Like a beloved mother or revered school principal, operators and staff are being counted on to make things right and keep things sailing smoothly. 

Some might consider this being taken for granted. But sometimes there’s a fine line between feeling used and being appreciated to extreme. Even after squinting really hard, you can confuse yourself trying to figure out which it is sometimes.

As a glass-half-full guy, I’m here to tell you that by leaning on you so heavily, your dependents are looking to you with trust and respect. After all, they don’t unload the hardest tasks to the weakest workers or least trustworthy leaders.

And there’s no question there are going to be some enormously hard tasks ahead in the year ahead.

The proposed minimum staffing mandate won’t come to pass in 2024, but by all accounts, the intense pressure to get, and keep, more staff will continue. Your very census-dependent life may be riding on it.

Then there’s the fact that the Centers for Medicare & Medicaid Services has already announced its intention to ratchet up scrutiny of infection control practices. And woe be to the provider who gets sloppy about its administration of antipsychotic or schizophrenia drugs, among others in the medicine cabinet.

Already underway is the Sisyphean quest by regulators to force more information about nursing home owners into the disinfectant called sunshine. You do know that eventually they’re going to get it right and close the majority of loopholes so the overly opportunistic scoundrels among you are put off, don’t you? The sooner that day comes, the better.

And that’s a position held not only by yours truly but also by most of the top provider leaders in the country, though they may be unable to too openly admit it, due to political, financial or other value-torquing reasons.

The earnest and sincere among the provider world can use all the help they can get building the sector’s reputation. Let them get on with the righteous work they’ve signed up for unencumbered, I say.

And that gets us back to expectations. They will, of course, be high in 2024. There should be no other way.

As I was informed my first day on this job long ago, long-term care is a needs-based field. With 10,000 people currently turning 65 every day, those care needs are only going to skyrocket.

Guess whom those multitudes of needy people are going to be looking to. 

James M. Berklan is McKnight’s Executive Editor.

Opinions expressed in McKnight’s Long-Term Care News columns are not necessarily those of McKnight’s.

I’ve written on topics ranging far and wide across the long-term care spectrum. But I’m pretty sure this will be my first foray into the world of fake butt accusations.

A suit filed earlier this month in New York alleges a nurse aide named Milouse Laguerre was subjected to workplace-related sexual harassment.

The catalyst? Other CNAs who insisted her gluteus maximus exceeded the maximus limit. There was simply no way its dimensions were within the boundaries of what her Mama could have given her, her co-workers allegedly claimed.

Not only did they judge that her backside’s dimensions were beyond what nature intended, they demanded for months that she provide the name of the physician behind such robust proportions. When Laguerre rejected both the allegations and the request, they allegedly proceeded to make her life a living hell.

So, is this really a story of buttocks envy gone bad? It could be that, too. But after reading the court documents, I’m not sure we’ve gotten to the bottom of this story.

You see, it appears that some of her colleagues were unhappy with Laguerre, who happens to be Haitian, being offered full-time employment in the facility three years ago. They allegedly claimed Haitians are “ugly.” They also insisted that Haitians, in the vernacular of Sir Mix-A-Lot, don’t have “back.”

While the facility’s CNAs were supposed to work as a team, her requests for assistance were largely ignored.

Moreover, when she repeatedly asked management for relief, her requests went nowhere. In fact, she was suspended, then fired, according to her attorney.

For other providers, there are two lessons to glean from this unusual case.  

The first is that turning a blind eye to harmful statements and toxic interactions among employees is a risky strategy that may lead to legal consequences. 

The second is that when employee conflicts persist, human resources must play a proactive role in addressing and resolving disputes, preventing them from festering into more significant issues.

This is an alleged situation that never should have been tolerated by those in charge, much less allowed to worsen.

And now the lawyers are involved. By the time this matter is resolved,  there’s a very good chance the facility will find itself paying out the, well, you know.

John O’Connor is editorial director for McKnight’s. Read more of his columns here.

Cats have one big plus over dogs, however: I’m told that if you want to, you can leave them on their own for a few days and they won’t starve.

Then again there is at least one really big negative: Cats have given curiosity a bad name. It supposedly killing the cat and all.

I’m a big fan of exercising one’s curiosity muscle, and I’m not the only one. The downfalls of not expressing enough curiosity can be found in many places online, as your next search session will easily reveal. As far as I’m concerned, though, you have to look no further than the delicious pub scene when TV’s cagey Ted Lasso reveals what can happen when one doesn’t ask enough questions.

Make no mistake: We all need to develop our curiosity trait more — and in both our personal and work lives. As one mentor of mine once said, he’s looking for ongoing intellectual curiosity in job candidates. That’s a no-brainer in journalism. It also fits well in long-term care.

Make the mistake of being judgmental instead of curious about that irritating/puzzling/withdrawn patient in the corner, and you might miss a great opportunity to improve someone’s day. Or avert a pending health tragedy.

Gloss over your misgivings about a certain drug combination during med pass and brace yourself for the potentially harmful fallout from a bad interaction.

Neglect to ask your staff members (or your own boss) about expanding their (or your) job responsibilities and miss out on golden opportunities to groom stronger leaders. They are needed virtually everywhere in the halls where you work.

Feed your own soul by exercising a variation on JFK’s “Ask not what your country can do for you; ask what you can do for your country.” Grow your sense of self-worth when you apply this line of questioning for serving your own local community, place of worship, food pantry or other laudable volunteer organization.

Quite coincidentally, while on the convention circuit this fall, I came across an outstanding example of the virtue of curiosity in a long-term care entity. I might not have fully grasped it until I got home. That’s when I started thumbing through the notebook I picked up at a Brio Living Services booth. 

As it turns out, the multifaceted provider rebranded with a new name last year. Brio means “life, vivacity, enthusiastic vigor — the very aspects of joyful living we aim to provide for older adults and our team members.”

The notebook and its slogan have to be at the core of this great, new image.

“The future belongs to the curious” is splashed on the notebook cover, which depicts a telescope aimed at a sky painted full of glistening and shooting stars. Inside, each blank writing page features a provocative, personal-reflection question at the top — and the provocative cover message again at the bottom.

That saying sums up things in a beautiful, constructive way. Forget about the fate of an inquisitive cat: When curiosity’s involved, expect the death only of off-target judgments, inner doubts and unanswered wonderings. A winning outcome anyway you slice it.

James M. Berklan is McKnight’s Executive Editor.Opinions expressed in McKnight’s Long-Term Care News columns are not necessarily those of McKnight’s.

But the holidays are here, and that means it’s time for the second-best advertising season of the year. Yes, I know it’s all consumerism designed to make me spend my hard-earned money, but I can’t help it when the sappy music and the family gatherings come together in perfect time.

For my money, Amazon has won the winter advertising blitz two years running by focusing on products that bring joy to seniors — and pulling all the elements together to sucker us younger folks into the feelings fest too.

Many of you will remember last year’s Alexa spot, which featured an elderly couple swaying to the Flamingos’ 1958 version of “I Only Have Eyes for You.” When the music stops and the woman begins to look lost, the husband tells Alexa to play their favorite song again. And just like that, the confusion lifts and she’s remembering a dance from decades ago. 

That look of recognition is one anyone will notice if they’ve had a loved one (or a patient) with dementia. While voice command technology can’t possibly erase memory loss, music has been shown to help sustain connections. Those moments of clarity are worth more than any physical gift Santa might bring on Christmas Eve.

Yep, that one got me everytime.

So I was grateful when Amazon put out a little more uplifting holiday commercial this winter. No, we can’t buy happiness, but as Amazon would have us believe in this ad, you can surely order up a little fun online!

The ad opens on three bored-looking older women, the snow-covered scene behind them dreary and depressing as we hear the opening strains of the Beatles “In My Life.” The ladies are wistfully watching children sledding on a nearby hill, when one decides she’s had enough.

The next thing you know, she’s used the Amazon app to order three orthopedic cushions that they use to make some cheap plastic sleds a little more comfortable. The sun comes out as the helmeted women take to the hill themselves, rushing downward with full-faced smiles as children stare in awe.

There’s a memory sequence here, too, and it’s fitting given that the holidays are all about creating new memories with the ones we love.

If you really want a good cry, though, I suggest you find a quiet room and carve out five minutes to watch a new Chevrolet spot produced in coordination with the Alzheimer’s Association. This may be one of the most emotionally powerful ads of all time, though with its length, it’s not an ad you’ll see on TV often.

Steve Majoros, Chevrolet’s head of marketing, developed the messaging and committed his company’s winter ad spend to the long-format holiday piece. (Chevy is skipping the markedly less emotional Super Bowl extravaganza in 2024.)

The result is a beautiful piece of storytelling in which a quiet grandmother seems to not notice her family arriving for the holiday dinner, even when the youngest kids throw gifts in her lap.

That changes when an unlikely hero, a grumpy looking teenager with a pixie cut, grabs the keys to her grandparents’ vintage Suburban and literally drives down memory lane with grandma. 

“We talked a lot about reminiscence therapy — not that it’s a cure or a solve, but the power of music, the power of memories are things that can enable the person going through it to feel more comfortable,” Majoros was quoted as saying in a USA Today review, “and the people that are the caregivers that are surrounding them, to also feel more comfortable.”

Some folks might not appreciate the ads, thinking they’re exploiting aging and dementia for commercial gain. But for many of us, the holidays may be the one time of year we see some of our older relatives. It’s important to remember what they might be going through, and why it’s worth the extra effort to stay connected in any way we can, for any moments that we can.

For that, I’m willing to keep the tissue box handy this commercial season.

Kimberly Marselas is senior editor of McKnight’s Long-Term Care News.

Opinions expressed in McKnight’s Long-Term Care News columns are not necessarily those of McKnight’s.

I’ll say this for Congress: Its members sure know a thing or two about aesthetics.

Let’s say you’re a lawmaker and believe nursing homes need a closer look under the hood. Why not make that proclamation at a union rally where you will be cheered like a conquering hero, as Rep. Jan Schakowsky (D-IL) recently demonstrated. 

Yep, find a friendly crowd and a good backdrop, and you’ve got the ideal mix for a Kodak moment. One that will surely look good on your next campaign video.

Of course, if such theatrics are not convenient, a damning speech recorded after hours to an empty chamber can be an effective alternative. 

I suppose such tactics are harmless enough. But let’s face it. In the long run, the grandstanding isn’t going to amount to much more than what the old folks call a hill of beans. That’s because those carefully chosen words are doing little to change the status quo.

But don’t take my word for it. The scorekeepers reveal that more than 95% of all proposed bills are never voted into law. 

To truly understand where Congress wields its power, heed the advice of Washington Post Executive Editor Ben Bradley during the Watergate era: “Follow the money.” More precisely, follow the money Congress approves.

But don’t stop there. Also follow where it doesn’t go. I was reminded of this latter addendum while reading colleague Kim Marselas’ excellent story Friday on new Centers for Medicare & Medicaid Services plans to streamline its survey activities.

Now the official reason for streamlined surveys is that inspections will become more efficient. I suppose that is true enough, as far as it goes.

But the announcement does beg a deeper question. Namely, what else is going on here? In a nutshell, Congress has been squeezing and continues to squeeze funding to CMS. And as a result, federal regulators are being forced to cut back on their activities, such as inspecting skilled care facilities.

I can’t imagine many skilled nursing operators are crying in their Cheerios over this particular development. Fewer, less intense surveys? Oh, that really is too bad, isn’t it?

But this episode does highlight how Congress serves as a significant agent of change. When lawmakers turn a funding spigot on or off, they really are making quite a statement.

Even if it’s one that’s unlikely to be captured in a photo op.

John O’Connor is editorial director for McKnight’s Senior Living and its sister media brands, McKnight’s Long-Term Care News, which focuses on skilled nursing, and McKnight’s Home Care. Read more of his columns here.

The Centers for Medicare & Medicaid Services is no different, and officials there have delivered an early gift to help providers like you map out where they should focus their compliance efforts — not just for 2024, but for 2025 as well.

In an otherwise very dry memo to state survey agencies Nov. 20, CMS prodded inspectors to focus on three core areas over the next two years. Federal surveyors will follow-up in those same areas to check that on-site surveys hit all the required investigative steps.

Not surprisingly, nurse staffing led that list. This will be central to the agency’s nursing home regulatory push, especially if it can somehow get a first-ever staffing mandate into final form and enact it in the next year or so.

CMS over the last two years has increased how much staffing information it collects and incorporated more of that data into its Five-Star ratings. Under Payroll Based Journal reporting will become even more critical, with the latest quarter of data determining whether facilities are meeting proposed per patient day hourly minimums for registered nurses and certified nurse aides.

That means, more than ever, that providers must capture fully and accurately their staffing levels and understand what might be excluded, and what won’t be.

CMS itself also is under more pressure to ensure staffing data remains a viable measure of actual hours worked. The Health and Human Services Office of Inspector General last month announced that it was adding a broad audit of PBJ nursing home data to its 2024 work plan.

And before that, we should get a look at how well CMS has used early PBJ data in having surveyors review whether nursing homes met the existing requirement for “sufficient” staffing. OIG said last January its aim was to push CMS to improve the enforcement of federal nursing home staffing standards by state surveyors. 

So it makes sense that CMS would want to shore up its data collection and reporting processes, and to make sure its inspectors know how to use what they find for compliance purposes. That know-how will lay the groundwork for measuring staffing success and giving providers the information they need for a waiver if their efforts are unsuccessful.

And for providers who fail to submit PBJ correctly or incompletely, let’s not forget that you won’t even be eligible to seek a staffing mandate waiver.

The other two focus areas shouldn’t necessarily come as surprises either.

Nearly a year after launching off-site audits of schizophrenia diagnoses, the agency wants its surveyors to follow up by poring over psychotropic medication uses that might be unnecessary.

CMS views antipsychotics as drugs of last resort. Emphasizing that state surveyors must pay close enough attention to their use is just a new way to keep pounding that message home.

Antipsychotic drug use and concerns about rampant schizophrenia diagnoses among elderly nursing home residents were two major areas hit on by CMS Director of Nursing Homes Evan Shulman on the conference circuit this fall.

So, too, was the idea that providers are too often invoking involuntary, facility-initiated discharges, particularly for patients with behavioral health or substance use disorders.

And that will be the third area of focus for federal survey follow-ups in 2024 and 2025.

Shulman himself has acknowledged just how tricky meeting the spirit of discharge regulations can be.

“[Discharges] are very, very complex, in that a discharge could happen and the resident may not agree with it, and that could be non-compliance,” Shulman explained. “But — and this is very important — a discharge could happen and a resident may not agree with it and it still could be a compliant discharge. It really just matters: Did the facility follow the regulatory structure?”

This is why it’s helpful to know what’s coming. The roadmap gives time to reexamine policies and procedures, reach out for more resources and get survey-ready — even for the most complicated issues. 

Don’t let the rest of the year dwindle away while you make resolutions for 2024. That fresh start? It can happen as early as tomorrow.

Kimberly Marselas is senior editor of McKnight’s Long-Term Care News.

Opinions expressed in McKnight’s Long-Term Care News columns are not necessarily those of McKnight’s.

Admittedly, some of the strategies and tactics being served up were quite detailed, and unless one diligently jotted down notes, most may have faded from memory by now.

That’s one reason why I am a big fan of pithy business advice. Brief quotes from those in the know have a way of quickly getting to what the receiver really needs to focus on. They also tend to stick in our heads.

In that spirit, here’s a sampling of some of my favorite business quotes.

• “Your work is going to fill a large part of your life, and the only way to be truly satisfied is to do what you believe is great work. And the only way to do great work is to love what you do.” – Steve Jobs
• “Success is not final, failure is not fatal: It is the courage to continue that counts.” – Winston Churchill
• “Your most unhappy customers are your greatest source of learning.” – Bill Gates
• “The function of leadership is to produce more leaders, not more followers.” – Ralph Nader
• “The only limit to our realization of tomorrow will be our doubts of today.” – Franklin D. Roosevelt
• “The way to get started is to quit talking and begin doing.” – Walt Disney
• “In the business world, the rearview mirror is always clearer than the windshield.” – Warren Buffett
• “The secret of change is to focus all of your energy not on fighting the old, but on building the new.” – Socrates
• “Opportunities don’t happen. You create them.” – Chris Grosser
• “The only limit to our impact is our imagination and commitment.” – Tony Robbins
• “The greatest glory in living lies not in never falling, but in rising every time we fall.” – Nelson Mandela
• “Don’t be afraid to give up the good to go for the great.” – John D. Rockefeller
• “The only thing standing between you and your goal is the story you keep telling yourself as to why you can’t achieve it.” – Jordan Belfort
• “The best way to predict your future is to create it.” – Peter Drucker

I hope you find these quotes useful. But more importantly, I hope you can find ways to incorporate this distilled wisdom into all you do.

John O’Connor is editorial director for McKnight’s.

Opinions expressed in McKnight’s Long-Term Care News columns are not necessarily those of McKnight’s.

But I also like to tell the truth. So there will be no pronouncements of grievous Medicare Advantage practices, and the leaders behind them, being yanked into line. 

It seems the weather isn’t the only thing people protest with inaction.

These past weeks have seen perhaps an unequaled amount of criticism leveled at these private Medicare Advantage insurance plans that are neither Medicare nor an advantage for so many. Long-term care operators have aired their displeasure for far longer than a few weeks. Perhaps more importantly, more and more hospitals are also starting to crab — and even fight back. These still rare instances are a scenario that LTC providers can only dream about. 

The din only has intensified when you add in national news reports about MA plans’ soulless use of algorithms to guide care decisions.

Maybe the rise in accusations being tossed by all sides coincides with increasingly bold MA marketing programs. Anyone who takes full-page ads in newspapers nowadays has to have something up their sleeves, don’t they?

The come-ons for added fluffy perks have almost gotten silly. They are now well beyond the original added vision and dental coverage. “We have a plan that’s perfect for you!” gushes at least one plan’s sales pitch. 

It’s almost taken on the air of adults waving candy at kids.

“But it’s giving consumers what they want!” is the justification that the enticers have offered.

This, of course, leads to even bolder “No soup for you!” door slamming on providers — and, somewhat ironically, beneficiaries. While patients might ease through the front door for coverage at their local SNF or rehab center, they’re also just as liable to get hustled early out the back.

It’s not an entirely new phenomenon, as long-term care sage Brendan Williams, the leader of the New Hampshire Health Care Association, pointed out to us earlier this week. 

“They’re getting away with banditry. They revel in it,” Williams quotes then Sen. Jay Rockefeller (D-WV) as saying back in 2009. (For another interesting, blood pressure-raising, take on how bad it’s become, check out the Zimmet Medicare Advantage Debt Clock.)

It’s almost as if we’ve all been watching bad weather bearing down from the horizon and we haven’t done anything about it. If we aren’t wet yet, we soon will be, and we’ll be getting more drenched by MA plans acting with apparent impunity with every tick.

One of the most galling things I’ve read about MA plans lately is our story about how some MA plans confide they are simply going to ignore or tap-dance around new federal rules that become live Jan. 1.

As Williams put it: The only thing that has changed since 2009 with MA plans is that taxpayers are not only getting fleeced, they’re willingly handing over the loot.

That’s right: Uncle Sam has found somebody to change the baby’s diaper. On top of that, he’s paying that baby-sitter upfront before heading to the movies, washing his hands of any mess that may come.

It’s in this way that the system has built an unsavory dependency on the hired help. 

The babysitter’s payout is more each time out, even if the baby isn’t getting cleaned up as well. But at least the kid will be given a sucker to stick in his mouth, and that counts for something, right? 

And the sitter will laugh all the way home. Only to be invited to do it again and again.

James M. Berklan is McKnight’s Executive Editor.

Opinions expressed in McKnight’s Long-Term Care News columns are not necessarily those of McKnight’s.

But the news last week that new unemployment filings climbed to their highest level in three months could be very good news indeed for the skilled nursing sector.

A downturn in hiring in other sectors has often been viewed as a way to fuel nursing home and other healthcare recruitment, and if there’s ever a time it’s been needed, this is it. Facing a federal staffing mandate that seems to give only a cursory nod to the challenging job market, providers need relief like a big, fat turkey needs a pardon this week.

That’s exactly why a morning news show piece on retail sales for Black Friday caught my attention, too. Retailers, it appears, are stepping back on their seasonal hiring, meaning even more folks might be looking for alternative work options.

Last year, a group of about a dozen major retailers hired nearly 600,000 workers for the season; this year that’s down to a projected 553,000, according to tracking data cited by Retail Dive. 

This is all because some employers are predicting fewer sales this holiday season. On top of that, inflation has fallen back to a more reasonable rate, which analysts at Challenger, Gray & Christmas say means companies have less ability to pass on extra staffing costs through higher product prices. The trend at the dozen companies named likely stops there, as others face a similar hesitance to overspend on additional workers.

Yes, lower hiring in general is good for long-term care, but fewer retail jobs whose hourly pay has outpaced some entry-level nursing home positions lately? Well, that would be even better news.

Would it be too much to call it an early holiday gift? Not if those would-be workers came knocking at your doors or websites instead of heading to your non-healthcare competitors’ winter wonderlands.

Several strong economic factors are lining up at the right time, at least temporarily, for skilled nursing and other aging services providers. Hiring could get a boost, at a time when inflation is cooling. Together, that could unwind some of the incessant, upward pressure on wages.

Add in the fact that the slowing labor market might convince federal banking officials not to make another rate hike, and that could mean providers will see their cost of borrowing start to moderate, and potentially fall in the New Year.

It’s OK for nursing home operators to hope they finally get their slice of the pie this fall.

Just be ready to respond quickly to job candidates when they do show up or inquire online so that you find yourself in a better staffing position heading into 2024.

That’s a far better strategy than relying on a lucky wishbone to get you through.

Kimberly Marselas is senior editor of McKnight’s Long-Term Care News.

Opinions expressed in McKnight’s Long-Term Care News columns are not necessarily those of McKnight’s.

It’s easy to take what we have here for granted. But the fact remains, this is a land of unmatched freedom and opportunity. Not that it’s always crimson and clover.

For example, consider what skilled care providers are up against. They are steering their facilities through some pretty turbulent waters these days. Many might be inclined to conclude that all things considered, there’s not much to be thankful for at the moment.

Starting with staffing shortages. Yes, it can feel like searching for a needle in a haystack when it comes to finding compassionate employees. Still, isn’t it wonderful that you have the rare chance to create a workplace culture that attracts people who want to make a difference? That opportunity to help build a team that cares as much about the residents as you do seems like something to be pretty grateful for.

Nor do inadequate payment rates and more regulations make the job easier. In recent weeks alone, we’ve seen proposals emerge that would put staffing requirements and new financial disclosure requirements in place. But here’s the thing: Your commitment to providing quality care despite such challenges speaks volumes about your character. You have chosen to persevere in the face of constant adversity. That you have been able to find and demonstrate that ability is indeed something to be grateful for.

And don’t forget, not everyone is given the chance to make a difference. You get to be a real hero — ensuring that the oldest and frailest among us receive the care and attention they deserve. It’s a tough gig on the best days. But the smiles you help bring to the faces of your residents in their time of need are truly priceless.

So, as you prepare to carve the Thanksgiving turkey, remember to carve out a moment for gratitude. Despite the challenges, your role is indispensable. And your commitment is changing lives. Here’s to you, and here’s to the immeasurable impact you make.

Happy Thanksgiving!

John O’Connor is editorial director for McKnight’s.

Opinions expressed in McKnight’s Long-Term Care News columns are not necessarily those of McKnight’s.