There are few silver linings to be found In the historic nursing home staffing rule that has been proposed by federal regulators. But a detailed examination of the rule and continued review of federal staffing data show there is reason to hope providers could meet stiff, new 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 at an even higher 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 in November 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.
Here, McKnight’s Long Term Care News explores factors at several facilities making the mark to understand how and why their operating conditions allow them to exceed national norms. Their experiences demonstrate how critical certain partnerships, reimbursement models and other special circumstances 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
Launched in 1977, Lorien has eight skilled nursing facilities across Northern Maryland. 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.
“It comes down to, today, 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 centers 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 that makes operating the property at a high
level feasible.
He’s not surprised that so many newcomers to the sector cut staff to make costs more manageable.
“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, he 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 U.S. 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.”
Maine Veterans’ Homes
Maine, which already has a state staffing mandate, is one of three states where at least 75% of facilities meet all of the mandate’s proposed requirements, KFF found. But even there, providers may need extra financial or other support to staff up.
Skilled nursing beds have dwindled among rising costs and falling labor supply. The state lost 10 nursing homes over the last three years, with several leaders citing staffing challenges as a reason for closure.
Jess Maurer, executive director of the Maine Council on Aging, told the Maine Monitor that the federal staffing proposal should include additional support and funding for rural communities where it could be hardest to find additional workers.
“We’re the first in the country to deal with this, but we will not be the last,” she said. “We should be the canary in the coal mine. The feds should be looking at how many nursing homes have closed in Maine and why and who is going to follow because they can’t meet these staffing ratios in small,
rural areas.”
At Maine Veterans’ Homes, which operates six facilities, Veterans Affairs regulations that call for RNs at all hours are already driving up staffing costs. But those are borne by the American taxpayers — rather than individual facility owners trying to keep the doors open on slim margins.
As it is, the facilities in January listed dozens of open positions on their shared job board, including at least 22 LPN and RN jobs. More nursing homes fighting for those same kinds of candidates will likely only drive those costs higher and limit access to services there.
“Although Maine Veterans’ Homes assumes that the recent change proposed by CMS concerning minimum staffing requirements is prompted by a priority of ensuring care for nursing care residents, we are concerned that the mandate will have the opposite, unintended effect of complicating the availability of services for Maine’s seniors as the industry continues to struggle to meet staffing levels,” Chief Financial Officer Rebecca Gagnon said in December.
From the January/February 2024 Issue of McKnight's Long-Term Care News
