Developing a Post-Acute Care System

Like many industries, long term care was forced to find places to cut their budgets during the COVID-19 pandemic. However, this creates an incredibly difficult balancing act of fiduciary responsibility. They must be profitable to maintain adequate cashflow while at the same time satisfying regulatory compliance. Failure on either side can mean the demise of their organization.

Complicating things is the lack of control that facilities have over labor, inflationary costs, and this year’s PPS PDPM parity adjustment.

So, what can facilities do to enter 2023 in the best position possible? They can start by developing a solid post-acute care system, or a few, that ensures all regulations are fulfilled and standards of care are met.

When is a System Needed? 

When we refer to a system in this context, we are referring to the carefully documented and laid out guidelines for how to fulfill a standard of care, a regulation, or an expectation.

What drives the need for a system?

  • Clinical standard of care as mandated by organizations like the American Disabilities Association, National Pressure Injury Advisory Panel, etc.
  • Federal, state, and local governmental regulations
  • Consumer standards required by advocacy groups and resident or family council, quality improvement organizations, or an ombudsman
  • Insurance, investor, or other payor requirements

Each department within an organization will have unique system needs. For example, CMS outlined a set of specific governing regulations that drive resident care and services. In addition, there is a separate set of requirements from the Life Safety Code & Health Care Facilities Code Requirements | CMS for the maintenance, housekeeping and laundry in each case these two departments will need to consult with one another. However, simply stating that the policies and regulations exists will not be sufficient. Facilities must clearly define a program and approach it systematically in order to address the standard(s) that is to be achieved. Operating without a comprehensive system places a facility at a much higher financial and regulatory risk 

How Do I Create a System?

Within each facility there are many systems which help fulfill the needs around regulations or standard of cares. These systems can differ from facility to facility based on a variety of things, such as the facility’s resident demographics or specialty focus. The components of a system, however, will remain consistent.

While a facility may understand the risks of not having the proper systems in place, it can be daunting to create these from scratch. This article will go through all of the components needed to develop a comprehensive system. We will be using the example of a patient with nutritional needs who will need to use a feeding tube. This is just an example and not representative of a complete system. Please find a system example linked at the bottom of the article.

Policy Statement

What is the driving need for this system? The policy statement should outline the standard of care or regulation you are addressing, and it should clearly define the desired outcome or expectation.


What are the action steps you will take to address the policy stated in the previous section? This should be step-by-step detailed directions that can be easily understood by anyone who will be taking on this task.

Tools and Equipment

This section will identify the tools needed, what is available, and acceptable working conditions. For example, in the scenario of what equipment is needed to supply nutritional care via feeding tube to a diabetic resident:

  • Identified: The tools needed are all the enteral supplies which include the proper formula, enteral pump, etc.
  • Addressing the availability and quantity become part of the facility’s formulary and physician order sets
  • Instructional items such as storage and shelf life along with par levels can then be established, which in turn become easier and more likely to be properly managed
  • Condition of equipment including the cleaning should come with concise instructions and be monitored. Feeding pumps need regular cleaning to promote sanitary conditions which in turn help prevent infection. Routine inspection by the proper staff and equipment suppliers can also be addressed in this section of the systems outline

Budgeted Funds

This includes the exact budget needed for each step of the system, and the overarching cost of this system for the facility. Most facilities look to an annual budget need but when in the development stage a cost analysis from the past 72 months of expenditures can be beneficial for benchmarking. Tracking cost becomes part of the budgeted funds process in a meaningful way when part of a system.

Assigning Oversight, Responsibility and Accountability

When developing a system, it is great to have the information laid out, but it is also important to have responsibility and accountability clearly defined. The first role that must be defined is that of the leader. This is the person responsible for ensuring the fulfillment of the system. They are not necessarily the person carrying out the actions but they are defined as the overseer of the process. This can be through delegation or by taking care of it themselves, depending on the task.

In addition to knowing who is overseeing the process, there needs to be a defining of who is the expert and making sure they are accessible. For example, the nutritionist will be responsible for doing a patient assessment for anything relating to enteral feeding. They need to be available if issues or concerns come up about the patient or for future patient needs.

The nutritionist in this example is not the one who administers the nutrition. This leads to the final role, or set of roles, that will carry out the direct action. This will need to include every role needed to complete this process. The nursing professionals roles need to be defined at all levels, for the CNAs, LPNs, and RNs, in terms of using and maintaining equipment, and the housekeeping crew who is responsible for cleaning, storage when out of use, and maintenance to ensure the working condition of the equipment.

 “Complicated? Yes, it can be if not approached methodically and without proper resources; that’s why having it is so important and necessary. Can you imagine not having a clearly defined system with a regulator asking you and not knowing?”

Education Modules

There cannot be an assumption that everyone coming into the facility will know how to do every task. There must be a way to ensure that every person involved in the system has been properly trained and ensure competency.

Not only is this stage necessary for teaching incoming, on-shift staff, but it also creates a cover from legal issues for the facility. If you have your comprehensive system in place, but an incident occurs that you may be cited for, it is important that you have the documented proof within the system that ensures your staff is competent and capable of the tasks they are assigned. That way it is understood that this was likely a one-off occurrence and not part of a bigger problem. There is also continued accountability and responsibility in place, which can be monitored.

Quality Assurance and Performance Improvement (QAPI)

Simply having your system in place is not enough if there is no follow up. There must be benchmarking and compliance status reports, continuous monitoring, and continuous iterating to improve the system. It is required to have QAPI, a new provision from the Phase III of Requirements of Participants, in place to monitor the system.

This stage should also identify and outline any risks in the system at every stage. This could be anything from ensuring there is always someone accountable on site, to the timeframes during which equipment may wear out and need replacing.

The heightened levels of regulations and pressure to remain profitable facing today’s SNF operators is historic. While it can feel like the factors that are out of your control are dictating the fate of your organization, taking control of the things you can is more crucial than ever. Developing a solid post-acute care system will put your facility in the best position to overcome both financial and regulatory risk in 2023.

To review an example of a completed system, please visit here.


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