The Centers for Medicare & Medicaid Services announced the change to the Medicare Physician Pay Schedule conversion factor in a broader pay rule published Nov. 1. The factor is part of a CMS formula used to reimburse for Part B care, including physician and nurse practitioner services, rehab, labs and X-rays for Medicare nursing home patients. Lobbyists are hoping for a repeat of last year, when CMS proposed a 3% cut that Congress eventually offset.

“Congress is becoming fatigued with restoring this cut, and so we are concerned that (it) won’t mitigate the entire 4.4% cut that CMS has now finalized,” Advion Executive Vice President Cynthia Morton told McKnight’s Long-Term Care News.

Physicians could see total Medicare payments cut by nearly 8.5% next year.

Read late-breaking developments on this story here.

Q: How did Marquis and Meadow Park Rehabilitation & Healthcare Center get involved with the UPLIFT-AD palliative care study?

A: We were in discussions with Gilchrist, a nonprofit provider of end-of-life care, about introducing palliative care services at Meadow Park when the study was introduced. This work has the potential to transform our approach to caring for skilled nursing residents with dementia diagnoses, and to extend their longevity.

Q: What is your approach?

A: Our collaboration extends facilitywide. Nurse practitioners from Gilchrist are providing the services and insights on the practice of palliative care and teaching staff to help identify residents who might be appropriate for the UPLIFT study. Outside UPLIFT — which is specific to long-term care residents with dementia diagnoses — we are introducing palliative care for residents with chronic illnesses, such as congestive heart failure. Moving ahead, Meadow Park will evaluate candidacy of new admits and residents transitioning from short- to long-term care.

Q: How will this teach others about palliative care?

A: Data collected via Meadow Park’s ERM system throughout the study will inform University of Maryland School of Social Work research on using palliative leaders to transform care for Alzheimer’s disease.

Q: We are struggling with what to document and who to notify when a resident falls. Any suggestions?

A: Falls are becoming one of the most cited deficiencies, and require some of the most documentation.
First, it might sound obvious, but look at your regulations and facility policy to ensure you are following all requirements. Regulations and policies exist for a reason and usually take a while to develop — so it behooves all of us to take them seriously.

Not following your own policies is one of the worst things you can do. It opens you up to all kinds of potential penalties and lawsuits, risk management experts and attorneys have repeatedly warned.

Consider starting a fall huddle focused on how to handle accidents like these. A group of staff involved with a resident who fell or candidates for falls should be assembled in order to take an educated approach to whatever happened, or could happen. The huddle can be a quick stand-up meeting in the resident’s room.

Act like you are writing for McKnight’s Long-Term Care News and answer all of the journalist’s typical W’s. Those would include who is the resident, what did you see and how (an honorary member of the “w” club) you became aware of the suspected fall. Also, expect to identify where the resident was, and when they were found (time of incident), as well as what they were doing at the time, and what you did for the resident.

Document all the notifications, such as those for family and providers. Update the care plan, and also ask: Did the incident cause any changes to what should be newly included in the MDS? Also, don’t forget to document in the chart everything necessary per your policy.

Many facilities chart every shift for 72 hours, so see your policy and what the regulation is for your state. If you did not witness the fall, but the resident is on the floor, treat the event as a fall and document it!

Sherrie Dornberger, RN, CDONA, FACDONA, is executive director of NADONA. Please send her your resident care-related questions at ltcnews@mcknights.com.

A healing protein that is active in fetuses, but largely inactive in adults and absent in diabetic adults, could be the key to improving treatment of diabetic wounds.

Indiana University researchers noted that the oxidant stress sensor protein, nonselenocysteine-containing phospholipid hydroperoxide glutathione peroxidase, or NPGPx, can repair skin while a baby is in the womb, but it becomes mostly inactive after birth.

“Nature essentially hides this fetal regenerative repair pathway in the adult body,” said Chandan K. Sen, (left) PhD, associate vice president of military and applied research, director of the Indiana Center for Regenerative Medicine and Engineering at the Indiana University School of Medicine. “We spotted its absence, and then activated it to improve healing of diabetic wounds.”

Researchers used tissue technology developed by other engineering faculty to deliver the enhanced healing protein to a wound site. They reported in Molecular Therapy that the targeted lipid nanoparticle delivery of the NPGPx was sufficient “to overcome the deleterious effects of diabetes on this specific pathway to enhance tissue repair.”

Q: How do pain management and wound care intersect?

A: In the US, the crisis of opioid abuse, dependency, overdose and death continues. Controlling the dispensing process in response to the addiction epidemic may have slowed it, but it did not eliminate it.

Mortality data shows that in 2018 approximately 67,000 people died from drug overdose, down from 70,000-plus in 2017. But what do these numbers mean for older adults living with chronic medical conditions in long-term care facilities?

How should I manage the wound pain of a 65-year-old patient who has multiple complex comorbidities versus a 90-year-old male with minimal comorbidities, who still walks three miles every day? Does it matter if the older adult has used recreational drugs in the past?

Pain is not just a subjective finding. It is well known as a biopsychosocial phenomenon that involves physical, mental, emotional and psychosocial components. Often, the main risk factors that predispose one to opioid misuse or addiction are past or current substance abuse, untreated psychiatric disorders, younger age and social or family environments that encourage these behaviors.

The post-acute environment is highly regulated and controlled with the supervision of nursing staff and leaders who monitor controlled substance count, supply, usage and proper disposal, which often minimizes drug diversions and abuse potential.

Pain management in older adults requires a thorough understanding of their age-related physiological changes, comorbidities, polypharmacy, and patient related factors in the particular condition of the wound, be it acute or chronic. Let’s decide together, and treat every patient as a unique individual requiring person-specific care.

Q: Recently, there has been an increase in the number of staff who like to cause drama and gossip. I can’t afford to lose workers. What can I do?

A: Managers are often concerned that if they intervene to stop gossip and drama, employees will quit. But when managers avoid confrontation, trust in the manager erodes. Further, productivity decreases, and staff become anxious and unhappy in a hostile work environment. Caring employees quit and the instigators of incivility remain only to repeat the behaviors.

The first step to stop the cycle is to develop relationships with staff and demonstrate acceptable behavior. Modeling professional behavior sets the example for others to follow but also sets accountability standards. Managers must never engage in gossip or drama themselves. If they do, they lose all credibility.

When gossip or drama occurs, take swift action. Meet with responsible staff individually. Determine why they are acting out. Gossip is often driven by emotions, a lack of problem-solving ability and limited conflict resolution skills. Knowing underlying reasons for uncivil behavior, a manager can help an employee formulate a professional response.

It’s also important to explain that the employee’s behavior negatively impacts residents and co-workers, and it undermines the organization’s mission. Make it clear that this type of behavior will not be tolerated. If the employee needs help to address a problem, they should seek help from management.

If an individual causing drama refuses to change, the manager must follow the organization’s policy to terminate. By addressing the issue, managers gain trust and respect and provide a pleasant, fun work environment.

Amy Stewart, MSN, RN, RAC-MT, RAC-MTA, DNS-MT, QCP-MT, is vice president of education for AAPACN. Send her your nursing-related questions at ltcnews@mcknights.com.

Creating a culture of well-being and providing mental healthcare for nursing home staff is a powerful tool for not only helping residents but attracting and retaining employees, the National Academy of Medicine said in its National Plan for Health Workforce Well-Being released in October.

The vision is that long-term care residents and others will be cared for by a workforce thriving in an environment that fosters their well-being as they improve population health, enhance the care experience, reduce costs and advance health equity.

In the US, 54% of nurses and physicians had symptoms of burnout before the pandemic, according to NAM data. A Mental Health America survey of 1,119 healthcare workers in the pandemic’s first year found 82% of respondents reported emotional exhaustion and 68% physical exhaustion. Nearly half of nurses said they had too little emotional support.

“Collective action is urgently needed to prevent a dissolution of the health professions and to ensure a strong and interconnected health system for the nation,” the report said. “Health workers have been operating in a survival state for a long time, but change is possible.”

A: As you may have heard, the Centers for Medicare & Medicaid Services released the draft Minimum Data Set Nursing Home Comprehensive Item set version 1.18.11 on Sept. 1. Among many other changes, Section G was notably absent.

You may recall substantive changes were originally planned for 2020 but were pushed back due to the public health emergency and stakeholder concerns. Now, CMS is preparing to move forward with implementation starting Oct. 1, 2023.

On one hand, the removal of Section G is welcomed as coding of the section has been confusing since its inception. On the other hand, what does this mean for other processes that rely on Section G data?

Medicaid payment — Several states rely on an ADL score calculated from Section G that is used, in part, to establish RUG scores that inform reimbursement. These states will need to hasten planning for a new approach, whether that is a PDPM-version for reimbursement or a requirement for completion of the Optional State Assessment.

Quality Measures — Some Section G items are used as part of QM calculations directly or via covariates or exclusions. A major overhaul will be needed.

Care Area Assessments — As part of the care planning process, Section V of the MDS houses the CAAs, some of which are informed by coding responses in Section G. This, too, will need to be revised as to what “triggers” applicable CAAs.

While there is a year before implementation, you should start preparing now. Review the draft item set for all changes — there are many besides Section G — and keep watch for the release of new information, including the revised RAI and QM manuals. As this is a draft, additional changes could still be made.

Eleisha Wiles, RN, RAC-CTA, RAC-CT, DNS-CT, is a clinical consultant at Proactive Medical Review. Send her your payment-related questions at ltcnews@mcknights.com.

A three-judge Pennsylvania Superior Court panel in October reversed a lower court decision dismissing conspiracy charges and remanded the case to trial court for further proceedings. The original lawsuit was brought by Edith K. Horan, administrator of the estate of Penny Raffa, a former resident of ManorCare-King of Prussia. Raffa is now deceased. The nursing home, ManorCare and the attorneys were named as defendants.

The suit contends that in 2011, representatives of ManorCare-King of Prussia and its legal counsel, Brian Scott Dietrich, conspired with a third-party attorney, Robert Feliciani, to have Raffa declared incapacitated as part of a plan to enrich themselves at the resident’s expense. It alleges nursing home officials and the two attorneys orchestrated an illegal collection action against the resident, which resulted in a default judgment against Raffa of more than $81,000, including facility and attorney fees.

The Superior Court ruled Horan’s amended complaint provides sufficient cause to support a civil conspiracy claim. “The allegations … furthermore, are sufficiently outrageous, that if true, they support Horan’s requests for punitive damages,” the judges wrote in their decision.

Julie Beckert, a spokeswoman for ProMedica, which took over ManorCare operations, said the company confidentially settled its portion of the case. She said the case still pending is against the two attorneys only. A lawyer representing the ManorCare counsel defended his client against the allegations of wrongdoing.

“Obviously, we’re disappointed and disagree with the ruling,” he said. “We look forward to addressing these meritless allegations against our client.”

Q: I heard that CMS terminated Public Health Emergency blanket waivers, including one that temporarily allowed SNFs to employ nurse aides for longer than four months without meeting all training and certificate requirements. Doesn’t this just put facilities back to square one in their efforts to overcome serious staffing issues?

A: You are correct. As of Oct. 6, 2022, nurse aides hired on or before June 6, 2022, must have completed a Nurse Aid Training and Competency Evaluation as required by 42 CFR 483.95. Similarly, CMS terminated the waiver of in-service training requirements for nurse aides. This means that nursing aides hired on or before June 6, 2022, must now complete annual training by June 6, 2023.

The CMS Quality, Safety and Oversight Group alerted SNFs in April that many of the PHE blanket waivers would sunset in either 30 or 60 days of the memorandum. CMS was true to its word.

Interestingly, CMS chose not to terminate the waivers for hospitals and critical access hospitals. The choice to terminate the waivers for nursing homes is curious since the long-term care industry still struggles with critical staffing shortages that were only slightly alleviated by the waivers. Simply put, this decision by CMS threatens to negate any progress made on staffing during the waiver period.

Granted, the waivers were never meant to be permanent, but were intended to be helpful at a time when the industry was suffering from the worst the pandemic had to offer. What has been forgotten is that the myriad issues that caused industry-wide staffing problems before the pandemic have not been fixed.

Removing certain flexibilities that have helped to lessen the burden on an over-burdened industry seems misplaced. Back to square one, indeed!

Norris Cunningham, Esq, is a member at Stoll Keenon Ogden, PLLC. Send him your legal questions at ltcnews@mcknights.com.