Long-term care providers were intent on dismissing undesirable memories of the COVID-19 pandemic as much as possible in 2023, but the year’s top stories revealed there were still remnants of it to deal with — and plenty of other issues to fill the gaps.

From unprecedented, increased regulatory pressures to newly introduced legislation, ongoing workforce challenges, image problems and more, there was a lot to digest.

Here are the top stories that grabbed our readers’ attention in 2023, the top handful of them inevitably related to the staffing mandate and the sector’s ongoing workforce challenges.

Federal minimum staffing proposal dominates

By the time the Centers for Medicare & Medicaid Services finally issued its first-ever rule to set nursing home minimum staffing levels, the sector had experienced a roller-coaster of tense emotions. The Sept. 1 announcement put providers and their advocacy counterparts in labor and consumer groups in an uproar.

Operators called the proposal an impossible, unfunded mandate, if not because of the estimated $4 billion or greater price tag, then because there simply aren’t currently enough registered nurses to satisfy the tripling of current mandated levels.

‘Accidental’ early study release, Biden unloads on providers

President Biden added fuel to the fire when he unloaded on nursing operators just days after the staffing mandate was proposed.

The administration, however, was undercut a few days before the proposed rule’s release, when a “draft” of it was briefly posted online before being pulled down. That gave outsiders an early look at study findings saying it’s impossible to settle on a specific staffing level(s) that would serve the White House’s desired goal. Despite officials calling it a “draft” study report, it was nonetheless included in the same form when the proposal was released later that week.

The intrigue persists: Was it truly an accidental early posting, or was it the purposeful act of an insider sympathetic to providers’ year-long criticism that an unprecedented staffing mandate would be a bad idea?

Staffing mandate’s costs greatly underestimated: report

Three weeks after the staffing mandate was officially proposed, a respected third-party analyst hired by providers found that its cost would be nearly 60% higher than the $4 billion annual cost estimated by the Centers for Medicare & Medicaid Services.

Nursing homes would need to spend more than $6.8 billion annually and hire more than 102,000 new workers under its proposed form, said an updated analysis issued by accounting and consulting firm CliftonLarsonAllen.

Bills would block federal staffing mandate

Within five weeks of the staffing rule’s proposal, Republican House members proposed legislation to block it. A similar Senate bill, this one bipartisan, was proposed in December. 

The legislative efforts are being led by lawmakers in rural states, which figure to be most severely hurt by any new staffing standard.

CMS delivers 4% Medicare pay raise

Nursing homes received a higher-than-expected 4.0% increase to their Medicare Part A payments for fiscal 2024. The July 31 final rule from CMS added 0.3% — or $200 million — to the agency’s original April proposal. Inflationary costs were deemed responsible for the largest annual increase in recent memory.

In addition, most of the recommended vast changes to CMS’ quality reporting and value-based purchasing programs were retained in the final rule.

Biden plan would tie pay rates to staff turnover rates

In mid-April, President Biden signed a massive executive order that included several measures intended to improve access to long-term care and bolster job protections for skilled nursing workers. Among them were calls to expand on the then-undisclosed staffing mandate and to tie Medicare payments to staff retention.

The White House called the 50-plus elements the “most comprehensive set of executive actions any President has ever taken to improve care for hard-working families while supporting care workers and family caregivers.”

Nursing home ownership transparency pushed

Federal authorities made good on their promise to increase transparency from anyone owning a stake in nursing homes, or doing top business with them, with a rule finalized Nov. 15.

The rule imposes many of the ownership transparency measures outlined in a February proposal and defines both private equity and real estate investment trust owners. A coalition of 18 attorneys general fueled aspects of the rule with a plea for more ownership information.

Feds lift COVID-19 vaccine mandate that Supreme Court upheld

Regulators made big news in late spring when they announced they were acting to COVID-19 vaccination requirements for healthcare workers. The mandate had been upheld by the Supreme Court in a historic court decision in January of 2022.

Other vaccine requirements also were lifted with the end of the public health emergency on May 11. Booster shot rates have plummeted since.

Among the other big story lines

As the referring examples in this sentence indicate, the skilled nursing sector saw a growing number of providers shedding or closing facilities, or filing for bankruptcy as access worries mounted.

Meanwhile, as Medicare Advantage plans passed the 50% market share level for the first time, regulators made moves to impose more standards on them, with providers appealing for even more.

On Oct. 1, the largest overhaul to the Minimum Data Set in years became effective, capping a hectic year of planning and worrying.

Also on the federal regulatory front, authorities quietly put into place new, stricter measures regarding infection control and general vaccine immunization matters. They also continued to increase scrutiny of the use of antipsychotics and schizophrenia medications.

In other pandemic-related matters, a federal jury found that the nursing home that was the site of the first major COVID-19 outbreak in the US was not liable for the deaths of two residents. It signified one of a number of heartening court victories for providers accused of wrongdoing in the early days of the public health emergency.

Tighter regulation should be expected going forward, no matter how the proposed Centers for Medicare & Medicaid Services rule may ultimately be altered, according to Erin Shvetzoff, the CEO of Health Dimensions Group.

“We continue to see this administration really pushing higher regulation and higher penalties around skilled nursing facilities and this will be pushed to our states,” she said during a webinar forecasting trends that her firm produced.

Nursing homes must be proactive about addressing these problems going into 2024, asserted Paul Branin, HDG’s vice president of business development.

“[Solutions] should be implemented regardless of whether the final decision is made on the staffing mandate,” Branin said, before outlining his suggestions for SNFs. “Overall, a difficult operating environment for skilled nursing operators exists, but there are opportunities for success for operators committed to quality care and overall improvement.”

Experts spoke candidly on both the challenges and opportunities facing skilled nursing operators, laying out industry trends for the coming year.

An eye-opening 94% of nursing homes across the country do not currently meet at least one of the three staff-hours requirements in CMS’s proposed staffing minimum rule.

Meeting those requirements will mean 100,000 new full time employees country-wide and cost SNFs nearly $7 billion annually. This is especially burdensome when the workforce has already contracted by 210,000 since the COVID-19 pandemic — a block of the workforce that likely won’t be regained until 2027, according to John Capasso, executive advisor at HDG.

Oriented toward solutions

Branin gave three top tactics for addressing the changing employment landscape in 2024. Staff retention led out of the gate. 

“What are you doing to keep your staff in place?” he asked. “Are you surveying them? Are you asking for their input? Are you implementing the recommended changes?”

He also highlighted pursuing new technology as a way of streamlining workflows. Shvetzoff endorsed the recommendation.

“[New technology] can help with monitoring profiles, changes in vitals, helping quickly respond to clinical needs, and assisting with staffing needs,” she said. “What tasks can we replace with technology to allow our people that we’re able to hire to take care of the amount and the acuity of people coming our way?”

Finally, Branin recommended outsourcing or centralizing administrative tasks as much as possible to continue freeing up time for care workers to focus on residents. 

“Revenue cycle management is one area that can be completed fairly easily offsite, which allows your community to spend more quality time taking care of their residents,” he explained.

Experts agreed that, overall, the key ways to weather current market challenges will involve holistically looking inward and finding innovative ways to maximize efficiency rather than hastily expanding outward in search of new profits. 

“When considering growth … thinking in a holistic approach is most important,” Branin stated. “Growth will bring new revenue, but what are the risks associated with this growth — reputational, regulatory or financial?”

Jo-Ann Heram S. Esturas, a registered nurse and Filipino immigrant, sued her former employer Nov. 20 — claiming she had been trapped into untenable working conditions and subpar pay. The terms of her recruitment allegedly threatened having to pay $25,000 to Glen Island Center in New Rochelle, NY, if she breached her three-year contract, as well as the loss of her residency status without work. 

The case is among the latest examples of immigrants being recruited to bolster the staff of US nursing homes, then allegedly finding themselves locked into years-long contracts and working conditions they found to be unbearable or dangerous. 

Some staffing agencies also have tried to make employees pay for the agencies’ legal fees if they are found to be in breach of their contract — a “loser-pays” practice that the US Department of Labor has argued is coercive and likely to dissuade immigrants from pursuing legal action to protect themselves from violations of immigration law. 

In a civil suit against one such agency, the DOL asserted that recruiting immigrant workers with contracts threatening to force repayment of wages and then pile on additional legal fees amounted to attempts to “use workers as insurance policies to unconditionally guarantee future profit streams.”

Increasingly vital workers

The long-term care sector has increasingly come to rely on foreign-born care workers in the midst of staffing shortages and increased staffing mandates. About 20% of direct care workers in nursing homes are immigrants in 2023, with research showing that the increase over time has improved overall care quality without impacting nurse skill levels or the cost of care. 

Immigration could become an even more important source of workers for the sector if a proposed federal nursing home staffing mandate goes into effect. 

However, exploitative labor practices have been a steep obstacle for some immigrant workers. 

Esturas’ complaint describes her recruitment as a “take-it-or-leave-it” offer that left her trapped once she arrived in the US and discovered her job involved overwhelming workloads and pay that never matched the DOL prevailing wage she had reportedly been promised.

The complaint alleges that Esturas and other staff commonly had no time to help residents with requests, assist them and manage their pain after falls or bring them their medication on time. 

Esturas resigned on the same day she sued her former employer, claiming that she was afraid she could lose her license or even be responsible for the death of a patient if circumstances continued unchanged. 

Immigrants are often recruited with the promise of higher wages than they can find in their countries of origin. But with cases like Esturas’ circulating, the question arises of how attractive these jobs will continue to be for foreign-born workers. 

Esturas is not alone — more than 40 other Filipino nurses filed a similar complaint against the same nursing home on Oct. 12 for alleged violations going back as far as 2013. 
Glen Island Center did not respond to a McKnight’s request for comment to the allegations by time of publication.

Speaking at the SEIU Care Champions Summit Thursday, Becerra called for additional accountability measures to ensure direct care workers see more of the money the government is spending in caregiving fields.

“We want 80% of the money we send out to be dedicated to the workforce for wages and benefits,” Becerra said in response to a roundtable question from the owner of a childcare business.

“You have a business so you have overhead and you have other costs, but we’re saying the business of care requires people, and if you’re going to have overhead expenses, most of it’s going to be to pay wages to the people doing the business.”

Refocusing toward nursing homes

In an interpretation of the event shared Friday by a communications firm on behalf of union representatives, Becerra’s remarks were edited to state that he was talking about the nursing home staffing mandate proposed in September:

“We want 80% of the money we sent out [to nursing homes] to be dedicated to the workforce for wages and benefits,” read a recap of the event sent out by PR firm Berlin Rosen. 

The staffing mandate would impose new cost reporting requirements but stopped short of proposing a minimum spending threshold.

“We were very intentional,” about creating an 80% threshold, Becerra went on to say in a video from the event posted Thursday. In fact, the Centers for Medicare and Medicaid Services in April did propose that 80% of Medicaid payments for personal care, homemaker and home health aide services be spent on compensation for direct care workers.

SIEU and other unions have brazenly boasted about their influence over nursing home policy setting in the Biden administration, and the admiration appears to be mutual. Earlier this fall, Becerra told a union rally that staffing regulations advanced to the formal proposal “because so many of you made the demand, quite honestly, the push to make sure that we establish real standards.”

SEIU national Vice President Leslie Frane made clear the union would like to see the administration further expand its spending requirements.

“This concept of putting strings on taxpayer dollars … seems like common sense to us,” she told Becerra.

The meeting in Washington, DC, was attended  by SEIU national and state leaders, as well as about 200 audience rank-and-file members. 

In an email Friday, a spokesperson for the HHS Office of the Secretary confirmed that Becerra cited the proposed regulation “to ensure the lion’s share of a Medicaid dollar for Home and Community-Based Services goes to pay the compensation of our care workforce. And we’re asking states to be transparent about how much they are paying.”

Staffing rule comments

On the nursing home side, Becerra touted the minimum staffing rule’s strong comment response from frontline workers, families and union representatives. He called for continued support for the rule, which received nearly 47,000 total comments, against strong headwinds.

“If you’re going to be a nursing home, you better have some nurses in your operation,” Becerra said. “If you are going to charge for that care, then give quality, and if you’re going to go out there and profess to people, to represent to people that you will safely and with care provide services to those people who are residents, then we have an obligation as our government to hold you accountable.” 

Becerra said some of the comments received “may lead us to make some changes to improve the way we enforce the standards to make sure that we’re covering all the bases.”

“We hope that we can finalize that rule with your support and then get to it,” he added.

Editor’s note: The union explained in an email after this story was published “that the attempt to provide clarity should not have singled-out nursing homes, and reiterated the Biden Administration and Secretary Becerra’s strong support for care workers across industries including nursing homes, home care and child care.“

Skilled nursing providers and associations representing them came out swinging in their official letters to the Centers for Medicare & Medicaid Services, which is poised to impose the nation’s first federal nursing homes staffing minimums dictating the amount of direct patient care provided daily.

Operators and leaders argued that the rule as proposed would devastate nursing homes financially and lead to reduced access to care for patients. While embracing the intent of the regulation, commenters argued a one-size fits all approach with an estimated cost of more than $4 billion annually, and no funding mechanism, will not lead to better patient care.

“For the first time in decades, our federal government is committed to meaningful action to ensure America’s older adults and families can receive quality care in nursing homes, and in their homes and communities. We applaud that interest and share that goal. However the administration is not getting this right, yet,” LeadingAge President and CEO Katie Smith Sloan said in a press release shared in conjunction with her Nov. 1 letter to CMS Administrator Chiquita Brooks-LaSure. 

“The proposal will fail because it does not consider two major issues: the ongoing workforce crisis and the proposal’s astronomical implementation costs,” Sloan added. “Should CMS opt to implement it as is, older adults and families’ already limited access to care will only get worse.”

Among the 46,000 comments received by federal regulators by the deadline were thousands of coordinated, organization-wide campaigns meant to outpace comments from the rule’s proponents. 

Executives told McKnight’s Long-Term Care News the Ensign Group submitted an estimated 1,500 letters from its partners and affiliates. Team members from the Good Samaritan Society shared more than 600, and Tennessee-based Diversicare, more than 500.

“Our hope is that our collective voice, both as an organization and as an industry, will be heard by policy makers resulting in a more reasonable and nuanced staffing rule,” Diversicare CEO Steve Nee told McKnight’s.

Read here a sampling of comments from this historic effort:

Mark Parkinson, President and CEO, American Health Care Association/National Center for Assisted Living

“Chronic Medicaid underfunding and soaring inflation mean many facilities are operating on shoestring budgets or are on the brink of closure, and these unfunded mandates could push them over the edge — severely impacting seniors’ access to quality care,” wrote Parkinson, who asked CMS to rescind the proposal.

“The Proposed Rule has a disproportionate impact on nursing homes that are committed to serving some of our nation’s most vulnerable. Nursing homes that do not meet at least one of the requirements are more likely to have a majority of their residents relying on Medicaid (56 percent average Medicaid census) compared to facilities that meet the criteria (43 percent),” he added. “If there is one single instance in which the nursing home doesn’t meet these requirements, they’re in danger of being cited, fined or even worse, removed from the Medicare/Medicaid program. Meanwhile, the hardship exemptions as proposed are virtually impossible for a facility in need to meet. The process is cumbersome and imposes all-or-nothing criteria.”

Citing case law, AHCA also argued that the proposal exceeds CMS’s regulatory authority

“Congress has already prescribed specific staffing requirements for nursing homes that participate in Medicare and/or Medicaid,” Parkinson wrote. “The establishment of nationwide minimum-staffing standards is a major policy decision with massive economic and political significance. By CMS’s own estimates, it will require about 80 percent of US nursing homes to collectively hire nearly 90,000 additional nursing personnel, at a cost of more than $40 billion over the next decade. … Given the importance and potential impact of the Proposed Rule, as well as the fact that Congress has already spoken to this issue, CMS must identify ‘clear congressional authorization’ to adopt standards that exceed those established by Congress.

Katie Smith Sloan, President and CEO, LeadingAge

LeadingAge conducted its own cost estimates and found providers and states that reimburse for Medicaid-covered care would spend close to $7.14 billion annually to comply with the mandate.

“Were CMS to push forward with this unfunded mandate, the unintended consequences would cripple the healthcare system,” Sloan wrote. “Nursing homes would scramble to lure the limited RN workforce away from other healthcare settings that concurrently struggle with a workforce shortage. Where nursing homes were staffing up to meet minimum standards, home health, hospice, and hospitals would be losing the staff they need and have relied upon. 

“Nursing homes that were unable to meet minimum staffing standards would be forced to deny admissions, take beds offline, or close the nursing home altogether,” she added. “This would mean that individuals who were no longer safe at home would have nowhere to go and individuals in need of post-acute care after hospitalization would either be stranded in the hospital, occupying valuable acute care beds needed for other individuals, or they would be forced to be discharged back home without the skilled nursing care that they need.”

LeadingAge does not support rule finalization “until CMS can assure enough qualified applicants and adequate funding to meet requirements.” Sloan also insisted CMS count direct care hours from all nurse jobs tracked in the Payroll-Based Journal system, including directors of nursing and other RNs with administrative duties — and for LPNs to count toward one of the hourly proposals.

Patti Cullen, President and CEO, Care Providers of Minnesota

“While we concur with your overall goal that workforce is key to providing quality care and services to nursing home residents, we believe the best way to meet that goal is to focus on initiatives that will incent workers to return to work in long term care or start their careers with us,” Cullen told CMS. She took special exception to the exclusion of LPNs from hourly care requirements.

“Omitting LPNs from a minimum ratio will have devastating effects on the ecosystem of LPN education, and the career ladders Minnesota established in partnership with educational programs,” she wrote.

Cullen also raised concerns about impacts on rural providers, who would have to be in compliance with the RN and CNA requirements five years after the proposed rule becomes final, versus three years for other providers. She said rural providers have “little opportunity” to meet waiver demands.

“To require a completed survey, be penalized first and then hurdle over all other requirements is an ineffective way to meet the identified program goals; it also places nursing facilities at regulatory risk given how survey cycles are defined. A more effective waiver process would allow nursing facilities to apply for a waiver of a specific requirement on a time-limited basis while they work on a compliance plan.”

Brett Salmon, President and CEO, Nevada Health Care Association

“Our estimates show that our annual costs to staff to the proposed level is $28 million. Nevada’s entire biennial (two-year) budget is approximately $62M. This single staffing requirement [over two years] would cost almost as much as the state, county, and federal biennial funding for our entire Medicaid program,” wrote Salmon, asking CMS to fund the mandate to avoid an historic “cost-shift” to state Medicaid programs.

“Please do not confuse our concern over the lack of funding as a lack of support for more caregivers,” he added. “Most nursing facility providers want more quality caregivers in their buildings. They are often caught between financial viability (low Medicaid reimbursement rates) and trying to find an adequate workforce. There must be a balance to keep doors open for our residents.”

He estimated that the proposed mandate would require his members to hire an additional 440 nurse aides and an additional 75 RNs.

Zach Shamberg, President and CEO, Pennsylvania Health Care Association

“CMS, as well as every regulatory and legislative body throughout the country, should start planning now for what will happen when a rapidly growing older population has nowhere to go to receive skilled nursing care,” warned Shamberg, whose association represents 267 of the 675 licensed nursing facilities in Pennsylvania. “There is a serious crisis upon us, and this proposal will make the environment far worse for our providers, workers, and patients. 

“If CMS does move forward with this regulation as proposed, mark our words: the end result will not be higher quality care in nursing facilities throughout the country,” he said. “Rather, we will see a dramatic loss of high-quality nursing facilities.”

Shamberg said CMS should work with providers and stakeholders to improve the long-term care continuum, and allow states to implement staffing policies that fit their needs. PHCA was instrumental in Pennsylvania’s adoption of higher staffing requirements that began to be phased in earlier this year — requirements that conflict with those proposed by CMS. He, too, raised questions about funding, noting particularly damning consequences for Medicaid-dependent facilities.

Steve Nee, CEO, Diversicare

“While the intention behind such a rule is to improve the quality of care in nursing homes, there are several reasons why this rule, as proposed, is inherently flawed and could cause more harm than good to our industry and, ultimately, to those residents and patients we serve,” said Nee, outlining now-familiar concerns about the rule’s rigid ratio, financial implications, the ongoing workforce shortage and potential to limit access.

Diversicare operates 44 skilled nursing facilities in Alabama, Kansas, Mississippi, Tennessee and Texas, and Nee drew specific attention to the rule’s “unattainable waiver.”

“As proposed, the waiver is incredibly difficult, if not impossible, to attain. Furthermore, it is unreasonably burdensome for those rural centers that may need it the most,” he wrote.

He asked CMS to: delay rollout of requirements until workforce stabilizes; allow a 5-year rollout for all providers; include financial assistance to help cover increased costs; allow for the 24/7 RN requirement to be met through remote oversight; allow LPNs to count in the overall nursing hour calculations; and allow support staff such as social workers and activities professionals to count in an overall calculation.

Susie Tack Beardsley, Chief Administrative Officer, Quality Life Services

“We have been spending money we don’t have in an effort to ensure our staff are being cared for, but the situation is becoming untenable,” wrote Beardsley, whose family-owned company operates 10 facilities in Pennsylvania. “The state of PA has recently put additional staffing requirements on us that do not align with what CMS is proposing, which could leave us either having to choose which one to follow or throwing our hands up and putting one more for sale sign in front of a LTC facility in Western PA. 

“We would be joining the over 30% that have changed hands or are in the process of changing hands since COVID,” she added. “These rules are creating the exact opposite of what they’re intended to do. Out-of-state buyers who have no interest or regard for residents are the only ones currently purchasing facilities because they’re getting them in a fire sale. PLEASE reconsider these ratios.”

Beardley said Quality Life spends “tens of thousands of dollars” monthly to recruit, using sign-on bonuses, referral bonuses, tuition support, tuition reimbursement, shift differentials, and twice-annual raises. The company’s wage scales have increased by almost 30% since the start of the pandemic, she added.

Cindi Janzing, Social Services Coordinator, Good Samaritan Society Miller 

Janzing used her letter to lay out the “grim events” that could happen in rural Miller, SD, should the community’s lone nursing home, a 5-star, 50-bed facility, be forced to comply with RN hiring standards and face closure. Ads for a permanent night shift nurse at the facility have gone unanswered by qualified candidates for three years, Good Sam officials have previously noted.

“There are 40 people that are housed and cared for here. They would be without a place to reside,” Janzing wrote. She went on to recount her work of relocating residents in another rural facility that was forced to close because of staffing shortages and rising costs.

“The difficult task for a resident to relocate after spending their entire life in the same community was heart-wrenching,” Janzing warned.

She asked CMS to consider seven changes to its proposal, ranging from the use of virtual RN support of overnight LPNs in small facilities to loan forgiveness to policies that address the explosion of agency nurse use in skilled nursing facilities.

PT has evolved from a non-licensed, early 20^th century, military-based, experience-based, on-the-job trained skill to one that now requires a doctorate. My first job out of college was in an osteopathic hospital whose rehab director was a WWII navy veteran with no specific training, and turned to me, a brand-new graduate, for physiology and treatment advice. 

Like my fellow students, I aspired to be a PT because of the adventure of helping, healing and improving lives. As the years progressed, my focus shifted to economics, financial dynamics and insurance outcomes. Because of the ways our efforts changed, so many of the PTs, OTs and SLPs who worked with and for me believed that our job was done when the patient’s progress “plateaued,” and that it was against our ethics and expectations to continue treating when that false measure was met. 

So much of my time has been spent explaining that “plateau” isn’t a thing, there is a specific legal measure that explains that, and that treatment dictated by a third party algorithm is in no one’s best interests and isn’t mandated. 

I recently attended a SNF care plan meeting for a distant family member, where the social worker said that since the patient’s progress had stopped, even though she would benefit from continued skilled care, they would be discharging her. I had to (gently) provide her with a Jimmo vs. Sebelius fact sheet. Imagine how many people she has misled with that pervasive mythology. Imagine how many people were discharged before they were ready. 

The nationwide shortage of therapists has changed the way we do therapy too. When I graduated, I had no trouble finding a job. At that time there were more empty PT positions in Ohio than there were licensed therapists. My inbox is still populated with job offers every day: near, far and travel. 

With the higher and more stringent requirements for PTs, and the longer path of tuition and subsequent student debt, the shortage is worse than ever. But paying a therapist the wage they deserve to continue their student loan payments seems to be beyond what some facilities and agencies can manage. And the 2024 proposed 3.4% cut in the Physicians Fee Schedule for therapy isn’t helping the landscape. The employers are at the mercy of the insurers, the therapists want to treat patients as they need and deserve, and the clients find themselves on a months-long wait list to get in. 

What’s the solution? A family member is the associate dean of the college of health at a nearby university, and though they have trouble finding students for the nursing program and the social work program, the therapy seats are still filling up. Where are those students going after graduation? 

COVID changed the landscape of healthcare in more ways than improved infection control. COVID also drove many healthcare workers into other careers because none of us had ever seen a horizon where we did everything right, but people didn’t get better. As fast as they’re graduating, positions are opening as veteran therapists leave us to become realtors, copy editors, retailers, mechanics or consultants. The “nobody wants to work anymore” fallacy we keep hearing is just that healthcare is not the same career we aspired to. In 2021, over 20,000 therapists nationwide left the profession in response to the pandemic. It kicked our buts, and for some, the trauma persists. 

What’s the solution? Our SNFs and HHAs can’t continue without physical, occupational and speech therapists. It’s our duty and obligation as caregivers to ensure the best possible treatment for those entrusted to our care, but before we can do that, we have to get staff and pay them properly. 

We need to write letters to our representatives, lobby, and talk to our legislatures to let them know how important it is to our elderly to stop the proposed cuts in order to keep our therapists. We did it successfully in 2018 to repeal the Part B therapy cap. We can do it again. As we get older, and as they get older, these services will be more important than ever. Spread the word and get our therapists back to the jobs they were meant to do.

Jean Wendland Porter, PT, CCI, WCC, CKTP, CDP, TWD, is the regional director of therapy operations at Diversified Health Partners in Ohio.

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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The financial problems threatening Linn Health and Rehabilitation in East Providence are emblematic of challenges faced across Rhode Island and the country, long-term care leaders in the state say.

Linn Health — founded in 1971 and home to 70 residents cared for by more than 150 staff — is now operating on a month-to-month basis, according to Rick Gamache, CEO of Aldersbridge Communities, the nonprofit organization that runs it. This is largely due to a significant gap between the costs of care and staffing, and Medicaid reimbursements from the state, he said. 

Linn Health’s residents have tried to pitch in, even running a bake sale that raised around $2,000. That is not nearly enough to cover operating costs, however. 

“During COVID, all costs skyrocketed, especially staffing, for which every penny going to staff is deserved and more, but state Medicaid programs have not kept pace,” Gamache told McKnight’s Long-Term Care News. “Our costs have increased by nearly 35% with Medicaid reimbursement increasing about 15% including the increase we received in October. We still lose over $100 per day per resident, and 80% of our residents are on Medicaid.”

Linn Health is far from alone, according to Jim Nyberg, executive director at LeadingAge Rhode Island.

“The precipitous decline in [nursing homes’] financial situation is unprecedented,” Nyberg told McKnight’s. “The gap between average Medicaid reimbursement and the average cost of care has spiked to over $60 per day in 2022, the last year for which we have cost data, and has presumably grown larger.”

Nyberg also noted that six Rhode Island nursing homes have closed and three more have entered receivership since 2022, which accounts for 12% of the long-term care industry in the state.

Battling funding struggles

Both Nyberg and Gamache are advocating for the state to provide some manner of “bridge funding” to Linn Health and other facilities in the state to alleviate financial struggles in the short term.

“We have been advocating with our governor’s office, the Medicaid program, and other stakeholders on potential remedies to try and provide a funding infusion into the industry,” said Nyberg.

Gamache spoke about how the financial emergency facing his nursing home is just one example of stories that are playing out across the US.

“All nursing homes are dealing with the same circumstances to some degree, and it’s not just here in Rhode Island. This is a nationwide problem that impacts independent not-for-profits, rural nursing homes, and those that are owned by individuals and families the hardest. Hundreds have closed with many more to come,” Gamache said. 

“I’ve had candid conversations with several others here and we’re all barely hanging on, operating month-to-month.”

Linn Health’s attempts to address the crisis have included everything from the bake sale, to advocacy with the state, to a media campaign to raise awareness. Still, Gamache says the facility is planning ahead for how to meet the needs of staff and residents if the facility is forced to shut down.

“We have two task forces working seven days a week to identify every way possible to prevent or at least minimize discharges and staff layoffs,” Gamache said. “We are looking at other ways we can utilize our building to care for the residents we love and provide jobs for the staff we painstakingly recruited and retained. It’s going to take a miracle, but sometimes miracles happen. I’m hoping the stars line up for this one correctly.”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Highlighted were plans for a new pilot for a nurse aide apprenticeship program, tools to strengthen resident councils, and meetings to raise awareness of facility renovation needs.

The Moving Forward Nursing Home Quality Coalition was formed in the wake of a 2022 report from the National Academies of Sciences, Engineering, and Medicine that industry leaders described as a wake-up call. 

The coalition of providers, residents, advocates and policymakers set out to develop actionable methods to fix the major issues, resulting in a nine-part plan they announced in July 2023. 

During Tuesday’s webinar, coalition leaders spent the most time focused on staffing issues. Coalition Chair Alice Bonner put a spotlight specifically on certified nursing assistants.

She referenced the struggles that nursing homes nationwide have had with retaining their workforce, including CNAs. 

“Across the country, CNAs are not well paid, they don’t get good benefits,” she pointed out. “We need to do something about that.”

Beyond simply offering higher wages and benefits, though, Bonner stressed the need to create a standardized career path for CNAs. 

More depth to training

She referenced a National Association of Health Care Assistants survey that asked CNAs who were thinking about leaving the industry what could keep them at their jobs. Better wages and benefits topped the list, but better training was a major factor as well.

“People really do want those additional skills,” Bonner said, “they want that additional training, and they want to get compensated after that.”

She noted that state and federal apprenticeship programs already exist for CNAs, but also that those resources lack the standardization that Moving Forward advocates for. 

“A lot of what we’ve learned is that there’s such variability and fragmentation. It’s not that these programs don’t exist — they absolutely exist — but some states have way more structure than other states.”

To address this, the coalition proposes that a national CNA apprenticeship program should be created with the specific goals of providing training that can be reliably replicated at the state level and providing skills and certifications that can be taken and applied in jobs around the country.

Moving Forward plans to pilot an apprenticeship program with at least two nursing homes by July of 2024 and leverage that momentum to advocate with policymakers at the state and federal level. 

“[CNAs] are the heart and the soul of the nursing home workforce and they spend the greatest number of hours everyday with residents. They know things about residents that nobody else does,” Bonner said. “They are a critical member of the interprofessional team and they really need to be recognized in a different way than they are.”

Resident councils and renovations

Other presenters took turns describing the progress Moving Forward is making on two other areas of their nine-part plan. 

Sumire Maki, program manager for Moving Forward, laid out the group’s progress on strengthening resident councils, including drafting a guide with tools that nursing homes can use to amplify the voices of their residents. Moving Forward also plans to test some of these methods in a four-facility pilot program starting in January 2024 in New Jersey. 

​​“Resident councils center resident voices and are truly a vital part of community life,” Maki said.

Isaac Longobardi, director of the coalition, also updated attendees on how the coalition is working to make renovations viable for nursing homes that want to create a more home-like atmosphere. They are in the process of partnering with state and federal policymakers on the issue. 

Next week, Moving Forward is meeting with the Department of Housing and Urban Development to discuss actionable steps that could be taken to incentivize renovations in the short term. 

At the state level, Longobardi said the coalition is meeting with policymakers from several states to make them aware that these renovations are a key part of improving resident experiences. Currently, awareness is low, he said.

“We need to make these changes part of state priorities overall in order to drive those changes,” he said.

The event was hosted by Gray Panthers NYC as part of the Transformation Tuesday series. A full recording of the webinar can be found here.