Q: Your foundation recently recommended creating an “adequately prepared workforce” as a key element of improving healthcare for seniors. What does that mean? 

A:We have to have a complete interdisciplinary approach. There can be no care without a workforce. They need dignity, respect and a livable wage. They need scholarships, loan forgiveness and training to be able to get ready for the care they have to give. I’m incredibly optimistic [the Biden administration] will bring infrastructure change and innovation.

Q: How do we attract LTC workers?

A:We’re looking at every model we know to get people involved. We can train those who didn’t finish high school or even get a GED and encourage them to take positions such as the universal worker in the Green House model. … We have to get the right people by screening them and having them get a sense of the work. Show them they have the opportunity to change people’s lives.

Q: Does career advancement work?

A:CNAs don’t want a career ladder. They’re so sick of hearing these things. They want a living wage.They want transportation. They want child care or eldercare for their own parents. We have to have culture change and help them find joy in the work.

That is wonderful that you are seeking ways to recognize those staff members who go above your expectations. Certainly, there are many ways to recognize them. Many of the state healthcare associations have a conference where they recognize staff members at those conferences. 

National associations such as Leading Age and the American Health Care Association also have conferences where staff are recognized. Check all of your respective state chapters. Nursing associations also have honors. NADONA, for example, has a nurse leader of the year and region awarded at their annual conference.

For RNs, you may want to try to nominate them for the Daisy Award (www.daisyfoundation.org).

An acronym for Diseases Attacking the Immune SYstem, The DAISY Foundation was formed in November, 1999, by the family of J. Patrick Barnes, who died at 33 of complications of idiopathic thrombocytopenic purpura. The  care Patrick received when hospitalized profoundly touched his family.  

On the DAISY website, administrators call the award “inspirational,” “a great morale booster,” “an excellent tool for nurse retention” and “a way to develop role models.” 

Efforts to express personal, heartfelt appreciation to nurses for the important difference they make in all the lives they touch is having a powerful effect, especially amid a nursing shortage.

I have nominated many nurses, and they are truly humbled and honored by receiving this award. I recommend you nominate your nurses now.

Most post-acute and long-term care settings routinely use pressure-relieving mattresses, typically made with a foam core. These are typically adequate for most patients. 

Pressure ulcers happen more frequently in patients who are immobile or confined to bed, incontinent, have contractures or other movement restrictions, have a history of previous PUs, or have any of numerous other characteristics. Each patient should be assessed on admission or change of condition for risk factors for pressure ulcers.

Patients who are at particularly high risk and those with higher stage pressure ulcers (typically stage 3 or 4) require consideration of a specialty mattress surface such as an alternating pressure, low air-loss mattress to adequately relieve pressure and promote wound healing. These mattresses are better suited to redistribute pressure and retain a dry surface in contact with the patient’s skin. They are, however, more expensive than the traditional mattresses.

When a higher stage pressure ulcer has healed, the question arises of when to discontinue the low air-loss mattress and return to a typical pressure relief mattress. There are times when wound experts recommend continuing low air-loss mattresses longer term or indefinitely. 

Mattress choice should be determined on an individual, patient-centered basis.

Patients who have a history of higher stage or recurrent PUs, have permanent contractures, or are at the end of life with overall skin failure, should have careful consideration of the appropriate pressure-relieving mattress as part of their ongoing, post-acute or long-term care plans. 

— Mary P. Evans, M.D., CMD, CWSP, Certified Medical Director and Certified Wound Specialist Physician

Whether or not to complete an IPA should be a case-by-case decision. Because the IPA is an optional assessment, SNF staff determine if and when an IPA will be completed. 

As the name implies, the purpose of the IPA is to establish a payment rate or billing code for billing Medicare Part A. Consider the current daily rate and if the projected IPA rate would increase reimbursement. If the changes will result in an increase, the IPA should be scheduled — allowing adequate time to complete supporting documentation, section GG interim performance and MDS scripted interviews. 

Do not set the IPA earlier than the day the team determined it was warranted, as dashes on the assessment could substantially affect payment because the team wasn’t allotted time to collect information for all sections. 

It is important to also monitor the skilled level of care. To continue to bill Medicare for this skilled stay, the resident must continue receiving daily skilled care (per Chapter 8 of Medicare Benefit Policy Manual). That requires seven day-a-week nursing coverage or at least five days of therapy coverage. 

If therapy reduces services below this threshold because of a COVID-19 diagnosis, the resident would no longer meet the skilled level of care criteria. The resident may be receiving skilled nursing services, but the Centers for Medicare & Medicaid Services has clarified that a “COVID-19 diagnosis would not in and of itself automatically serve to qualify a beneficiary for coverage under the Medicare Part A SNF benefit” (per COVID-19 FAQ on Medicare FFS Billing). The focus must be on the skilled services being provided on a daily basis.

The waivers are still in place, but there are many variables that may contribute to the denial of payment.  

It’s possible that the resident exhausted his or her 100-day benefit and stayed skilled in the other facility prior to the hospital transfer. This resident would not qualify for another 100 days and definitely could put the receiving facility at a disadvantage.  

Therefore, it is important for evaluators at the new facility to do due diligence to determine exactly how many days were used, how many are left, and if the 100 days were exhausted, whether or not the resident remained skilled. 

In addition to denials, Recovery Audit Contractors are authorized to conduct medical review. They are reviewing for Medical Necessity and Documentation Requirements in general, but as of September 2020, specifically related to Patient Drive Payment Model characteristics.  

Even with waivers in place, the Medicare requirements have not changed.  If the resident does not require skilled care, then the requirement is not met. It can be as simple as that.

Also, remember that non-hospital transfers do not have the presumption of coverage. While the waivers are intended to make it easier to care for our residents, there are a lot of areas which can open up the facility to financial risk. It is imperative that providers move with care and precision, in order to avert potential costly litigation or corrective actions.

As always, I would encourage the facility to appeal any denial and review any other residents in this situation to avoid potential concerns.

The general answer is likely yes, but you must check with a labor and employment lawyer who is familiar with the state statutes and cases in the state where the facility is located.

Each state’s laws may impose different or additional requirements on employers.

Elderly individuals are more susceptible to the dangers of COVID-19, as well as other communicable diseases. Thus, organizations serving seniors are exposed to increased liability. The local lawyer should review your employment policies regarding infection control, policies which should be written clearly and enforced to protect your residents.

Due to the potential legal liability exposure to the facility serving seniors and their residents’ health and safety, it is permissible to require employees to report symptoms as well as to require testing. Having coronavirus symptoms or testing positive may prevent employees from working with the residents. 

Your infectious disease policies must be written and clear. Furthermore, you should uniformly enforce those policies to protect your residents.

Failure to enforce such policies to protect your residents may open up a facility serving seniors to an increased liability if residents contract COVID-19 from infected employees. This financial liability could be very large. 

Exposure will continue to increase as the COVID-19 pandemic continues and strains of the virus mutate. Unfortunately, despite the introduction of vaccines and more personal protective equipment and testing in many areas, it is no time to let up on vigilance and safety precautions. Your staff should be reminded of this regularly.

The building concentrated resources, including an infectious disease consulant, infusion nurses and equipment needed to fight the disease. It also allowed administrators to quickly move sick patients out of buildings where they had been living, decontaminate their rooms and minimize spread.

As of February, Principle had four Special Care Units encompassing 300 beds.

In a sure sign that the pandemic is far from over, the North Carolina-based nonprofit planned to open two more units this month.

The move not only centralizes care of stricken residents, it protects the reputation of individual Principle facilities as they begin the quest to win back referrals and fill beds. It also serves as tacit acknowledgement that, despite progress on vaccinations, COVID-19 isn’t done targeting seniors and those who care for them.

After a year of constant crises and pivoting, experts say now is not the time to relax.

“We have a big cliff coming up,” Hood said. “First of all, we don’t know how long the vaccine protection is going to last, and we haven’t had a big holiday since Christmas. We don’t know what the next gatherings are going to look like. I’m also concerned about communities’ complacency once they start seeing early positive signs emerge.”

As of Feb. 1, the federal government reported 77.8% of skilled nursing residents in the Pharmacy Partnership for Long-Term Care program had received at least one dose of a COVID-19 vaccination.

In smaller pockets across the nation, a majority of residents had already gotten both shots and time to build immunity. In some cases, that meant a return of indoor visits (with continued precautions) and some daily activities.

But the Centers for Medicare & Medicaid Services had yet to revise last fall’s visitation guidance, even as families clamored for access.

“It’s too early,” Evan Shulman, director of the agency’s Division of Nursing Homes, told LeadingAge members in mid-February.

Chief among the agency’s concerns: whether the Pfizer and Moderna vaccines actually stymie transmission. An analysis by the American Health Care Association found vaccinated nursing homes experienced a 48% decline in new resident cases three weeks after the first clinic. AHCA asked the Centers for Disease Control and Prevention to “rapidly evaluate the vaccines’ effectiveness among the long-term care population in both preventing spread and in reducing morbidity and mortality.”

For now, Shulman urges patience, noting issues around vaccine protection length and effectiveness against emerging variants. she said.

Vaccine unknowns

“We have outstanding questions on the vaccines,” he said. “Everyone needs to keep doing what you’re doing: Adhere to all infection control guidelines; when it’s your chance to get vaccines, get vaccinated; and as more people get vaccinated, then more visitation will occur.”

Ruth Katz, senior vice president of policy for LeadingAge, agrees “now is not the time” to let up.

“We need to double-down on the mitigation strategies that we have been using and that we know work: masking, social distancing, screening and testing, with immediate action taken when symptoms develop or asymptomatic cases are identified. We need to continue facilitating access to PPE, testing, and vaccination for residents and staff,” she said.

At the Maryland Baptist Aged Home in Baltimore, conditions are still far from routine.

The 29-bed facility has had zero COVID-19 cases, according to the Rev. Derrick DeWitt, director.

“We acted early,” DeWitt said during a LeadingAge update. “We were excessive. We were extreme. We were emotional.”

The emotion ratcheted up when DeWitt, the first on his team to be vaccinated, found out only 11 of 42 employees followed his lead during the first on-site clinic.

“I was shocked,” DeWitt said. “It never crossed my mind we would have that type of hesitancy.”

He redoubled his efforts, appealing to his employees as a boss, as a pastor who prayed over vaccination, and as someone who valued science over rumor. He took a hard line when some staff members seemed to buy into conspiracy theories about the shot, telling them, “I can’t guarantee your job here if you don’t take the vaccine.”

DeWitt said his building doesn’t have the luxury of isolating patients by wing or floor. If staff members complain about mask wearing weeks after their second doses, he points out that six employees remain unvaccinated.

“Not being at 100%, we’re stuck in this COVID status quo environment,” he said. “To me, 86% is equivalent to 0% … It’s only going to take one person to infect everybody else who’s not had the vaccine, and then the vaccine is only a percentage (of risk) that I won’t get severe disease.

“Until we get to 100%, it’s going to have to be business as the new normal.”

Infinite vaccine wave

In larger facilities, 100% vaccination rates may be even more challenging to attain and sustain.

As federal officials encourage more Americans to get vaccinated on a quest for national herd immunity, Steven Fuller, D.O., Ph.D., said nursing homes should not think of themselves as fully protected by high compliance.

“Herd immunity cannot be achieved in a congregate setting,” said Fuller, a former executive and medical director with Presbyterian Senior Living. “After the third wave of vaccinations, (residents) continuously come in. What about them? What about staff members? Turnover is about 15%.”

He’s calling for an “infinite wave” of vaccines, and for individual nursing homes to establish policies that ensure access to vaccinations for months to come.

Ohio officials in February were the first to outline a plan requiring providers to begin that process by picking a pharmacy partner and having new staff and residents vaccinated before admission.

Fuller said it’s critical for providers to consider how they will treat residents or staff or who are partially or not-at-all vaccinated.

“Do you force the unvaccinated to be stuck in their rooms while the vaccinated can roam freely and take advantage of everything?” he asked. “That’s a battle that will be temporary … But at least they know they’ve defined the battle, and they know the fight ahead.”

Return on investment

At Principle, Hood and her team have developed 80 COVID-19 policies, which they continue to rely on as North Carolina allows small group gatherings for meals, group therapy and activities.

Compassionate care is allowed for end-of-life situations and for residents experiencing social isolation or depression. Visitors must undergo symptom checks and wear PPE on isolation units.

Principle spent more than $2 million on PPE and “multi-millions” on testing and other interventions.It installed technology such as cold plasma air purification in all buildings. And working with a hospital infection preventionist, Hood also purchased extra PCR tests and screening panels that could better identify patients at risk of severe disease because of clotting issues or dehydration.

State priorities key

Hood said innovation was possible only because North Carolina prioritized nursing homes for federal matching funds. Principle also operates in Kentucky and Virginia, where nursing homes got considerably less financial help.

As the chain continues to vaccinate and offer monoclonal antibody treatments and Special Care Units, Hood is “cautiously optimistic.”

By press time, 92% of residents had accepted at least their first vaccination, and about 60% of full-time employees had done the same. In the first week of February, the entire chain had just 12 new positive patients — 85% from a small group that had not yet been vaccinated. At Special Care Units, the COVID-19 survival rate was 95% to 97% compared to 80.5% among U.S. Medicaid or Medicare beneficiaries.

Amid these successes, many nursing homes are struggling with access to supplies and cash flow in the face of unprecedented occupancy declines.

A proposed $35 billion Provider Relief Fund boost would fall short of the $100 billion AHCA wants. LeadingAge’s Katz added that COVID costs “will continue for the foreseeable future, as will reduced revenues.”

Hood wants permanent Medicaid funding increases that recognize today’s nursing homes are caring for some of the nation’s sickest patients.

“For me, the way forward has to be through funding and a commitment from the industry to deal with what’s upon us,” she said. “I don’t think we need a way back. We need a way forward.”

Most of the heavy lifting generally falls on the entity actually putting shots in the arms. As a corporate Walgreens spokesperson said, “Walgreens will be reporting all vaccines/doses administered to the CDC and state immunization registries.”

As the CDC notes, any entities that actually administer vaccines are required to document vaccine administration in their medical record systems within 24 hours and use their best efforts to report administration data to the relevant system for the jurisdiction as soon as practicable.

However, Walgreens added, it is “leaving documentation of vaccine recipients for the facility.”

2. Be fully aware of provider responsibilities.

Actually, nursing homes play a key role in documenting the COVID-19 vaccine rollout and are the only type of long-term care setting affected. They will be heavily scrutinized for getting it right. Two members of Congress in early January urged the federal government to regularly post fresh LTC vaccination data in the MDS, and on Nursing Home Compare.

Facilities are required to register residents online and complete consent forms, and for each person getting the vaccine, document  administration date, vaccine manufacturer and lot number, individual who administered the vaccine and address where the permanent record resides. Also required is a dated vaccine information statement and when it was tendered to a family member.

John Ederer, president of American Data, urged facilities to document and “track all services they provide related to COVID-19, even if those services are provided by a pharmacy or other provider,” including physician orders, side effects, allergic reactions and second dose dates.

Claire Stephens, senior vice president, Post-Acute, American HealthTech, echoed Ederer’s advice as a backup for potential liability concerns.

“As this is a new vaccine against a new virus, it is important to monitor each person receiving it and documenting any unexpected side effects,” said Debi Damas, RN, Prime Care Technology’s senior director of Customer Success-Applications. “This information will be very important to help develop guidance on who should or should not get the vaccine down the road.”

Facilities must also report the following data to the CDC’s National Healthcare Safety Network: counts of deceased residents and staff, newly suspected and lab-positive cases; staffing shortages; PPE availability; ventilator capacity; and supplies for ventilator units.

Providers using point-of-care  rapid response testing for staff and residents must also regularly report back data they generate. 

3. Voluntary reporting and documentation is a key aspect of the process.

Walgreens adds that facilities are encouraged, but not required, to report pharmacy-administered vaccines to NHSN, with Walgreens providing documentation.

Facilities also are encouraged to report adverse events through the CDC’s Vaccine Adverse Event Reporting System, and to have staff use the “V-safe” app to receive second-dose reminders, participate in surveys and text with CDC officials following vaccinations.

Genice Hornberger, senior product advisor at PointClickCare, reminds providers of the FDA requirement that vaccine recipients or their caregivers be provided with vaccine-specific Emergency Use Authorization information to help make informed decisions. In any case, she urged SNF leadership “to ensure the team is clear on all the pertinent regulations they must abide by, to avoid any compliance issues.”

4. The value of the electronic medical record must be appreciated.

IT companies remind facilities to exploit the ability to integrate all COVID-19-specific information into residents’ medical records.

A.J. Peterson, vice president and general manager of interoperability for Netsmart, encouraged facilities to use EMR reporting capabilities to schedule vaccination. “As COVID-19 vaccines are distributed, it is critical we avoid vaccine wastage and spoilage,” Peterson said. “This is where scheduling becomes key with second doses.”

Stephens urged providers to exploit their EMRs’ capability to record data such as side effects and vaccination dates in real time, rather than end of shift, to ensure accurate documentation. “This not only avoids mistakes but also produces more accurate data analytics for better outcomes,” she added.

Fast forward to the present, and Ed sat in his wheelchair in an Oregon long-term care facility, waiting eagerly for his second dose of COVID-19 vaccine. With his Pearl Harbor cap pulled down tight, he faced me and a row of local news cameras and reporters, recounting the harrowing experience that won him a medal for bravery.

“It was a harbor of hell, I’ll tell you,” he said. “That was the day I became a man.” 

So many decades after serving heroically in one of the deadliest conflicts the world has ever known, Ed has had to face yet another terrible ordeal — this time, a global pandemic.

The virus has already taken the life of one of his dear friends, and it has left him and countless other seniors vulnerable and isolated. So like everything else he’s done in his life, he stepped up bravely to do what was necessary and got vaccinated. 

“We meet again,” he told the nurse as she approached with the needle and gently jabbed it into his arm. “I didn’t feel a thing. I’m disappointed,” he said when she removed it. Then turning to the cameras, he added, “She does a good job. I think maybe she hypnotized me.”

Naturally, a reporter asked what he’d tell someone else about taking the vaccine.

“Get right in there and get it,” he said without hesitation. “I’ve had shots all my life, but there’s nothing to this one. I was surprised when she was done, because I didn’t think she’d started. It was a pleasure, really.”

In a life book-ended by two hellish, worldwide conflagrations, Ed is still pushing through with courage, grace, positivity and humor.

Not a bad lesson for the rest of us.