Centers for Medicare & Medicaid Services contractor Abt Associates will stage visits at select facilities through October. The White House plans to have staffing minimums in place by March 2023.

Abt researchers are collecting information and opinions from staff, residents and family members at facilities in 15 states, spanning all 10 CMS regions. Buildings with a variety of quality star ratings and in disadvantaged areas will be visited to gauge variances in needs and abilities of various providers.

Providers remained wary. The American Health Care Association released a report late last month stating that a poorly thought out minimum staffing mandate could cost $10 billion annually to implement. n

A: The Qualifying Hospital Stay waiver can be used multiple times for the same beneficiary if the following is true:

The beneficiary has had a 60-day break since the last day requiring skilled care. Once the beneficiary has a 60-day “wellness period,” she is eligible under a new benefit period.

With that in mind, remember that other existing Medicare requirements for SNF coverage are not changed by the waiver. You need specific documentation on a case-by-case basis that clearly indicates how the decision for use of the waiver is directly related to the ongoing Public Health Emergency, in addition to continuing to focus on the individual’s skilled need and medical necessity requirements.

Also consider whether the skilling condition would have required an inpatient hospital stay in the absence of the pandemic.

As expected, recent medical review activity has included a close look at waiver use. Notably, Supplemental Medical Review Contractor (SMRC) Noridian reports in their current project that data analysis done by CMS and the SMRC identified a potential area of vulnerability, and the SMRC is tasked to perform medical review on SNF claims (3/1/2020 – 12/31/2021) that had zero hospital days prior to admission.

To avoid potential denials, the IDT should determine and document:

• What the skilled service(s) is/are,
• How SNF level of care is met,
• How the skilled stay relates to the PHE,
• If an inpatient hospital stay would have likely been necessary to manage the condition(s) in absence of the pandemic (QHS Waiver)
• Whether the PHE prevented the beneficiary from beginning/completing the 60-day break (Benefit Period Waiver).

A: Frankly, it means trouble. To begin addressing the minimum staffing requirement, CMS added new requirements for surveyors to incorporate the use of Payroll Based Journal staffing data in their inspections.

This will identify potential noncompliance with CMS nurse staffing requirements, such as lack of a registered nurse for eight hours each day, or lack of licensed nursing for 24 hours a day. This guidance aims to uncover instances of insufficient staffing and will, allegedly, yield higher quality care.

CMS also intends to issue a proposal in 2023 on a minimum staffing measure. In April, CMS issued its 2023 Skilled Nursing Facility Prospective Payment System Proposed Rule. It was then CMS announced it was seeking input on the effects of direct care staffing rules to improve the LTC requirements for participation and promote thoughtful, informed staffing plans and decisions within facilities.

CMS received more than 3,000 comments on the rule, with one-third calling on CMS to consider current staffing shortages and provide more financial resources to facilities before even considering a minimum staffing standard.

Apparently, the commenters are better than CMS when it comes to comprehending the folly of imposing minimum staffing levels without adequate remedies to address structural issues causing staffing shortages. They recognize those structural issues existed long before COVID-19 and have only been exacerbated by the pandemic.

We should expect that any minimum staffing requirements will further burden operators and embolden trial lawyers who seek to exploit these requirements to inflame juries.

Contactless monitoring sensors were installed in a New York skilled nursing facility in November 2021 as part of a pilot program involving radar-based technology maker Xandar Kardian. TapestryHealth’s healthcare providers monitored residents’ vital signs continuously using in-room XK300 devices, including during sleep.

Data analysis showed that an elevated resting heart rate could predict an upcoming medical crisis, even when a resident’s respiratory rate was stable, Xandar Kardian reported. In the case of one resident, the company’s sensors detected multiple sustained elevations of resting heart rate in the week before her cardiac arrest.

The devices use radar to detect micromovements of a person’s heart beating or lungs pumping within a room. They are the only commercially available FDA 510(k) class II medical devices cleared for monitoring resting heart rate, respiratory rate, motion, and presence, according to the firm. Data is processed and delivered at a rate of thousands of measurements per day.

A subsequent analysis suggested that care providers could in the future combine the data collected on resting heart rate and respiratory rate to detect the need for intervention within the first six hours of respiratory rate deterioration, the firm said in a statement.

“If a patient’s heart rate or respiratory rate spikes while they are at rest, this is a strong indication of patient deterioration and can point to an oncoming occurrence of a serious medical event such as cardiac arrest,” said Sam Yang, managing director of Xandar Kardian. “Ultimately, this technology saves time, money and, most importantly, patient lives.”

The latest fund will target equity and equity-like, usually minority, investments in early to mid-stage, emerging-growth companies. Targets will operate in or develop businesses focused on aging and related care. Key investment themes will include, but are not limited to: workforce solutions, emerging managed care models, patient and provider engagement solutions, coordination of care, and telehealth, including telemedicine, virtual care and
remote monitoring, Ziegler said.

With the population of older adults who require care continuing to grow amid a decreasing number of eligible caregivers, Ziegler and Link•Age said they see the marketplace for technologies and tech-enabled service solutions to address the health, care and wellness of the aging population as
crucial.

“While many things have slowed in the market and elsewhere of late, one area that continues to increase is the demand for longevity services and technology to improve the quality of life for older adults,” said John Hopper, the fund’s chief investment officer. “We are excited to play a role in funding the high growth innovators providing solutions.”

Ziegler President and CEO Dan Hermann added that the firm is committed to driving increased society and community benefits, and greater awareness of technologies and services that will advance successful aging.

“Our goals are aligned with those of our limited partners — to positively impact the lives of seniors and improve the healthcare experience,” he said. “The investments we make advance solutions for older adults by supporting development of new technologies and services, streamlining evaluation and adoption of emerging technologies among senior living and care providers, and fostering connections. As these companies grow and scale, they build the tools and technology senior living providers and older adults need to support healthy aging.”

That was trailed slightly by administrators at 52%, further proof that the turnover threat at the highest in-building levels is all too real. The 2022 findings come as regulators are putting more emphasis on staffing consistency.

The survey drew nearly 750 responses from directors of nursing, assistant directors of nursing and administrators, who sent mixed signals about job satisfaction and their willingness to remain in leadership positions at the nursing home level.

Data was collected through email solicitations over a two-week period in July and August.

Among the most positive aspects of the survey remains the meaningful nature of the work. This year, 73% of respondents said they found their work “very meaningful.” It’s still, however, a significant slide from 81% just last year. 

“DONs and administrators really like what they do. They really do love serving the residents, running the building and the mission of what they do. They don’t want to quit,” Cara Silletto, president and chief retention officer at HR consulting firm Magnet Culture, told McKnight’s. “But what I’m picking up on is that organizations continue to push these leaders beyond their limits and beyond what is sustainable long-term. That is a huge wake-up call that these organizations need to realize.”

Those thoughts were echoed by geriatrician and Regenstrief Institute researcher Kathleen Unroe, MD. She recently authored a Journal of the American Geriatrics Society editorial noting the negative effects of turnover at the administrator level. It creates a void that may be disruptive, prompt other staff to leave, and require process reorganization under a new leader, she wrote.

“The administrative team, their leadership sets the tone, creates the culture,” she told McKnight’s in August. “Their level of experience, their investment in the building is so evident when it is present. You can have all kinds of innovative, quality type programs under way, and when you have turnover in the clinical and administrative leadership, they have different priorities.”

Too much sacrifice?

Consistency may be a key goal for nursing homes, but this year’s survey indicates skilled nursing hasn’t staunched the kinds of wounds that lead workers to quit.

Just below 40% of administrators reported being “very” satisfied with their jobs, higher than the 32% among nurses. Overall, 71% of respondents said they were somewhat or very satisfied with their jobs in 2022, down from 74% in 2021.

Experts said that could be because many of them are not working at the full scope of their licenses, and they don’t get to devote much time to things they enjoy most about their work.

“Satisfaction is surveyed as (relatively) high, yet half the people surveyed pondered leaving their jobs in the last three months,” Silletto said. “The people we talk to are hitting their breaking points. There’s too much sacrifice, and their support systems are crumbling underneath them.”

Salary and workload blamed

Other Mood of the Market results indicate the numbers could be skewing lower due to salary and workload concerns.

Only 14% of nurse leaders said they were “very well paid” for the work they do. Among administrators, that share rose to 23%. Across both job categories, the portion claiming to be “very well” or “somewhat well paid” fell nearly 5 percentage points this year to 53.6%, from 58.2% in 2021. 

“That is a little bit lower than I would have thought just because so many people are giving across-the-board increases and market adjustments,” said Matt Leach, a compensation associate at Total Compensation Solutions. “Right now, the environment is, if you’re an administrator or a nurse, especially a nurse, if you feel like you’re underpaid, you can definitely get more money going somewhere else.”

That kind of thinking may drive the number of nurse leaders and administrators seriously considering quitting. But so, too, may the crushing workload of the pandemic; continued regulatory, infection control and PPE-related challenges; and a workforce shortage that has left facilities nationwide looking to fill some 223,700 openings.

Nearly two-thirds of nurse leaders told McKnight’s they were asked to do too much at work “generally” or “very much.” The 64% combined rating beats last year’s 63%. It’s also a full 10% higher than the share of administrators reporting they’re asked to do too much in 2022.

Overall, slightly more than 58% of respondents said they were asked to do too much, with 35% saying generally they were not, and just 7% saying they didn’t think that “at all.” In 2021, just under 56% said they were asked to do much.

Too much hiring

In addition to filling multiple roles within the same building or overseeing more than one building while a new leader is hired, many are often seeing one routine part of their job explode.

“The volume of employee turnover means that all of these administrators and DONs who are considered hiring managers, the recruiting portion of their current job has to take up way more time sourcing, interviewing, selecting, onboarding, training, mentoring all these new people,” Silletto said.  “How do we expect these leaders to sustain that additional workload that is not going away?” 

Leaders clearly want additional help. “More staff” edged out “higher salary” as the No. 1 way to increase job satisfaction, with 52% of survey-takers saying they would choose more staff as one of two biggest satisfaction drivers. That was down significantly from 2021’s 59%. The second-place 2022 choice was higher salary at 51% of respondents — a nearly 10-point jump since the 2021 survey.

When broken out by category, more nurse leaders chose higher salary (53%) to more staff (52%); the preference was flipped among administrators, who chose more staff most often (52%) and higher salary second most (50%).

“We’re seeing nursing homes give raises, market adjustments pretty much across the board but even with those higher salaries, they still cannot fill all of their positions,” said Leach. “I don’t think there’s an end in sight. Employees see that, and that’s the biggest issue.”

Big ‘Walk-Out’ projected

Most workers told McKnight’s they have “some” or “a lot” of latitude at work (90%), are valued by their colleagues (82%) and have good or excellent opportunities to advance their careers (56%).

But COVID continues to wreak havoc on staying power: More than 43% said the pandemic has made them more likely to leave their profession.

Following the mass exodus of the Great Resignation, Silletto is forecasting the “Great Management Walk-Out” as more leaders tire of “new normal” workloads. Despite mounting evidence of frustration among leaders, Silletto said she still hears about providers delaying advertising — or choosing not to hire at all — when people in positions without regulatory implications quit.

Silletto said many are frustrated by corporate decisions, sometimes made by higher-ups who have been out of the field for years and don’t understand increased patient complexity or ongoing pandemic pressures. Organizational leaders need to take demands for more staff seriously, she added.

“If they are telling you that they need more staff, it’s not just to fill the open positions,” she said. “Are you by chance, or have you in the last five years, not replaced people who left? Have you asked any of your leaders to just absorb more responsibilities when people have walked away?”

She pointed to the disappearing roles of assistant DONs and assistant administrators and recommended restoring them in larger buildings, or adding retention specialists or hiring support.

Seeking satisfying solutions

Signature HealthCare has kept its assistant DONs at all buildings, in addition to trainers and other unit heads who serve nurse leader roles. Chief Nursing Officer Barbara Revelette told McKnight’s earlier in August that the company will be focusing on recruiting and retaining more DON and related staff over the next 12 months.

It includes a DON council that will convene in-person meetings and try to address areas where managers feel squeezed.

“It’s listening. It’s being with them. I need to see how they’re trained, what their competencies are, to be able to truly develop and retain and also provide the best quality of care to our residents,” Revelette said.

Indeed, training factored into job satisfaction for DONs in the McKnight’s survey. After salary and staffing, rounding out the top choices were better health insurance or benefits; more training or learning opportunities; and more paid time off.

Matt Stokes, a compensation analyst with Total Compensation Solutions, said it was important to consider the age and market of employee groups when trying to assess the meaning of falling interest in benefits. Just over 25% of nurses asked for better insurance or other benefits this year; last year that figure was close to 27%. 

“When you’re talking from the nurse’s point of view … it’s just gotten so expensive to live where they really need that cash in hand as soon as they can get it, and they’re willing to forgo anything in benefits, retirement just to get more cash upfront so they can afford their monthly bills,” he said.

Among administrators, the top five wants were rounded out by better health insurance or benefits; more paid time off; and a more flexible schedule.

Nearly 15% of all respondents wrote in other responses, including being able to “use the PTO I have” and “take time away from work” and “not being on call EVER AGAIN.”

Operating pressures, too

In addition to all the other pressures, building leaders are scrambling to cope with inflation and costs that have driven up the price of everything from personal protective equipment to pharmacy services.

With fewer job candidates, high demand and persistent pandemic conditions, it’s no surprise that building leaders put nurse staffing costs first. Nursing home nurses averaged double-digit pay increases this year, with hourly rates for certified nurse aides soaring by 11.2% to $16.87. Registered nurses reported a jump of 11.1%, according to the 45th annual HCS Nursing Home Salary & Benefits Report issued in late July.

But rising construction costs also were a strong contender, with about 36% of all respondents citing it among the costs most affected by inflation. The number rose to over 40% among the administrators-only crowd.

“We know of projects that were priced six months ago with certain financial models and now the project costs are 50% to 80% higher,” Lisa McCracken, research director for investment firm Ziegler, told McKnight’s. “It has been difficult to estimate costs with the needle constantly moving.” 

Just under 50% of respondents said they’d put off a building or capital improvement project, while that portion climbed to more than 53% among administrators. Nurse leaders chose restricted admissions as a cost-saving measure (second most often at 40%), about 1.5 points higher than administrators. Twenty-nine percent in each job category said they’d discontinued services such as recreation activities, trips or entertainment.

Limiting investment in physical plant while also limiting admissions sets a dangerous precedent for skilled nursing operators, whether or not it’s due to costs of staffing shortages, McCracken said.

“There may have been providers who were going to embark upon reinvestment projects going into the pandemic, put those on hold and are now putting them on hold again because of cost escalation,” she said. “In those instances, you are now years behind a reinvestment that is needed to remain competitive and aligned with what the customer wants.”

6% more say census is back

McCracken said that overdue projects also are affected by lower census, which leads to reduced revenue.

Overall, almost 27% of all Mood of the Market respondents said that their census had already returned to pre-pandemic levels. Last year at this time, only 21% of survey-takers were there.

But for the rest, when more beds will be filled is scattershot. Fifteen percent predicted either the third or fourth quarter of this year, while about 19% chose the first half of 2023. Another 27% predicted full recovery in the second half of 2023, in 2024 or 2025. And just over 12% said they “never” expected a return to pre-pandemic levels, up from 9% last year.

“Reduced occupancy leads to financial challenges, which further pressures the ability to reinvest, and that is where the downward cycle comes into play,” McCracken noted. “We understand that these can be difficult decisions on the cost front, but we would encourage providers to explore all possible scenarios before pulling the plug on a project. Downsizing or a multi-phased approach might be the more balanced alternative, given all of the considerations at hand.”

Studies have shown that prospective residents and their families want to be in a safe, protected and supportive environment. Offering better bathing and personal hygiene experiences is one way to deliver on those expectations, experts explain here.

1. “The driver should be patient satisfaction and focusing on patient-centered care,” stressed Patricia Howell, RN, BSN, WCC, CFCS, clinical support manager for McKesson Medical-Surgical. Of course, other important considerations include regulatory compliance, updating outdated and worn-out bathing areas and the need to stay fresh in a competitive market, she added.

To Mary Madison, RN, RAC-CT, CDP, a long-term care/senior living clinical consultant for Briggs Healthcare, bath upgrades are largely overdue in many communities.
“If anything is responsible for such motivation, it should be the past two-plus years of dealing with the pandemic and all things infection prevention and control,” she said. “Bathing was most certainly a challenge.”

2. To ensure the most success in any bathing-related upgrades, do your homework.
“To re-invigorate the bathing process to accommodate residents and utilize the hydrotherapeutic benefits of spa bathing, several things have to happen,” said Todd Binsfeld, chief growth officer of Apollo Corp.

They should include inspecting weaknesses in all plumbing connections, ensuring any fast reservoirs have been adequately maintained, replacing worn-out seals and addressing weaknesses in purification systems.

Above all else, make a thorough list of any new infection control rules to ensure they will be accounted for in your renovations, and address needs of both bariatric and frail elderly residents, Madison cautioned. Ensuring your residents’ safety, comfort and dignity are paramount.

“Bath time shouldn’t resemble an automated car wash,” she added. “Transfer chairs to and from the resident room. Stop wrapping bath blankets around residents for their trips to the shower room. Allow space in the bathing/shower area to undress and redress.” Ensure you address any fall risks with non-slip surfaces and shower shoes. And avoid mounted lifts above tubs, experts advised.

3. Consider various options when funds are limited.
“The biggest bangs for the buck certainly include the spa model, with its soothing music, pleasant scents, warm towels — towel warmers are a great investment in LTC bathing areas — as well as soft fluffy towels,” said Madison. “Most folks appreciate those amenities.”

Howell stressed the tangible and at times subliminal benefits that even the simplest of tweaks can bring to what should be a regenerative and healthful experience.

In an article titled “The Substitutability of Physical and Social Warmth in Daily Life” in the journal Emotion, for example, researchers demonstrated that people who have high levels of loneliness feel higher levels in social warmth after taking warm baths or showers.

“My takeaway from this article is that there is a tendency for people living in nursing homes to be lonely, and therefore providing them with a warm bathing environment can help increase not just their physical warmth but also their social warmth,” said Howell. “You don’t necessarily need a lot of money to have a big impact on patient satisfaction.”

Some low-cost ideas include towel warmers, high-quality towels, quick coverups upon exiting showers or tubs, updated “non-institutional” wall and floor accents, decorative room dividers, privacy curtains, soft music and addressing unpleasant smells.

4. Pursue larger upgrades if budget allows.
Many elderly residents are big fans of “walk-in” tubs because of the comfort and ease they provide over conventional, low-lying bathtubs. Binsfeld suggested such considerations as rapid fill and drain models to ensure the resident isn’t left shivering before or after her bath.

When larger scale remodeling or renovations are needed for a bathing area, Howell advised creating an “environmental task force” including direct care givers, residents and family members.

“Perform an assessment of features in the bathroom environment and make a wish list of the luxuries they would like to include,” she recommended.

Who, with a huge smile, and mystifying levels of energy and vitality, seem to approach the final chapter of life like a kid running to the swings on their first visit to the park.

We gravitate to them, we celebrate them.

As I’ve spent time in long-term care facilities over the years, folks like that have quickly become my favorites. On return visits, I seek them out first. I ask about them when I’m not there, and I am devastated when the news is bad.

My list of beloved residents is long, and bittersweet.

People like Fran, who I refer to as my Zen master; Julie, a feisty World War II veteran; and Fernald, who fought in the Battle of the Bulge.

They amuse and inspire me; they’re mentors and friends. I grow from their wisdom, am strengthened by their optimism, feel better when we talk.

I’m incredibly grateful for the gifts they give to me — or too often, gave.

We all have favorite grandparents, favorite uncles and aunts — and even, dare I say it, favorite children.

So it stands to reason that we sometimes establish favorites among our facility residents, too, even with the best of intentions to care equally for all of those we serve.

The risk is that maybe we’re subconsciously drawn to do more for our favorites, to be more patient and attentive, to spend more quality time with them than we do with those who are not as infinitely adorable, articulate or funny.

And I suspect the seniors we most admire would probably tell us the same thing. They know that sometimes there are others who need our time and attention far more than they do.

This is not remotely a criticism, since long-term care is filled with the most obsessively compassionate staff I’ve ever encountered.

But whatever your role, even if you’re just an occasional visitor, seek out those who aren’t quite so magnetic. Give them a little more of your undiluted focus, intention and, most of all, presence.

I won’t ask you to stop playing favorites. Just do it with everyone.

In his role as executive director of Leading Age’s CAST, Majd Alwan is seeing a notable uptick in use cases of telemedicine and telehealth in nursing homes.

One popular time-saving application is using telehealth devices to either automatically collect or upload residents’ biometrics into an electronic health record.

Janine Finck-Boyle, LeadingAge vice president for health policy, believes telemedicine is a most valuable complement to a thinning skilled nursing workforce.

“Hundreds of thousands of workers have left the long-term care sector,” she noted. “The reality is that we are looking for professionals that, at the present time, don’t exist.”

In fact, the association has added a sense of urgency to its Workforce Now advocacy campaign by asking Congress and the Administration to make permanent those gains made in telehealth over the course of the pandemic.

Erin McGill, vice president, business development for telemedicine provider Curavi Health, notes some of the more “compelling” uses include:

• Having a distant RN who can do assessments with the help of an unlicensed staff member “telepresenter” at the patient’s bedside.
• Providing “a great teaching tool” to support new, inexperienced nurses. Many facilities are in an endless cycle of training and re-training.
• Increasing morale and improving outcomes by having 24/7 access to licensed physicians.

Teresa Remy, director of consulting for LeaderStat, said telemedicine is an increasingly important workforce adjunct.

“We need to start looking at long-term care through a different lens,” she said. “We need to be proactive and think a bit differently on how we deliver care. The time is now to develop a plan that incorporates all the drivers — reimbursement, technology, and delivering quality and timely care.”

Crippling staffing shortages are beginning to feel permanent to some.

“Staffing shortages, exacerbated by burnout stemming from the pandemic, have left many providers scrambling to fill schedules, and have led to additional, increased burnout across remaining skilled nursing staff,” said Julieann Esper Rainville, president of PointClickCare. “This has impacted the delivery of care tremendously, as there are simply fewer providers for the amount of patients who need quality care.”

The historic staffing shortages continue to limit new admissions, creating more hospital bottlenecks and reducing access to necessary care for seniors, noted Deric Blattenberger, CenTrak‘s general manager of senior care.

The number concerned about possibly having to close their doors has continued to grow, he added.

Tim Ashe, chief clinical officer of Wellsky, reports “seeing many agencies and organizations turning away referrals and admissions due to capacity constraints.”

Perhaps now, more than at any other time in recent history, information technology could be the thing that keeps the long-term care industry vibrant and vital. It never gets sleepy, grows bleary-eyed or calls out.

At the center of IT’s heart are powerful machine learning and artificial intelligence mechanisms. One example of innovation suited to LTC are powerful algorithms that can precisely predict the number and kind of workers needed, and where and when, on any given shift, based on resident acuity. Such a feature could ensure staff resources are allocated precisely while saving money and preventing mistakes and burnout.

Providers also are adding automated functions to help with back-office workforce functionality as the labor crunch hits there, too.

What does the near future look like?

“One in which technology has gone from a ’nice to have’ to a ‘need to have’ in terms of boosting efficiency, experiences and overall care,” said Rainville.