The Centers for Medicare & Medicaid Services released a draft of an update to MDS 3.0. Section G, used by many states to determine Medicaid reimbursement, is gone. The changes will be official in October 2023.

Gloria Brent, president and CEO of MDS Consultants, told McKnight’s it was a “bombshell” that A 0300 A, the Optional State Assessment, was removed. It’s needed by states that calculate RUG scores for payments.

“Without Section G, they don’t have a score,” said Brent. “If you take away the opportunity for the software to put in Section G, which would be A 0300, the OSA, what are the states going to do to generate an algorithm that calculates a score for the nursing homes to get reimbursed by Medicaid using Case Mix Index methodologies.”

A: Meeting state minimums does not guarantee compliance with federal staffing standards.

Federal regulations require facilities to “have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility’s resident population in accordance with the facility assessment.”

States with minimums require a specific number of staff, while the federal rule is more dynamic; more nursing staff may be necessary to meet federal mandates.

Each surveyor will observe and interview to consider nurse staffing; if they find issues, surveyors then investigate further. These investigations may uncover resident care or safety issues linked to insufficient nurse staffing.

Providers can use the CMS staffing analysis form to evaluate sufficiency of nurse staffing. Self-assessing can help determine if residents and staff feel enough staff are present. Similarly, the form asks if the facility used the facility assessment, containing resident census and acuity, to determine needs.

Make sure this data guides staffing decisions. State surveyors also use the Payroll Based Journal system to examine staffing, so ensure PBJ data is submitted timely and accurately. By using these surveyor tools as a resource, facilities can ensure they meet staffing mandates at both the state and federal levels.

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

A: It is not uncommon that a skilled nursing facility will find itself between a rock and a hard place when it comes to patients’ rights and civil rights of staff members.

A patient’s right to choose is not the only consideration in these instances. Facilities must balance the regulated need to adhere to patient preferences with the requirement to protect staff members’ rights under Title VII of the Civil Rights Act, which applies in all states.

Courts have held that the balance should tip in favor of the staff member and not the resident’s preference. Simply put, the right to choose a care provider under the Federal Nursing Home Reform Act excludes the right to choose based on the race or ethnicity of a care provider.

Federal courts have found that a practice that seeks to honor the racial preferences of residents regarding caregivers may give rise to an actionable claim for creating a hostile work environment.

The courts have found that Title VII forbids employers from using race as a bona fide occupational qualification, and that the regulations merely require facilities to allow residents access to healthcare providers of their choice, not to assent to the racial preferences of its residents.

These approaches will help skilled nursing facilities navigate this difficult terrain:

1. Warn residents before admission of the facility’s non-discrimination policy.
2. Secure the resident’s written acknowledgment that assignments will be made without regard to race.
3. Attempt to reform the resident’s behavior after admission.
4. Assign staff based on race-neutral criteria that minimize the risk of conflict.
5. Advise employees that they can request protection from racially harassing residents.

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

Study participants included 65,000 adults aged 65 years and older who were discharged to SNFs following acute care for stroke. Investigators examined the prevalence of pressure wounds upon admission and investigated factors that contributed to deep and superficial injury.

When compared to patients with superficial wounds, patients with deep pressure wounds were more likely to be younger than 75 years, non-Hispanic Black and have a lower socioeconomic status. Many had experienced an intensive care unit stay, had higher functional impairments, skin integrity issues, system failure and infections

Providing care for pressure injuries early in stroke rehab may help improve these patients’ overall clinical outcomes and reduce costs, said Shilpa Krishnan, PhD, PT, of the Emory University School of Medicine in Atlanta, and colleagues.

The findings, including more analysis of SNF skin care and restorative treatments for these patients, were published in JAMDA.

A: Begin to think outside the box in regard to internal assistance if you can’t hire. How about considering a career ladder and making promotions within your building easier and more desirable?

Ask your medical director to do some lunch-and-learns for staff on a variety of disease states, including dementia, overactive bladder, Parkinson’s disease and falls. Perhaps the maintenance department can do lift training or fire and emergency training, Dietitians can work on fluids and meals, specialized diets, thickened liquids and feeding.

Meet with your staff RNs and LPNs and find out who is good at audits, mock surveys, doing QA audits of the rooms and med carts. Call vendors such as those in hospice, pharmacy, psychiatry or maybe even a consultant on staff, and ask them to do training.

Perhaps you received a deficiency or know through your QAPI program that you have an issue in a certain area. Call a vendor or a department head to present that topic. Compile a list of education topics and develop your clinical ladders to train and assist staff in learning and developing leadership. You will gain respect for recognizing small stars who needed your help to shine a bit brighter.

Break your education into categories so staff complete a certain number of programs before they can move to the next level.

Perhaps encourage certification after staff have accomplished your clinical ladders to enable them to achieve a leadership position. I am positive your clinical outcomes will improve. If staff members are happier, the residents tend to be happier and the families are happy. The surveyors will feel this upon entering your building. Well-oiled wheels don’t typically squeak.

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

Welcome to hub-based long-term care. It’s not a reality yet, but it might be in the near future, if some of the field’s deepest thinkers have their way.

This new approach lets consumers go through central doorways to find best-fit services. Regardless of whether that means skilled care, senior living, home care — or another option.

The full details appear in a brilliant September report by Nexus Insights titled, “Where Am I, Where Do I Go: The Missing Entry Point to Long-Term Care Solutions for Older Adults and Their Caregivers.”

The organization’s founder, Bob Kramer (also cofounder of the National Investment Center for Seniors Housing & Care), is a key advocate. He said such a shift would make the search for LTC less confusing and more efficient.

“Skilled nursing more than ever has to recognize it’s not about fighting to get people to come to their setting and holding onto them as long as possible so they can bill as much as possible,” Kramer told my colleague Joe Bush. “It’s rather demonstrating they’re very much part of a larger continuum and for many skilled providers that means an opportunity to think about their customer and resident in a much broader sense.”

The late Steve Jobs said that good ideas are worth nothing unless executed. There’s no doubt that a hub-based approach would greatly improve the way long-term care is delivered. But will it ever be executed?

Clearly, at least two hurdles will need to be overcome.

One is the nursing home industry itself. Yes, some of the 15,000 or so of the nation’s facilities would benefit under a hub-based approach. Others, however, would not. And as a general rule, organizations don’t typically rally around changes that might prove harmful or worse.

Then there’s the small matter of paying for this new system. The report recommends a public-private partnership for LTC. That might be a tough sell.

This project might have to join the back of a very long line.

Regardless, I want to wish Nexus Insights good luck in improving our nation’s dysfunctional long-term care system. We’ll certainly keep an eye on what happens. Or doesn’t.

“A lot of people are afraid of heights,” says comedian Steven Wright. “Not me, I’m afraid of widths.”

After years of hiking, I’ve had a similar but opposite experience. It’s not the width of a trail that causes me trouble, it’s the length.

On a recent weekend, the hike I chose to tackle was one of the hardest I’ve ever attempted in distance and elevation gain, and I was determined to finish it at all costs. But as my strength ebbed, I asked a passing hiker coming down from the top how much farther it was, and whether going all the way was worth it.

“Absolutely, it’s gorgeous up there,” he said, as his eyes betrayed deep concern for my survival.
“But like they say, getting to the top is optional, but getting down is mandatory.”

I didn’t realize at the time that he was quoting renowned mountain climber Ed Viesturs, the only American who has conquered all 14 mountains above 26,247 feet.

It was good and timely advice. I wanted so badly to keep going, to devote everything I had to my mission that day, and I felt like a complete failure when I turned around. But at least I lived to hike another day.

Long-term care is an endlessly self-sacrificial profession, and we all know facility staff whose compassion isn’t passive or abstract — they actively care for residents and co-workers. Whatever is necessary, they do, at any hour and expense, regardless of the toll it takes on themselves.

On even the most hectic days, they get their work done and still keep on caring.

Maybe you’re one of those folks, and since you chose this mission-driven line of work, there’s a good chance you are. If so, the supply of emotional energy you bring is astounding, and I’m not remotely suggesting you limit your caring.

But when I see you in action, I sometimes wonder, like my fellow hiker did, whether you’ve left enough in reserve.
If that’s you, I hope your love extends to yourself, as well as others, because this profession needs people like you for the long haul.

Every day, you’re climbing mountains for your residents and colleagues, fueled by your selflessness. Just make sure you save enough of yourselves for the trip home.

Things I Think is written by Gary Tetz, a two-time national Silver Medalist and three-time regional Gold and Silver Medal winner in the Association of Business Press Editors (ASBPE) awards program, as well as an Award of Excellence honoree in the APEX Awards. He’s been amusing, inspiring, informing and sometimes befuddling long-term care readers worldwide since the end of a previous century. He is a writer and video producer for Consonus Healthcare Services in Portland, OR.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

The pilot came about after investigators discovered that, as a result of fears over contracting COVID-19, in-person visits to Stanford’s dermatology clinics by older adults had declined by 37% in 2020, compared to 2019, and that the number of skin cancer diagnoses among this population decreased by 23% during the same time period.

In an effort to help older patients get the care they needed, the dermatology team turned to the SkinIO app, which allows patients and clinicians to capture high-quality photos of lesions without going into a clinic. The mobile app delivers the images via a secure portal to a dermatologist to review.

The pilot tested the app’s effectiveness with residents of an LTC facility in the San Francisco area, employing guided, in-residence skin scanning and outlier lesion identification. Three skin cancers were identified among 27 participating residents; 11 were scheduled for follow-up appointments and four started treatment at their facilities.

Some of the skin cancers were lesions that the patient had not previously noticed. Without the app’s full body images, they could have been missed, said study co-author Kavita Sarin, MD, an associate professor of dermatology at Stanford.

Results published in Skin Health and Disease suggest that teledermatology programs such as this one may help combat some barriers to care for older adults, particularly those who are immobile or whose health is compromised.

“In some cases, skilled nursing facilities have to send patients to the clinic using an ambulance, which can be time consuming and costly,” Sarin said. “If we could send out staff to take pictures of these patients, that could be incredibly helpful to these patients and a great application of this system.”

The $125 million, state-of-the-art facility will distribute thousands of individual products and devices to Midwest and US healthcare providers across the continuum of care, including hospitals, nursing homes, ambulatory surgery centers, hospices and physicians’ offices. More than $1.3 billion in annual orders are expected to be handled from the facility.

“At Medline, we help healthcare providers activate the clinical and supply chain resources needed to deliver the best care possible for their clinicians and patients, and we’re really proud of that,” said Doug Golwas, Medline executive vice president for acute care.

“Medline is a company where we have continued to invest in the resiliency of the supply chain. The size of this building allows us to take care of our customers as they continue to grow.”

The latest distribution center in Illinois created 350 new jobs, and that total will climb to nearly 700 when it reaches full capacity. It is a part of Medline’s $2 billion Healthcare Resilience Initiative, a national capital expenditure campaign that includes new distribution centers, manufacturing capabilities and information technology upgrades to further the company’s commitment to delivering superior customer service.

To commemorate the opening, local politicians and dignitaries, including Grayslake Mayor Rhett Taylor, representatives from Medline, nursing homes, major hospitals and other healthcare providers in the region gathered onsite for a celebratory ribbon-cutting ceremony.

The company’s other new facilities include a 1.3-million-square-foot distribution center in Montgomery, NY, and an 800,000-square-foot distrubtion center in St. Peters, MO. Medline has been based in Lake County, IL, for nearly 50 years.

Scientists at Singapore’s Nanyang Technological University believe the frog skin-based wound dressing will speed healing of chronic diabetic skin ulcers in particular. Fish skin has been used in the same approach previously.

Frog flesh is a common food in Singapore, where the skins of farm-raised bullfrogs are typically discarded during processing. Associate Professor Dalton Tay and team developed the patch both because it would be compatible for human use and because it could reduce waste.

Their dressing features a porous layer inside which white blood cells and other healing agents coagulate. It also creates a barrier that keeps the wound moist and promotes healing. The collagen, meanwhile, acts as a scaffold for neighboring skin cells to move onto during the late-stage healing.

The researchers are working with the medical technology firm Cuprina Wound Care Solutions to conduct human clinical trials within two years.