“As Wall Street firms take over more nursing homes, the quality in those homes has gone down and costs have gone up,” Biden told Congress. “That ends on my watch. … Medicare is going to set higher standards for nursing homes and make sure your loved ones get the care they deserve and that they inspect and will get looked at closely.”

Providers balked at the president’s portrayal and questioned the timing of a reform package the White House has proposed for the nursing home sector. Among 21 focal points outlined Feb. 28 are a federal staffing minimum, a shift away from shared rooms, higher penalties and methods to increase ownership transparency.

Q: Among the March recommendations from APIC, you specifically called for every U.S. nursing home to have a “dedicated” infection prevention expert. Why?

A: It is an interdisciplinary role and a separate profession. If you’re a director of nursing or assistant director of nursing and you’re trying to deal with [IPC job challenges], in addition to all of the components of a mature infection prevention and control program, it’s frustrating.

Q:What else has to happen to be better prepared moving forward? 

A: Evidence shows that infection preventionists working in these facilities are generally not as well equipped as their acute-care counterparts. To prepare for the next pandemic, while limiting the spread of healthcare-associated infections, long-term care facilities should dedicate more staff time and appropriate resources to supporting IPC to maintain safety for patients and employees.

Q:What advice do you give to those overwhelmed by changing infection prevention strategies? 

A: The pandemic requires a new approach. We need to be doing something different. The tools are out there, and there is support. You don’t have to reinvent the wheel, you just have to reach out.

A: I am sure you have probably tried many things already, so forgive me if I repeat some..

Something as easy as a sign in the bathroom may deter flushing. Say “STOP! Do not flush your underwear/briefs,” using whatever term the resident uses. If she refers to them as “underwear” and you post a sign about flushing “briefs,” it won’t work.

Shut the water off if it’s a private bathroom. If she tries to flush, nothing will happen. Of course, you will have to assign staff to check on her frequently in the event she needs to use the facilities.

Alternatively, use a commode, to prevent use of the toilet.

There is a product called Traptex with an almost funnel-like device that fits down into the toilet to prevent garments from being flushed. I know some facilities that have these standard in their toilets to prevent the unnecessary flushing of clothing or disposable briefs. Many facilities swear by them, saying they have saved their facility from water damage.

Just be sure that no matter what you try, it is OK with facility policies and state or federal regulations.

Also, care plan everything. Meet with the family if they are available to ask for suggestions. If you install the Traptex, also care plan it.

Educate the family and the resident. I know dementia residents may not remember, but explain to the resident what you are installing. Documentation is very important.

Count yourself lucky your resident is only flushing briefs. I once had a plumber as a resident. He took everything apart, including uninstalling toilets with the water running. He would confiscate every tool he could find to help himself succeed!

A: Skin is an organ that provides barrier function and protection against microorganisms, and it has functions that include maintenance of blood pressure, temperature and water balance. 

Biologic mechanisms of aging are both intrinsic and extrinsic. Intrinsic aging refers to genetically dependent changes, including disease processes and comorbidities, while extrinsic aging refers to environmental influences, primarily sun exposure.

Reduced cellular proliferation and less acidity in the epidermis alter bacterial balance. Cells that govern the immune process and deter pathogenic organisms decrease. Skin becomes thinner with fewer macromolecules such as collagen and elastin. The result is loss of elasticity and moisture needed to maintain the barrier function.

Age-related deficits are further impacted by stressors and comorbidities that can be both acute and chronic. This increases vulnerability to mechanical stress with predisposition for skin failure and impaired wound healing.  Wound healing is prolonged in older individuals, with increased rates of postoperative wound disruption and dehiscence.  

Skin changes profoundly over a lifetime, becoming progressively compromised in both structure and function. The compromised physical structure, along with deficits in microcirculation and impaired delivery of oxygen and nutrients, and removal of waste products, predispose the skin to damage and impaired wound healing.

Medical technology and improvements in public health have endowed us with an extended life span. This, in combination with the prevalence of multiple comorbidities, has given rise to an expanding “silent epidemic” of chronic wounds that will multiply the demand for wound care practitioners in the foreseeable future.

A: The DNS is accountable for monitoring nursing activities and supervising nursing staff — a complex role for one person to perform alone. Working with an ADON, however, you can more readily improve quality and outcomes for residents and the work environment for staff. 

Consider how the two roles could complement one another. Develop a master list of DNS tasks and determine which you can delegate. Evaluate the ADON’s strengths. If the person is well-organized, assign tasks requiring these skills. If analytical, consider assigning investigations. Here are other tasks to consider: 

Daily tasks: reviewing new admissions to ensure all assessments are completed timely, reviewing incident reports, reviewing new orders to ensure they are care-planned appropriately, reviewing discharge paperwork. 

Weekly tasks: leading resident-at-risk meetings, reviewing wound documentation, reviewing SBARs, reviewing infections and antibiotic prescribing, logging employee infections, reviewing weight logs, tracking and following up on lab data, reconciling narcotic count sheets.

Monthly tasks: monthly order reviews,  systems auditing, reviewing restorative programs and monthly restorative notes, gradual dose-reduction monitoring. 

Quarterly tasks: data tracking for QAPI, staff in-services; medication auditing, survey prep audits and education. 

Make sure the delegations are equitable and fair, with clear expectations. For both delegated and retained tasks, list requirements and frequency. Then, if one of you is unavailable, the other can fill in or delegate to another person..

UMD scientists and clinicians worked with administrators and providers at three Baltimore-area SNFs to design and implement a telemedicine program between June 2017 through August 2018. The program integrated telemedicine services into standards of care, made it an opt-out service for new residents, helped SNFs acquire telemedicine equipment, trained staff on the equipment, and added more resources for employees. 

When a change in condition was identified, staff conducted an evaluation to determine whether it might warrant an ER visit, was potentially life-threatening, could be handled by internal nursing staff or delayed contact with a physician, or could be assessed through telemedicine. For those fitting telemedicine criteria, visits were scheduled with ER physicians, available 24/7. 

Staff were able to identify changes in resident conditions with telemedicine among 42% of patients requiring further evaluation. Of those, nearly 70% were able to remain at the SNF for treatment while the other 30% were transferred to the emergency room. 

Researchers said the findings revealed that telemedicine visits benefit SNF residents by allowing them to remain in place for treatment, limiting exposure to transport, infectious agents and unnecessary testing that often occurs with an ER visit. 

“Telemedicine services may be one solution to address the need for rapid evaluation and treatment of resident acute conditions and access limitations during outbreaks of infections,” the authors noted. “With the post-pandemic changes in Medicare and Medicaid reimbursement for telemedicine SNF visits, telemedicine may improve access and quality of care for SNF residents.”

Full results were published in the Journal of Post-Acute and Long-Term Care Medicine.

A:With only a few exceptions, ICD-10-CM code assignment must be based on documentation by the patient’s provider that a specific condition exists. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient’s attending provider should be queried for clarification when coding an active diagnosis. 

The American Health Information Management Association defines an official query as a question presented to a healthcare provider to gain additional documentation so the HIM professional can more accurately assign a code or codes. CMS supports the use of query forms as a supplement to the healthcare record. Be wary of telephone or verbal orders for diagnoses that don’t do enough on their own to adequately describe clinical indicators and reasons behind diagnosis assignment.  

Establish processes including record review promptly after admission to identify gaps in documentation and formally query the provider if information is ambiguous, inconsistent or missing specificity.

The query process should not be used to gain “NTA points” or other reimbursements without evidence.When creating the query, include the patient’s name, date of service, date the query is initiated, name and contact information of the individual initiating the query, the patient’s background information and clinical data, and the open-ended, non-leading question. Follow up with the provider within 48 hours if the query has not been answered.  

Staff assigning diagnosis codes should be involved in coding accuracy monitoring processes, including review of documentation to support the condition(s) as active.

A: The Biden Administration has indicated that, in addition to exploring a move from per-incident to per-day penalties as a default, it would like to see the fines for those per-instance penalties increased from $21,000 to $1 million.

However, the administration would need both houses of Congress to pass a measure increasing the top dollar limit on per-instance financial penalties.

And, while such a law conceivably could pass muster with the U.S. Supreme Court, I think it is more likely that the conservative majority on the Court would view it as an overreach. 

So there is little to fear.

Getting both houses of Congress to approve such stiff penalties on an industry already beset with the twin structural issues of understaffing and underfunding is most likely wishful thinking.

Frankly, draconian penalties such as these should be viewed as an indictment of the punish-first, quality-second oversight system currently in place.

Increasing fines will not make facilities more compliant. This is particularly true as it relates to issues of understaffing. We know that more than a quarter of COVID deaths in this country have been nursing home residents and staff, while the industry also suffers through a historic staffing shortage caused by record numbers of staff resignations.

Clearly, increased fines for understaffing won’t cause more staff to be available. 

Instead, such increased fines, along with the budget increases for enforcement agencies, would certainly take away resources that would be better spent on nurse-aide training, as well as scholarships for nursing students who choose to work in long-term care.

The data reflects a wider effort afoot as long-term care operators seek to minimize the impact of staffing shortages by outsourcing and automating office functions when possible. The most widely mentioned timekeeping and payroll vendors among those who outsource included UKG (Kronos), ADP, Paycom and Paylocity. The majority of providers (72%) indicated their timekeeping/payroll system is cloud-based, while some are vendor-hosted or hosted in-house. In addition, most of the timekeeping/payroll systems (61%) are vendor-managed.

Most operators outsourcing timekeeping and payroll reported they are somewhat or very satisfied with their systems, according to Lily Ludwig, a Ziegler research assistant. 

Ludwig noted, however, that some survey respondents expressed concerns, most notably a lack of good support from the vendor. Reporting and/or scheduling functions drew some criticism, and there were complaints about cost as well.

“A few providers indicated they are considering switching to a new timekeeping/payroll system in the future, but this was not the majority of respondents,” Ludwig said.

The survey also asked respondents to identify the platform they use for their core financial system. Most (98%) providers stated they use MatrixCare, with Microsoft Dynamics the second most-mentioned at 49%. Some respondents indicated that they use more than one system. 

The most-used functions within financial systems included general ledger (99%), procurement and/or accounts payable (88%), generation of core financial statements (78%) and billing and accounts receivable (60%)

More than 260 not-for-profit senior living and care chief financial officers and financial professionals responded to the survey, which was conducted in January, with 60% representing single-site organizations and 40% multi-site organizations.

During the State of the Union address the next night, President Biden took aim at private-equity ownership within the field, while promising tougher Medicare standards. He also claimed care quality is declining as operators charge more.

“That ends on my watch,” he concluded.

Predictably, the sector responded with a few questions of its own. Questions like:

•  If nursing home operators can’t hire enough people now, how will they hire more?

•  Where is the money for these numerous new initiatives?

•  How do massive fines help fiscally struggling facilities improve?

There were more questions, but you get the general idea.

To quote Yogi Berra, “It’s like déjà vu all over again.” Several variations of this kabuki dance have been playing out since President Johnson signed Medicare into law more than a half century ago. That landmark legislation created the long-term care system as it now functions.

Ideally, Medicare payment provisions would have covered more than a small fraction of actual nursing home caregiving costs. But several key lawmakers balked, fearing the economy might suffer. So providers suffered instead.

Now, are there bad actors in the industry who have played fast and loose with payment rules? Absolutely. In fact, we report on them all too often.

In my view, lawbreakers should be arrested and prosecuted. These characters give the industry a tarnished reputation. And they give critical policymakers and lawmakers ammo. Moreover, long-term care as it is delivered at more than a few facilities could be better.

But if the government is going to keep setting unrealistic expectations — such as demanding Ritz-like amenities while offering Motel 6-like payments — it should hardly be surprising when corners get cut. For as the saying goes, you get what you pay for.

It’s really not a difficult concept to understand. Except in Washington, apparently.