These measures are aimed at addressing one facet of the ongoing nursing home staffing crisis in the US, as administrators face similar burnout and shortages that care workers are experiencing.

By the midpoint of 2023, Wisconsin’s Department of Safety and Professional Services had already issued more licenses to nursing home administrators than in recent full years, according to DSPS Secretary-designee Dan Hereth. That coincided with a 44% year-over-year increase in new licenses for all healthcare professionals issued by the department. 

To achieve these results, the department focused on streamlining its licensing workflow and added both new avenues and clarity to existing paths for those seeking licenses. 

“We’ve been able to improve our processes and invest in technology to speed up our department’s role in licensing,” a representative from DSPS told McKnight’s Long-Term Care News. “We’re licensing more professionals more quickly than ever, and we’re hopeful to keep those numbers up in 2024.”

To that end, the department also is working to clarify which classes and programs help candidates meet the requirements for licensure. It is partnering with the University of Minnesota to have some of its classes pre-approved for the licensing process. 

Welcome changes

The new policies will help nursing homes address an increasingly worrisome turnover rate of nursing home administrators, according to Rene Eastman, vice president of financial and regulatory services at LeadingAge Wisconsin.

“LeadingAge Wisconsin members are extremely grateful that the state DSPS has made new paths to licensure available,” Eastman told McKnight’s. “Our state experienced 148 nursing home administrator turnovers in the first five months of 2023, and that’s in a state with only 336 licensed facilities — so we were on pace to a bad place.”

The new policies should be a significant help for people working in long-term care as they seek to advance through the profession and further their career goals, Eastman said. 

Making such new paths available will become increasingly vital across the country, as will ensuring reciprocity between states, according to Doug Olson, president and CEO of Vision Centre. 

“One of the things that the Vision Centre is interested in is making the career pathway more seamless and transparent so people can understand how they can move into that next level of practice,” Olson told McKnight’s. 

He emphasized that states across the country should focus on increasing the reciprocity of their licensure policies, including recognizing the qualifications of health services executives certified by the National Association of Long Term Care Administrator Boards. Without such measures, long-term care could be staring down a serious administrator shortage by the end of the decade, he added.

Measures to increase clarity, transparency and inter-state reciprocity for licensing nursing home administrators will be vital to removing the existing barriers to the profession, Olson said.

Without the extension, which was granted by the Centers for Medicare & Medicaid Services in late July, the license for the 38-bed, nonprofit Island Nursing Home in Deer Isle would have lost all value if not sold before its October 2022 expiration, according to published reports. The facility has now managed to retain its “temporarily closed” nursing home status and its license until October 2023.

The nursing home closed in 2021 due to a lack of nurses and has been working feverishly since then to replace workers and reopen. The facility used social media to announce it would close at the end of October after 40 years in business, as McKnight’s Long-Term Care News reported. The facility has blamed its inability to attract workers on its “remote location, Maine winters, and the lack of affordable housing near our facility.”

Dan Cashman, a facility spokesman, said a years-long nurse staff shortage in Maine was exacerbated at Island Nursing Home by a 2021 COVID outbreak in the facility in 2021. Then 23 workers resigned when a vaccine mandate was announced, leaving the facility with just two clinical staff. 

But the problems run deeper than COVID.

Maine estimates that healthcare facilities will be short 2,700 nurses over the next two and a half years, Cashman told McKnight’s. Two other state nursing homes — Country Manor Nursing Home in Coopers Mills, with 30 beds, and the 21-bed Somerset Rehabilitation and Living Center in Bingham — announced closure plans around the same time as Island. Meanwhile, Maine Veterans Homes in Machias and Caribou received additional state appropriations and play to remain open indefinitely, according to a spokeswoman.

For now, Island Nursing Home’s plans to sell its bed licenses are still on the table.

Leon Weed, the president of Island Nursing Home’s board of directors, said he hopes the board will “move forward with more flexibility. The staffing issues for nursing facilities remain problematic not just in Maine but around the country.”

Stonington’s town manager, Kathleen Billings, has said she understands that businesses are having trouble finding staff, but hopes the home will use the extra time to develop a new plan or at least reopen on a smaller scale.

The prospect of losing the small nursing home has many townspeople worried. For one, the next closest skilled care facility is about an hour away from Deer Isle, an island that has an aging population.

Some townsfolk remain optimistic the nursing home will eventually reopen as an active skilled nursing facility, following a packed community meeting in late July.

Weed told observers that while “these issues are not going away,” he and others close to management have vowed to continue to do their best to find the best use for the facility.

Others in the town are taking a more reserved position.

“That takes the pressure off. The beds will still be worth something a year from now,” James Fisher, the Deer Isle town manager, told the Bangor News.

But Cashman told reporters solutions to solve the struggle to find enough nurses likely won’t disappear by the end of the extension. He added that while all options are on the table, the home is still pursuing a sale of its license. 

“It’s still a staffing issue,” Cashman told the newspaper. 

Editor’s note: This article has been updated to clarify that the veterans homes in Machias and Caribou will remain open indefinitely. An earlier version had indicated otherwise.

Medical directors play a largely invisible role in the care of residents, said AMDA—The Society for Post-Acute and Long-Term Care Medicine, in response to the president’s recent nursing home reform proposal. There is no simple way of finding out who leads care at a facility, leaving residents and their families in the dark about care quality, the organization stated Friday.

A detailed public directory of the clinicians who oversee medical care in federally certified facilities should be made available to residents, their families and government stakeholders, AMDA proposed.

The data could live on a public website — perhaps within the Centers for Medicare & Medicaid Services’ Nursing Home Compare site, Karl Steinberg, M.D., president of AMDA’s board of directors, told McKnight’s Clinical Daily. CMS does not currently collect such information, he said.

“It is not information that is generally communicated to new residents and their families when they are considering admission to facilities, but it should be,” he said. “This is all the more important because, unlike in hospitals, the only real quality assurance for physicians who care for residents of the facility comes through the medical director.”

Such a directory would also aid information sharing, he added. In many cases, these  clinicians are disconnected from the flow of important and timely public health information.

“It would have been extremely useful during the pandemic to be able to push out important clinical updates to those medical directors if such a registry did exist,” he said.  

A medical license alone won’t cut it

Hiring practices and a lack of training requirements contribute to the profession’s underutilization and invisibility, Steinberg and colleagues said. One outcome of these problems is the glaring COVID-19 care disparities seen during the pandemic, AMDA contends.

“We have seen a stark contrast in the response to COVID-19 in facilities where the medical director is well-trained, fully engaged and knowledgeable about geriatric medicine and infection prevention and control practices, versus those where they are not,” the organization said in its statement. 

“Facilities now can hire anyone with a medical license to serve as medical director,” Steinberg added. This allows “unethical operators to select physicians merely on the basis of referral volume, or because they will not speak out against inappropriate practices in the facility,” he said.

The only training for industry medical directors available now is through the American Board of Post-Acute and Long-Term Care Medicine, Steinberg noted. California, for one, requires all nursing home medical directors to obtain certification from this program within five years. But there is no national requirement to do so. 

Steinberg foresees a system in which medical directors bill their coursework time against their medical director hours and/or stipend. Alternatively, facility owners could cover the costs of the certification, which can run to about $4,000, he said. Enforcement could be encompassed within the normal federal survey process, he said.

“While obtaining a [certification] might not be the only way to ensure a basic knowledge level pertinent to nursing home medical direction, it is probably the simplest way,” he told McKnight’s. 

“The sad reality is that many current nursing home medical directors do not know complex geriatric medicine principles and have zero knowledge …  in the regulations we need to practice under, which creates risks for the vulnerable population we care for,” Steinberg said.

Hiring qualified candidates

People have the right to know who a facility is engaging to take on federally mandated duties, said Steinberg. When a nursing home operator hires medical directors who are knowledgeable about geriatric medicine, bioethics and the complex regulatory framework that nursing homes operate under, they “can post the information prominently in their facility, include it on their websites and promotional materials, and generally feel confident that the care being provided in their building is both clinically sound and compliant with regulatory requirements.”

AMDA also encouraged the administration to issue a self-identifying specialty code for post-acute and long-term care medicine, something it said it has been urging CMS to do for four years.

In addition to greater transparency for the role of medical director, the organization supports other aspects of the reform plan. These include a transition to reduced-occupancy or single-occupancy rooms, a requirement for full-time infection preventionists and the establishment of a nursing home career pathway. It rejects punitive measures outlined in the plan, however, saying that these have not worked in the past.

The threats came during a March 17 call with at least two leaders of state nursing home associations, parts of which were captured on an audio recording cited by the New York Post.

During the call, state Department of Health Commissioner Howard Zucker and Beth Garvey, special counsel to the governor, accused hundreds of nursing home operators of failing to pick up vaccine shipments they had ordered.

But association leaders later contacted members the state threatened to penalize only to learn most didn’t ask for the unretrieved doses or had actually already gotten them. 

“Why the over-the-top threatening?” one association leader asked in recounting the accusations. “Why wasn’t it a phone call of, ‘What are you guys hearing and are there issues getting the vaccine out?’ You call people up with no notice, start threatening licenses and penalties — that’s your starting position? The first I heard something was wrong was on that call. Before that? Nothing.”

McKnight’s Long-Term Care News verified the veracity of story with one association source Tuesday but did not have access to the recording.

The Post reported that Zucker is heard threatening fines, ramped up enforcement and “shaming everyone.”

“I would think that each and every medical director at these facilities should feel personal jeopardy for their medical licenses,” Garvey added, according to the Post. “We have literally bent over backwards to try to see if the nursing homes would do the right thing. I think our only recourse at this point is to try to clean it up, because we have liability.”

After receiving a list of more than 400 facilities the state accused of leaving vaccines unclaimed, the New York associations called members that appeared on it.

Some facility leaders told them the state may have confused required tallies of unvaccinated residents and staff with requests for doses. Others had already partnered with a pharmacy for their outstanding vaccine needs or previously picked up allotments.

The state health department maintained, however, that the nursing homes in question — still not publicly identified — do, in fact, need the supply that’s been set aside.

“We made repeated calls, determined if they could do shots themselves or needed a third-party provider, and have asked them daily for six-and-a-half weeks how many doses they need,” spokesman Gary Holmes said in a statement. “For some inexplicable reason, hundreds of nursing homes are letting vaccine doses sit on shelves — these failures border on malpractice.”

In a court hearing that started Monday, officials from the state’s agency of healthcare administration argued they should be able to revoke the facility’s license after a deadly air conditioning failure caused by Hurricane Irma.

But attorneys for the Hollywood Hills Rehabilitation Center argued before administrative judge Mary Li Creasy that their pleas for help during the hurricane and in the days after went ignored by the state.

The hearing is supposed to last through the week, with a second one scheduled for March.

On day one, J. Stephen Menton, an attorney representing the state mapped out a timeline of the residents’ deaths and the evacuation of the 152-bed facility on Sept. 13.

According to the Sun-Sentinel, he planned to present testimony from emergency medical responders, police and medical examiners over the course of this week to explain the evacuation and the discovery of dead and dying residents.

“When you hear the descriptions from the first responders as to the conditions that existed within that facility, it’s hard to come to any other conclusion but that the facility failed to maintain a safe environment for its residents,” the newspaper quoted Menton as saying.

Geoffrey Smith, an attorney representing the nursing home, said Hollywood Hills reached out to to state officials, including Gov. Rick Scott (R) the emergency operation center and Florida Power & Light during the storm’s aftermath. The building was not treated as a priority, he said.

“We believe the evidence is going to show you clearly that Hollywood Hills through its professional staff acted as reasonable, prudent professionals in the face of a natural disaster both in the preparation for the storm and in their subsequent response,” he said.

At least four lawsuits have been filed in response to the deaths, some looking to hold both the nursing home and Florida Power & Light accountable. The 12 deaths were ruled a homicide, but no criminal charges have been filed.

Florida’s Agency for Health Care Administration issued an emergency suspension order for The Rehabilitation Center at Hollywood Hills in Hollywood, FL. Authorities cited information that found staff “overwhelmingly delayed” calling 911 and evacuating residents after the building lost air conditioning.

The agency’s notice also stated that nursing staff made “late entries” to residents’ records hours after checking in on them that “portray an inaccurate depiction of the situation.” One “very egregious” entry claimed a resident was resting in bed with “even and unlabored” respirations when, in fact, the resident had already died before the entry was made, AHCA said. In another case, an entry documented a resident’s temperature being taken when the resident already had been moved to the hospital.

“No amount of emergency preparedness could have prevented the gross medical and criminal recklessness that occurred at this facility,” AHCA Secretary Justin Senior said.

Kirsten Ullman, co-counsel for the facility, told the Huffington Post that the facility denies the allegations made in AHCA’s order, especially that the late entries were “somehow being indicative of something.”

“Documentation, many times, is done at the end of a shift,” Ullman said. “The facility was evacuated 45 minutes before the end of shift. Accordingly, certain entries had yet to be made and were designated for the reader as ‘late entries.’ Late entries document care given during the shift, but which was not documented due to circumstances ― in this case ― beyond control.”

The storm-related facility death toll rose to 10 residents on Wednesday with the passing of 94-year-old Martha Murray. The number of legal actions taken against The Rehabilitation Center also has grown, with at least four lawsuits filed as of production deadline. Two of those suits also blame Florida Power & Light for not making the facility a priority for power restoration after the hurricane passed through.

That’s why it was informative to visit two legal sessions at the LeadingAge Institute in St. Paul, MN, this week. One tackled the need to have documentation and delegation to reduce nursing liability and another reflected an in-house counsel’s perspective on hot legal topics.

In the first, attorney Peter Gregory of Bassford Remele in Minneapolis reminded the audience that “documentation in these cases is everything,” especially when a resident is non-compliant.

“If it’s not documented, it didn’t happen,” is often stated, but remains true, he said. His co-presenter, Cyndi Siders of HCIS/Vaaler Insurances and Siders Healthcare Consulting, listed risk factors around leadership skills, delegation skills, volume-based staffing, competency and missed nursing care as areas where one weak pillar can cause a collapse.

As important as those areas are, administrators also would benefit from Benedictine Health System’s Assistant General Counsel Trent Pepper’s insights into day-to-day issues that can cause your in-house counsel to arrive at your door with a pained expression.

For example, mandatory flu vaccinations. I don’t want to rehash the debate about flu shots for long-term care employees, but Pepper brought up a point I hadn’t heard before: Union bargaining. He noted that with union workers, mandatory vaccination may be on the table or addressed in a contract.

He also noted that while some healthcare providers have defaulted to “vaccine or mask” for an option for those who don’t want the flu shot, a human resources employee at a medical center sued last year with the help of the Equal Employment Opportunity Commission. She said she refused the shot on religious grounds and was terminated when she refused to wear the mask due to it inhibiting her ability to recruit. The EEOC has said an organization can’t make the flu shot mandatory without carve-outs for medical (such as allergies) or religious exemptions.

Another area Pepper reminded attendees about is music and movie licensure. Traditionally, based on conversations I’ve had with administrators, facilities could play the radio, have in a music group, or put in a CD without anyone complaining. Now, however, many music licensing companies are zeroing in on long-term care.

While the licensing companies start with a friendly letter asking the facility to sign up, don’t ignore it, Pepper warned.

“Take it seriously. The law is on their side,” he said. The fee is generally based on specific uses of music with the facility.

With movies, the Motion Picture Licensing Corporation is looking at movies in groups or closed circuit channels. The fee is often based on the number of residents and use. Here is the application for senior living providers.

Moving onto contracts, Pepper reminded administrators and managers to review each contract, rather than handing it off to legal. This is something I know happens a lot and I’m sympathetic — the gobbledegook of contracts can strain the eyes and the soul. But Pepper noted that while counsel “can help determine what reasonable is” for standard terms, “attorneys are often not experts on pricing or workforce issues.” In other words, the administrator or director of nursing may need to be the person to say, “Um, that’s not going to work with our shifts or staff.”

Also remember that shorter terms favor providers, because the vendor wants that business back. It’s tricky with a system or program that you know will take time to pay off, but my advice is to think realistically about anything longer than three years.

Another aspect to consider in a contract, as Pepper noted, is whether it is auto-renew. To my horror, I recently had a smartphone app auto-renew, as I had mistakenly assumed my one-year contract was finite. Despite my best attempts to push back, I failed, and learned my lesson about auto-renewing.

Finally, both in my session on handling the media and in Pepper’s session, HIPAA was high on everyone’s list, as was the future of the Affordable Care Act.

Let’s assume, as both Pepper and I do, that a full repeal of the Affordable Care Act is unlikely right now. That means there are a lot of regulations, ranging from Section 1557 nondiscrimination regulations to Payroll-Based Journal submissions, that are unlikely to go away.

“If it’s piecemeal, I have a hard time seeing PBJ or compliance being high on anyone’s list,” he noted.

With the latter, of course, many nursing facilities are swimming along with PBJ and have robust compliance programs. If not, having written compliance standards, a person in charge, reasonable steps to implement and enforcement of standards isn’t going to cause a facility to fall apart, especially with time to prepare. If anything, compliance guidelines should be marketed to prospective employees and residents as reflecting the high standards of your community.

But all of this reminds us that it’s worthwhile to both have in-house counsel, and to take them to lunch occasionally. They may not be conducting direct caregiving tasks with residents, but they will often save your bacon.

Follow Elizabeth @TigerELN.  

“The licensing agreement provides the opportunity to reach the growing healthcare market with the Simmons brand,” said Todd Merker, Director of Global Licensing for Simmons Bedding Company.

While nursing homes and assisted living facilities are free from paying video licensing fees, the agreement states communities with independent living units must acquire a license based on the number of individual apartments in the community. Additionally, any senior community that has a closed circuit television system (such as an in-house channel) playing videos also needs a license. The American Health Care Association/National Center for Assisted Living and LeadingAge brokered the agreement, which also includes a 10% discount on MPLC rates for some facilities with continuing care.

The issue of nursing homes paying licensing fees is not new. In the 1990s, Congress worked with the LTC industry to set guidelines for exempting facilities from paying movie licensing fees. But that agreement ended in 2000. Few instances were pursued by the licensing agency due to an established “pattern of practice” with the profession, according to a statement from providers. Some operators remained confused, however, and providers said when the issue came up again in recent years, they sought clarity.

“Movies don’t just provide residents with entertainment. They offer opportunities for interaction, engagement and a higher quality of life,” noted Larry Minnix, LeadingAge CEO.