With just four days left to submit comments on a proposed first-ever federal nursing home staffing rule, providers who haven’t already offered the Centers for Medicare & Medicaid Services their concerns and suggestions are fine-tuning their messaging today.
Total comments posted to a site associated with the Federal Register surpassed 24,000 by Thursday night. While those comments represent a wide range of stakeholders, skilled nursing advocates are already well represented among the masses.
Emboldened by serious operational and financial stakes, many operators and owners have taken a broader view of the comment process and asked mid-level managers, individual administrators and other staff to weigh in on the rule, which was officially proposed Sept. 6.
Among those embracing such an approach, executives told McKnight’s Long-Term Care News this week, were the Ensign Group, with an estimated 1,500 submissions from its partners and affiliates; Idaho-based Cascadia Healthcare, with more than 400 as of Monday; and Tennessee-based Diversicare, with more than 500 unique comments.
“We found it incredibly important to gather as many comments as possible from various roles throughout our organization so that each could be well represented,” Diversicare CEO Steve Nee (pictured) told McKnight’s Thursday. “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.”
Here, McKnight’s shares excerpts of a few formal provider comments shared with us or posted on the official comment portal.
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 time horizon for the rollout for all providers
• Include financial assistance to help cover increased costs
• Allow for the 24/7 RN requirement to be met through inclusion of remote oversight
• Allow for LPNs to count in the overall nursing hour PPD calculation
• Allow for other support staff (such as social workers and activities professionals) to count in the overall nurse aide PPD 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.”
Beardsley 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.
Brittney Bright, Administrator, Radford Health & Rehab Center
“As an administrator who has run buildings prior to and after the pandemic, I am here to tell you this staffing mandate is not going to fix the issues that many long-term care facilities face,” said Bright, whose 90-bed Virginia facility has a 4-star rating and is an AHCA Bronze Quality Award winner. “I am very much a proponent for more staff and higher quality outcomes, but mandating a certain level with no funding nor solution as to how to fund it or find the staff to meet it will not work. All it will end up doing is forcing quality facilities to close, leaving many communities without the necessary places to assist in taking care of their loved ones.”
Like many commenters who work in skilled nursing, Bright offered constructive criticism of the rule and offered alternatives she thought would produce better, more sustainable results.
“Instead of an unfunded staffing mandate, invest money into programs across the nation to help solve the current issues we are facing with our inability to hire staff,” she wrote. “Work to build programs that engage high school students in healthcare and nursing careers. Invest money in scholarships for nursing students, incentivizing them to go into nursing to begin with. Utilize CMP money to boost the rates of those facilities who have a proven track record of quality outcomes to allow them to offer higher wages to their front-line staff and be competitive with non-healthcare sectors from a salary standpoint.”
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 said previously.
“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:
- Allow 24/7 RN coverage with a virtual RN support of LPNs on evenings and overnight for facilities with fewer than 120 beds.
- Adopt loan-forgiveness policies for staff
- Fund staffing increases
- Prioritize permanent staff over agency
- Count LPNs in a broader “professional nurse” category required to provide 0.55 hours per patient per day
- Address the national nursing shortage and attract more caregivers to the profession
- Add a 5-year phase-in for all requirements in both rural and urban locations
Donny Pelligrino, Director of Financial Services, Bridgeway Senior Healthcare
“I have been working in the Long-Term Care industry for almost ten years and staffing has been a consistent issue,” wrote Pelligrino, whose organization owns two skilled nursing and post-acute facilities and two assisted living communities in Somerset County, NJ, with a combined 447 beds. “Covid exacerbated the problem and it has made it extremely difficult to attract new workers for our company and into the industry.”
Pelligrino also advocated for full funding to staff at the proposed levels, as well as a 5-year phase in. And he pushed CMS to include staff other than RNs and CNAs in its hourly requirements, “mainly LPNs for licensed staff and other workers, such as activities, social workers, and other employees who spend just as much time with our residents as the CNAs do.”
“Most of the time if there is a decline in health, activities [are] the first ones to notice that a resident does not seem as engaged as usual.”
Cary Wolf and Anne M. Dunne, Board Members, Gurwin Healthcare System
“While CMS acknowledges that nursing homes might bear the cost burden, it has not taken action to address the variable and often inadequate Medicaid rates provided by states,” the board members wrote.
They said providers had not received a cost-of-living increase for more than 14 years in New York, where Gurwin operates two nursing and rehab centers as part of its Long Island life plan community.
“This funding stagnation, coupled with the recent challenges posed by the COVID-19 pandemic, has been particularly trying for both our residents and families,” they added. “The proposed staffing minimums are poised to exacerbate our existing struggles in talent acquisition and retention due to the increasing demands on our services.”
The board members urged CMS to not overlook that nursing homes like theirs “rely on LPNs to deliver essential services.” They advocated for their inclusion in the existing hourly requirements for CNAs or RNs.
CMS will accept comments on the “Medicare and Medicaid Programs: Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting” proposed rule through Monday night at 11:59 p.m.
