The leading industry groups in mid-March unveiled a $15 billion legislative package targeting systemic issues in the nursing home sector — many of them worsened by the pandemic. It called for requiring nursing homes to have a registered nurse on staff 24 hours a day; a minimum, 30-day supply of personal protective equipment; and enhanced infection control preventionist resources. 

The plan also highlighted the need for an enhanced survey system that focuses on improvement rather than punishment. 

To pay for the reform measures, the groups proposed four interrelated investment strategies, which include enhancing the Federal Medical Assistance Percentage, establishing federal guidelines for state allowable or reasonable cost definitions, and requiring states to set Medicaid rates to match the cost of care. 

Mean turnover was 141% among registered nurses, 129% for certified nursing aides and 114% among licensed practical nurses, according to a study in Health Affairs. Using Payroll-Based Journal data, researchers  found wide swings in turnover depending on state or quality indicators, such as overall star ratings and health inspections. One-star rated facilities had the highest median turnover for all nursing staff at 136%.

“Lower-quality facilities may induce staff to separate more frequently,” lead author Ashvin Gandhi, Ph.D., assistant professor at UCLA’s Anderson School of Management, told McKnight’s. “They may choose to leave facilities that are low-quality specifically for the reasons that make them low-quality.”

Total nursing staff turnover rates also were higher at facilities that were for-profit, chain-owned or predominantly reimbursed by Medicaid.

Gandhi and co-author David Grabowski, Ph.D, suggested states could reduce turnover through higher Medicaid reimbursement and targeted incentives. They called for public reporting of turnover rates to leverage better wages and generate better state funding. 

A:We need to improve vaccine confidence and access, if we want to end this pandemic. I’m concerned that if we don’t get the majority of the country — and the world, for that matter — vaccinated and achieve herd immunity, then we’ll be in a constant battle.  

Q: How can providers ensure they vaccinate new residents and staff after the federal partnership?

A:Public health officials must continue to prioritize vaccines for long-term care residents and staff. We need the CDC to ensure the vaccine is readily available for new admissions and hires as well as current residents and staff. Providers need to spend time talking with staff to answer their questions and concerns in a non-judgmental manner. Also, promote practices people can get back to once they are vaccinated, such as visiting family and traveling.

Q: Will vaccines be effective against emerging variants?   

A:We have to continue to watch. The benefit of the technology that the first two of these vaccines used in their development is that they can manufacture new mRNA targets to the new spike protein or new variants and substitute those, so we can address these variants pretty quickly. We may need more frequent booster shots … We can manage that.

It depends on the needs and type of your facility. A skilled nursing or rehab will need a more aggressive approach than an assisted living facility, for example.

Any facility should seek a cost-effective therapy company, one that knows Medicare B and how to bill and what the regulations are for all of Medicare. 

Great companies excel at communication. They need to attend morning meetings and interdisciplinary team meetings. Therapy also needs to work with CNAs on residents’ ADLs. 

They need to be flexible with resident schedules and with residents while they eat, use the phone, take a bath and so on. They also need to work weekends since admissions occur seven days a week. It’s very important that a resident requiring a wheelchair has one that fits them correctly on admission. Sitting in an improper chair even for two days can cause skin breakdown or begin a contracture, so giving a therapist access to the resident on admission is extremely important.

The therapy company needs to be aware of changes in regulations, and provide in-servicing to all staff — not just about regulations but also to assist staff with lifting and moving residents safely. Because therapists should be part of the “team” even if they are with a consulting company, they should still wear the facility’s badge to show they are team players.

And as team players, therapists should attend and participate in facility events. When staff and residents see them involved, it proves they are part of the team. It makes everyone aware therapists are working for the good of the residents, staff and facility, which makes their company better than another that is not as involved.

Patients who reside in nursing facilities and have wounds should have excellent nursing care so that all wounds heal appropriately and that no new ones occur. Because wounds, particularly pressure ulcers, can increase the risk of litigation, it is especially important to document each wound correctly, thoroughly and regularly.

In addition, wounds are a frequent focus of state and federal regulatory survey reviews. Great documentation shows attention to detail and vigilance.

A best practice is that nursing staff record progress on each wound at least weekly, or more often if there are changes or deterioration of a wound. The progress note should include the etiology, anatomic site and the stage of a pressure ulcer. Each wound should be measured at least weekly and each note should contain the current length, width and depth of the wound in centimeters. The presence of any slough or eschar tissue in the wound bed, any abnormal odor, and the condition of the skin around the wound should be described. 

The progress note also should include the current wound status compared to the previous observations, and whether the wound is improving, stable or deteriorating. It  should include the current wound treatment; documentation of communication with healthcare providers, caregivers or family; and any changes to the treatments. Care plans also should be updated with any changes.

Excellent documentation leads to improved care because there is regular, focused review of the wound status and treatments. This, in turn, leads to better risk management and regulatory outcomes. If the quality of care is ever called into question, accurate and timely documentation goes a long way to show that there is a good faith effort in play.

Advance care planning is a collaborative process between healthcare providers, patients and family members, where all parties come together to discuss future healthcare, including end-of-life decisions. Eliciting and documenting patients’ wishes ensures that, even if they become incapacitated, their preferences are known. This honors residents’ voice and choice and reduces stress on family members. 

Advance care planning encompasses more than just CPR; it also addresses topics such as ventilator use, artificial feeding, artificial hydration through intravenous fluids, and other emergency treatments. This is an opportunity for the patient to express care decisions based on their values and preferences. 

Staff often avoid these crucial conversations because the subject can be difficult; education does a lot to help ease these fears. 

Consider appointing a staff member to serve as an advance directives advocate and educator for patients and staff alike. This person should be able to share materials that help patients and family members understand various options. 

To incorporate advance care planning into care delivery, address it upon admission and during every care conference. Begin by asking patients what kind of treatment they would or would not want in a few emergency scenarios. For example, if they have a stroke, cannot move, and their heart stops, would they want CPR?

Documentation can take place in an advance directive or living will. Be sure to check your state’s laws to ensure advance directives are valid. 

Keep copies of the directive in both the medical record and the patient’s plan of care. 

The Function Score calculated from coding responses to certain Section GG items impacts your PDPM rate in the nursing component and the OT/PT component. Not surprisingly, reviewers are focusing on usual performance accuracy as well as documentation to support the IDT collaboration for assessment data. 

In medical review, positive or negative discrepancies identified between the final MDS coding decisions and supporting documentation will contribute to the medical review error rate and potentially result in recoupment. If the documentation in the medical record does not support MDS coding, this could result in a need for repayment, or even lower initial reimbursement due to inappropriate case-mix assignments.

Ensure your team consists of qualified clinicians involved in assessing the individual during the appropriate three-day assessment period. If GG data collection begins on day four, none of that assessment data can be considered for the Function Score calculation. 

At minimum, documentation should be collaborative from nursing and therapy, but the RAI guidance also includes incorporating resident self-reports and reports from qualified clinicians, care staff or family documented in the resident’s medical record during the three-day assessment period. 

Also, the usual performance coded in Section GG must be consistent with the clinical assessment documentation in the medical record. You may consider documenting an IDT note to clarify coding decisions. This could include justification for determining coding decisions when the usual performance is not obvious, as well as noting necessary information such as data determined prior to the patient’s benefit from treatment interventions. 

You are not alone. The pandemic has impacted every type of facility or organization serving seniors, including licensed nursing homes, continuing care retirement facilities, assisted living facilities and independent living facilities. Such facilities must comply with Centers for Disease Control and Prevention or state guidelines to prevent spread of contagious diseases. 

Communication about your efforts was made more difficult by the state requirement that the residents be isolated and not allowed visits by family members. This isolation increased fears among residents and their families that the residents are victims of abuse, neglect or theft — ironically because of the actions you’re take to serve them better to protect them from contagious disease!

To protect itself from liability or claims of wrongdoing, any organization serving seniors must communicate thoroughly about its policies and its efforts to protect the residents or staff serving residents from disease or abuse. These messages about the steps taken regarding pandemic precautions, as well as what’s being done to protect them from abuse or theft of belongings, will reduce unfounded fears or claims of wrongdoing.

As the isolation of residents, vaccines, masking and social distancing efforts continue to reduce the spread of diseases, claims of wrongdoing should be reduced or defeated.  

Even with the best of plans and good briefs, ancillary products can play a major role in incontinence care. But caregivers need to do their homework. Taking the appropriate time to make wise choices can make all the difference in outcomes, experts remind.

1. Use products with a positive record of efficacy.

Working with a company with a broad product line based on clinical needs can be a big plus, said Michelle Christiansen, vice president of clinical sales and marketing for the Medline Personal Care Division. 

The care taken during the products’ formulation also is important. This includes ensuring the highest standards are followed in choosing ingredients.

Skin care products developed by leading specialists that undergo continuous and rigorous product research and refinement also are important.

Christiansen advises choosing products with formulations that are clinically proven. 

“It’s also important to leverage these resources to help caregivers use the right products, the right way, at the right time,” she said. “Color-coded and educational packaging, by usage, helps standardize inventory, simplify training and may reduce the chance of staff error and ultimately improve outcomes.”

2. Providers need to follow the formularies in place.

There are multiple reasons for using formularies as a guide when choosing these kinds of incontinence-related skin care products.

Almost all items offered by the manufacturers of skin care or incontinence product lines have been tested and developed with specific skin care in mind for those receiving services, according to Christine Berke, MSN, a nurse practitioner at a midwestern wound and ostomy clinic. She also is a preceptor and guest lecturer at UNMC Colleges of Medicine and Nursing.

“If a caregiver provides services in a facility, the facility should have a formulary for skin and bathing care products,” Berke said.  “Usually these products are designed to be pH-balanced (neutral around 7.0 pH) and free of known chemicals that may irritate compromised skin.”

She tells caregivers to consult facility policies and guidelines “and ask lots of questions of the manufacturer representatives.” It’s their job to be responsive.

Queries may fairly — and most often should — include requests for items like testing data, user case studies or white paperss. 

Like Christiansen, Berke advises working with a supplier with a broad skin care product line.

Request testing data, if available, and review real-word case studies  that have been conducted among product users that are closely matched to the patients your facility serves. 

3. Consider ancillaries’ possible interactions.

Caregivers should be mindful of the way products interact with the patient’s skin and other incontinence products.

That advice comes from Bonnie Grady, senior product manager, Briefs and Skincare, Essity Health and Medical Solutions.

Also choose products that don’t hide affected areas. Instead, use materials that allow the caregiver to visualize the skin after application, Grady said. For example, many zinc products provide effective protection, but are difficult to remove and prevent proper assessment of the coverage area.

Products that remain in place while being easy to remove are a huge plus, Grady said. 

For example, avoid thick pastes or creams. Remember: Damage can occur to sensitive skin when multiple swipes are required to remove any skin care product.

Finally, choose products that, when properly applied, will not coat the inside of the incontinence brief.

“When this happens, the brief is then inadvertently ‘waterproofed,’ preventing proper absorption of fluids,” Grady said. “This can create the potential for greater moisture-associated skin damage.”

4. Realize the critical manner and sequence in which various products are used.

During each absorbent product change, no-rinse cleansing should occur, Grady says. An oil-in-water emulsion will properly moisturize the skin and be free of surfactants.

“If your cleansing product does not provide moisturization, a second product/step will be required,” she added.

Berke cautions caregivers to use these products shortly after skin cleansing to prevent over-dryness.

“We always want to ensure we are using products and techniques that are going to not only lead to great outcomes clinically, but also ensure we are promoting dignity and comfort,” said Christiansen. “We also want to make sure that we have products that go hand-in-hand with the outcome we are trying to achieve.” 

This includes cleansers, hydrating moisturizers, barriers, protectants and treatments for fungal infections and to relieve associated symptoms.