips commented that the reason for this call was to put a face on the issues and discuss whether there are possibilities for flexibility in rulemaking.

Evan Shulman expressed appreciation for providers’ feedback, whether or not changes can be made. He said it’s important to improve circumstances without changing quality expectations and said that CMS wants to help nursing homes comply with requirements.

Follow-up issues: Evan Shulman restated the desire of CMS to explore better care models “and resources” for mental illness in the nursing home, as well as how best to deploy telemedicine in the nursing home setting.  

LeadingAge and its members are very interested in these further discussions.