A 10-percentage point increase in staff vaccinations delivered fewer weekly cases and deaths among residents after shots first became available, according to an analysis of more than 15,000 nursing homes published Dec. 29 in JAMA Network Open. Over a year, that would have meant 20,000 fewer  deaths, researchers estimated.

But staff-to-resident benefits waned as the omicron variant took hold in late 2021. Rules mandating that workers have updated COVID shots still don’t exist.

“As the pandemic evolves to include newer, more infectious strains of the virus, evolving policies in the form of extending mandates for booster doses for staff in nursing homes will be critical,” said co-author R. Tamara Konetzka, PhD.

CLA estimated more than 191,000 nurses and nurse aides would be needed at an annual cost of $11.3 billion under a 4.1 hours per patient day minimum. 

That’s up from the firm’s original estimates of 187,000 caregivers and a yearly cost of $10 billion in July. The latest report used updated Payroll Based Journal and Medicare data. 

Skilled nursing, which lost about 200,000 COVID-era workers during the pandemic, still lags other sectors in recovery.

“This report once again highlights how our nation’s policymakers should be investing in our long-term caregivers, not mandating quotas,” said Mark Parkinson, president and CEO of AHCA. “Nursing homes have been doing everything they can to recruit and retain staff — including increasing wages — but it has not been enough to stem the tide.”

A: Transferring nursing home residents to the hospital is very costly, but perhaps even more important is the physical and emotional toll that transferring the resident has. In as many as 60% of cases, the transfer is avoidable. If interdisciplinary communications are timely and centered around evidence-based, high-quality care, then more appropriate transfer decisions can be made.

Q: How will you tell if texting is a valid way to improve the process?

A: We’re using natural language processing to apply computer-based algorithms to extract salient information [from 86,000 texts], to help us capture meaning and to detect relationships. We’re very interested in the concept of what matters to the resident or their family, honoring their preferences.  

Q: What matters when choosing a text message platform?

A: We used Mediprocity. It includes features specifically designed for long-term care and even users external to the organization can be added to this secure texting environment. That’s really important because in long-term care, a lot of times the people that you need to help make decisions — physicians, family members — are not in the facility physically.

Read more about the project here.

A:  Enhanced barrier precautions have certainly caused a stir in the profession, especially among the nurse leaders who write and are responsible for the facility policies.

The Centers for Medicare & Medicaid Services has stated that it is not surveying for enhanced barriers as yet, but at least two states currently are surveying for them on their own. 

I will also say, don’t shoot yourself in the foot by writing  your policy with too many promises. 

For instance, don’t claim to have enhanced barrier precautions on every cut or skin tear in your building. You know the day the surveyor arrives you will have a new skin tear and someone will not have on enhanced barrier precautions and care for the resident Remember: Surveyors will be looking for the difference between the care and the policy.

Contact precautions 

Gown and gloves for all rooms and all activities

Private room ideal

Room restriction except for medically necessary care

Recommended to be time limited

Enhanced barrier precautions 

Gown and gloves for only high-contact resident care

No Private room

No room restriction and may participate in community activities

Recommended for duration of stay

Check the CDC website at CDC.gov for more information on enhanced barrier precautions. You will find great resources!

Two similar suits, also blasting providers for allegedly putting profits over patients, followed in quick succession.

The first lawsuit was filed against owners and operators of Comprehensive at Orleans LLC, doing business as The Villages of Orleans Health and Rehabilitation Center, a 120-bed nursing home in upstate New York.

The suit alleges Ephram “Mordy” Lahasky, David Gast and Sam Halper, identified in the complaint as some of the facility’s owners, illegally diverted $18.6 million in Medicare and Medicaid funds, or more than 20% of The Villages’ $86.4 million operating budget between 2015 and 2021, as part of a scheme to increase their personal profits.

As a result of the alleged financial scheme, the attorney general’s office further contends staffing levels and patient care at the facility suffered, leading to physical injuries, hospitalization, and even the death of some residents. 

“The abject failure of The Villages and its owners to uphold their duty under the law caused residents to suffer inhumane treatment, neglect and harm,” James said in a news release.

The AG’s lawsuit seeks to remove Gast, Halper and Lahasky from their ownership and managerial roles at The Villages; prohibit the nursing home from admitting any new residents until staffing levels meet appropriate standards; and reimburse the state and federal government for investigation costs.

In December, James brought similar financial fraud cases against two facilities on Long Island: Cold Spring Hills Center for Nursing and Rehabilitation and Fulton Commons Care Center.

Representatives for the targeted nursing homes could not be reached for comment prior to press time.

A:While there is not a lot of information about this yet, you are correct. Recently, the OIG updated its 2023 Work Plan to include a planned audit of Medicaid nursing facilities’ percentage of revenue used for direct patient care. 

In its summary announcing the audit, the OIG notes that improving safety, quality and transparency of Medicaid nursing facility care is a top priority for the Centers for Medicare & Medicaid Services to ensure that seniors, people with disabilities and others living in nursing homes receive reliable, high-quality care. My view is that CMS often forgets that this is also the top priority of skilled nursing facility providers as well.

The OIG notes that states have broad flexibility to establish base and supplemental Medicaid payments to providers, and this audit will focus on the percentage of revenue being expended on direct patient care. This seems to imply that states may not be assessing the effectiveness of Medicaid payments as it relates to direct patient care. It is too early to ring alarm bells as to this planned audit, but operators should certainly regard this as an issue worth monitoring. 

If you are among the many providers that already track this metric, there may be even less cause for concern.

However, if you are among those who do not, I suggest you do so in case you find yourself among those included in the audit. 

OIG officials said they will “judgmentally” select three facilities in selected states (one each from the following facility types: for-profit, not-for-profit and governmental) to determine what percentage of Medicaid nursing facility revenue is being expended on direct patient care. 

A: Perhaps. The Informal Dispute Resolution (IDR) process gives nursing homes one informal opportunity to dispute cited deficiencies after any survey of Federal requirements for participation. 

Facilities also have the opportunity to request and participate in an Independent IDR if CMS imposes civil money penalties (CMPs) against the facility and these penalties are subject to being collected and placed in an escrow account pending a final administrative decision.

With either of these processes, you must understand the Federal Requirements outlined in 42 C.F.R. §488.331 and 488.431 to make sure that you adhere to the directives and understand when you can and cannot dispute cited deficiencies.

For example, for the IDR process, the request must be submitted in writing within the same 10-day window that would be used for a plan of correction, along with a specific explanation of what’s being disputed. 

Facilities may not use the IDR process to challenge any other aspect of the survey process, such as scope and severity assessments of deficiencies, with a few exceptions: perceived inconsistencies of the survey team; or alleged shortcomings of the IDR process itself. 

Regarding the IIDR process, you must request an Independent IDR within 10 calendar days of receipt of the offer and should submit the request in writing to the proper agency or entity, as appropriate.

Your request also should include copies of any documents such as facility policies and procedures, resident medical record information that is redacted for confidentiality, and other information useful in disputing the survey findings.

Citing amputation and five-year mortality rates among diabetic wound patients, they argued that “quality measures need to be considered at each patient inflection point to drive increased compliance with best practices in order to redirect patients whose therapies fail.” The International Wound Journal study was co-authored by William Tettelbach of the College of Podiatric Medicine, Western University of Health Sciences and biologist Allyn Forsyth of San Diego State University.

Despite broad research showing regular sharp debridements are key for diabetic patients with lower-extremity ulcers, a Medicare analysis found only 21% of such beneficiaries received it often enough to stave off amputation. The same analysis found wound care providers have not been applying skin substitutes early enough.

“Evidence-supported practices will provide the best patient outcomes and lower amputation rates,” authors wrote of promoting quality measures. 

A Stanford University research team has created a smart bandage made of a thin, flexible printed circuit and a wireless power source that provides electrical stimulation to injured tissue.

The bandage also monitors the skin beneath it for signs of healing or infection, according to an NIH Research Matters brief published in December. NIH funded the work of Stanford surgeon Geoffrey Gurtner, MD, and chemical engineer Zhenan Bao, PhD, who described a study of their bandages in Nature Biotechnology.

The bandages are adhered using an adhesive gel that loosens when heated above body temperature. In mouse testing, it caused no irritation to healthy skin. Wounds in the mice healed about 25% more quickly when provided electrical stimulation, with the new skin showing an increase in new blood vessels and overall thickness.

“It is an active healing device that could transform the standard of care in the treatment of chronic wounds,” said post-doctoral study co-leader Yuanwen Jiang.

The researchers will next enlarge the bandage for use on larger animals before beginning human trials.

A: Developing a wound while a person is in a post-acute or long-term care setting carries a significant health and economic burden. Whether or not patients have wound risk factors, it is often assumed that wounds develop due to insufficient or negligent care.

Some wounds may be inevitable and unpreventable due to the risk factors of the patients. Quality markers may not differentiate. 

Most facilities shy away from accepting patients with wounds even if the wounds are secondary to venous stasis or arterial disease. This poses an excessive burden on families who are searching for a better and safer place for their loved ones.

In 2018, Samuel R. Nussbaum et al. published an article studying Medicare patients who developed and underwent treatment of acute or chronic wounds for any reason. They found that approximately 8.2 million residents/patients had wounds. The most common types were surgical and diabetic wounds, and total Medicare spending on wound care ranged from $28.1 billion to $96.8 billion. 

Although this study on economic burden may not be recent, the number of patients involved in wounds and the cost of care remains  eye-opening. We should be asking ourselves: What can be done at the state and federal levels to review acute and chronic wounds based on the person-centered quality matrix and reimbursements?

Do we consider patients’ pre-existing risk factors, presence of chronic conditions, mobility and post-surgical status before labeling a facility with sub-optimal quality indicators? The care of older adults with wounds is a subspeciality like neonatology or hand surgery. It is not just adult medicine.