Updates to the Centers for Medicare & Medicaid Services’ Requirements of Participation had been in the works since 2016, but final elements were delayed through a change in presidential administrations and the pandemic.

More than 800 pages of guidance, announced in June and now in effect, focus on major areas such as staffing, infection control, resident rights, abuse and neglect, trauma-informed care, substance-use disorder and room requirements.

The guidance calls on states to more quickly investigate complaints where residents could be in immediate jeopardy. Providers expressed concerns in October about potential increases in citations for behavioral health and rights violations.

DENVER — Promoting a return to normalcy where pandemic conditions allow, a top Centers for Medicare & Medicaid Services official said that nursing homes will not return to stringent isolation policies used during COVID-19’s early days.

Evan Shulman, director of the CMS Division of Nursing Homes, told attendees at the LeadingAge 2022 Annual Meeting that recent revisions to resident rights guidance aim to prevent isolation and its potential clinical and cognitive consequences.

“If this ever happens again, we will not go back to a visitation restriction setting like we had previously,” Shulman said. “We have to be able to do better than that. When you’re working on your emergency preparedness plans, don’t write a plan that says how you’re going to look at [limiting] visitation if there’s an infectious disease outbreak. Write a plan that describes how you’re going to ensure visitation can still occur.”

Shulman also attempted to clear up lingering confusion about new Centers for Disease Control and Prevention infection control guidance and encouraged uptake of bivalent COVID boosters.

While nursing home cases had fallen to 7,000 to 8,000 weekly, public health officials were anticipating a possible bump in cases following a similar trend in Europe.

“I don’t think we should get too complacent,” Shulman said.

Q: What is the Skilled Nursing Facility Value-Based Payment Total Nurse Staffing Measure?

A: The Centers for Medicare & Medicaid Services awards incentive payments through the SNF VBP Program to encourage improvement in the quality of care provided to Medicare beneficiaries. CMS has long identified staffing as a vital component of quality care and uses staffing data to gauge its impact.

The Total Nursing Hours Per Resident Day Measure uses auditable electronic data reported to the Payroll-Based Journal system to calculate total nursing hours per resident day. It is one of two new measures that will begin affecting payments in the FY 2026 SNF VBP program year, the other being SNF Healthcare Associated Infections Requiring Hospitalization.

The numerator for this measure is the total nursing hours derived from PBJ data. Total nursing hours include RN, LPN and CNA hours per resident day. The denominator is a count of daily resident census derived from MDS assessments. The daily MDS census is summed across all days in the quarter.

The measure is also case-mix adjusted to account for differences in acuity and resident care needs. One bit of good news is that this measure is calculated using information that you already submit for the Five-Star Quality Rating System. It will not impose any new data collection or submission burdens.

The measure will be reported for the SNF VBP Program as an average rate of total nurse staffing per resident day across available quarters in the 1-year performance period of Oct. 1, 2023, through Sept. 30, 2024, for the FY 2026 SNF VBP program year. Performance periods will then advance by one year from the previous program year’s performance period.

Whether you knew it or not, the baseline period for this measure is already over, having ended on Sept. 30, 2022.

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: Care planning to address past trauma requires understanding what happened to the individual and the effect it has on the person. Screening or assessing for past trauma can help to identify affected residents. Several screening tools exist.

Many ask residents what reminds them of a stressful event from the past, what triggers them to relive it, and what helps them cope. This information can then inform a care plan that addresses the person’s individual trauma.
To relieve trauma’s effects, a care plan must address triggers for re-traumatization and include interventions to avoid it.

Although there is no federal requirement for a specific care planning template, each care plan should address the problem, contain a goal, and include interventions that help achieve the goal. The problem statement should include the effect the trauma has on the person. For example, if a resident experienced an act of violence by a person of the opposite gender, the problem might be “Mrs. Smith is untrusting of male caregivers.”

The goal could be that Mrs. Smith will feel safe during ADL care, as evidenced by no verbal outbursts and allowing staff to assist with her care. Interventions may include requiring female staff for toileting and ADL care, using a soft tone of voice, and approaching her in a calm manner.

This is only one example. A proper care plan for trauma must be individualized to that specific trauma, what triggers it, and how the person responds. When trauma is complex, multiple interventions may be necessary for the resident to feel safe.

The key is to address trauma and prevent retraumatization by centering the plan on the person and his or her experiences.

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.

Nearly 4,000 respondents surveyed had recently taken the ATI Test of Essential Academic Skills to determine preparedness for nursing school. Of those surveyed, 15% had not yet applied to nursing programs, reported surveyor ATI, which provides test support and technology. Most of those (86%) said they were delaying their application or not yet ready to apply, with 69% citing a desire to improve academic preparedness first.

In addition, 14% of nursing students said that they were no longer considering a career in nursing. The top reason given for this change of mind was lack of academic preparedness (35%). Other reasons included the inability to afford schooling (23%) and family obligations and other responsibilities (13%).

“It is clear that students want to pursue careers in nursing, and equally apparent they need more support throughout their education to make these dreams a reality,” said Patty Knecht, PhD, chief nursing officer for ATI and Ascend Learning.

Q: What kind of restrictions do we have regarding arbitration agreements as part of the admissions process?

A: Although the Centers for Medicare & Medicaid Services has recognized the benefits of arbitration, it has expressed apprehension that the “superior bargaining power” position of long-term care facilities could result in residents feeling coerced into signing arbitration agreements, and that the prevalence of pre-dispute arbitration agreements could be detrimental to residents’ safety.

The US Court of Appeals for the 8th Circuit upheld a CMS rule prohibiting LTC facilities from conditioning admission on signing a pre-dispute arbitration agreement. The rule also provided residents the right to rescind the binding arbitration agreement within 30 days of signing it and certain other rights.

In summary, CMS rules say that signing an arbitration agreement cannot be a condition of admission to, or a requirement to continue to receive care at, a facility. The provider must make this clear, and communicate in a suitable language to do so.

The parties must agree on a neutral arbitrator when the time comes for one, as well as a mutually convenient location.

The agreement must explicitly grant the resident/representative the right to rescind the agreement within 30 calendar days of signing it.

In addition, any arbitration agreement must not contain any language that prohibits or discourages the resident/representative from communicating with federal, state, or local officials, particularly agencies with oversight responsibilities for LTCs.

A copy of any signed agreement for binding arbitration between the parties must be retained by the facility for five years, and also be available for inspection.

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

In 2022 alone, wages for certified nurse aides grew by 11.15%, with registered nurses just behind at 11.08% and licensed practical nurses netting about 9.38% more over the previous year.

Those findings headlined the 2022-2023 Hospital & Healthcare Compensation Services’ Nursing Home Salary & Benefits Report, which also found surging turnover among all three key employee groups.

The report is an annual bellwether of just how tough it can be for providers to hire and pay for consistent, quality frontline staff. But some indicators show pressures to increase rates may be easing just the slightest amount as the economy cools.

“I have never seen anything like that. It’s just unprecedented to see 20% in two years, there were so many factors that went into that increase that I would hope we’re not going to see 20% again in the future,” said Matt Leach, a compensation associate at Total Compensation Solutions who has been in the field for more than two decades. “It’s still hard to attract and retain, but there might be some signs of slack being created,” he added. “There’s a good chance the worst is over. We’re seeing some stabilization in the rates.”

Should that prove true over the next few months, it would be welcome news to providers.In 2022, as the pandemic raged on and unemployment dropped to near-historic lows, nursing homes were forced to dole out unheard-of raises simply to garner candidates.

The pay rate for CNAs jumped from $15.23 in 2021 to $16.87 in 2022, an 11.15% increase that followed a 7.13% bump in 2021. RNs saw their average pay hit $34.88 hourly, while LPN rates jumped to $26.30.

Those rates represent the 50th percentile of data in the annual nursing home salary report, now in its 45th year. The reference book is created annually in cooperation with LeadingAge and the American Health Care Association.

Top nursing home leaders saw smaller average pay jumps than caregivers between 2021 and 2022, with nursing directors gaining 5.4% to bring them to a mean of $108,799.

Meanwhile, nursing home administrator salaries rose an average of 4.9%, up to $124,297. In a companion report issued in February, HCS found long-term care executives at multi-site companies realized an average overall salary increase of 2.67% in 2021. The highest ranked among them did not receive increases, on average year.

“The biggest finding is that lower-level jobs increased at a much faster pace than higher-level jobs, and that goes against historical trends we’ve seen,” Leach said. “It really speaks to the market for talent and the limited supply of workers who can do jobs such as CNAs and resident assistants.”

DON salaries don’t move the needle

Director of nursing vacancies also remain among the toughest to fill, according to Julie Osborne, director of recruitment at LeaderStat, a national firm focused on executive recruiting and interim leadership solutions for healthcare providers.

“The landscape hasn’t changed a lot with the greatest need being for the director of nursing,” Osborne told McKnight’s Long-Term Care News. “It’s just a critical position. The stress level that those folks encounter on a daily basis has not changed, and it’s probably increasing because of the staffing issues.”

DONs account for about 80% of the permanent placements LeaderStat is hired to fill. Increasingly, job candidates refuse to be moved by high-dollar offers alone.

“If we just go in and say we have a DON opportunity at another facility, they get 10 of those a day and they a) aren’t going to return our calls and b) many times say they don’t want to make the change because they want to stick it out where they are from a commitment standpoint,” Osborne said.

“You have to change the narrative to what they’re interested in hearing about because they get so many calls a day for different opportunities, and typically, they know what’s in their market,” she added. “Do they see themselves retiring from that organization? Do they want a higher-level position or a regional opportunity? Or are they looking to relocate to a better climate, so looking at what we might have available in the warmer states?”

Providers who want an experienced DON will need to pony up plenty of cash and expect to wait a long time to fill the role. Osborne’s clients used to ask for DONs with five years of experience at one location, but that’s no longer a viable request because it limits searches too much, she said.

Many nurses in leadership roles have used the increasing pay and other incentives of the last two years to find jobs that fit more of their needs and wants.

Mixed reliance on bonuses

Bonuses remain a key way for many providers to attract talent, especially the workers needed for RN positions and higher-level roles.

Just over half (50.7%) of HCS respondents said they had used some type of sign-on bonus to recruit new staff. Facilities paid averages between $622 for housekeeping staff and $6,950 to entice DONs. RNs averaged $4,566, while the average for all positions was $1,083.

“It’s a way to offer more to new employees without having to redo your whole salary structure,” a tactic many providers already explored early in COVID, Leach noted. Just 13% of providers included in the survey said they had increased their merit pay or overall staffing budgets.

Leach also said nursing homes have been awarding bonuses at time of hire and after certain time thresholds to encourage longevity in the role.

Osborne said the ranges in the report reflected what she was seeing in the market this fall.

“It ranges anywhere from about $5 to $10 [thousand] for a sign-on bonus, but then the performance-based bonuses and the retention bonuses, they really have ratcheted that up,” she said. “What I have found is that they do a retention bonus, where, if you stay one year, you get this amount. But if you stay two, that’s doubled. It really speaks to high turnover for those particular positions.”

Although Osborne was surprised bonuses being awarded to RNs weren’t higher, she believes some providers are spending more to improve their experience on the job. She’s seen some operators reduce burdens for nurse managers by adding more frontline workers like med techs, which may then allow higher level nurses the time they need to focus on assessments and other duties.

Leach noted that some providers also have taken up targeted or building-wide spot bonuses “to try to get through these current times.” Those can often entice employees to stay longer, but the amount needs to be substantial enough to appeal to a broad range of workers.

“That can be a pretty nice chunk of change for some of these folks, and it doesn’t affect your fixed costs,” he said. “But the negative is, it doesn’t stop them from leaving (the day after) the spot bonus is given.”

Questionable future

One key observation is that the complete revamping of pay ladders and pay scales due to COVID may be over. But the new pressures keep piling on providers.

In addition to low unemployment, many areas have adopted new minimum wage laws or pay transparency and equity rules that will increase worker demands. Unmitigated inflation also has an outsized effect on low-income employees, forcing them to consider better paying jobs even if they might not want to leave otherwise.

“The hiring is tough because it’s like a snowball effect,” Leach said. “The CNAs, their salaries, their wages are at such a rate that they’re depending on that check to pay their increased costs in rent. If they can get $2 or $3 more an hour down the street, they’re almost forced to take it just because of what it means for their ability to pay all of their bills.”

The reality, though, is that most providers are unable to keep up with the competition from other employers because they can’t increase the rates they charge their customers.

“I think things are starting to level, so I think that the conversation has changed,” Osborne said. “The unfortunate side is that we see budgetary constraints. Every client we have brings that up. Reimbursement has not changed significantly.”

Facilities are projected to begin seeing additional baby boomer demand within the next two to five years. That may complicate the typical storyline, in which it gets easier and cheaper for nursing homes to hire in a recession.

But if demand remains elevated, the sheer lack of new caregivers willing and able to enter the workforce may continue to push wages higher, albeit at a slower pace.

“I don’t think all of these problems are going to be solved if we have a recession or a downturn,” Leach said. “That’s because within healthcare, with nursing homes, so much of this is demographics and just a shortage of workers.”

Q: Why should diabetic wounds be taken more seriously than non-diabetic wounds?

A: Diabetic foot complications are one of the most common complications that lead to hospitalization. In the United States, the lifetime risk of developing diabetes is approximately 40%.

As of 2014, approximately 29.1 million (9.3%) of Americans were said to have diabetes. It is the leading cause of cardiovascular morbidity and mortality, renal failure, blindness and amputation. Prognosis of a foot ulcer is changed dramatically due to the presence of diabetes, because the underlying pathology is not reversible.

Some of the complexities of diabetic wounds are as follows: Previous foot ulcers, non-healing wounds, recurrent infections, previous or pending amputation, recurrent hospitalization, financial burden, and compromised social, psychological or mental health.

Prevention with early detection is the best initial strategy. Risk factors for developing a foot ulcer in patients with Diabetes (Type I and Type II) include: uncontrolled diabetes, smoking history, presence of neuropathy; or its signs and symptoms, previous foot ulcer or amputation, signs of toenail fungal infection or inflammation, dry skin, and other skin abnormality of the foot (e.g., toe webs, bottom of the foot). For example, psoriasis, corns, calluses, blisters and dermatitis can predispose to skin ulcers, presence of bony abnormality, foot/ankle edema (swelling), arterial disease, absence of foot pulses and venous disease.

Perform an appropriate history and physical exam with risk assessment upon admission. Patient-centered standards of practice for foot ulcers, along with early prevention and optimal treatment, are crucial for preventing complications.

The same review of data for more than 643,000 Medicare beneficiaries diagnosed with DFU between 2012 and 2017 also found men were more likely to have an amputation sooner than women.

Researcher Shane R. Wurdeman of the Hanger Institute for Clinical Research and Education and colleagues theorized disparities resulted from non-Black populations having better access to “conservative wound management techniques.”

“The decision to amputate may be influenced more by other unexplained underlying variables as race/ethnicity independently persists as a significant factor even while controlling for other sociodemographic variables,” the researchers reported in Diabetes Care in late September.

Delayed amputation among women aligned with evidence from Sweden that women were more likely to have a proximal level amputation at later ages. Researchers believe amputation could be delayed until minor amputation isn’t viable.

Their study examined the level of health information technology (HIT) adoption across 719 US skilled nursing facilities using federal data. Participants rated their HIT maturity on nine subscales, including HIT capabilities, extent of HIT use and degree of HIT integration in resident care, clinical support and administrative activities. Each facility’s HIT maturity stage was rated from 0 (no HIT) to 6 (residents or their caregivers could use the system to generate clinical data and drive self-management).

More than two-thirds (68%) of the facilities were not able to communicate electronically with staff from other facilities, including outside clinics, labs or pharmacies, according to survey results. Researchers also found HIT adoption levels were likely to be higher in larger nursing homes. The number of certified beds and facility location were associated with HIT maturity.

They theorized that the structural disparities may be due to inadequate infrastructure, unavailability of a knowledgeable workforce and a lack of financial resources.

“This lack of connectivity can result in reduced levels of electronic data sharing, leading to deficiencies in care delivery, substandard care coordination activities and poorer resident outcomes,” researchers noted in JMIR Aging, where they encouraged national leaders to incentivize HIT adoption.
“It is crucial that we begin to consistently identify a means to address these disparities, first by increasing transparency and public reporting about the trends in nursing home HIT maturity in the United States, followed by implementing national policies to level these deficits,” the research team concluded. n