That’s been the case for Greystone Healthcare Management Corp., based in Tampa, FL, with a network of 27 facilities. It provides an array of services that include skilled nursing, assisted living and home health. In January, the company had to use about 5,000 nurse agency hours to meet patient needs. That ballooned to about 18,000 in April, said Chris Masterson, senior vice president of clinical innovation.

A robust economy means companies pay more than a certified nursing assistant’s typical starting wages, and schools are unable to churn out licensed practical and registered nurses fast enough to meet demand.

“We just can’t compete with the labor-intensive work that a CNA has to accomplish for $10 or $11 an hour, compared to Walmart or Amazon for $15 an hour,” Masterson said.

That’s led to Greystone collaborating with a team of doctoral students from the University of South Florida and Purdue, trying to come up with a better way than the typical one-size-fits-all approach to staffing, that has relied on past experience, government mandates and nurse-to-resident ratios.

Greystone shared one year’s worth of de-identified patient data — along with other info, such as “anecdotal” electronic health records, and past payroll reports — from one of its SNFs in Pinellas County, FL, which the students have used to a create a predictive model that forecasts upcoming service demands. It then helps managers determine the ideal mix of RNs, CNAs and LPNs to help meet the complicated demands of each nursing home resident.

“The nursing home is a complex system and we want to improve performance using engineering technology,” said Mingyang Li, Ph.D., an assistant professor at USF.

The team is currently testing a trial version of the model at the same SNF. Masterson and Li presented at the International Society for Gerontechnology World Conference in May, and have submitted a grant proposal to the National Science Foundation.

Dutch researchers compared the effects on staff burnout symptoms and job characteristics, including job autonomy, social support, physical demands and workload among 114 staff members in 28 homelike dementia care facilities (i.e. small-scale living facilities) against those of 191 workers in 21 regular SNF psychogeriatric wards.

They sent questionnaries to the nursing staff at the two types of long-term institutional nursing care settings.

The researchers found that, although nursing staff working in small-scale facilities were expected to experience fewer burnout symptoms and more social support, no overall effects were found on these subjects.

Findings showed staff members in homelike dementia settings experience more autonomy and significantly fewer symptoms of physical demands and workload when compared with staff in regular psychogeriatric wards.

It was released as a proposed rule on April 27 and is anticipated to go into effect Oct. 1, 2019. This is a revision to what we previously discussed as RCS-1, which was floated as a possibility to replace RUGS IV.

The Patient Driven Payment Model (PDPM) would break down payment based on case mix scores in five different areas: physical therapy, occupational therapy, speech language pathology, nursing, and non-therapy ancillary services. Each component of reimbursement will be calculated based on diagnoses, clinical factors and other criteria.

This shifts the focus from therapy minutes to making nursing payment dependent on a wide range of clinical characteristics. Non-therapy ancillary services would reflect high-cost services such as HIV/AIDS, parenteral/IV feedings, infections and other high-cost comorbidities.

CMS’s goal of a more simplified payment system will not be achieved with the PDPM. It will be important for each facility to understand the impact on its reimbursement. CMS expects this new system to improve payment accuracy as each component is based on a predicted resource utilization and introduces a variable per diem rate for PT, OT and non-therapy ancillaries.

Important items to consider are that ICD-10 coding will be critical to accurately reflect the resident’s condition and points will be dependent on diagnosis and therapies. Variable per diem means reduced payment as your resident’s length of stay increases.

Also, the number of required assessments will significantly decrease from the current PPS schedule to only a five-day PPS assessment, significant change in status and discharge assessment.

Please send your payment-related questions to Patricia Boyer at ltcnews@mcknights.com.

Investigators described the pilot study’s successes in the Annals of Long Term Care. A five-year-old law allows certified medication assistants — MA-Cs — to give skilled nursing residents their meds, as long as it’s under the supervision of a registered nurse.

Since previous research found no significant changes in medication error rates when medication techs were used, this program was designed to examine staffing costs after using medication assistants who had received specialized training through the Geriatric Interest Group of Spokane.

The program improved medication error rates, staff satisfaction, rehospitalization numbers, call light response times and fall rates — all without costing the test home significantly more in salaries, researchers said.

The model was first tested in a 50-bed long term care unit, using nursing assistants who had at least three years of experience, limited absences, emotional maturity and positive attitudes.

Also factoring into the success, observers believe, was the fact that trainees’ pay rose to $16 per hour, which is typically a midway point between the facility’s average rate for CNAs and LPNs.

Each CMA received 104 hours of training before being certified for medication administration.

Based on what it calls “encouraging” findings, the Geriatric Interest Group said it plans to test the pilot at three more nursing homes this year.

Overall, 31 items were added to the program, according to a June 1 notice from the Centers for Medicare & Medicaid Services.

A Government Accountability Office report released in May, which urged continuation and/or expansion of pre-approvals, preceded the CMS announcement.

States that were in the initial phase of the program were involved because they historically had high rates of improper payments and fraud. They were: California, Florida, Illinois, Michigan, New York, North Carolina and Texas. A dozen more were added later.

The GAO estimates the program, which was set to expire Aug. 31, has saved the government about $1.9 billion.

Now, however, CMS has declared that pre-approval requirements will go nationwide for all named devices on Sept. 1.

The national rollout will differ slightly. Items on the Required Prior Authorization List require prior authorization as a condition of payment. Without it, claims will be denied. Under the demo, requesting prior authorization had been optional, with claims submitted without prior authorization subject to prepayment review and a 25% reduction.

As you know, there are many benefits from maintaining tax-exempt 501 (c) 3 status. When the IRS receives an application for exemption, it grants a preliminary tax-exempt status, but it requires the organization to show that it has meet the projected budgets and donations filed with its application. Subsequent filings with the IRS after several years of operations allows the agency to grant a permanent exemption.

An exempt organization can lose exemption by modifying the governance documents, or removing or modifying the charitable public benefit purpose. The exempt organization may run into trouble if it acts contrary to the governance documents. For example, the New York attorney general has taken the Trump foundations to court to challenge their exemptions because the foundations may have used their funds to pay the business expenses of the Trump for-profit business enterprises.

The IRS can challenge exempt status if executives of the organization receive compensation in excess of fair market value. Also, exempt organizations are prohibited from participating in elections. They cannot endorse or fund candidates running for public office.

Exempt organizations must file Form 990 every year. If an exempt organization’s tax-exempt status is ever challenged by the IRS or state attorney general, the organization should retain legal counsel who specializes in exemption laws. Attacks seeking total loss of exemption are unusual but can happen if the rules granting the exemptions are not followed.

Please send your legal questions to John Durso at ltcnews@mcknights.com.

News of the successful appeal came just days after an update of the Centers for Medicare & Medicaid Services’ Nursing Home Compare website ranked the Watermark’s $1,019,766 fine as the sixth-largest levied against a nursing home nationally in the last three years.

Federal regulators originally slapped the $1 million fine on the 109-bed rehabilitation and skilled nursing facility for a September 2016 incident in which an 87-year-old patient slipped out through a fire escape. He was found lying injured in the street about a half mile away from the facility and then hospitalized.

A state health inspection in February of this year found no evidence that “additional interventions were implemented or that the care plan was updated” after the incident, according to a review by the Philadelphia Inquirer.

But the administrative law judge ruled that Watermark was out of compliance for just three days, trimming the penalty to $8,791 per day, for a total of $26,373.

In a similar case in April, the state Health Department reduced the fine imposed on Charles Morris Nursing and Rehabilitation Center in Pittsburgh by about $220,000 in connection with the September death of 89-year-old patient Robert Frankel.

Frankel died after his head became caught between a side rail and the bed’s mattress, according to the health department’s report, which concluded that improper use of bed rails contributed to his death. The nursing home turned down all the rails in the facility within an hour of the event and has since removed all bed rails. Through the appeals process, the penalty was reduced from $235,000 to $15,250. The Charles Morris administrator said Frankel’s death was a “tragic accident,” leading to removal of all bed rails “out of an abundance of caution.”

After a two-week trial, a Lancaster County jury declared Maple Farm Nursing Center in Akron, PA, and its parent company 85% liable for the 2013 sexual assault.

The jury also found that the facility, owned by Garden Spot Village, had shown reckless indifference in failing to prevent the assault by a resident with a known history of sexual violence, according to the law website The Legal Intelligencer.

The law website reported that the case broke new ground with a Superior Court decision that the Older Adults Protective Services Act does not prevent individuals who report elder abuse from testifying in subsequent civil litigation. A three-judge panel rejected the nursing home’s argument that its employee’s testimony was privileged under the act.

The plaintiffs, two members of the victim’s family, were allowed to depose the nursing home employee who reported the abuse to the Lancaster County Office of Aging.

A plaintiff’s memo contended that accused resident, Glenn Hershey, who had cerebral palsy, targeted the 82-year-old victim because of her dementia. Maple Farm knew Hershey was a registered sex offender who had pled guilty to felony indecent assault, serving seven years in prison. In its own filing the provider said it had screened Hershey before admitting him, according to court documents.

Rather than appeal the jury’s decision, Garden Spot Village agreed to settle the case for $6.5 million “in conjunction with its insurer,” according to Garden Spot spokesman Scott Miller.

Hershey, 71, was convicted in 2014 for sexually assaulting the victim and sentenced to eight to 20 years in prison. His victim has since died.

Opened in early 2017, the 65,000-square-foot Chesapeake campus boasts 120 beds and features the “household” design model with 20 residents in each section. The new center replaces a 46-year-old facility that planners concede was long overdue for modernization.

“A lot of research went into this project — we visited other models out there to determine how to proceed,” says Carole Guinane, interim president and vice president of orthopedics for Sentara Healthcare. “What attracted Sentara to the household format is that it is more like a home for residents, provides a lot of space and facilitates the healing process.”

Centerpieces of the new community include the 40-bed Great Bridge Pavilion for short-stay rehabilitation patients, and the Sentara Back & Neck Center of Excellence, which opened April 12.

The $18 million project took about six years to complete, with conceptual discussions starting in 2011 to replace the nearly half-century-old nursing facility. Two buildings were demolished in the process — the original nursing center came down after residents were relocated to the new Rehabilitation & Care Center, and residents of the Assisted Living Village went to the other Sentara (and non-Sentara) senior living sites before it was razed.

Project manager Melissa Pritchard of Roanoke, VA-based SFCS oversaw the process and says it represents a strong commitment from Sentara to modernize its property portfolio.

“The old building was institutional and clinical,” she says. “Sentara wants to provide a better quality of life for residents and doing that meant moving away from the large-scale institutional environment. By adopting the household model, they have chosen a decentralized approach to care, dining, activities and living spaces.”

Four different types of environments comprise the property, designed to offer care to people from different socioeconomic backgrounds — from private pay to Medicaid. Two households have 20 residents each — one for skilled nursing, the other for memory care. Two 40-bed neighborhoods are subdivided into 20 residents each for short-stay rehab and traditional long-term care.

To obscure overt clinical facets of care, in-room medication storage and linen carts have been moved out of hallways. Other innovations include a “transitional suite,” where rehab patients practice activities of daily living before discharge, and a secure “Garden Spring House” for residents with dementia has specialized safety features. There’s also lavender-laced aromatherapy, an absence of alarms, an enclosed courtyard and a clinic with telemedicine capabilities.

Lessons learned

1. Housing stock that is nearly a half-century old is irrelevant in today’s competitive long-term care environment and needs to be modernized in order to attract new residents.

2. Dedicating space to specialty services, such as a back and neck center, can attract more hospital referrals.

3. Baby boomers are the key demographic for short-stay rehab, and community design should appeal to their tastes.

The most serious and costly staff injuries typically entail repetitive motions, heavy lifting or exposure to aggressive resident behaviors, making nursing assistants the biggest target, says Betsy Hardy, vice president of business development for the American Association of Directors of Nursing Services.

The rate of injury among nursing assistants is similar to the rate among construction workers, police and firefighters, according to 2016 data from the U.S. Bureau of Labor Statistics. Two years ago, skilled nursing facilities became required to submit their workplace injury and illness data to OSHA.

Other positions high on the list for possible injury include dietary aides, housekeeping and laundry workers, says Trey Mullins, senior director, post-acute operations for HealthcareSource.

Peter Corless, executive vice president for OnShift, believes “injuries most often occur when employees ignore policies that require two-person transfers, the use of gait belts or the use of a mechanical lift because they are rushed, short-staffed or simply think that they are strong enough to move a resident on their own.”

2 Attractive safety programs are a major staff retention tool.

Some managers may be surprised to learn that, among all of the other perks that seem to bolster loyalty, showing employees attention and caring go a long way toward creating worker trust.

Gary Johnson, leadership development consultant for Monarch Risk Management, cites a recent Gallup Employee Engagement Survey that found “the leading reason employees call off, show up late, steal, quit or get injured is because they don’t feel their supervisor listens to them or even cares about them.”

Efforts such as safe resident handling programs and equipment training clearly signal that the facility genuinely cares about their workers’ safety, adds Mullins.

The more regular such efforts are, the better. Mary Madison, RN, a clinical consultant in long-term and senior care for Briggs Healthcare, supports frequent and repeated training on proper body mechanics and how to use assistive devices such as lifts.

Corless strongly urges facilities to adopt “no lift” policies and even market them as part of their staff recruitment program.

3 Establish and maintain a culture of safety.

“Education, accountability, equipment, always doing what’s right even when no one is looking” are the key components, says Teresa Remy, DSc, LNHA, BSN, RN, director of consulting for LeaderStat.

A safety culture is high on the list of any worker advocate.

Based on conducting thousands of department safety audits for hospitals, nursing homes and CCRCs and interviewing many thousands of employees who were injured at these healthcare organizations, Joe Caracci, founder of Monarch Risk Management, is one of those advocates.

“I believe the root cause of the majority of preventable injuries in healthcare is the relationship between frontline supervisors and their staff,” he says.

Successful safety cultures are DNA-level ingredients in the best facilities and rooted at the highest level, says Robert Phelan, president and CEO of TriPoint.

4 Reinforce the concept of personal responsibility.

If the lift and the training to operate it are provided and a worker ignores both, that’s a major problem.

“Start with a culture of safety on Day One of hire,” Madison says. “Counsel the employee and add that counseling session to their personnel file and follow up at a reasonable point to see if the improper behavior has been corrected. If it has not, reinforce again with consequences. If it happens again, terminate the employee. Facilities cannot risk allowing individuals to work in unsafe manners in their buildings.”

5 Positive reinforcements can go far in ensuring staff buy-in.

Remy and Madison offer a few ideas to keep employee enthusiasm and momentum headed in the right direction. They include a pizza or dessert party to mark injury-free periods; reminder notes about fundamental safety practices in paychecks; annual or quarterly “skill fairs” to brush up on safety;  or even modest rewards to employees “caught” performing a task in an exemplary manner.
Most important: Make staff feel they are an integral part of the facility’s safety efforts, says Hardy. “Let them be part of the solutions,” she says. “Most of the time I was amazed at the answers I got when I asked the staff for the solution to a safety problem.”
Make it a “personal” issue with everyone, as Corless says.

“Ask your staff, ‘What impact would it have on your family if you were injured?’” he says. “That can have a big impact on getting the message to resonate.”

Mistakes to avoid

Investing in basic safety equipment without proper training. All the high-tech equipment in the world is useless if staff don’t know how to use it.

Creating a safety culture sounds like a lot of work, but a facility that makes safety ubiquitous will experience fewer injuries.

Ignoring personal responsibility. Staff must be constantly reminded of the role they play in ensuring a safe workplace.