Lorien -- nursing home staffing

There were few silver linings to be found In the nursing home staffing proposal earlier this year. But a detailed examination of the rule and continued review of federal data show there is reason to hope that providers could meet its stiff requirements — with the right support.

More than 75% of nursing homes would not meet the proposed hourly requirements for registered nurses and certified nurse aides or 24/7 RN coverage if it were enacted now, according to the Centers for Medicare & Medicaid Services’ own rule. A KFF research brief issued weeks after the rule’s September proposal put that share even higher, at 81%.

That leaves somewhere between 19% and 25% of nursing homes that are already capable of meeting all three new standards. In addition, U.S. News & World Report last month published a list of 700 nursing homes (or about 4.6% of all those in the US) that meet both current requirements for eight hours of RN coverage five days a week, and proposed requirements for round-the-clock care.

McKnight’s Long Term Care News spoke with leaders of three facilities achieving the mark to explore how and why their operating conditions allow them to exceed national norms. Their experiences demonstrate how critical certain types of partnerships and reimbursement models could be in making higher staffing goals achievable nationwide.

Permian Residential Care Center, Texas

This 5-star, 90-bed nursing home is in the midst of oil country. When local seniors need care, they typically turn to Permian; there are no other skilled nursing facilities within a 25-mile radius.

That lack of local competition for the area’s few nurses, paired with the backing of a well-regarded, nonprofit community hospital have helped Permian maintain high levels of CNA and RN staffing. It staffs at 5 hours and 30 minutes of total direct care per day, according to CMS data, far surpassing the national average of 3 hours and 47 minutes. Permian beats national averages in the CNA, LPN and RN categories, too.

Being under the same umbrella and top-level leadership as the hospital makes it easier for Permian to operate fully staffed versus peers in a corporate structure with layers of regional overhead, Administrator Cydney Fulks told McKnight’s

“I think one of the things that helps us afford our nursing is we don’t pay a landlord fee. We don’t pay any operators’ cost because we are able to operate individually. We’re not paying a management company,” she said. “And if we need to make decisions here [about staffing], we’re able to have a discussion and go to our hospital CEO for the support that we need.”

Another major benefit that helps Permian recruit? The Andrews County Hospital District, the health system with which it’s aligned, has established level pay rates across settings.

“We don’t compete with the clinic for rates. We don’t compete with the hospice for rates,” Fulks said. “We have the same rates across the board, and I do find that to be very helpful whenever people are making decisions on where they’re going to work.”

Though Permian has a CMS-reported turnover rate of just 31%, it still dedicates resources to ensure leaders can more easily recruit when that’s needed.

Two local colleges offer clinical training at Permian, and Fulks said leaders aim to make those rotations educational and fun to expose students to the kind of activities regularly happening in nursing homes. The facility also runs a CNA training program, which it relied upon as it was staffing up a new 22-bed memory unit. 

During those in-house exposures, students experience a high nurse-to-patient environment.

“On my first day here, I thought they were having a staff meeting. There were so many people working,” Fulks recalled. “I didn’t know because it was my first day, but that was actually the staffing pattern. It alleviates a lot of burnout for there to be that many people.”

On a recent Wednesday afternoon, the building had 55 residents being cared for by six nurse aides, two shower aides and two restorative aides.

“They know that they can come to work and do a good job with their residents, and they’re not going to be stretched too thin,” Fulks said. “They can feel comfortable providing care because they know they’re not going to be one nurse providing for 50 people.”

And should Permian receive a sudden rush of patients, it only has to reach out to the hospital next door to find an RN quickly or get overnight coverage. Leaders work together on the ground to come up with long-term approaches and new strategies as needed.

“If we were in a different situation, like some of the communities around us, [the mandate] is going to be very difficult,” said Paul Slaughter, Permian’s certified medical director. “One, they don’t make their own decisions. Two, they’re going to say they don’t have the money. Three, if they have the money, it’s going to be somebody in Dallas or Houston making these decisions.”

While Slaughter has empathy for other facilities that may soon find themselves struggling to recruit and to afford anyone they can hire, he also believes a mandate may be necessary — especially for buildings without local control.

“In seeing the way these other places operate, if they don’t get given some direction on regulatory issues, they’re not going to do it. They’re masters at how to get around it anyway.”

Lorien Health Services Bulle Rock and Mt. Airy, Maryland

Lorien, with eight skilled nursing facilities across Northern Maryland, launched in 1977. Each  building has been built and continuously owned by the same family, and they are led by long-time CEO and President Lou Grimmel.

Two Lorien facilities made the U.S. News & World Report list of nursing homes that meet both the current RN daily coverage standards and the round-the-clock coverage proposed by CMS.

While both buildings have ventilator care units that require the presence of an RN or respiratory therapist at all times, Grimmel told McKnight’s that’s not the only reason its buildings have so many caregivers.

Higher staffing levels are part of the culture at Lorien, Grimmel said, although that comes with a steep cost that must be offset in some way. For now, it’s being borne by the owners’ tolerance to fund losses.

“We can’t make it work on the reimbursement itself,” he said. “We have ownership that cares and funds it, but how sustainable is that?”

Until COVID and its trailing inflationary pressures, the Lorien model worked because most campuses compensated for lower paying nursing home residents with a larger number of  Assisted Living units charging adjustable market rates.

Bulle Rock, which opened in 2018, was supposed to share its campus with a hospital that was never built and an assisted living component that was paused due to COVID. Instead, Lorien added a ventilator care unit there to help drive up reimbursements and support higher staffing levels.

“We can’t make it without it. We have to add something,” Grimmel said, adding that he’d like to work with the state on some kind of grant funding for behavioral health or other services that would help keep operations affordable.

He’s not surprised that so many newcomers to the sector cut staff to manage costs.

“What are you expected to do when your reimbursement stays basically consistent and because of the pandemic, your operating expenses, mainly labor, have skyrocketed?” Grimmel asked. “We don’t have a choice like the airlines to cancel flights. We don’t have a choice like the restaurants to close down tables. We have to get staff, regardless of what it costs us.”

But often, money isn’t enough to stem the tide. Sometimes, the right workers, especially RNs, simply aren’t available. Lorien is looking far and wide, but the federal government has stalled its efforts to bring in 31 new contracted RNs from the Philippines.

“We staff what we can get. It’s really that simple,” Grimmel said. “If we could get the RNs, we would staff all our buildings like Bulle Rock.”

But, Grimmel warned, not all owners will fund ongoing losses due to staffing, and none can do it without end. Even those driven by mission will need more financial support to survive, Grimmel said.

Government policies are too reactive, Grimmel said, noting the lack of funding for initiatives for senior care amid a rush of regulatory activity.

“Six of our eight facilities just won US News & World Report recognition. How are they doing it?” he asked. “It’s not because of the regulations. It’s because of our core principles.”