Among sought-after measures is the Building America’s Health Care Workforce Act, which would extend a COVID-era temporary nurse aide program for 24 months after the public health emergency’s end. The Centers for Medicare & Medicaid Services had waived certain rules to allow aides to work without passing the Certified Nurse Aide exam, but requirements go back into effect Oct. 6. The bill gained more cosponsors in late spring and has the backing of major provider groups. 

House members in June also introduced three immigration-related bills that could clear the way for the hiring of additional healthcare staff, as well as offer some grant support for training and hasten the time to license those trained in other nations. 

A: We had great strengths in engineering and in medicine — especially geriatric medicine — and biology, but there hasn’t been a lot of work in synthesizing those in ways that really accelerated treatments and interventions that would slow down both functional and cognitive decline in older adults. The last years of life sometimes can just be fraught with illness and decline and loss. It doesn’t have to be that way. We’re searching for new ways to … give people a really high-quality, high-function, high-cognition end of life.

Q:What role does tech play? 

A: As physicians trained in geriatric medicine … we’re in a unique position to really be able to inform both engineering and biology of the major issues that need to be addressed and work closely to find solutions that can be quickly implemented. We have a huge, new National Institute of Aging grant through our Artificial Intelligence and Technology Collaboratory to help us use AI approaches.

Q:What are some of your early research lines? 

A: We’re working on ways to pick up subtle changes in people’s speech patterns that may predict the development of Alzheimer’s. Devices for balance and gait influence; better detection of cataracts [and]falls prevention; and Alzheimer’s diagnoses. All of those things are on the near horizon.

Q: We have a problem with urinary drainage bags touching the floor when the resident is in bed, especially if they have a low bed. Do you have any suggestions for us? 

A: This is one area the surveyors love to look for. It’s an easy infection prevention tag to give out when the catheter bag touches the floor. 

Over the years, I have seen many things used to prevent the bags from touching.Those ideas include placing a basin on the floor so the urinary bag touches the basin and not the floor.

In the morning, the basins are collected, sanitized and replaced when the resident goes back to bed. 

Also, there is a urinary bag called a Fig Leaf cath bag. It’s a cover bag, which protects it from the floor. Leg bags also are a consideration. There is a 1,500 cc leg bag available. Medicare B may not pay for this type of bag, but it may be worth purchasing to prevent a deficiency.

Don’t forget to constantly educate your staff about not allowing bags to touch the floor and the potential dangers if they do.

Of course, it also should be a facility’s goal to have as few catheters as humanly possible. Many facilities have made reducing use of catheters — and, by extension, reducing potential infection — part of a Quality Assurance & Performance Improvement program.

But when you do have to use bags, good tools exist. One interesting one I saw for a resident in a wheelchair was when a facility used a paint roller pan — the kind you use when you roll paint to cover a room. They took elastic cords and managed to strap the pan with the elastic cords under the wheelchair, so it laid evenly under the chair and was held straight with the lower cross bars of the wheelchair. They then laid the Foley bag on the pan. It kept the tubing from touching the floor or getting  caught in the wheels or the brakes, and it worked quite well, too.

Have any tricks to share? Email me.

Q: Does tube feeding help wound healing? 

A: The decision to place a percutaneous endoscopic gastrostomy tube (PEG) is a difficult one. The inability to eat or drink often accompanies people debilitated by a stroke and/or dementia, and PEG tubes have become one of the most commonly employed methods for providing long-term nutritional support. As pressure injuries often accompany malnutrition and weight loss in debilitated patients, PEG tubes may offer a last chance to enable healing.

But PEG tubes are not an easy fix. While some patients benefit, this feeding modality can bring a new set of complications including infection and dislodgement. 

Administration of tube feeding necessitates elevating the head of the bed to avoid aspiration, which decreases the ability to turn and causes increased pressure on the buttocks and sacrum. Long-time diabetics may have gastroparesis, whereby liquid nutrients do not easily pass from the stomach into the intestine. Some patients have tube feeding intolerance and develop diarrhea, which increases risk for pressure injury and perineal infections. From an ethical standpoint, artificial administration of food and fluids can prolong suffering.

Other considerations include contraindications such as bleeding disorders, history of gastrectomy, severe ascites and concomitant diseases such as malignancy. Advance directives to avoid artificial nutrition should not be overridden. If the clinical team deems death imminent, there is little point in inserting a PEG.  

Finally, the nutrients and liquids provided through the tube must be adequate. This is the job of the nutritionist, who should add a “wound healing factor” to the feeding prescription, which includes extra protein and calories. Even in situations where adequate nutrition is provided, there is no guarantee that a pressure injury will heal.

Q: I am struggling to select the most appropriate primary diagnosis at I0020 of the MDS for skilled Medicare Part A residents. Is there a way to do this efficiently? 

A: The best way to select the primary diagnosis is through a team approach. The interdisciplinary team should have daily meetings to discuss new admissions and select their primary diagnosis.

That selection must be done early in a patient’s stay so the 5-day PPS assessment includes the most accurate primary diagnosis. To qualify, the diagnosis must be documented by a physician/NPP during the 7-day look-back, and ICD-10 coding guidance must be followed. You cannot use documentation after the assessment reference date (ARD) to set the diagnosis.

If the diagnosis is not documented, someone from the IDT must obtain documentation from the physician/NPP before the ARD of the 5-day PPS assessment. 

The team’s decisions must be driven by the primary need for skilled care. This may or may not be the reason the resident was initially hospitalized. For example, a resident had hemiplegia from a stroke three years ago and was hospitalized with a urinary tract infection. During the qualifying hospital stay, physical therapy provided treatment for the residual effects of the stroke. Upon SNF admission, the UTI was resolving and was being treated with  antibiotics, but the resident continued to have functional impairments related to the hemiplegia. The team agreed that the hemiplegia and daily physical therapy now required the most skilled care.

Lastly, ensure the medical records contain documentation indicating how and why the primary diagnosis was selected. In the event of an audit, this information is crucial to demonstrate that the primary diagnosis was appropriate.

Two years ago, operators mostly prioritized fall prevention and medication management, Direct Supply Innovation and Technology Manager Justin Smith told attendees. But the pandemic bumped infection control and staffing to the top of the list. He said his company is winnowing down a list of 70-plus robotics solutions to find those with the best potential for the sector.

“The way to think about robotics is to think about the tasks you spend time on that are not adding value and how to wipe those out,” he said.

For Cypress Cove, a Florida life plan community, that was having dining employees run food and dirty dishes back and forth between the kitchen and dining area. The operator introduced Bear Robotics’ Servi robots, three-tiered food runners that make trips to and from the kitchen to deliver food and bus tables, allowing employees to remain in the dining area with residents.

“Staff are having to make far fewer trips between their section and the kitchen and are staying in their section to be more responsive and supportive of our residents,” said Joe Velderman, Cypress Living’s vice president of innovation. The move also reduced by 330 hours per week the tasks of front house culinary services employees. The savings were invested in wages.

Army Distaff Foundation Vice President of Development and Strategic Operations James Michels said one of his communities had used robotics to augment therapy with exoskeleton rehabilitative therapy — a bionic suit, of sorts. It addressed the needs of a resident who had a series of strokes, lost mobility and had became depressed.

A:According to the latest Comprehensive Error Rate Testing report from the Centers for Medicare & Medicaid Services, inadequate documentation for Physician’s Certifications/Recertifications accounted for over 35% of errors contributing to improper payments. No specific form is mandated, but the documentation must include all required components, be timely and be signed and dated by a physician or nonphysician provider.

Certification:

• The individual needs skilled nursing or rehabilitation services

• Services are required daily (or five days a week for therapy)

• Services can only be provided in the SNF

• Services are for an ongoing condition for which the individual received inpatient hospital care or arose during a SNF stay

Recertification:

• Reason for continued post-hospital SNF care

• Estimated time to remain in the SNF

• Discharge or home care plans

• Whether continued SNF services are for a condition that was treated or arose during the SNF stay

Timing:

• Certification must be obtained at  admission or as soon as reasonable

• First recertification is required by the 14th day of post-hospital SNF care

• Subsequent recertifications are required at least every 30 days

There may be times of isolated oversight or lapse. In rare instances, delayed certs/recerts will be honored with an explanation or other relevant evidence.

A: Simply put, it’s difficult to determine if there was actually an increase in drug diversions. The myriad problems facing long-term care facilities — including resource depletion, isolation, staffing shortages and the constant emotional fallout tied to COVID-related illness and death — contributed to increased substance use disorder for clinicians, mainly nurses, in our skilled nursing facilities. 

While the data shows substance use disorder is on the rise, reports suggest the pandemic negatively impacted the availability of credible data on the issue. According to Protenus, a healthcare technology organization specializing in risk-reduction solutions, the true scope of drug diversion in 2020 may have been concealed by COVID-19. The 2021 Protenus Diversion Digest reported that “health organizations’ defenses against drug diversion were jeopardized in 2020.”

An analysis of 2020 data identified a significant lack of reported incidents of drug diversion in 18 states and the District of Columbia compared to previous years.

“A complete lack of reported incidents in more than one-third of states in 2020 indicates that an alarming amount of drug diversion is going undetected,” it found. “Given that the pandemic placed tremendous stress on healthcare professionals, and stress is a known contributor to drug misuse, it is possible that diversion did not decrease but rather appeared muted due to under-reporting.”

We know that long-term care residents face greater risk of becoming victims of drug diversion. This places increased onus on operators to adopt and implement protocols focused on aggressive oversight of controlled substances.

They must also address the pressures that can lead staff to fall victim to substance use disorder and divert drugs. 

This transcendent classical composer, one of the greatest ever, was also blessed with a hot temper, bad manners, deep suspicions, dark moods and a ravenous ego. 

Definitely not the sort of humble, huggable genius you’d want to have a beer with had you been alive in the 1800s. 

But as he alienated friends, mistreated the hired help, sank into despair and wandered the streets looking like a wild man, Beethoven was concealing a terrible secret — he was going deaf. By the time he finished his Ninth Symphony masterpiece in his early 50s, his hearing was almost completely gone.

“O you men who think or say that I am malevolent, stubborn and misanthropic, how you wrong me. You do not know the secret cause which makes me seem that way to you,” he wrote in an unsent letter. “How could I possibly admit an infirmity in the one sense which ought to be more perfect in me than in others, a sense which I once possessed in the highest perfection.”

In the face of this unimaginable loss, if Beethoven was admitted to your long-term care facility today, he would probably be incorrigible, perhaps even despised by staff and other residents. He’d wander aimlessly, ungrateful and ill-tempered, finding fault and berating those just trying to help him. 

 We wouldn’t be able to fully see or understand the feelings of fear and isolation triggered by his disability.

“I must live almost alone like one who has been banished,” Beethoven achingly lamented, probably speaking for many long-term care residents suffering in unwanted silence nearly 200 years after his death. 

The truth is, all who come to us bring a story like his — one of internal struggle, pain and loss, about which we know relatively little. All we can do is be patient. Compassionate. Forgiving.

Recognizing that every life, including our own, is a deeply flawed work of priceless art that’s still deserving of respect and kindness.

So the next time that resident lashes out unfairly and we’re tempted to judge and pull away, let’s all just close our eyes for a moment and acknowledge what he or she might have faced along the way, what they used to be and do, and the unseen losses they’ve suffered. 

Because after all, everyone is Beethoven.

Then it hit me: We spend money on things that deliver some kind of reward. That insight into the human condition helps explain why our long-term care system finds itself in a precarious position these days.

Advocates for reform insist care must get better, much better. Operators counter they can’t make payroll as it is. It’s no secret what the answer is: more money. More money for training, salaries, supplies, equipment and other outlays a well-run facility requires.

The problem is finding that money. Let’s face it, taxpayers are in no mood to spend more on long-term care services. Where’s the reward in that? 

But you know what the public and lawmakers eagerly support? More money for defense. Both seem to go Coo-Coo for Cocoa Puffs when defense spending is mentioned. It’s the one budget area where suggested amounts are routinely dwarfed by final allotments. Almost universally, generous funding here is viewed as not just warranted, but essential. The general sentiment amounts to this: We’ve got to support the men and women in uniform. Plus there’s the payoff of demonstrated patriotism.

So here’s a suggestion: Let’s morph the Department of Health and Human Services into the Department of Defense. Attitudes about funding support would shift overnight. Suddenly, we would have lawmakers fighting to devote more of the Treasury to Medicare, Medicaid and other programs for the elderly. Operators and vendors would see unprecedented support. And care would improve.

Look, I realize such a transformation has a snowball’s chance. Perhaps merely suggesting the shift is a bit ridiculous.

But is it any more ridiculous than MedPAC reports that routinely call for reduced funding? Or CMS trying to claw back Medicare dollars at the end of a pandemic? Or a White House alleging opaque ownership structures when such information is publicly available? Or scapegoating skilled care settings for COVID-19 deaths?

We already have silliness in abundance. Why pile on?