Providers were bracing for the first federal minimum staffing proposal, the details of which could have broad implications for all nursing homes.

The Centers for Medicare & Medicaid Services first said in February 2022 that it would research a staffing mandate as part of a White House nursing home reform effort. Officials in January announced they had completed a study, but no rule had been issued at press time.

Skilled nursing facilities have not made significant job gains in the last year, and several groups have asked CMS to delay a rule until recovery is evident. In January, AHCA said a staffing minimum “without the proper resources to recruit staff will only worsen the crisis.”

“This labor crisis will not go away on its own or through government enforcement,” said AHCA President and CEO Mark Parkinson. “We need immediate support, but we also need long-term investments.”

For the second time, President Joe Biden announced during a State of the Union that his administration would be tightening its grip on nursing homes. 

“We’re protecting seniors’ life savings by cracking down on nursing homes that commit fraud, endanger patient safety and prescribe drugs that are not needed,” Biden trumpeted in his Feb. 7 speech to the nation. 

The 12-second mention was in direct reference to the administration’s Jan. 18 announcement that the Centers for Medicare & Medicaid Services would start audits to determine if providers are properly assessing and coding patients with schizophrenia. The agency also announced at that time that it will publicly display disputed survey citations before cases are resolved.

The White House also directly indicated in a new Fact Sheet that more regulatory belt-tightening will be coming for nursing homes. Less than a week later, the Department of Health and Human Services proposed a new nursing home ownership disclosure rule intended to make ownership and management roles of facilities more clear.

Despite symptoms such as fever, lethargy and dehydration, rehabilitation during COVID is beneficial, helping decrease the odds of long-term atrophy and improve functional outcomes, the researchers reported. The study was conducted in a nursing home operated by The New Jewish Home in New York. Investigators followed outcomes in 71 long-stay residents and 177 post-acute care recipients with symptomatic COVID for 30 days between March and May 2020. 

Post-acute patients were more likely to receive rehabilitation than long-stay residents, they found. Occupational and physical therapy were provided to nearly 60% of the ill residents, while speech therapy was provided to 13%. Residents who received rehabilitation were more functionally dependent while ill than peers who did not receive therapy. But the rehabilitation group’s functional status declined less than their peers. 

“Clinicians should feel comfortable prescribing rehabilitation at moderate amounts to COVID-19 patients in nursing facilities, if consistent with goals of care,” the authors concluded.

A: This is definitely the most asked question at the moment. It seems that the facilities that have had some success have made several specific moves. Meet with your staff, one-on-one and ask where the help is most needed.

Look at your medication pass time and the number and type of meds being passed. See if you can combine some of the med passes, as many facilities have meds every hour, which potentially can keep a floor nurse anchored to the cart for her entire shift. 

Meet with the medical director and other physicians to see what meds you can move, combine or discontinue.

Think about scheduling and hiring nurses for three- , four- , or six-hour shifts. Maybe there are some moms who can work only while their kids are in school — or after the kids go to bed. Or there’s a nurse getting her degree and only has a few hours here and there. Hire them! Give your overworked nurses some assistance!

Same with nurses aides. Perhaps hire some high school students to pass water and ice, deliver the mail, read the mail, make the beds or tidy up the rooms. They may love what they are doing and decide to become certified or even apply to nursing school. Bring them in during your busy times, or activities times. Many high school groups, such as the Future Nurses of America, may be perfect, or approach church youth groups and the Girl Scouts and Boy Scouts.

I know thinking out of the box can be hard to do and hard to be accepted by others, but it could be a way to help you. It bears stating that raising salaries, granting paid time off and offering incentives also helps!

The Co-Worker Observation Reporting System (CORS) allows users to anonymously report behavior to a trained peer, without involving nursing leadership or human resources unless necessary. Data collected over 10 years shows most people listen to peer criticism and self-correct, according to the tool’s Vanderbilt University developers.

The current study implemented CORS for staff nurses at three medical centers. Researchers examined 590 reports from September 2019 to August 2021, with a total of 1,367 negative behaviors including dispresctful or unclear communication, concerns about medical care, possibly “egregious” errors and more were reported.

While most nurses were willing to use the tool, 92% said they never received a CORS
behavior report themselves.

“The findings of this study really highlight the fact that professionals will respond if we approach them in respectful, nonjudgmental ways,” said study author William Cooper, MD, MPH, whose work was published in The Joint Commission Journal on Quality and Patient Safety.

A: The interrupted stay policy applies when a resident on a Medicare Part A stay discharges from a SNF and resumes skilled care in the same SNF for a Part A-covered stay during the
interruption window.

That window is the three-day period starting with the first day of the Part A discharge and including the two following calendar days. If a resident on a Part A stay discharges from Part A, the resident must resume Part A services by 11:59 p.m. of the third consecutive non-covered day to constitute an
interrupted stay.

If the resident remains in the facility after Part A services end and skilled services resume before 11:59 p.m. on the third non-covered day, it is an interrupted stay. Since there was no physical discharge, no new assessments are required.  However, if the Part A stay ends due to physical discharge and the resident returns for skilled services before 11:59 p.m. on the third non-covered day, OBRA discharge and entry tracking records are required. A PPS discharge assessment is not. In either instance, the nurse assessment coordinator and team should consider an optional Interim Payment Assessment. 

If the resident returns for skilled services after the third day, it is not an interrupted stay; OBRA and PPS discharge assessments are required. Upon return, an entry tracking record and a new 5-Day PPS assessment are required. Subsequent OBRA assessments depend on the type of discharge. If a return is anticipated, the assessment schedule continues where it ended. If a return is not anticipated, a new OBRA Admission assessment is required; it can combine with the 5-Day PPS assessment. 

Aeo, the newest robot from tech firm Aeolus, was designed with an ability to deliver food and medicine to older adults. Its appendages can lift an 8-pound cooler and hold a phone without dropping or crushing it. This robot also can learn the difference between caregivers and patients and tell by looking at a person’s posture whether they might have fallen or need help.

The Kalogon Orbiter wheelchair cushion senses pressure points and redistributes weight to increase blood flow, improve comfort and prevent pressure sores. The cushion has five regions corresponding to the tailbone and left and right thigh and butt areas. By keeping four of the five inflated, the user is supported with alternating pressure. 

Whissp artificial-intelligence-powered speech technology can aid residents who have issues with voice disorders or stuttering. Whispp enables smartphones and computers to convert whispered speech and vocal cord-impaired speech into a person’s natural voice in real-time, with intentional intonation and emotion.

XanderGlasses display real-time captions of in-person conversations to help residents with hearing loss. XanderGlasses are designed to be used like a simple “on” and “off” device. They don’t rely on smartphone or cloud connectivity, making them reliable and private. In this augmented reality experience, captions are displayed right in the wearer’s field of view.

A: Except for items using a dash-filled value to indicate an event has not yet occurred, i.e. the Medicare stay end date, a dash shows an item was not assessed. 

Almost all MDS 3.0 items allow a dash (—) value to be entered, and this most often occurs when a resident is discharged before the item could be assessed. Even though there will be times when dashes are unavoidable, the Centers for Medicare & Medicaid Services expects the use of dashes to be rare.

You and other members of your interdisciplinary team should always strive to thoroughly assess all residents to ensure an accurate assessment. Dashing MDS items can lead to ineffective care planning and financial repercussions. 

Resident interviews in MDS sections C and D are a great example. These interviews must be conducted during the assessment reference period. If they aren’t, the interviews must be dashed. Had the interviews been conducted and reported according to RAI requirements, PDPM reimbursement for a Medicare beneficiary could have been increased if the resident exhibited cognitive impairment and/or indicators of depression. 

Additionally, be wary of unnecessarily dashing items used for SNF QRP data, including items in Section GG. Not only can a lack of information in this section lead to PDPM reimbursement concerns, but trends in dash use also can negatively affect the Annual Payment Update. For a given data submission period, submitted MDS assessments must meet the APU minimum data completion threshold of no less than 80% of MDS assessments having 100% completion of the required SNF QRP data elements. 

Bed reduction rule lowering patient access

MASSACHUSETTS — Four nursing homes in the same county announced they would close by June, chased out of the state by a “reconfiguring” reform meant to improve the quality of care.

The Northeast Health Group said in February that it planned to shutter four facilities in the western part of the state, according to the Department of Public Health. Twenty-five nursing homes in the state have closed since the start of the pandemic, with at least half shutting down over the last 12 months, said Tara Gregorio, president of the Massachusetts Senior Care Association.

Northeast pinned its reason on a 2021 state rule prohibiting more than two residents per room. It took effect in May 2022. Limiting beds per room has reduced revenue, even as some facilities are limiting admissions due to staff shortages.

“Government leaders must prioritize nursing facility care by increasing funding for this vital service, while simultaneously investing in proven workforce development initiatives and adopting smart immigration policies that further expand the number of available workers,” Gregorio said.

The Northeast Health Group unsuccessfully applied for a waiver to exempt it from the two-bed rule. Meanwhile, a Suffolk Superior County judge in January kept alive a lawsuit from 31 providers looking to block the capacity mandate. 

Long-term care workers lobbying for $25 minimum wage

CONNECTICUT — Nursing home workers and labor advocates in February began a public push for hourly wage adjustments that would bring their minimum pay to $25 hourly by 2025.

Workers represented by SEIU 1199NE made their arguments during an event hosted by Sen. Richard Blumenthal (D) promoting the federal Better Care Better Jobs Act. While that bill largely focuses on home and community services, it also would make states eligible for a 10% Medicaid increase if they meet certain pay and benefit standards.

“All of these goals that we are talking about, they are all achievable, they are all real,” said union president Rob Baril. “This is a real conversation. People are going to tell us that we are crazy. I don’t believe that the idea of ending poverty for long-term care workers is crazy.”

Desired raises and related benefits would cost about $700 million, but union leaders pointed to a state surplus of more than $3 billion. Lawmakers hadn’t proposed a budget at press time, but the funding was not expected to be in Gov. Ned Lamont’s (D) spending plan.

NORTHWEST

Bills address hospital backlogs with SNF pay

WASHINGTON — Nursing homes in Washington state in February were awaiting a reprieve from a labor crisis that is stranding potential residents in hospitals.

Companion bills introduced in the state Senate and House would update Medicaid funding for skilled nursing facilities every year and create an inflation adjustment.

Washington nursing homes were underpaid by $620 million over the last five years, according to the Department of Social and Health Services, which, combined with labor shortages have resulted in facilities closing units or halting admissions. Worsening hospital logjams led the Washington State Hospital Association to make post-acute funding a 2023 legislative priority.

WEST

Bill would double nursing home inspections

ARIZONA — Legislation moving through the state senate would privatize nursing home surveys and double the number required annually, a shift sector advocates said would hike costs without improving quality.

“You cannot punish facilities into good behavior,” Dave Voepel, CEO of the Arizona Health Care Association testified. “If you want to truly improve quality, you must examine the very nature of the current regulations and create new standards of care.”

The legislation stems from a 2019 audit of the state Department of Health Service that found neither inspections nor follow-ups on complaints were happening. It alleged the department failed to conduct onsite investigations within a required 10 days for 73% of 156 high-priority complaints and “inappropriately” shifted 98% of high-priority complaints to a lower status.

Nursing home advocates warned that third-party inspectors won’t resolve these problems and would double provider work and state costs.

Bill would eliminate predatory agency fees

COLORADO — Lawmakers are poised to prohibit staffing agencies from collecting damages when a facility wants to permanently hire a worker.

Doug Farmer, president and CEO of the Colorado Health Care Association, told the State of Reform website that contract restrictions put in place by agencies create a major barrier in bringing workers on board at a reasonable cost. One of the bill’s sponsors called it a “ransom fee.”

“There’s a separation fee that must be paid contractually and it is often $5-7,000 in average cost” Farmer told State of Reform. “But the challenge is really less about the one-time costs than it is about the fact that it’s not a guarantee.” 

Workers might still leave the nursing home for a competitor, or another job, and the facilities are still out the buyout fee. Under the bill, any agency that charges damages would be subject to a monetary penalty up to $5,000.

A: CMS has announced it would begin publishing citations against nursing homes even while those citations are appealed. Thus, it will immediately post deficiency citations under Informal Dispute Resolution and Independent Informal Dispute Resolution (IDR/IIDR). 

This is a stark change from the traditional policy. The clear purpose behind not posting citations under IDR/IIDR until the dispute is complete was simple: Any family doing due diligence regarding a facility should not be unduly influenced by cited deficiencies when they have not been finally adjudicated. Though the deck is stacked against them, nursing home operators do actually win appeals.

Now, CMS will display disputed items on Care Compare with a note. If upheld, they will remain posted. If overturned, the citation will be removed. If the severity is reduced, the citation will be displayed at the reduced level. Still, citations will not be included in calculating a star rating until the dispute is resolved.

The above “safeguards” are insufficient to address the key drawback. Families will be making decisions about nursing homes based upon premature information. It is exceedingly unlikely that subsequent changes will be known by families in sufficient time to counter the earlier information.  

CMS stated that “consumers should have as much information about nursing homes as possible to support their healthcare decisions.” Here’s my fix to the that: “Consumers should have as much [accurate] information about nursing homes as possible to support their healthcare decisions.”

Putting out premature information about a facility increases the likelihood of families relying on inaccurate information. That helps no one.