The Centers for Medicare & Medicaid Services revealed in its 2022 payment proposal that the agency plans to amend PDPM’s parity adjustment as quickly as possible. SNF spending under the new model, which was intended to be budget-neutral, actually increased by $1.7 billion, or 5%, CMS said. 

CliftonLarsonAllen Principal Deb Emerson forecast a potential reduction of $12 per patient day, which “will certainly have an impact on reimbursement and the operating decisions being made.” 

Emerson suggested SNFs “critically analyze their organizational operations now” to better adjust to coming recalibrations. 

CMS noted COVID-19 likely pushed spending higher. The agency has asked providers to recommend specific targets, methods and best timing of any future pay changes. Comments will be accepted through June 7. 

Pre-COVID “if we could qualify [patients] for a skilled stay, that’s where we took them,” said Mark Terpylak, D.O., senior vice president of population health at Summa Health.

“We don’t do that anymore,” he said. “We fundamentally ask ourselves at the time of discharge from acute care, ‘Can we send them home, first and foremost, and support them in a home environment?’” 

Bryan Crum, director of post-acute care management at Summa Health, added that lower patient volumes, which convert to fewer downstream referrals to SNFs, also are driving the philosophical shift.

“That’s something I don’t think switches back,” Crum said. “I think we’re going to have a new normal. That new normal is going to likely be less admissions for the hospital, and I think that’ll be more compounded for some of the skilled nursing in the community.”

A:Long-term care workers reported an average burden of 5.1 on the M5’s 0-10 scale. Scores in the 5’s are alarming, and if sustained over a period of months, increase risk of developing clinical mental illness. Long-term care rehab therapists reported a stress burden of 5.6, followed by case managers at 4.6, nursing staff at 4.5 and behavioral health and social services staff at 3.6.

Q: How are you using the data?

A:We’re trying to quantify the stress to make an economic case for reducing it. We’ve launched a pilot (15 Minutes for Me) to determine how well short bursts of physical exercise, brain exercises and meditation lessen psychological burden, and whether employer-supported programs improve retention. It’s not our mindset to find an immediate cure. It’s to delay onset. 

Q: Why would employers opt in to such a program?

A:It’s inexpensive, and you don’t have to do it for an hour a day. An employer can give 15 minutes, but they’re not going to give an hour. The goal is to lower stress over time, help prevent burnout and reduce turnover among frontline staff.

There are a few definite resident caregiving tips in this regard. First of all, start goals of care conversations early. Advance directives should come up: 

• On admission (family and resident should be present, and a clergy member, if the resident wants one)

• At care conferences, with family

• At the start of an outbreak  (families and residents often change their mind, so revisit their desires)

• Again, with symptoms or positive tests or any changes in condition

Some main talking points on this topic:

• COVID can be lethal for elderly clients and for those with multiple diseases or comorbidities.

• Your facility has and will continue to offer robust symptom management as well as palliative care. 

• If a resident develops acute respiratory failure, experience and studies have shown that it is highly unlikely they will recover even with hospital transfer and ventilation. 

• Transfer to the hospital will put a frail elder at further risk of trauma, exposure to diseases and interventions that will be unlikely to help. 

• Comfort care in a familiar setting by staff who know the resident’s history and personality is the kindest, most humane way to ensure dignity at the end of life. 

• Ensure that RESUSCITATION and TRANSFER PREFERENCE information is clearly marked and accessible for ALL HEALTHCARE WORKERS.

Medical device-related pressure injuries (MDRPIs) are not uncommon in the post-acute and long-term care setting, especially with an increase in more medically complex patients. A proactive, vigilant approach to the assessment and prevention of these pressure injuries can reduce the incidence of MDRPIs.

They are typically associated with medical devices commonly seen in the post-acute setting — namely, feeding tubes such as percutaneous endoscopic gastrostomy (PEG) tubes, supplemental oxygen therapy tubing such as nasal cannulas or positive airway pressure devices like continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) devices, foley urinary catheters, or orthopedic splints and casts. MDRPIs typically present as pressure injuries that mirror the size and shape of medical devices in place. These MDRPIs can, for the most part, be anticipated, given device use in patients who are already compromised by advanced age, decreased sensation, a decrease in tissue tolerance to pressure, altered nutritional status and immobility. 

A proactive approach can be implemented to ensure best outcomes. For example, patients who require supplemental oxygen by nasal cannula should have foam covers added to plastic tubing to reduce pressure over the external ear. 

Patients with a PEG tube should have protective gauze placed beneath the flange of the tube between the device and the skin to minimize direct pressure and absorb excessive moisture. Urinary catheters should be secured to the thigh with an elastic band and not left to lie beneath the resident’s thigh.

Regular inspection of the skin underlying any medical device should be part of the routine nursing care of all patients and can minimize MDRPIs. 

Changes to the leadership team can be stressful for all staff, but especially for the director of nursing, who works closely with an administrator. Because the relationship affects so many aspects of care delivery, it’s critical to collaborate effectively. 

First, establish expectations. Clarify not only what he or she expects of you, but also what you need. 

One shared need should be time for regular meetings. Mutual respect takes time to grow, but working through challenges together establishes a solid foundation. Ensure communications are frequent and discussions transparent. While being honest builds respect, secrets undermine it.

In addition to how you communicate behind closed doors, bolster one another with other staff. The administrator and DON are the two top leaders in a facility; staff will be watching your relationship closely. Present a united front, and agree to work through disagreements behind closed doors. 

Since you’re a team, support one another. Offer and accept help. In the last year, support has become more important than ever, and no one can understand the struggles of long-term care like the administrator and DON. When stakes and stresses are high, support each to better support staff. 

Learn about the financial aspects of the administrator’s role and discuss expenses openly. Don’t let large expenses surprise the administrator. Instead, share information openly and work with the administrator to manage the nursing budget effectively. 

New administrators are often unsure what to expect from their new position. Encountering an open-minded DON who wants to co-lead the facility will be a welcome introduction. 

The Centers for Medicare & Medicaid Services continues to waive the requirement for a three-day prior hospitalization for coverage of a SNF stay during the Public Health Emergency. While this is a blanket waiver, documentation needs to support how the skilled stay relates to the PHE, and in the absence of the pandemic, that the condition would have required an inpatient hospital stay.

This calls me back to the March 13, 2020, letter to HHS from then-CMS Administrator, Seema Verma, which states, “SNF care without a 3-day inpatient hospital stay will be covered for beneficiaries who experience dislocations or are otherwise affected by the emergency, such as those who are (1) evacuated from a nursing home in the emergency area, (2) discharged from a hospital (in the emergency or receiving locations) in order to provide care to more seriously ill patients, or (3) need SNF care as a result of the emergency…”

Furthermore, CMS states in its FAQ document: “SNF coverage isn’t based on particular diagnoses or medical conditions, but rather on whether the beneficiary meets the statutorily-prescribed SNF level of care definition of needing and receiving skilled services daily which, as a practical matter, can only be provided in a SNF on an inpatient basis.”

To avoid potential denials, the IDT should determine and document: (1) what the skilled service(s) is/are, (2) how SNF level of care is met, (3) how the skilled stay relates to the PHE, and (4) how an inpatient hospital stay would have likely been necessary to manage the condition(s) in absence of the pandemic.

You must carefully follow the regulations as to what actions you are allowed to take to protect your residents and those who serve them. You must also document expenses for reimbursement under federal or state programs.

Your accountants should advise you what expenses are covered under the program you participated in. Your advisors also should study the specific program and establish procedures for you to follow to properly document all qualifying expenses. 

Paycheck Protection Program borrowers, for instance, may be eligible for loan forgiveness if funds were used for eligible payroll costs, payments on business mortgage interest, rent or utilities during an eight- or 24-week period after disbursement.

A borrower can apply for forgiveness once the business has used all loan proceeds, any time up to the loan’s maturity date. But if PPP borrowers do not apply for forgiveness and supply payroll, mortgage or other documentation within 10 months after the last day of the covered period, then they must begin loan repayment.

Refer to www.sba.gov/ppp for a complete list of requirements and forms needed for forgiveness.

Getting advice on how each program works may help protect the seniors you serve from COVID-19, keep your employees or volunteers from contracting it and help cover your bottom line. But you must fully understand what you have to do to comply with the program, as well as what you must do to document and apply for coverage of expenses under the program.

Last fall, Terry Burch, R.N., wrapped up an agency contract and transitioned to a permanent position at Briarcliff Health and Rehabilitation in Indiana.

But the promotion required he split his time as both a unit manager and the infection preventionist for the entire 87-bed facility —  initiating a constant struggle for balance amid the backdrop of COVID-19.

“Day to day, there aren’t any guarantees as to how I spend my time,” says Burch. “It’s heavy on both sides.”

The nation’s nursing homes are still awaiting final interpretive guidance from the Centers for Medicare & Medicaid Services that will dictate who meets the agency’s definition of an IP, how many hours they should commit to infection work and what qualifications or training they must have.

The position was mandated as part of a broader focus on infection prevention and control in the 2016 Requirements of Participation. But just weeks before the IP provision was to go into effect in 2019, CMS leaders announced they wouldn’t push out guidance — and would limit related penalties — until the second quarter of 2020.

Then COVID-19 hit, and at a time when infection prevention remains mission-critical, federal officials again put off issuing binding guidance. CMS told McKnight’s in mid-April that it will introduce full guidance “in coming months” and that, for now, “regulatory language provides general parameters about the requirements.”

But some providers feel they have been left to fill the infection preventionist role in a vacuum. Some states already require the hiring of nursing home IPs, but their standards, too, are often open to interpretation, leading to concerns about program quality.

In Illinois, for instance, a 2011 rule requires each building to have an infection preventionist, but the scope of that job was never truly defined. While intended to give providers flexibility, that approach allowed preventative efforts to fall through the cracks, says consultant Deb Burdsall, Ph.D., RN-BC.

“The pandemic has made clear that a lot of people that were trying to fulfill that role — a lot of times with good faith efforts — found it was an independent profession, not an ‘other duty as assigned,’” says Burdsall, a certified infection preventionist who spent 25 years in that position with Illinois-based Lutheran Life Communities. “It requires time. It requires training and education. It requires maintaining contact with the local health department and local organizations and with your colleagues. You can’t do this in a silo.”

What counts as training?

Nursing home IP standards during COVID-19 have been dictated by the Centers for Disease Control and Prevention, which called on facilities to have “one or more individuals with training in infection control to provide on-site management of the IPC program.” CDC also insisted the IP be full-time in facilities with more than 100 residents, or if ventilator or hemodialysis services are offered.

But even that guidance leaves providers grappling with what counts as training. The CDC offers a nursing home infection preventionist course, and some states have also established their own training programs. 

The Association for Professionals in Infection Control and Epidemiology, or APIC, strongly recommends more comprehensive training that prepares IPs to earn an endorsement from the Certification Board of Infection Control and Epidemiology.

Evelyn Cook, RN, CIC, is associate director of the statewide program for infection control and epidemiology at University of North Carolina at Chapel Hill and serves on APIC’s long-term care task force.

She says certification and membership in a professional infection control organization are key ways for IPs to grow their knowledge and stay updated on emerging threats. But just 1,200 APIC members currently identify as working primarily in long-term care, representing less than 10% of U.S. nursing homes.

In a 2018 study, Columbia University School of Nursing’s Patricia Stone, Ph.D., RN, found that just 39% of nursing home IPs had received “specialized training” and less than 3% of those held any IP certification.

A second study, published in 2020, found that nursing homes with IPs increased from 3% to 7% from 2014 to 2018, a period when facilities strengthened antibiotic stewardship, outbreak control and urinary tract infection prevention. But in 2018, 44% of nursing homes still reported their IPs had no specific infection control training.

More pay elsewhere

One of the challenges is that the CBIC, APIC’s gold standard, tests on a significant amount of acute-care information — such as sterilization of surgical instruments — that nursing home IPs would never need. To that end, APIC is working to create a competency designation for IPs that work in long-term care. Expected this summer, it would be distinct from a certification but cover essential elements of infection control and prevention for SNFs.

Another major issue? Many nursing home workers who earn IP certification are drawn to other healthcare segments, where they are almost certain to earn more money. Stone found turnover among nursing home IPs was 41%; greater IP turnover was associated with receiving an infection control citation. 

Cook says any position that requires the IP to continue in other duties, particularly nursing, will allow them to be pulled away from the infection control mission any time a colleague is sick, or more permanently in the event of a staff shortage.

“That doesn’t happen in the acute-care world, and it can’t happen here,” says Cook, who wants CMS to mandate a full-time requirement with few exceptions. 

Burch also believes the position should be full-time. While he feels supported by his employer, he’d like to spend more time training colleagues and creating programs that become entrenched in building culture. 

“COVID was at the forefront for so long, that some of the other stuff was overlooked,” he says. “There are a lot of things to be completed and rounded on that aren’t COVID, and a lot of facilities, because of the hyper-government focus on COVID, aren’t doing them.”

Time to do the job right

A dedicated full-time IP professional would maintain standards even as conditions fluctuate, and provide an additional monitoring and retraining presence in any crisis.

And another crisis will come, Burdsall says.

“These organisms that are out there, there are more of them,” she says. “It’s not just COVID.”

In addition to being tasked with running antimicrobial stewardship programs that could lower drug resistance, a well-trained IP also could organize and track vaccine efforts of all kinds, monitor water management to cut the risk of Legionnaires’ disease and ensure devices are properly sanitized to prevent device-acquired infections. They also should lead QAPI efforts as part of an interdisciplinary team.

The possibilities are limitless, but an IP needs time to visualize the threats, research mitigation strategies and build an organization-wide response backed by healthy buy-in. Given those resources, IPs’ salaries should eventually pay for themselves in reduced infections and hospitalizations and improved quality of care, Stone says.

“I know sometimes nursing homes are running on low margins, and some small nursing homes don’t want another full-time position,” she says. “But they’re going to have to see the value. If not, people will have died because of it.”

CMS officials have repeatedly urged providers to name IPs prior to their final guidance. An agency official told McKnight’s that 94 related F-tags were issued in 2020 and 2021, indicating that enforcement actions are underway.

More than regulation

A highly qualified preventionist, whose efforts are well-documented and marketable, will appeal to potential partners and “very sophisticated” consumers, says Donna Nucci, manager of infection prevention for Yale New Haven Health and head of an IP consulting business.

Still, Nucci says she doesn’t know of a single nursing home with a full-time IP. 

“It’s a very, very difficult challenge to find somebody who can deliver competent care, especially in the LTC setting,” she says, noting tech that tracks goals, prompts reporting and offers educational modules can help.

Even with assistance, Nucci believes an IP should be a licensed nurse. The role, she said, is dictated by an intense clinical focus on surveillance, followed by efforts to identify infection among residents or staff, manage those infections and educate staff.

Nucci had expected hiring of IPs at all long-term care facilities to take up to 10 years, but COVID-19 has ramped up the transition. It’s similar to what she witnessed in surgery centers during the healthcare-associated infection crisis around 2000.

Stone remembers related calls to increase acute care’s infection control knowledge through the addition of dedicated specialists.

“IP nurses weren’t considered key players. The change happened when hospitals started having to report their infections,” she says.

COVID-19 has ratcheted up similar data reporting pressure on SNFs, with some states moving to make all disease outbreak information highly public. 

Watching nursing home case and death counts climb a second time last fall convinced each of the IPs interviewed by McKnight’s that nursing homes either haven’t learned enough about infection control or still don’t have enough resources to protect against infection. That CMS proposed an IP position five years ago and still hasn’t given providers a full playbook is equally frustrating.

“We did know there were issues (before COVID-19), but we just didn’t do enough,” Cook says. “We cannot lose sight of this opportunity to make everyone aware that they really need more resources. Not only time, but education and support and empowerment.”