By Nov. 6, the agency had heard from 46,881 commenters, more than 30,000 of them offering unique criticisms or arguments. Each requires a federal response.

The proposed rule would require nursing homes to staff registered nurses around the clock, provide 0.55 hours of direct RN care per patient per day, and ensure another 2.45 hours of certified nurse aide care daily.

Associations  representing nursing homes and their members contributed tens of thousands of those comments, but so, too, did frontline workers whose unusually high level of participation was well organized by local and national union leaders.

The massive outpouring likely means a lengthy delay, possibly a year or more, before CMS can proceed with any final action.

“The Congressional Review Act gives us [Congress] the ability to pass a law that says that the minimum staffing rule is repealed because it was a bad rule,” said Ryan during a keynote presentation at the National Investment Center for Seniors Housing and Care (NIC) conference in October. “It can’t be filibustered in the Senate. If it passes in the Senate, it happens and it goes away, no matter who the president is. That kind of stuff can happen.”

He noted that aligned interests need to control Congress and certain circumstances need to fall into place for that to happen.

“But you can repeal recent rules if you have Congress,” he said. “So there’s a lot you can do.”

Ryan also expressed his disdain for the Biden administration’s proposed staffing mandate.

“Even the Obama administration didn’t do that,” he said with a shake of the head.

A: I still say the workforce issues are the number one challenge, and one of the reasons they’re a big challenge is the demographics that we’re working with in our aging population. It is going to be with us, and it’s going to require incredible creativity. In terms of where I’m hoping to work with our team in the coming months, it’s being leaders and innovators in workforce development, and contributing to solutions rather than just passively having to watch this situation and be frustrated.

Q: What do you imagine that could look like?

A: We need to provide even earlier, more formative educational support that might involve things like language training, basic jobs skills and tech literacy. We’re trying to develop some resources to go that far ahead in the process to try and really get people interested in long-term care and support them in their development at an earlier place.

Q: How do you do that in a place like Boston, which is both incredibly diverse and stacked with other healthcare providers who are also recruiting nurses?

A: We can compete with one another for whoever’s out there … but that’s a zero-sum game. Ultimately, we need new entrants. That requires casting a wider net and also [putting] support services around these workers so that they can get training and still address issues like child care and transportation. And then we’re talking about people that are new to our communities. Maybe they’re not native English speakers. We need language skills support and work skills in computer literacy training. There’s all sorts of stuff we have to do to create that pipeline.

A: We hear this concern often from nurse leaders and medication nurses! Expecting one nurse to do vitals, meds, eye drops and handle interruptions is nearly impossible, especially with more than 30 residents. Because of multiple diagnoses, one resident can be on 18 different medications.

If you have more than one nurse on duty, have one handle care needs and other  interruptions, while the other passes meds. Train the staff which nurse to seek out while the med nurse is passing meds. Consider a medication aide, who may assist the nurse after being trained and passing any state- required tests.

Meet with your pharmacy and therapeutics committee. Are there medication times that can be changed? Can you schedule the 6 a.m. or 7 a.m. medication to be given from 6 a.m. to 10 a.m.? Expand dinner medications from 5 p.m. to 9 p.m.?

Are there any medications that you can combine or discontinue? As William Vaughan RN, BSN, has said, if you have a medication that requires you to sit your resident at a 90-degree angle for 30 minutes before giving the drug, then following the administration with 8 ounces of water, and you know your resident will be combative at 6 a.m., and will not tolerate sitting at a 90-degree angle for 30 minutes or drink a full 8 ounces of water, then talk to the pharmacist and medical director about discontinuing it. 

Keeping a medication scheduled, knowing you are unable to administer it correctly, is  setting your nurses and facility up for failure. 

Having a flexibly timed med pass, combining and discontinuing unneeded medication and limiting the med nurses’ interruptions will help you gain a better hold on your med pass times — and hopefully eliminate any future deficiencies.

A: A 2014 analysis of Medicare spending found between $28.1 billion and $96.8 billion per year was spent on wound care in the US. 

Limited data was available for costs specific to post-acute or long-term care settings, but wound care is undoubtedly expensive. Wound care standards require that the initial assessment of a patient at every skilled nursing facility must include a head-to-toe skin assessment. Staff must also complete an assessment to determine if risk factors for skin breakdown are high, moderate or low. Post surgical and diabetic wounds require rigorous observation and care since they are at higher risk of complication. 

Unfortunately, scrutiny is severe at nursing facilities compared to hospital settings. Wound experts at the hospital are mostly part-time contractors, while many SNFs have wound experts visiting the location weekly to provide hands-on education during the wound rounds. 

There is no comparison of one location versus another in terms of patient care, though often nursing facilities have restricted treatment options due to Medicare or Medicaid reimbursements. 

It is important to understand the barriers to efficient wound care management. Often providers feel uncomfortable handling wounds and leave the matter to the rounding wound experts who come into the facility once a week. This trickles down to the nursing team who are required to assess the wound with every wound care treatment. It is reminiscent of a famous saying: “We are the enemy of what we don’t know.”

It is important to have adequate knowledge and expertise in wound care for improved patient care and cost efficiency. After all, as another famous saying goes, “An ounce of prevention is worth a pound of cure.”

Published in mid-October, the guidance identifies risk factors including immobility, lack of pain perception, obesity, poor nutrition, dehydration, dementia, and a history of previous pressure injuries. People with diabetes  and circulation problems also can be more prone to pressure injuries. The Commission also pointed out that PIs can be an unrecognized cause of systemic infection.

Staff need to be trained on using equipment to evaluate and treat wounds, understand best practices and know when to seek a specialist, the guidance states.

The guidance also includes useful warning signs of pressure injuries, including a thin or blood-filled blister on the skin; a deep red or purplish color under unbroken skin; tissue that is warmer or cooler compared to the skin around it; and lack of elasticity around an affected area. 

Additionally, the Commission warned, staff should be on alert for symptoms of infection or sepsis in patients with a potential pressure injury.

The RAI user’s manual that went into effect Oct. 1 clarifies that the terms “healed” or “unhealed” indicate whether a pressure ulcer is “closed” or “open.” That definition affects coding choices in the MDS v1.18.11. Also, a previously closed pressure ulcer that opens again should be reported at its worst stage. New details also help determine whether a reopened PU was present on admission, or needs to be coded as new.

“NACs may need to work with clinical leaders to establish a process for wound documentation that supports MDS coding more accurately and tracks the history of skin problems for a resident,” AAPACN Curriculum Developer Jessie McGill noted. “These clinical processes will lead to improved accuracy of assessments and quality reporting.”

Also, said wound expert Jeanine Maguire, Kennedy (or terminal) ulcers have been removed from a quality measure calculation, meaning they no longer should be checked in Section M.

A:The three aspects of the emergency preparedness plan most important for the nursing department are: staffing, supplies/resources and communications. Let’s consider each in depth.

During an emergency, staff may be personally impacted and therefore unable to report to work. A recent Office of Inspector General study found that 77% of facilities reporting challenges with preparedness activities rated having adequate staff available in an emergency as most problematic. The DNS will need a plan to ensure adequate staff are available to meet residents’ care needs. Have a list of staff who live near the facility who can come help in an emergency. Also, include in the plan a place to offer rest periods for staff unable to leave the facility. 

During an emergency, the facility can lose access to resources and supplies. Loss of power, water or heat may involve backup resources,such as generators, or require patient transfers. The DNS should ensure the facility will have adequate resources, even in a disaster.

Stocking up on supplies is another important aspect. The facility will need backup inventory for water, food and medical supplies, and weather-related events like snow storms or hurricanes can delay deliveries for days or weeks. 

Facilities also need to inform family members and staff how the facility is handling an emergency. In advance, develop a communication plan and assign someone to oversee it. Test the plan before a real emergency occurs.

Facilities in areas at high risk for natural disasters may need to review plans more than once a year. Community outbreaks  also can constitute emergencies, so monitor risk. As that risk increases, review plans before they must be implemented. 

During that same time period, 44% of nursing homes experienced technology growth, while 27% experienced no change in their technology adoption.

The scope of abandoned tech is not merely discontinued services such as outdated software, but rather a failure to provide or nurture certain technologies across an entire facility or organization, according to the study authors from the Sinclair School of Nursing at the University of Missouri and Columbia University’s nursing school. With nursing homes more reliant than ever on technology, conducting analyses on why they abandon tech are as important as studies about tech growth, the researchers stated.

The majority of nursing homes that abandoned administrative technology were larger operations of 120 beds or more, according to the study.

“Technology abandonment can increase strain on scarce resources and may impact administrators’ ability to oversee clinical operations, especially in large nursing homes,” the study authors stated. “This study can serve as a building block for others working to ensure limited resources are used effectively to improve care for nursing home residents.”

While the research doesn’t indicate whether some technology was abandoned to put new, better systems in place, some may have been discontinued to create greater efficiencies, the researchers speculated. They added that other studies have shown tech doesn’t always turn out to improve caregivers’ and staff’s workflow.

The study was published in the Journal of the American Medical Directors Association.

A:The Patient Health Questionnaire-9, or PHQ-2 to 9, is a widely used screening tool for depression, and in the context of nursing homes and PDPM it takes on even greater importance. This nine-question self-report tool screens for symptoms of depression in residents and provides a standardized severity score and a rating for evidence of a depressive disorder. 

The interview covers various aspects of depression, including mood fluctuations, sleep patterns, and appetite changes, among others. Completing the PHQ-2 to 9 effectively is crucial for accurate assessment and quality care under PDPM.

PDPM categorizes residents into payment groups. Clinical assessments, including the PHQ-2 to 9, can influence the placement of residents into the proper category. Accurate assessment is crucial to ensure residents receive the care they need, and that you are appropriately reimbursed for it.

Staff who are conducting interviews should follow guidance in Appendix D of the RAI, Interviewing to Increase Resident Voice in MDS Assessments. This guidance should be reviewed routinely, along with Steps for Assessment for conducting the PHQ-2 to 9. Interview techniques to include “disentangling” and “unfolding” will be important as indicators of moderate to severe depression (total severity score = ≥10). If identified through the PHQ-2 to 9, that can increase daily reimbursement by approximately $40 per PPS day to support the services that residents experiencing moderate to severe depression require.

Effectively addressing depression also can enhance your facility’s “Percentage of Residents Who Have Depression Symptoms” quality measure. This measure utilizes two questions from the PHQ-2 to 9 and considers the total severity score.