CMS Administrator Chiquita Brooks-LaSure told participants at an event in Washington, DC, on Wednesday that the agency’s operations will be in peril if the fiscal standoff continues, news first reported by Politico, a media publication focused on Congress and federal agencies.

The federal government is moving closer toward a shutdown, after narrowly averting one last month. Lawmakers have until Nov. 17 to reach a deal, but once again, agencies are activating contingency plans and preparing to close down, if lawmakers can’t strike a broad deal or at least pass stop-gap, continuing resolutions to fund specific agencies. 

In September, CMS said that it had “sufficient funding” for Medicaid through the end of the year, due to its 2023 appropriations. At that time, the agency would not say if all of its operations would continue. McKnight’s Long-Term Care News attempted to reach CMS Friday, but there was no response with federal offices closed in observation of Veterans Day.

Politico reported that Jon Blum, principal deputy administrator for CMS, provided a statement that said state survey agencies “would likely not be able to complete all statutorily required nursing home surveys” if funds expire and the partial hiring freeze continues. The agency has been working to improve oversight of nursing homes and other facilities, the publication noted. 

But McKnight’s recently reported that year-end data for FY2023 for CMS shows that there has been little improvement in long-standing survey delays that were worsened by the pandemic. Nearly 30% of nursing homes have not had a recertification survey in more than 15 months, according to CASPER data captured between Oct. 1, 2022, and Sept. 30, 2023.

US Sen. Bob Casey (D-PA) issued a report in May that was severely critical of CMS’ survey system. The report from the Special Committee on Aging gathered 2,000 pages of documents and data on survey lapses and found 32 survey agencies had inspector vacancy rates of 20% or higher, with the highest in Kentucky, Alabama, and Idaho.

“The current funding uncertainty poses an immense threat to CMS and nursing home state survey agencies around the country,” Casey, who chairs the Special Committee on Aging, told McKnight’s in a statement Friday. “These critical agencies are already facing a crisis of understaffing and underfunding, and a hiring freeze extended by an unnecessary government shutdown would exacerbate a problem that is putting nursing home residents at risk.”

If the government does shut down at the end of this week, agencies will furlough staff unless they are deemed “essential.” Federal contractors would also cease work, although some may continue in essential roles.

Just as in October, it remains unclear what impact furloughs will have on CMS. Last month, the agency said that 49% of its staff – 3,236 employees – would be retained in roles that are already funded, are exempt, or are “deemed necessary.” Those roles were not defined in the agency’s contingency plan.

The director of the nursing homes division at the Centers for Medicare & Medicaid Services made it clear at the start of his policy update session at the LeadingAge annual meeting here that he would not be discussing the controversial staffing rule. At last count, it was approaching 50,000 comments from providers, consumer advocates, union members and others. But the topic received just a few indirect references from CMS’ Evan Shulman. 

He hit high points about the agency’s renewed points of emphasis on the survey process, infection control practices in the post public-health emergency era, and his agency’s campaign to make the nursing home sector more attractive to would-be job candidates. Antipsychotic use and more equitable use of civil monetary penalties also were key topics.

In preempting any open discussion about the staffing proposal, Shulman acknowledged that CMS was looking forward to reading about “counterproposals.” Sticking with the status quo would not “help anything,” he added.

And while he didn’t talk about the proposed staffing regulation, he did speak optimistically about CMS’ planned nursing home staffing campaign, for which the staffing rule allots $75 million.

One prong will be an awareness campaign where the vast opportunities to work in long-term care will be emphasized to job seekers. This will “highlight how important it is to care for this vulnerable population, and not get your perceptions from the negativity that you may see about nursing homes,” Shulman said Tuesday.

It will raise awareness “that this is a great industry to work in because of the people we serve.” And not to “listen to the negativity that is out there.”

The second prong will emphasize tuition reimbursements and scholarships that will be offered to work in the industry, he said. The program is only in the very beginning stages, with more details expected in 2024, he emphasized.

Discharges in focus

LeadingAge Vice President of Health Public Policy Janine Finck-Boyle said that one of the more important segments of Shulman’s comments came when he called out providers over involuntary discharges, particularly those involving patients with behavioral health or substance use disorders. Shulman acknowledged discharges are not a simple topic and noted that ombudsmen had repeatedly told CMS that providers are trying to “discharge patients they can’t care for.”

In 2022, CMS added language to its Requirements of Participation that requires surveyors to ensure staffing is adequate to supervise residents with mental, psychosocial and substance use disorders.

On Tuesday, Shulman acknowledged that skilled nursing providers may be receiving hospital transfers without a complete picture of a patient’s condition. He noted that is one reason guidance was issued to hospitals in June, warning them to supply post-acute providers with adequate discharge information.

“[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? It is one of the top complaints that ombudsmen receive.

“Do what you can to educate residents as much as possible so they are aware of when they are going to be discharged, and follow the regulatory requirements while you’re doing this,” he advised.

Providers also need to better adhere to guidance about antipsychotic drug use and schizophrenia treatments, he said. The underlying message was that antipsychotics must be used only as a last resort and schizophrenia meds only after other options have been exhausted.

Survey priorities, CMP changes

On the surveying process, Shulman said the agency is renewing its prioritization on three aspects: accuracy, consistency and efficiency.

In addition, he touched on the major reason for the web of changes to the Civil Monetary Penalty reinvestment program that were announced in September. In a word: equity.

“This program is now structured so every nursing home and every nursing home resident has the same amount of access to the same programs as everyone else,” he explained. “There’s no longer a system where some nursing homes got access to some programs just because of where they were or who they knew, and other nursing home residents did not have access to that.

“What we saw [in recent years] was a lot of applications and funding for projects that may be good, but they were very expensive and created an inequity between nursing homes.”

As with past annual LeadingAge addresses, Shulman engaged attendees with personal anecdotes and illustrative examples. He also agreed with some of their pointed observations and openly disagreed with others, like in the past. And he stuck around to answer a long line of questioners after his session, breaking off only when another session had to begin in the same room.

As to attendees’ interest in asking about access to care, particularly in rural settings, Shulman said that CMS also is concerned about the issue and that he would take word of their inquiries back to CMS colleagues.

The report’s forward concludes that the Senate investigation should serve as a “wake-up call” about the increasing strain placed on our long-term care system by population aging. 

But it raises the question: After there have been so many wake-up calls as a result of the COVID-19 pandemic, are we missing the window for meaningful action in nursing home quality improvement? It’s a concern that we as members of the Moving Forward Nursing Home Quality Coalition hear often. We’re not deterred. 

On July 18th, the Coalition launched our nine Action Plans – the culmination of a year of collaborative deliberations on next steps for quality improvement across the country. Here are three reasons we believe the Coalition will drive meaningful nursing home quality improvement in the year ahead. 

First, we’re working on feasible, small steps in state and local settings. Each action plan describes a particular challenge facing nursing homes today, explains why it is important to residents’ quality of life, defines focused goals to address those challenges, and provides a step-by-step approach the Coalition and partners will take to achieve them over a year. Each also describes how nursing homes, state agencies, federal policymakers and others can collaborate with us in the short term.

Consider survey agency capacity. Funding and staffing are, of course, top priorities to improve survey agencies’ ability to meet their quotas. But it’s also clear that the survey process is neither as efficient nor as responsive to the concerns and experiences of residents and their care partners as it could be. 

Two of the action plans address these issues – efficiency and resident responsiveness – directly. The first looks to boost surveyor training in identifying, tracking and encouraging practices of person-centered care. The second looks to collaboratively design and pilot a targeted recertification survey for nursing homes with strong, consistent evidence of high performance based on pre-survey data analytics. Ideally, a tracked approach would free up surveyors to focus more of their time on nursing homes with the highest risk or existing evidence of harm, as well as on resident and family-focused engagement. 

In each case, the Coalition’s Quality Assurance Committee will collaborate with state survey teams in the design and piloting of the initiatives – with the aim of building a base for scale and spread in subsequent years.  

The engagement of state leaders, nursing home providers and local advocates is what’s giving each of these action plans life in the real world. 

Second, we’re piloting and amplifying great ideas and initiatives that already exist. For example, in our work on resident councils, we’re not starting from scratch. While in some nursing homes resident councils may be less effective at amplifying resident perspectives, we also know there are many successful and innovative approaches. In Connecticut, resident council presidents across the state convene as part of a statewide coalition. And the iQuality and Innovation Group at the Centers for Medicare & Medicaid Services (CMS) is piloting a new model – the Resident Family Community Advisory Council – to engage community members outside the nursing home in lifting up resident voices. Our work on resident councils builds on these efforts to help with effective scale and spread so that all residents have access to a resident council that gives them a chance to be heard. 

Our action plan on ownership transparency and accountability takes a similar approach. This year CMS has taken a number of meaningful steps to improve ownership data collection at the federal level. But all 50 states also play a role in ownership transparency through licensing, Medicaid enrollment and cost reporting. Building on federal advocacy and policymaking, the Coalition is working to document ownership data policies across states, highlight trends and best practices, and develop a blueprint for state leaders to follow as they look to strengthen their own systems of transparency and accountability. 

Third, we’re bringing people to the table with deep and diverse expertise and experience in nursing homes. So far over 1,000 stakeholders have raised their hands to get involved, and it’s not just the usual suspects. For example, as we’ve worked on financial incentives for the transformation of nursing homes from institutional settings to more homelike communities, we’ve been excited to bring the Department of Housing and Urban Development as well as lenders into the conversation. 

The most important participants in the Coalition are nursing home residents themselves. Since our launch in September 2022, the Coalition has sought to engage residents in all our decision-making. It’s residents, for example, who told us that ownership transitions were often when quality of life and care dipped the lowest.

Residents also indicated that we’re still not having the active conversations needed about goals, preferences and priorities. Many shared that they had never had the opportunity to participate in care planning. Others shared that if they had, they didn’t have the chance to revisit whether care had met the goals they outlined. That’s why one of the Coalition’s biggest undertakings is to help make tools and resources for goal documentation, care planning, and tracking care quality more person-centered, more accessible for nursing home staff, and better integrated into regulatory and payment systems. 

So we hope the answer to that concern – Have we missed our chance for action? – is clear. If you want to be part of the solution, the Moving Forward Coalition is for you. Whether you want to join the conversation or get your organization or community (no matter how small) involved in piloting meaningful change, we invite you to join us. Together, we can move nursing home quality forward.  

Isaac Longobardi is the Director of the Moving Forward Nursing Home Quality Coalition.

Alice Bonner is Chair of the Moving Forward Nursing Home Quality Coalition and Senior Advisor for Aging at the Institute for Healthcare Improvement.

Jasmine L. Travers, Ph.D., MHS, RN, is an assistant professor at NYU Rory Meyers College of Nursing and affiliated faculty of the Hartford Institute for Geriatric Nursing.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

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Bob Casey (pictured) (D-PA) added Senate Finance Committee Chairman Ron Wyden (D-OR) and Budget Committee Ranking Member Chuck Grassley (R-IA) to the fight with a letter Thursday to the Centers for Medicare & Medicaid Services asking the agency to “take immediate steps to strengthen the Nation’s nursing home oversight system.” 

The letter comes two months after Casey, chairman of the Senate Committee on Aging, held a hearing and issued a report that detailed severe deficiencies with state survey agencies. The 2,000-page report, “Uninspected and Neglected: Nursing Home Inspection Agencies are Severely Understaffed, Putting Residents at Risk” found that 1 of every 9 nursing homes in the US had not had an annual survey in two years, and that 32 state agencies had vacancy rates of 20% or higher among facility surveyors. Surveys are supposed to take place roughly every 16 months.

“Many states have turned to using costly contractors to bridge these gaps, raising concerns about efficiency, effectiveness, and conflicts of interest,” the senators’ letter said. “CMS has an integral role to play in addressing many of the current failures of the nursing home oversight system, especially to improve monitoring and reporting on the capacity of state survey agencies to carry out statutorily required inspections in mandated timeframes.”

The letter makes two specific requests of CMS to “regularly collect” information from state survey agencies about staffing levels and report on state agencies’ ability to conduct appropriate oversight of nursing homes. 

Zach Shamberg, president and CEO of Pennsylvania Health Care Association, struck out at the letter as though it were rain on a wedding day. 

“As singer and songwriter, Alanis Morrissette said, ‘Isn’t it ironic…don’t you think?’,” Shamberg said to McKnight’s Long-Term Care News in an email. “Senator Casey and the Biden administration have been in dogged pursuit of a federal staffing requirement for nursing facilities at the same time our country has become immersed in a workforce crisis. Both long-term care providers and regulatory agencies are vying for workers, yet the only support offered has been to oversight, rather than to care.”

A spokeswoman for CMS acknowledged receipt of the letter Thursday and said the agency “remains committed to improving safety and quality of care for all nursing home residents.” 

“The President’s FY 2024 Budget includes a request for needed resources to strengthen nursing home oversight, as annual funding for survey and certification activities has remained flat for over eight years while complaints have increased,” the agency said in a statement to McKnight’s.

During the May 18 hearing, the board president for the Association of Health Facility Survey Agencies testified that “Immediate Jeopardy” complaints had risen 102% since 2015. Shelly Williamson, who is also the administrator of long-term care regulation for the state of Missouri, said there has been no additional national funding to support the increase in required inspections. 

Stephen B. Hanse, president and CEO of the New York State Health Facilities Association, told McKnight’s on Thursday that Congress, CMS and providers need to be partners on these matters.  

“After nuclear power, nursing homes are arguably the most regulated industry in our nation,” Hanse said. “As such, skilled nursing providers are subject to extensive and extremely transparent federal, state and local health department oversight and reporting requirements. It is vital that Congress, CMS and nursing home providers work together in partnership to enact beneficial solutions that ensure the continued provision of essential long-term care services. Solutions that include, among other things, addressing the long-term care workforce crisis and chronic underfunding of Medicaid.”

In response to Casey’s latest missive, the American Health Care Association reissued its statement from the May 18 hearing that said the shortage of surveyors is “indicative” of the LTC sector workforce crisis. 

“We need a concerted, supportive effort to help recruit more individuals to serve our nation’s seniors, and we have proposed a comprehensive set of policies that would help grow and strengthen the nursing home workforce,” read the statement, which was attributed to Holly Harmon, the association’s senior vice president of Quality, Regulatory and Clinical Services.

The answers started immediately; opinions fling out like fairy dust. When the dust finally settled, out of the one hundred and eight answers, one person took the time and researched what the print might be. That one person bravely put it out there that it might be something different from the many comments. 

Like seagulls on an unattended sandwich, they flocked against the lone commenter. When the dust finally settled again, the individual who posted the question and picture thanked the one individual who had taken the time to research the problem. The person did know what they were talking about and was right about what animal had made the print. The individual who posted the answer did their research, called experts, and thoughtfully put together an answer to help the individual who was asking. 

The rest of the commenters were confident in their responses but drew upon their experience or opinions. When an alternative answer was presented, they immediately were defensive and justified their response. Comments such as, “you do not know what you are talking about” or my least favorite, “well, that is just your opinion, and your opinion means nothing.”

My contribution was, “I do not know, but would not want to meet whatever it is in the woods at night.” Clearly my contribution was not helpful. But I really would not want to meet the animal anytime. The prints left behind were big and appeared that they could do some damage if irritated. 

You might ask why am I sharing this observation with you? Because the behaviors exhibited on social media are being duplicated daily within healthcare settings across the nation. An issue is poised, individuals immediately give their thoughts or opinions based on knowledge, experience and biases. There is rarely exploration of causations, influencers and unknown reasons for the issue. Exploration is defined as, “the action of traveling in or through an unfamiliar area in order to learn about it.”

I recently had an administrator tell me that he did not have time to do exploration on quality issues. He was there to make decisions based upon his judgment and experience. Except, his facility was being cited for the same issues, every survey. The plans that had been put into place, were ineffective. 

When something is not improving, it is because assumptions are flawed. 

Additionally, many times strategies are limited to a perceived course of action based on the assumptions. That same administrator told me to stay in my swim lane and let him address the issues. My swim lane was to address the workforce issues. The administrator forgot that a swim lane is just part of a greater body of water that comprises the whole. The workforce issues were directly correlated to the quality issues. 

The stumbling of the administrator was the same stumbling of the social media posts; defensive posturing, inability to see beyond their own confidence in their knowledge, experience and yes, biases. Very few issues are one dimensional in context, yet many times that is what we try to make them. 

Always look for causations beyond the most obvious. 

When you feel your confidence surge like the phases of a pandemic, ask yourself, “What do I really know…?” Then ask yourself, “What do I not know…?” Research has demonstrated that when we engage our brain, the brain becomes more expansive. By asking questions, listening and exploring the multifocal causations that might have influenced the issue, you are discovering true causation, which leads to the most productive actions. 

In case you are wondering, the print in the dirt was made by an oversized lynx with unusually large pads. Typically, not seen around the area of the individual posting the picture. Most felt that it was a bear, because of the large pads. My response was absolutely correct: not something I want to meet in the woods at night or during the daylight. 

Martie L. Moore, MAOM, RN, CPHQ, is the President/CEO of M2WL Consulting. She has been an executive healthcare leader for more than 20 years. She has served on advisory boards for the National Pressure Injury Advisory Panel and the American Nurses Association, and she currently serves on the Dean’s Advisory Board at the University of Central Florida College of Nursing and Sigma, International Honor Society for Nursing. She was honored by Saint Martin’s University with an honorary doctorate degree for her service and accomplishments in advancing healthcare.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

The Iowa Capital Dispatch this week reported that the state Department of Inspections and Appeals had increased a recent citation against Lantern Park Speciality Care in Coralville from $10,000 to $30,000. The change came after the newspaper inquired about surveyors’ apparent disregard of a requirement that facilities docked for the same high-level offense more than once in one year’s time face triple the penalty.

The Dispatch investigation cited records showing Lantern Park Specialty had been tagged for “violations that contributed to a resident’s death from an infection.” The inspections department then fined the home $10,000 for failing to provide residents with the required nursing services, plus $10,000 for separate violations related to resident safety. But it did not triple the fine until the newspaper contacted officials.

The department was required to fine at the higher level because the facility had just six weeks earlier been cited for failing to provide residents with required nursing services, according to reports.

It’s not the first time the newspaper’s intervention led to higher penalties. In 2020, the newspaper investigated the survey agency over repeat fines of Rowley Memorial Masonic Home in Perry, which had been cited for contributing to a resident death and other regulatory shortcomings. At that time, the department blamed a “clerical oversight” for lower-than-mandated fines and tripled that penalty as well.

Fines in Iowa are typically suspended to allow federal inspectors to issue their own monetary penalties. But nursing home operators would likely struggle with ultimately being on the hook for three times over a repeat offense, given the current financial challenges for the sector.

In another case the Dispatch wrote about in January, Iowa’s inspection department doubled the fine for a repeat citation, rather than tripling it. After that, the Dispatch asked officials whether they had “a system in place to eliminate, or at least minimize, errors of this kind.”

The department did not respond to the newspaper’s query. The department also did not respond to a request for comment from McKnight’s Long-Term Care News submitted to its media team on Thursday.

In the 94-page document, the agency focuses on the top 25 unimplemented recommendations it believes would most positively affect U.S. Department of Health and Human Services programs by way of either cost savings, public health, and program effectiveness and efficiency.

I’ll give you one guess at what type of healthcare provider the first two recommendations dealt with… yes, nursing homes.  

The previous year’s OIG top 25 recommendations also dealt with nursing homes as the first listed recommendation. That focused on ensuring that nursing homes are implementing actions to prevent COVID-19 and protecting residents, placing a higher priority on infection control surveys.  Probably not surprising given the pandemic and the Centers for Medicare & Medicaid Services’ view of nursing homes during the pandemic. (Check out this.)

Significantly, OIG explicitly states in each of its top recommendations that the order of listings in its top 25 recommendations does not necessarily indicate the agency’s priorities. But certainly being at the top of the list perhaps signals something about OIG’s focus these days, and that focus seems to be nursing homes.

This year, not only were nursing homes listed as part of the top recommendations, but they were listed in both numbers 1 and 2 of OIG’s top 25 recommendations to reduce fraud, waste and abuse. Specifically, OIG listed the below recommendation measures that it also believes would assist in protecting patients:

1. CMS should take actions to ensure that incidents of potential abuse or neglect of Medicare and Medicaid beneficiaries, including those in nursing homes and hospice care as well as children enrolled in Medicaid, are identified and reported. 

2. CMS should address inappropriate nursing home discharges through training, by implementing deferred initiatives, and by assessing the effectiveness of its enforcement against inappropriate facility-initiated discharges. (This is the first time this particular recommendation is appearing).

These two (again, listed as the first two) top unimplemented recommendations are telling for a few reasons.  First, with regard to No. 1, clearly OIG sees that CMS enforcement is somehow lax, because by making it a top recommendation, the watchdog is signaling that this is an “easy” way, in its eyes, to help eliminate this noted problem for waste, fraud and abuse. Namely abuse and neglect in nursing homes. 

That is troubling, as we have certainly seen increased enforcement by CMS over the last two years in nursing home surveys and penalties. But OIG is basically saying that abuse and neglect must be focused on even more through CMS’ survey process.

Second, with regard to No. 2 above, OIG believes that nursing homes are inappropriately discharging residents, and that they are being cited for not complying with involuntary discharge notice requirements. OIG noted that CMS is attempting to fix this problem, and it remains a top focus for both agencies:

CMS stated that it plans to provide training, including clarification of guidance around facility-initiated discharges and/or transfers. CMS will also incorporate an assessment of the effectiveness of enforcement actions in response to inappropriate facility-initiated discharges.  Top Recommendations, p. 7.

If that weren’t enough, OIG also provided an update on last year’s infection control recommendations for nursing homes. In the Top Recommendations, OIG stated that it is aggressively focusing on staffing as a way to improve infection control, suggesting OIG’s belief or assumption that staffing shortages are causing infection control problems:

“Regarding nursing home staffing data, in January 2022 CMS began posting weekend staffing and staff turnover measures on the Care Compare website. CMS also shares Payroll Based Journal staffing data, including lists of facilities that potentially have insufficient weekend staffing, with state survey agencies.”  Top Recommendations, p. 10.

OIG goes on to highlight its heightened focus on nursing homes in this regard:

“This progress is part of larger nursing home reforms that the administration and CMS are pursuing. OIG continues to invest substantially in oversight of nursing home quality and safety and will continue to monitor CMS’s progress on related reforms.”  Top Recommendations, p. 10 (emphasis added).

So clearly, OIG and CMS are working together to “reform” nursing home care, and OIG is fixing its gaze on nursing homes. But their idea of reforming nursing homes is not to physically or monetarily help facilities per se with staffing shortages or by providing money for more staff.  

Their idea of reform is further enforcement, more aggressive enforcement, and a focus on monitoring and enforcing against facilities with staffing shortages. Ignoring the exorbitant CMS fines and penalties in the survey process currently, and the difficulties that facilities are having with recruiting and maintaining adequate staff, the OIG recommends that increased oversight and enforcement will force facilities to improve staffing as a means to affect change (… that “reform” they are focused on) in nursing homes for years to come. 

Neville M. Bilimoria is a partner in the Chicago office of the Health Law Practice Group and member of the Post-Acute Care And Senior Services Subgroup at Duane Morris LLP; nmbilimoria@duanemorris.com.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Its survey, which collected data earlier this month, showed data point after data point reflecting the damage done by the pandemic and staffing shortages. Among the results from the 163 nursing homes responding:

• 4 of 5 have placed a hold on admissions during the pandemic
• 7 of 8 regions showed 90% or above of facilities that put holds on admissions turned down more admissions from hospitals than before the pandemic
• More than one-third of all the nursing facilities reported turning down at least 21 admission referrals in October
• Insufficient staffing, inability to meet specific needs, and difficulty of weekend admissions to staff to and process were the top three criteria given for admission decisions.

“Seniors and their caregivers are being left behind,” the LeadingAge Minnesota analysis found.

The same story is told in other states, such as Kansas, said Rachel Monger, vice president of government affairs for LeadingAge Kansas. A large health system in Kansas City recently complained about not being able to discharge patients to post-acute facilities, she told McKnight’s Long-Term Care News 

“We had to explain to them that nursing facilities can no longer staff enough beds, even in major metropolitan areas, to meet demand,” she said. “If you are an older person in need of services right now, you are feeling the full effect of the staffing crunch. 

“It is a frustrating and frightening situation we find ourselves in,” she added. “The next question is how long we think the government is willing to put an entire population of people at risk before they step up to the plate and properly fund long-term care.”

The Pennsylvania Health Care Association surveyed its workforce in 2021 and got responses similar to the Minnesota statistics. In March 2022 the PHCA dug deeper into the access-to-care issue analyzing information from December, 2021 to February, 2022.

“It was during that time we were hearing about hospitals reaching capacity because they were unable to discharge patients to nursing homes and COVID-19 cases were spiking with omicron,” PHCA director of external communications Eric Heisler told McKnight’s. “What we uncovered was that 60% of the respondents said they declined admission referrals during that three-month period. Of those facilities that declined admissions, each facility averaged about 20 referral declines a month. The survey gave us a better look at what waitlists look like to get into nursing homes with an average of eight people on a nursing home waitlist, and that residents were traveling further distances to receive care.”

Heisler said another key highlight from that survey was that nearly 50% of respondents revealed they had, on average, 32 licensed beds they were unable to use because they didn’t have enough workers to staff them. He said a federal nursing home staffing minimum mandate that many view as inevitable could be disastrous.

“When you think of Pennsylvania averaging 32 open beds, requiring more workers for one resident doesn’t necessarily help staff those open beds, especially when there currently isn’t a pool of caregivers to hire,” he said. “Pennsylvania developed staffing ratios that not only can help enhance care, but the ratios were attainable and somewhat funded. If a federal staffing mandate is unattainable and unfunded, you will continue to see many open beds and growing waitlists of seniors and adults with disabilities trying to access care.”

Historically, emergency preparedness programs in long-term care facilities have been less prioritized, with facilities understandably focusing on patient care and operations. 

But with the pandemic and President Biden’s nursing home reform plan, a focus on emergency preparedness is key, and facilities should concentrate on, and perfect, their emergency preparedness programs now.  And we don’t mean just on paper.

An emergency preparedness program describes a facility’s comprehensive approach to meeting the health, safety, and security needs of the facility, its staff, its residents, and the community prior to, during, and after an emergency or disaster. 

The program encompasses four core elements which are briefly summarized in this article: an emergency plan that is based on a risk assessment and incorporates an “all hazards approach”; policies and procedures; a communication plan; and a training and testing program. The full emergency preparedness program must be reviewed and updated at least annually for LTC providers. The fact that other types of providers may perform program reviews every two years signals the heightened focus placed on LTC facilities’ emergency preparedness. 

Requirements of the emergency plan

Based upon the facility and community-based risk assessments, the emergency plan ensures a facility’s ability to collaborate with local emergency preparedness officials. It specifically identifies how the facility will continue to operate and ensure the safety and quality of resident care during a disaster. The plan is to account for hazards most likely to occur in a facility’s area, whether man-made disasters, weather, cyber security attacks, equipment failures or pandemics.  

For LTC facilities, written emergency plans must address missing residents, as well as residents’ access and functional needs. The plan must also acknowledge underlying conditions that may place residents at higher risk, such as the impact that infectious disease may have on immunocompromised individuals, e.g., the COVID-19 pandemic. 

The LTC facility must develop and implement emergency preparedness policies and procedures that are based on the emergency plan, risk assessment and the communication plan. The policies and procedures must be reviewed and updated at least annually and must address a host of things such as needs during an evacuation, and much more. See 42 C.F.R. § 483.73(b).  

The facility must also develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and this also must be reviewed and updated at least annually. The communication plan must include names and contact information for various persons and other sources of assistance. 

Lastly, initial training of all policies and procedures for all new and existing staff is required as well as ongoing training on an annual basis.  Notably, the regulation requires that LTC facilities must demonstrate that staff is knowledgeable of the emergency procedures.  And this is where the rubber meets the road.

What does this all mean?

Experts are predicting that nursing home surveyors are going to start digging in on facilities’ emergency preparedness plans.  Facilities, thus, need to take this seriously now to avoid increased penalties and tags as a result.  It is common for staff members to be unfamiliar with the policies and procedures on emergency preparedness, to the extent that they would be unable to demonstrate knowledge if questioned by a surveyor.  This is technically a violation of the federal regulations.  Facilities should address this now with a review of their plan, policies and procedures, and in-services to retrain their staff.  

Further, it will not be enough for staff to simply demonstrate knowledge of the plan by paper compliance.  Facilities will need to show that they are able to implement the plan.  To do this, facilities should conduct exercises to test staff proficiency of the policies that are announced.  The regulation suggests mock drills, a tabletop exercise or a workshop led by a facilitator that includes group discussion.  

Angela Rinehart is an associate attorney in Stoll, Keenon, Ogden’s (SKO) Health Care and Litigation groups. She joined the firm in 2022 following its merger with Katz Korin Cunningham PC. Contact her at angela.rinehart@skofirm.com.

Norris Cunningham is a member of Stoll, Keenon, Ogden’s (SKO) Indianapolis office specializing in healthcare. He co-founded Katz Korin Cunningham PC, which merged with SKO in 2022. Contact him at norris.cunningham@skofirm.com. 

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.