Sen. John Tester (D-MT) led 28 senators in sending a letter to Centers for Medicare & Medicaid Services Administrator Chiquita Brooks-LaSure, calling for the mandate’s withdrawal because it came at the “worst possible time.”

“A one-size-fits all staffing mandate significantly undermines access to care for patients, particularly in rural communities,” they wrote Sept. 29, the same day a House bill to stop the mandate was introduced.

Nursing home advocates continue to press owners and operators to share their concerns about implementing the rule with CMS. The American Health Care Association was aiming for 10,000 comments by Nov. 6. Officials must review and address each as part of the rule-making process. n

Protecting Rural Seniors Access to Care Act, HR 5796, would prohibit federal officials from finalizing the Sept. 6 draft rule, convening a nursing home workforce panel instead.

The act “will keep CMS from implementing this rule until it can prove it will not result in the closure of skilled nursing facilities, will not harm patient access, and will not make workforce shortage issues worse in areas that are already struggling,” Rep. Michelle Fischbach (R-MN) said in introducing the bill on Sept. 29.

The measure had three co-sponosors by Oct. 10. It created a major buzz in the long-term care sector,  which has expressed intense concern about the ability to hire during an ongoing workforce crisis, particularly in rural areas.

“Getting this wrong will undercut equity and access in care,” warned LeadingAge President and CEO Katie Smith Sloan.

A: Unions fight to make jobs better for workers, and that could mean higher wages and better benefits, safer working conditions … infection control policies, PPE and protection from COVID-19 during the pandemic. So in all the ways that unions fight to make jobs better, we would expect workers to stay in those jobs because they’re better jobs. I don’t think there’s anything particularly surprising about this. That being said, there hadn’t been previous studies of the determinants of nursing staff turnover in US nursing homes because of data issues.

Q: How is the positive effect on turnover magnified when a majority of  nursing homes have a union?

A: In counties with very high unionization rates, that is 75% or more of nursing homes are unionized, we’re finding a 17% relative drop. … When that [competition] from non-union nursing homes, when that goes away, the results suggest that unions at the nursing home level are much more successful in getting the things that they’re fighting for. If you’re in a place where most nursing homes are unionized, you don’t have to worry as much about those non-union competitors bidding down in a sort of race-to-the-bottom.

Q: Unions and nursing home owners and operators have traditionally been adversaries. What about these findings might undercut that?

A: If employers can come to see unions as a partner in this, then there’s also an argument for broader acceptance of unionization throughout the nursing home industry as way of raising the floor throughout the industry in a way that could be beneficial for workers, for employers in terms of staff turnover, and especially for residents.

A: This depends on several factors, including the individual’s specific medical condition, the policies and regulations (state and federal) of the facility, and the guidance of the medical or IP team.

Here are some considerations:

They can use the swimming pool if their colostomy is well-managed and they are stable.  However, it’s important to consult with their physician or nurse practitioner to assess any potential risks or concerns.

Proper care of the colostomy bag and stoma is crucial when using a pool. Waterproof ostomy pouch covers may be necessary to prevent water from compromising the seal of the colostomy bag. A nurse can provide guidance on maintaining a secure seal.

The facility should have specific policies regarding the use of any pool by residents with medical conditions like a colostomy. These may include requirements for medical clearance, supervision or precautions. 

The facility should supervise and assist residents in the pool area to ensure safety, especially if the resident requires assistance with their colostomy. It’s important that staff members are adequately trained and available to provide support in situations like these. Maintaining proper hygiene and infection control measures in the pool area also is crucial. 

Each resident’s situation is unique, and  his or her ability to use the swimming pool should be assessed on an individual basis.

Factors such as mobility, balance and any other medical conditions should be considered with this assessment. Keep in mind, too, that the above factors are liable to evolve over time for long-time residents. Staff clinicians should make a point of regularly re-evaluating each patient’s conditions and abilities.

As a leader, you are in charge of financial stability, quality standards and patient care. After 11 months of hard work, you take vacation for 10 days. Upon return, you find out there was survey with an F-Tag 314 for an in-house Stage IV pressure ulcer. 

The surveyor interviewed then observed the nurse performing the wound dressing and reviewed the wound documentation. The wound nurse in your facility comes every Tuesday, and the surveyors came on Wednesday. The regular nurse got anxious and was not able to answer questions and missed the Braden Scale assessment.

Documentation showed skin assessment was missed at the time of admission, and the wound was discovered when it was stage II. Secondary to the patient’s immobility and recent back surgery, the wound progressed to stage IV quickly. No one documented a wound description, risk factors or the unavoidable status of the skin injury. Late detection, inadequate risk assessment and poor documentation lead to this citation.  

Long-term care can be a punitive environment. No matter how many boxes you check, something may be missed. But  this may not be the case if we develop a system of accountability.  For example, in the above case, simple steps like conducting a Braden  assessment at admission, performing a  weekly skin assessment, providing nurse education, ensuring diligence to accurate risk assessment and better documentation could have prevented the F-Tag. 

The F-Tag was given to the facility secondary to the lack of assessment and documentations at the time of admission. For providers to have knowledge regarding skin injury, risk factor and the possibility of healing or non-healing are empowering for the patient and the staff. Every patient deserves respect with empathy and should not be treated as “just a number.”

The results among a group of seniors 70 to 73 years old are important for older people who “typically face unique treatment challenges,” wrote study authors, led by Joseph F. Merola, MD, a researcher from Brigham and Women’s Hospital.

“Treatment for moderate-to-severe disease can be challenging, as they can experience more active and severe disease, increased comorbidity, polypharmacy, and a higher risk of infection,” the authors reported in JAMA Dermatology online ahead of print. “Other challenges include potential safety risks and low adherence to conventional therapies, like corticosteroids, phototherapy, and immunosuppressants.” n

The Post Acute Wound & Skin Integrity Council, or PAWSIC, will primarily be an educational organization, but President Jeanine Maguire, PhD, MPT, CWS, told McKnight’s Long-Term Care News she hopes to work with federal officials to develop better national guidance around wound care.

“There’s a major gap in wound management, particularly for post-acute care,” said Maguire,  a former vice president of wound care at Genesis. “The gap that exists is an interprofessional team, teamwork between all different professions, for all different wound types through the lens of the regulations that are very nuanced in post-acute care. There are not necessarily national guidelines to guide this sector. If you’re an operator, you’re maybe not sure if what you’re doing is appropriate for all wound types in regards to care delivery.”

PAWSIC’s work will center on comprehensive approaches to address chronic wounds and skin issues, including pressure injuries and diabetic foot ulcers. In-person events and resources at pawsic.org will serve the gamut of post-acute providers.

A: This fall and winter, facility staff may face outbreaks of several respiratory illnesses, including influenza, respiratory syncytial virus (RSV) and COVID-19. 

Nurse leaders, with the help of the infection preventionist, should start by re-educating all staff on hand washing and hand hygiene. To ensure compliance, have a plan for auditing hand hygiene. Keep “Clean Hands Count” posters from the Centers for Disease Control and Prevention posted prominently and remind staff frequently of hand hygiene’s importance. 

Educating residents and staff about cough etiquette also will help decrease the spread of respiratory illnesses.

Also teach staff signs and symptoms of influenza, RSV and COVID-19 so they can report them. When individuals present with respiratory illness symptoms, follow standard and droplet precautions to limit the spread. Maintain precautions for seven days after the onset of illness or 24 hours after the resolution of a fever, whichever is longer. Allow staff to stay home when sick. 

The facility also can prepare by stocking up on personal protective equipment  and reviewing proper donning and doffing with staff. An ample supply can help contain outbreaks — if used correctly. 

Lastly, educate and offer vaccines. Influenza, RSV and COVID all have vaccines available. Ensure that the facility has them on hand and is offering them to eligible individuals to help prevent the spread of illness. Make sure nursing staff understand proper vaccine storage to maintain the efficacy of the vaccine. 

Having a plan in place to identify and respond timely to respiratory illnesses will assist in mitigating the scale of the outbreak and can help ensure the safety of residents and staff.

But underscoring providers’ ongoing workforce struggles, doing more to recruit and retain at the upper levels hasn’t precluded them from having to make major investments on the front lines.

Nursing home administrator salaries averaged $127,763 in 2023, up 3.6% from $123,324 in 2022. Assistant administrators enjoyed a 5.69% average increase, up to $92,514 from $87,533. Meanwhile, directors of nursing saw their average pay climb 4.67%, up to $108.809 from $103,954 in 2022.

Those figures come from the 2023-2024 HCS Nursing Home Salary & Benefits Report published by Hospital & Healthcare Compensation Service (HCS) in cooperation with LeadingAge and supported by the American Health Care Association. The survey provides compensation data on more than 111,600 employees in 46 management and 54 nonmanagement positions in both nonprofit and for-profit settings.

“The executives … are starting to get a higher percentage after the staff getting the bulk of the increases for probably the last two to three years since COVID. It probably started last year, but it definitely is more pronounced this year,” said Matt Leach, senior consultant with Total Compensation Solutions LLC. “When I talk to the HR folks, when I talk to executives, they almost just throw their hands up and say they’re getting hit from both sides.”

That’s because raises for RNs, LPNs and CNAs remain nearly double the traditional increases of 3% to 5%, even if they are a bit more moderate than 2022 increases. RNs saw an increase of 7% (down from 11.1% in 2022); LPNs enjoyed an increase of 8.9% (down from 9.4% a year earlier); and CNAs saw an increase of 9.7% (down from 11.15% in 2022). 

Need for increases persists

Those numbers were collected in March and published for the first time in late August. But already, providers are facing fresh whiplash, Leach warned.

“Six months ago, it seemed like it was leveling off somewhat, but in the last three months [since mid-summer] we’ve started to see again the need for increases, especially on the staff side,” he said in late September.

“I still think things are calmer than they were a year or two ago, when you couldn’t even get people for interviews,” he added. “But we’ve gotten a lot of calls in the last two months about organizations just not being able to retain talent.”

Workers are constantly asking for more money and expecting mid-year or annual raises of 4%, 5% or even 8% for CNAs, Leach said, adding that meeting such pressures is unsustainable over the long haul.

Staff demands have been compounded by inflationary effects. Many other businesses can keep upping the ante and pass increased staffing costs onto their customers. But in skilled nursing, increases in reimbursement have largely failed to keep up with higher costs in all kinds of categories, making it harder to keep pouring limited resources into salary budget lines.

That only adds to the ongoing workforce crisis, pushing cash-strapped operators closer to the brink. Consulting and accounting firm Clifton
LarsonAllen, using national data, found skilled nursing providers saw their cost of direct care nursing jump by about $4.4 billion, or 12.6%, in 2022, with hourly nursing wages up 10.6%.

“Financial viability and sustainability are a key concern as operators in many states are strategically increasing wages rates far in excess of revenue increases,” said Stephen Taylor, a principal in the firm’s healthcare group. 

“For example, Colorado operators have increased wage rates approximately 27% in the three-year period between 2020 and 2022, while experiencing a median increase in patient revenues of approximately 8%.”

Salary resistance grows, as do bonuses

Leach said some clients are now “taking a harder stand” and trying to limit pay increases while reducing the use of high-cost agency nurses, too.

And that may be accelerating the use of bonuses, which are budgeted as one-time expenses. Leach noted that both higher salaries and bonuses could be due to having to attract new talent as a result of turnover.

Higher compensation in any form is needed to attract younger or recent nursing school graduates as job candidates, added Adam Chambers, founder of Nurse Recruitment Experts. About 30% of his clients are in skilled nursing, and he’s finding it harder than ever to recruit for that setting, in some cases doubling ad spending to net the right RN for a job.

“We’re seeing greater competition because there are fewer qualified nurses compared to the demand, especially in skilled nursing,” Chambers said, noting increases in pay and nurse candidates’ willingness to ask for even more than advertised. “The demand is growing faster because of the aging population, but it tends to attract older nurses. As they retire, they aren’t being replaced quickly from the graduate nurses because they want to work in the hospital.”

While providers must try to offer competitive salaries, that alone isn’t enough to close the deal, Chambers added.

“If they want to earn money as a nurse, then they’ll do travel nursing and hospitals,” he said. “But we find that emphasizing that you’ll have the opportunity to rotate and work with more high-acuity patients [can work]. The best candidates want jobs that challenge the perception that it’s for older nurses and that there isn’t a lot of clinical skill required, which is false.” 

Turnover, vacancies compound 

Leach agreed that higher average pay and bonuses for RNs and higher positions in 2023 likely reflect losses in the leadership ranks. In many places, leaders in top positions stayed in the skilled nursing workforce throughout the early pandemic, even when pulling double duty as the lower ranks thinned.

But burnout caught up with the sector, leaving more mid- and upper-level management positions in skilled nursing facilities vacant, HCS found. The 2023-2024 report is the first to include vacancy rates by position. Providers reported a 14.5% annual vacancy rate for executives, and nearly 21% of all positions were vacant across job roles throughout the year.

Younger nurse leaders and administrators might be more interested in early career bonuses instead of waiting for a larger payout at retirements, Leach said.

HCS found 80% of those providers who offered signing bonuses did so in three or more positions or departments: 48% of participants reported offering sign-on bonuses for RNs, with an average bonus of $4,879; 46% offered bonuses for LPNs, at an average of $3,770; and 40% gave CNAs bonuses, averaging $2,157.

Some providers have taken the bonus strategy to great new heights in recent years, with a New York healthcare system recently offering RNs as much as $35,000 to sign on with its facilities, which include nursing homes and hospitals.

But among staff nurses, Chambers has seen those types of outliers might actually harm recruitment efforts. His recruitment firm conducted its own survey during the pandemic and found that 80% of nurses said they would be less likely to apply for a position offering a high sign-on bonus.

“It seems like common sense to throw money at it,” he said. “But it makes the employer look a little desperate. It’s a red flag on their staffing situation. … And existing staff don’t really like it if someone is getting $35,000 to come in the door and do the same job.”

Instead, he suggests providers try a trick often employed by hospitals to boost early retention efforts. Offer a bonus at signing, after the job has already been offered, to increase employee satisfaction and encourage positive feedback about the organization’s hiring process.

More changes ahead

Hiring and salary strategies will be even more important in coming years, as states and the federal government move toward mandated staffing levels. Leach said pay for some positions may start to bump up even ahead of the federal mandate’s enactment, especially if workers see their value.

Improving retention is a key long-term strategy, and could help save employers money. And the 2023 HCS survey shows that year-over-year turnover declined for the first time since 2020. It noted that turnover rates for RNs dropped to 39% in 2023, approaching the typical rate of 30% to 35% seen prior to 2020; LPN turnover, meanwhile, decreased to 38% in 2023, moving closer to the standard 30% rate seen pre-2020; and CNAs declined to just under 51%.

Reducing those figures to even lower rates will be critical if providers also will have to ramp up hiring for newly created positions needed to meet specific minimums.

“There could be significant implications on labor costs related to the proposed minimum staffing mandate,” said Taylor, whose firm has estimated the annual cost of the federal mandate at $6.8 billion nationally.

“Although there have been improvements in workforce availability in some areas of the country, SNFs in many parts of the nation are still challenged to find the appropriate workforce,” he explained.

“Ultimately, without conduits to building a sustainable supply of direct care nurses, as well as funding to support competitive wages for direct care nursing, the supply and demand could become imbalanced, creating very real [issues with] access to care.”

Researchers from the University of California-San Francisco evaluated the program, which was hosted through the telecare platform Care Ecosystem, on 780 older adults with dementia. Participants were randomized into two groups. One received telephone-based collaborative dementia care through the platform, delivered by a trained care team navigator, who provided education, support and care coordination with a team of dementia specialists, including an advanced practice nurse, social worker, and pharmacist. The other group received dementia care as usual.

After approximately one year, those in the telehealth group had average Medicare costs $526 lower than those receiving the usual model of care. This finding follows previous research by UCSF that found that the percentage of caregivers in the Care Ecosystem program with moderate-to-severe depression dropped from 13.4% to 7.9% over the course of a year, versus an upswing in depression among caregivers in the usual care cohort. Additionally, quality of life for patients in the Care Ecosystem was ranked higher, according to this research.

The investigators noted that the telecare program will launch even more broadly in July 2024, and will be available to patients with dementia who live either at home or in assisted living communities. They must be covered by Medicare fee-for-service or have dual Medicare and Medicaid eligibility. The program will include navigators that assist with drugs, transportation, respite care and day care.

“The challenges of providing constant support to patients with dementia can take a heavy emotional, physical and financial toll on unpaid caregivers. This program will enable the caregiver system to shift from crisis-oriented to proactive,” said senior author Katherine Possin, PhD, of the UCSF Department of Neurology, and co-founder of the Care Ecosystem.