As had been warned, potentially “devastating” 15% pay cuts for work by therapy assistants were included, leaving advocates another uphill battle to get them removed or softened. Last year, similar 9% cuts were eased after aggressive lobbying.

Pay cuts are slated for outpatient occupational and physical therapy services provided, in whole or in part, by an occupational or physical therapy assistant.

“With margins razor thin, this reduction literally means that often the cost for an assistant to provide services is often more than the amount of reimbursement,” Melissa Brown, COO of Gravity Healthcare Consulting, told McKnight’s. “This is, unfortunately, squelching the value of assistants and endangering their careers.”

Brown added that the 2,414-page rule doesn’t address that the 3.75% COVID bonus from the Consolidated Appropriations Act of 2021 is also disappearing, which will effectively yield “a significantly more than the 1% cut for PT, OT and [speech therapy] listed in the final rule.

The Nov. 10 issuance was in direct response to criticism from some sectors that CMS and state survey agencies hadn’t been able to exert a traditional level of visibility and check-ups during the pandemic. 

Surveyors are being directed to pay special attention to nurse staff abilities and actions, use of antipsychotics, and areas of care where residents’ health and safety may be at an increased risk. That means having a more critical eye on unplanned weight loss, loss of function/mobility, depression, abuse/neglect and pressure ulcers. 

The new memo also laid out steps to address the backlog of complaint and recertification surveys.

States that fail to perform certain survey activities “timely and completely” could forfeit up to 5% of their federal COVID-19 relief funding. 

A: Those who reside within the halls of an LTC facility are vulnerable to any infection that is brought in by employees, visitors and vendors alike. This infection control compendium has gathered information from all over the world. The hope is that people use it to help prevent the spread of disease and help care for people in nursing home settings. It will ultimately save lives by preventing disease spread.

Q:Who is it for? 

A: The compendium goes beyond the measures taken by nurses and certified nursing assistants. We designed it to cover everyone from the receptionist you meet at the front door to the kitchen staff, laundry services and family members who are part of a facility’s ecosystem.

Q:How does this tool differ from others already out there? 

A: No other resource I know of compiles all of this information into a “one-stop shopping” toolkit, where almost all answers one is looking for related to infection control can be found. This tool was created by those who are passionate about geriatrics and those living within facilities, including researchers and medical professionals working at the bedside during the pandemic.

The nation’s two largest associations representing nursing homes have both sought federal government intervention that would force temporary staffing agencies to play by similar rules as nursing homes.

LeadingAge first asked the Federal Trade Commission to use its “resources and expertise” to address the “anticompetitive practices and pricing gouging of nurse-staffing agencies.” The American Health Care Association / National Center for Assisted Living followed suit, with President and CEO Mark Parkinson saying in November that his letter was “the beginning of our activity.”

“What some of the staffing agencies have done is just unconscionable,” Parkinson added at the National Investment Center for Seniors Housing & Care fall conference. “Unfortunately, there is no single, silver bullet solution.”

Anecdotally, tales of prices beyond what might be considered premium continued to mount as December approached.

In Iowa, providers reported base agency hourly rates had increased as much as 40% since 2020. In Pennsylvania, providers were reporting rates at two to four times the norm.

Lawmakers in the Keystone State were shopping legislation in late November that would regulate temporary staffing agencies and set maximum pay rates for agency healthcare personnel. Agencies would have to register with the Department of Human Services as a condition of operation, and the state would likely set their rates in a method similar to existing agency cap rules in Massachusetts and Minnesota.

The New York State Health Care Facilities Association also took the issue of inflated agency pricing to state lawmakers, but leaders there were still watching costs mount at press time.

“We’ve seen significant price-gouging for CNAs and LPNs,” President and CEO Stephen Hanse tells McKnight’s Long-Term Care News. “Whether or not the legislature will do something on that for providers remains to be seen.”

‘Vultures pecking’

Getting some kind of protection from highly inflated staffing rates remains essential as providers in many states are limiting admissions for want of workers. Others are blowing through their workforce budgets and operating in deficits.

Brendan Williams, president and CEO of the New Hampshire Health Care Association, tells McKnight’s providers in his state were offering $17 per hour, plus shift differentials, for licensed nursing assistants this fall. But staffing agencies were paying rates as high as $69 an hour, and charging agency fees on top of that.

“We’ve got to staff to be able to serve the needs of our residents,” says Williams, who likens the rates he’s seen to “vultures pecking” at operators. “You’ve got to pay whatever ransom the staffing agencies are demanding of you.”

The crisis is compounded by both a lack of workers and acts of worker “poaching” being reported across the country. In some anecdotes offered by providers and competing agencies, frontline staff resign and then return the next day as agency help — though now making substantially more than their former colleagues.

Other times, agency staffers don’t show up, despite agreed-upon rates, leaving operators and their staff struggling to fill rosters for a given shift.

And it’s not just a battle for CNAs.

“If you need an RN, you may as well turn over a blank check. The bidding is not unlike eBay, where desperate providers are actually bidding against one another and bidding up the price of that RN,” Williams says. “We really do feel like it’s predatory at this point.”

Hurting more than just providers

Companies that provide staffing services say the practices of a few bad actors are making their work more challenging, too.

Dan Silver launched his small agency in Chula Vista, CA, two and a half years ago. His company has increased the rate it charges to staff CNAs by about one-third since opening, he says, attributing part of the increase to pricing b market values in his early days. But even offering $22 below ourly for CNAs, Silver began to run into trouble recruiting, first among LVNs and RNs who could make much more working at COVID-19 testing sites and, later, at vaccine clinics. 

“They found opportunities that paid so much more and were less stressful than a med pass position at a skilled nursing facility,” Silver says.

But the bigger challenge came around the same time, when two national agencies “flooded” the San Diego market — the only area Silver Medical Staffing serves. Those two firms, Silver says, pay employees as 1099 contractors, meaning they don’t have the overhead of collecting and paying taxes. Suddenly, CNA candidates were turning down job offers, saying they had other opportunities at $25 per hour.

“They moved the bar in terms of the expectation that CNAs had for hourly pay,” Silver says. “We really struggled to explain the difference between W2 and 1099 employment, especially to CNAs who were often early-career.”

Silver acknowledges other factors also are contributing to wage growth, including regulatory effects such as state minimum wage; market-based inflation where there is not enough labor supply; and the lingering influence of hazard pay.

Chris Sund is director of business development and sales for long-term care at Fusion Medical Staffing, a national contract nursing agency. He says he’s seen agencies — and some individual providers — ramp up pricing for specific jobs, which then results in a vicious bidding cycle. That can lead to a rush of applicants for a single position but create disillusionment with other jobs posted at more reasonable pay rates.

Facilities using his agency set their own price after consulting with a platform that allows them to see what other providers are offering in the same areas. Sund says, based on internal formulas, his agency clears a smaller margin when providers have to pay more for a contract. 

Fusion saw its positions-to-fill more than double from a baseline of 3,000 to 4,000 weekly pre-COVID to a peak of 10,000 weekly as mandate debates raged in July and August. That level of need has held through the fall. 

Sund adds that some state officials were so concerned about possible additional needs around the federal Dec. 5 vaccine mandate deadline that they had begun trying to hire and place staff through their own health departments.

FTC to the rescue?

In LeadingAge’s Oct. 8 letter to FTC Chairwoman Lina M. Khan, President and CEO Katie Smith Sloan outlined “incredible hardships, including crippling workforce and staffing challenges,” that “have been exacerbated and exploited by the actions of nurse-staffing agencies.”

“Most long-term care is paid by taxpayers through the Medicare and Medicaid programs; neither program is structured to respond to excessive costs and so monies that should go to caring for residents are diverted to paying private agencies,” she pointed out. “We request the FTC use its authority to protect consumers and taxpayers from anticompetitive and unfair practices to investigate these activities and take appropriate action to protect long-term care providers and the seniors they serve.”

It’s not just small shops or mom-and-pops struggling with agency challenges. The real estate investment trust Welltower acknowledged in its third-quarter earnings call that the costs of agency staffing experienced by its operators had hit its bottom line, although the firm was seeing some stabilization.

New Hampshire’s Williams, an attorney, says there is a strong case to be made at the FTC.

“Under a Democratic administration, it might be an easier case to make, arguably, than it would have been under a Republican administration,” he says. “I think there’s a lot of antitrust issues that are worth exploring.”

Betsy Lordan, an FTC spokeswoman, confirmed to McKnight’s that the agency was in receipt of the letters from LeadingAge and AHCA. FTC investigations, however, are non-public so Lordan would not confirm the existence of an investigation.

“An investigation is made public when and if there is a complaint (by the agency),” Lordan said. A complaint can be accompanied by a proposed settlement, which would be negotiated beforehand with the parties, or it could be the first step in a legal process tried either by an Administrative Law Judge or in federal District Court. Either way, Lordan said, the process “takes time.”

Time is a resource providers argue they don’t have, with many operating in the red because of increased staffing and COVID-related costs and the door closing on what appears to be the final round of provider relief funding.

 State solutions?

 There is a dangerous game afoot, notes Pennsylvania Health Care Association President and CEO Zach Shamberg.

“There is a place in the long-term care continuum for direct care staffing agencies, but their service should not come at the expense of jeopardizing care for the residents they are hired to serve,” he says. “Price gouging is simply not sustainable for providers, especially those reliant on the state’s Medicaid reimbursement rate, which hasn’t kept pace with rising healthcare costs since 2014. As providers attempt to emerge from the COVID-19 pandemic and make resident-focused investments, these exorbitant costs are pushing nursing homes … to the brink of financial collapse.”

Shamberg is pushing hard for state intervention, saying providers there “can no longer wait for a federal solution or regulatory effort.” Others, though, have doubts a state-by-state approach will work, especially in areas where would-be workers or agencies could just opt to concentrate their efforts in border states without caps.

 “Regulation might be able to fix it, but it’s going to have to be all 50 states together,” says Sund. “If one state does it, unfortunately, a lot of their staff is coming from outside of the state and they’re going to limit their pool to just what they already have. They’re not going to be able to pull the resources from other areas and they’re just going to hurt themselves.”

 He says another solution would be for individual states to adjust their licensing standards. With a shrinking labor pool, temporary travel nurses can be more selective about where they want to go. But few will choose to go to, for example, New Hampshire, where it takes 120 days to be licensed. They’re more likely to pick a job in a state like South Carolina, with walk-in temporary licenses available, or Florida, which typically issues them in three to six days.

“The biggest thing anybody could do to drive down the cost is to make it easier to get staff,” he says. “Those states with really hard regulations to get people there or that are slower in their process, the price drives up because they have such a small pool. If you’re an easy-license state, those jobs get filled so fast and they don’t have to pay as much because they have the whole country to get people from.”

Silver says his agency could work with caps, given high averages in California. 

“It would be helpful to know we are on equal footing with other agencies,” he says.

But Silver adds that operators can help themselves right now by adopting a few best practices, chief among them: finding an agency that works as a partner to communicate and help patch holes and adopting a longer-term scheduling strategy that anticipates ongoing shortages. Hiring an extra staff member for a month-plus — instead of just plugging daily holes — builds better relationships between internal staff and the temporary staffer.

It also could help providers compensate for time-consuming, constant training that comes with hiring only once an absence is noted or another employee quits.

“There are certainly agencies that are probably opportunistic in their pricing. They are unethical in their hiring practices. They don’t attempt to operate as true partners to their client buildings,” Silver says. But “I don’t think even a great agency is going to often be a truly beloved partner when they are coming into a chaotic, chronically understaffed kind of situation.”

Folding temporary staff into regular scheduling alongside permanent team members instead creates stability and entices workers to return without needing extra wage enticements, he says.

A semblance of stability is certainly a goal providers and ethical staffing agencies could come together on amid so much other uncertainty. 

A $23 million modernization of the 30-year-old building includes a three-story, 10,204-square-foot tower at the south end of the structure, featuring a therapy gym on the first floor and dining rooms on the second and third floors. Finished an astonishing six months ahead of schedule, the project capped off a $74 million transformation of the larger life plan campus that began in 2006.

CEO Kevin McGee grew up in the working-class Irish neighborhood where Smith Village is located. His parents both reside in the community, with his mother in independent living and his father in skilled nursing. They were among the community members and residents who offered their valued input about how Smith Village should go about the modernization project. Focus groups, conducted methodically as information sources, established the project’s blueprint, McGee says.

“Overwhelmingly, people wanted private rooms and skilled care,” he says. “Hospitals started doing it, so that became the expectation from the community.”

The new Johanson Wing has 66 private rooms and six spacious semi-private rooms (that are divided by a wall) for skilled nursing and short-term rehab residents. Michael Martin, managing partner of RLPS Architects in Lancaster, PA, says a dedicated entrance and “front door” to the health center is an integral part of the redesign because “previous access to the wing was from the independent living community’s main entrance that went through a labyrinth of corridors.” 

A dedicated physical therapy area is adjacent to the main lobby, with easy access from the new entrance as well as the private rehab resident rooms on the first floor. The rooms for short-stay rehab care residents have been modified to include bathrooms with fully accessible, European-style showers allowing residents to stay in their rooms for bathing.

The upper floors for skilled residents feature a contemporary dining venue and new living and gathering rooms. Renovations for both upper floors include the circulation spaces, common areas and resident rooms. The footprint of the first floor was larger than the upper floors, providing the opportunity to expand the volume in a portion of the therapy gym.

A: Wound care products represented a global market valued at nearly $20 billion in 2020, and that is only expected to grow with an aging population and the increased incidence of diabetes and other comorbidities that affect healing.

Choosing a cost-effective wound care formulary and ensuring proper use of products presents a daunting challenge to most post-acute care facilities, one complicated by a lack of research on effectiveness and comparative efficacy.  

Most wound care products are classified as “medical devices” by the FDA and are not subject to controlled clinical trials to prove efficacy and safety. These include foam dressings, hydrogels, alginates, silver-containing dressings and more. The variety of products is bewildering, and suppliers often present long-term care facilities with an array of expensive, high-tech goods when simpler and less expensive choices often will suffice in many cases.

Choices are based often on availability, insurance coverage, patient comfort, expert opinion, and intrinsic rationale for product type. The guiding principle, however, should be the concept of “wound bed preparation,” which is a tool to conceptually organize the array of wound products in a manner that achieves maximal benefit. 

Wound bed preparation focuses on critical components of management, including control of moisture and exudate, minimizing contamination with harmful bacteria, and removal of dead tissue and foreign material.

The goal is to reestablish the balance of biochemical factors in wounds, thereby stimulating the healing process. This, in conjunction with basic hygiene, pressure redistribution and nutrition, will heal most chronic wounds. Once wound bed preparation is understood, construction of a formulary and product choice become easier.

“Former colleagues came from far and wide — that’s a testament to the truly amazing person she is,” marveled Loretta Shopene, Crest Pointe’s director of community relations. 

It was a celebration that other operators would do well to replicate for their respective super long-term employees.

Staff at the 118-bed long-term and post-hospital care facility in Point Pleasant hosted the surprise bash and presented Roberts with a lifetime achievement award in November. 

The celebration included pink and purple decorations, which are her favorite colors, “45” balloons, flowers from her fellow staff members and cake. The town’s mayor presented her with an engraved plaque and gift for her years of service.

Roberts enjoyed every minute of the celebration — and said she has no intention of slowing down. 

“Everyone here at Crest Pointe is family to me,” she said. “I can’t thank them enough and couldn’t stop smiling that day. It was very special.”

A different kind of ‘smart’ bandage described in Frontiers in Physics could provide a promising, non-invasive answer. It contains a sensor that measures wound moisture levels and transmits readings to a phone, without removing bandages. By changing bandage geometry and materials, researchers hope to develop solutions for various wound types. Spanish researchers applied a conductive polymer called poly (3,4-ethylenedioxythiophene):polystyrene sulfonate (PEDOT:PSS) onto gauze using screen printing, and then incorporated the gauze into commercially available bandage materials.

“We also incorporated a cheap, disposable and bandage-compatible RFID tag, similar to those used for clothing security tags, into the textile patch,” said co-author Marta Tessarolo, Ph.D., a mechanical engineer with the University of Bologna.

The tag wirelessly communicates moisture-level data, alerting clinicians of a needed dressing change.

Reggie Hartsfield grew up in a spiritual home. He spent many mealtimes listening to his parents talk about the voice of God and refers to his mother, Margaret, as a prayer warrior. Every night, Margaret would pray on her knees before bed. Hartsfield curiously watched her, wondering what she was asking for — until he realized she was praying for his safety.

“As a young African-American boy growing up in the streets of Detroit, that made an impact on me,” he remembers. 

So when Hartsfield was eight years into the executive track at IBM and had the gut feeling it was time to leave, he took it as a spiritual sign. A logical thinker by nature, he was skeptical about leaving such a steady job. But when he called his mother, her advice was to listen to that voice of God, and go. 

Hartsfield listened, embarking on a transformative journey toward a career as co-owner and president of one of the nation’s few Black-owned nursing home chains. Today, he supports the work of more than 2,000 team members across 12 skilled nursing and senior living facilities and uses his business sense to lead the organization through acquisitions, negotiations and strategic planning. But he relies on his listening skills and intuition to lead his team through compassion, grace and service.

Around the time he left IBM, Hartsfield was listening to the stories of his close friend, Nina, a hair stylist. Working in a big salon, she had to pay a high percentage of her proceeds to the owners even though her clients were coming in to see her.

He asked Nina a lot of questions and used her answers to help her create a business plan for an upscale salon in Detroit. Together, they opened Harbortown Salon in 1992.

“That’s the first day I ever felt alive in a job,” Hartsfield recalls. “That’s when I realized I was an entrepreneur.”

One day his current partner at Advantage Living, Kelsey Hastings, came in for a manicure. She and Hartsfield got to talking about her career as a nursing home consultant. It was the first time he considered eldercare as a career, and he was intrigued. Soon after that chance meeting, Advantage Living was created as a consulting firm. Seven years later, in 2003, it bought its first nursing homes. Most acquired across the Detroit area since then were found through relationships with local hospitals, good timing and Hartsfield’s knack for listening to the market. 

Single, he has been a father figure to six godchildren who needed full-time parenting for various reasons. He also is a COVID long-hauler who almost died of the virus in spring 2020, 

He spoke emotionally of his lasting personal health struggles at the American Health Care Association’s 2021 annual convention in October. He identifies with empathy about what the entire profession has gone through since March 2020. Compassion keeps his drive alive.

“If I hadn’t followed that inner spirit — or listened to my mom — and left IBM all those years ago, I would have missed my calling,” he reflects. “Your calling is right in front of you most of the time. You’re going to get there eventually, but if you can just listen, you’ll get there faster.”

Resume: 1984, Graduates from Western Michigan University with a bachelor’s degree in business administration; 1984, Joins IBM as territory manager; 1992, Leaves IBM and opens Harbortown Salon in Detroit; 1996, Opens Advantage Living Centers/Advantage Management Group with Kelsey Hastings; 2003, Purchases first two skilled nursing facilities; 2008, Joins Health Care Association of Michigan board; 2014-2016, Chairs Health Care Association of Michigan; 2015, Selected to Michigan Chronicle’s Men of Excellence; 2021. Joins AHCA national board