Archive August 2023

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The 2023 McKnight’s Mood of the Market Survey

The staffing crisis in long-term care is showing signs of easing, but many building leaders still want higher pay in exchange for the extra work they’re putting in, according to results from the fifth annual McKnight’s Mood of the Market survey.

Overall, however, job satisfaction rose noticeably over the last year. And an overwhelming share of respondents reported they still found their work meaningful, even if fewer believed their efforts were fully appreciated.

Employees last year clamored for more co-workers to improve their job satisfaction. But the most desired change this year was a higher salary, with more than half of survey takers choosing that option. And despite three-quarters (75.1%) reporting being “somewhat satisfied” or “very satisfied” with their current jobs, almost one-quarter (22.6%) said they were “not so well paid” or “not at all well paid.”

The 2023 survey drew more than 500 responses from directors of nursing, assistant directors of nursing, and administrators and their assistants. They sent mixed signals about the meaningfulness of their work, their willingness to remain on the job and the changes today’s employers need to adopt to keep them.
The share of workers “very satisfied” or “somewhat satisfied” with their current job rose about 4%, up from 70.9% in 2022.

Cara Silletto, president and chief retention officer of Magnet Culture, said she’s hearing from clients that some staffing stability has been gained over the last six months. But she cautions that any relief from the workforce shortage shouldn’t be viewed as a return to pre-COVID normalcy. In fact, she believes many nursing home leaders see themselves with a new, lower staffing baseline — one that is leading them to demand better pay even after years of solid increases.

“On this particular question saying more staff will solve my problem, they’re now rolling their eyes and saying, ‘Yeah, yeah, that’d be nice,’” Silletto told McKnight’s Long-Term Care News after reviewing results. “They just want higher salaries because they’re thinking, ‘We’re gonna have to deal with this churn. And so I just need more money because I am never fully staffed. I am never going to get caught up. I am never gonna be not trying to fill tonight’s shift.”

Katie Piperata, a workforce engineer with 15 years experience recruiting for skilled nursing, counters that the boost in satisfaction rates and some of the other positive findings from this year’s survey are reflective of the labor crisis “getting a smidge better.” 

She noted the negative “trickle-up” effect of a DON being routinely called to the floor to cover for missing nurses or aides. Administrators then have to step in on some of the DON’s duties, a reality that has hurt satisfaction among both categories of workers in the COVID era.

These workers have also seen less external support as inflation cut into margins and led to regional staffing changes at many nursing home chains.

“Now that we have more staff and staffing is becoming less of an issue, hopefully, corporations that are managing these buildings will start adding back in some of the FTEs that they’ve cut over the last couple years,” added Piperata, with Tampa-based MedBest. “A lot of what I saw cut was more on the regional side, not the administrator or the DONs, but the people that they report to. I’m hoping that some of that support starts coming back because that’s how you mentor your administrators and DONs. You have to have enough people above helping and grooming and growing them.”

At National Health Care Associates, which operates 33 facilities in the Northeast, leaders are trying to combat inflationary pressures with fair salary increases and a culture that prioritizes retention. They’ve seen increased demands for raises and higher asks from new candidates, says Anthony Scarpino, the company’s vice president of talent acquisition. 

“It’s a factor of the rapid inflationary growth of salaries,” he told McKnight’s. “Your salary may fall behind in a single year.”
That could be one explanation for the 52.2% of respondents who said a higher salary would most improve their job satisfaction. That share was 51.3% among DONs and 52.8% among administrators.
Just 17.5% of all McKnight’s survey respondents said they were “very well paid,” a finding that remained flat from year-to-year, despite recent raises that exceeded historic averages nationally. Among administrators, that figure was 18.5% and it was just 16.1% among nurse leaders.

Nursing home administrator salaries averaged $127,763, up 3.6% from $123,324 in 2022, while directors of nursing saw their average pay climb 4.67% from $103,954 in 2022 to $108,889, according to the annual HCS Nursing Home Salary & Benefits Report.

National currently has no openings in its DON or assistant DON ranks, but the perception that wages are stagnant makes it that much tougher to hire when there is a vacancy, Scarpino added. Strategies to retain rather than replace get high priority at the company.

“I can tell you that we have thought of every bonus incentive, either motivational or retention activity, that is known to man. Depending on the location that you work at, there’s a different combination that may be in place. We’ve tried things in one building that didn’t work and work really well in another building,” Scarpino said. “I think the only time that I’ve seen it more competitive is not necessarily during [the first wave of] COVID, but right after, as we were all trying to open at the same time, we were all trying to return to business.”

Although many providers are focused on competing for staff with agencies, travel nurse firms and other local healthcare entities, Silletto says there is a new foe they may not even take into consideration. That’s a massive increase in healthcare pay transparencythanks to social media, publicly available surveys and websites and even new legal requirements for job postings in some states.

“People talk more today about how much money they make than ever before,” she said, also quoting the adage that says “Comparison is the thief of joy.”

And comparisons between DONs and admins may be driving one split identified in the McKnight’s survey: Nearly 23% of DONs said they were “not so well paid” or “not at all well paid,” compared to 14.3% of administrators.

“It never surprises me that a second-in-command is less thrilled with their pay than the top paid person at any organization,” Silletto observed. “A lot of people just think, ‘I should be paid just as much as the next person,’ if they see themselves in a more collaborative role.”

“I honestly think there is nothing companies can do — outside of actually paying more — that can overcome this frustration people find,” she said. “When they learn how much money other people make, it is human nature to feel frustrated or jealous or angry.”

Years of unrelenting stress may also be undercutting the teamwork that so many facilities count on to keep operations stable. The share of respondents saying they feel their contributions are valued by their colleagues “a great deal” fell more than 4%, from 45.7% last year to 41.5% this year.

That doesn’t necessarily equate to dislike of the job, though. For the second year in a row, about 73% of respondents said they found their work “very meaningful.” Among DONs, that share inched up to 75.8%, while 68.7% of DONs reported their work was “very meaningful.”

This is the first in a four-part series revealing the finding of the 2023 McKnight’s Mood of the Market survey.

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US Department of Labor Announces Proposed Overtime Pay Rule

From McKnight's Senior Living:

Proposed overtime rule would worsen workforce, resident access issues, provider groups fear

A Labor Department-proposed rule that would make approximately 3.6 million more salaried workers and so-called highly compensated employees eligible for overtime pay is “ill-timed” and would worsen workforce issues for providers, threatening access for residents, senior living industry leaders told McKnight’s Senior Living on Wednesday, the day the rule was announced.

The Fair Labor Standards Act requires covered employers to pay their workers a minimum wage and, for employees who work more than 40 hours in a week, overtime pay of at least 1.5 times the employee’s regular rate of pay. Certain executive, administrative and professional employees are exempt, however.

If the proposed rule becomes law, most salaried workers earning less than $1,059 per week, or $55,068 per year, would be eligible for overtime pay when they work more than 40 hours in a week. The rule would increase the standard salary level for eligibility to the 35th percentile of weekly earnings of full-time salaried workers in the lowest-wage census region (currently the South). Currently, employees earning up to $684 per week, or $35,568 per year, are eligible for overtime pay.

“ASHA is deeply concerned about the impact this proposed rule will have on our industry, which is still recovering from the COVID pandemic and also facing its after-effects, including record inflation, a historic workforce shortage and rapid and dramatic increases in interest rates,” American Seniors Housing Association President and CEO David Schless said. “The proposed rule from the Department of Labor layers additional regulatory cost and compliance burdens on employers.”

Annualized direct employer costs over the first 10 years of the rule would total $664 million, according to a Labor Department estimate. But the proposed rule also gives employees higher earnings in the form of transfers of income from employers to employees, and the department estimates that those annualized transfers would total $1.3 billion.

Noting that the proposed salary threshold represents an increase of almost 55% since 2019, Schless said that the rule is “tone deaf, ill-timed, excessive, and will needlessly make senior living less affordable to some older adults and their families, if implemented as proposed.”

The rule also calls for increasing the total annual compensation threshold for the highly compensated employee exemption to $143,988, which would match the annualized weekly earnings of the 85th percentile of full-time salaried workers nationally. Currently, the threshold for highly compensated employees to earn overtime pay is $107,432 per year — they are considered exempt from overtime pay if they earn more than that amount.

In total, the Labor Department estimates that 3.6 million more salaried workers would be eligible for overtime pay under the changes in the first year after implementation, including 3.4 million people earning $55,068 or less per year annually and 248,900 highly compensated employees.

Acting Labor Secretary Julie Su said in an agency press release that “the right to a 40-hour workweek” has been “a cornerstone of workers’ rights in this country” for more than 80 years.

“I’ve heard from workers again and again about working long hours, for no extra pay, all while earning low salaries that don’t come anywhere close to compensating them for their sacrifices,” she said as the department announced the proposal.
But Argentum Senior Vice President of Public Affairs Maggie Elehwany said that the proposal comes “at a difficult time for employers, who are already facing higher inflation and costs related to care.”

Approximately 600,000 of the 3.6 million employees who would be newly eligible for overtime pay under the proposal work in the healthcare industry, she said, adding that the proposal “would have a disproportionate and potentially devastating impact on the long-term care industry.”

To recruit and retain needed staff members, 92% of assisted living communities already offer higher wages, 69% provide signing bonuses, “and many are dipping deep into their reserves to cover staffing agency fees, which cost two, three, or more times as much per hour as full-time employees,” Elehwany said. “A significant percentage of these costs cannot be absorbed and will ultimately be passed on to residents and their families and exacerbate affordability challenges.”

Senior living providers collectively will need to attract 3 million more workers by 2040, according to Argentum, and the long-term care industry as a whole will need 20 million.

“The long-term care sector lost more than 402,000 jobs during the pandemic, almost 7% of the total pre-pandemic employment base,” Elehwany said. “While the workforce crisis is showing some signs of improvement in other sectors, 70% of assisted living providers report experiencing a ‘significant’ or ‘severe’ workforce shortage, and 64% say that their workforce situation has not improved in the past year.”

Schless and Elehwany said that ASHA and Argentum, respectively, plan to seek input from their members and prepare official comments for the Labor Department.

“If enacted, today’s proposed rules would exacerbate the workforce crisis in senior living, increase costs and likely reduce access to assisted living at the same time that the population is aging at the fastest rate in more than a century,” Elehwany said.
A spokeswoman for the American Health Care Association / National Center for Assisted Living said that staff members were reviewing the rule.

The Labor Department is also proposing to automatically update all of the earnings thresholds beginning three years after the overtime rule’s effective date and every three years thereafter, to reflect current earnings data. The rule also would restore overtime protections in US territories, where the overtime threshold applied from 2004 until 2019.

Wednesday’s announcement follows months of outreach by the department to employers, workers, unions and other stakeholders. The DOL said that it held 27 listening sessions with more than 2,000 participants to inform the proposed rule.
Stakeholders, however, will have additional time to provide input. The department will accept comments on the proposed rule for 60 days after it is published in the Federal Register; those submitting comments can refer to Regulatory Information Number (RIN) 1235-AA39. Comments can be submitted online at or by mail to Division of Regulations, Legislation, and Interpretation, Wage and Hour Division, US Department of Labor, Room S-3502, 200 Constitution Avenue NW, Washington, DC 20210.

The rule has not been published in the Federal Register yet, but a 267-page PDF is available for review.
Publication of the proposed changes originally was slated for May but was pushed to August. The current overtime rule was finalized in September 2019 and went into effect in January 2020.

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Update on Federal Minimum Staffing Rule

The long term care sector has been waiting for CMS to announce new minimum staffing levels for the nation’s 15,000 nursing homes. This anticipated rule is part of the Biden Administration’s plan to address what it perceives as issues with quality in long term care. In an interesting development, earlier this week CMS accidentally posted the minimum staffing study on its website. 
A reporter from KFF Health News saw the study on the website and downloaded it. They then wrote a story about the study. CMS has since removed the study from its website. 
The study is over 400 pages long, so we are still analyzing it but essentially, it outlines the cost and work force challenges with a minimum staffing ratio requirement that our sector has been saying all along. A one-size fits all approach does not work for staffing. The new study demonstrates that there is no single staffing level that would guarantee quality care, although the report did note that higher staffing levels would lead to fewer hospitalizations and emergency room visits, faster care, and fewer failures to provide care. 
The rule is still anticipated to be released sometime in September. AHCA and MHCA will continue to keep members up to date on this important topic.
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2024 National Quality Award Intent to Apply (ITA) Period is Now Open!

2024 National Quality Award Intent to Apply (ITA) Period is Now Open!
The 2024 National Quality Award Intent to Apply period is your gateway to a journey of excellence. By taking a few minutes to submit your ITA, you're contributing to the advancement of quality care while opening doors to recognition, growth, and positive change. Don't miss this opportunity to be part of something exceptional. Start your journey today!

Why Should You Submit an ITA?
The doors to the 2024 National Quality Award Intent to Apply (ITA) are officially open, and there are compelling reasons why you should consider taking this step. By submitting your ITA, you're not only helping AHCA/NCAL, but you're also helping yourself. Wondering how? Read on to discover the benefits and simple steps involved in declaring your intent to apply.

Submitting an ITA plays a pivotal role in gauging the interest and participation levels for the National Quality Award. This preliminary step aids AHCA/NCAL in enhancing the review process and improving the overall application experience. Additionally, as a token of appreciation for your proactive participation, submitting an ITA qualifies you for a discounted application fee.

While submitting an ITA is entirely voluntary and has no bearing on your actual application consideration, it is strongly encouraged for all long-term and post-acute care providers to declare their intent to apply. Your contribution matters, and this simple gesture sets the stage for a remarkable journey towards quality excellence.

How Long Does it Take?
Believe it or not, it's a breeze. Following these three easy steps, you can complete the process in a matter of minutes. If you're already verified in the Quality Award application Portal, it'll take around 5-10 minutes at most.

Step 1:
Navigate to and click on the Portal.
Step 2:
Log in using your designated username and password. If you're unsure about your credentials, don't sweat it! Reach out to the team, and they’ll assist you in setting up your account.
Step 3:
Once you're on your center's dashboard, select the "Payment" option to submit your Intent to Apply. And just like that, you're done!
Important Dates:
Mark your calendars! The ITA submission period is open from Tuesday, August 15, 2023, through Thursday, November 16, 2023. While the deadline provides ample time, consider submitting your ITA sooner rather than later for a chance to receive a complimentary application fee for the 2024 National Quality Award cycle.

Access Additional Resources:
You're not alone on this journey. The National Quality Award website provides a plethora of helpful resources, including FAQs and application packets for the 2024 cycle. Whether you need guidance on the Portal or insights into the application process, you'll find the information you need to make your journey smooth and successful.

Exclusive Opportunity:
As an added incentive, the first 100 ITAs received will be automatically entered for a chance to win a complimentary application fee for the 2024 National Quality Award cycle. It's AHCA/NCAL  way of thanking you for your dedication to quality care.
Need Assistance?
Questions? Concerns? Reach out to, and the team will be more than happy to provide the assistance you need.
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AHCA training on New SNF value-based purchasing measures beginning Oct 1st!

New SNF value-based purchasing (SNF VBP) measures take effect October 1, 2023, which will determine Medicare Part A rates beginning October 1, 2025. Don’t wait to get your team on board with what’s changing.  
AHCA’s one-hour SNF VBP Essentials course details the new CMS measures including how CMS calculates VBP measures, risk adjustment, facility score and payment adjustments. You will learn how to use a SNF VBP prediction calculator tool (included with the course) to estimate the financial impact Medicare Part A revenue. In addition, you will delve into the existing all-cause hospital readmission measure and the three new measures to be counted this October 1, and more.
The cost is $40 for AHCA members and $80 for non-members. To take advantage of the member rate, AHCA Members must login to ahcancalED with their AHCA/NCAL usernames and passwords. For assistance obtaining AHCA/NCAL usernames and passwords, please e-mail with your name and facility contact information.
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Welcome New Member!

Join us in welcoming the following new Associate Organizational member:
Capsid Consulting, 2903 Philadelphia Pike #2820, Claymont, DE 19703 Tel: 888.461.3932 / Company contact: Dost Sarpel, MD, Medical Director Email: dsarpel@capsidconsulting.comCapsid Consulting provides infection control and antibiotic stewardship tele-consulting. It's mission is to enhance infection prevention and antibiotic stewardship programs in long-term care facilities via tele-consulting services.
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Are you Reporting C-Diff in NHSN?

Rule 90-590 Chapter 270, Uniform Reporting System for Health Care Quality Data Sets requires all nursing facilities to submit Clostridium difficile Lab ID Events for all facility-wide residents effective July 1, 2023.  You must report each Quarter including reporting of NO events.
The following is information on the steps you will need to take to submit C. diff surveillance data into NHSN for your facility, as well as the steps you need to take for NHSN to accept the information.
1.  VIDEOS:  The content in the links to the videos below was developed by the Health Services Advisory Group, Inc. for the National Nursing Home Quality Care Collaborative, and review the steps you will need to take to submit C. diff surveillance data into NHSN for your facility, as well as the steps you need to take for NHSN to accept the information 
Note:  These videos are a few years old, so the Social Security question is not required and no longer available in the field you use to submit C. diff events.
2.  Long-Term Care Facility Component Manual:  Here is the link to the NHSN manual for long-term care facilities. There is useful information throughout the document, but the most helpful sections for C. diff reporting are below. They include instructions and paper forms that can show you the information you'll need to have before entering data into NHSN.
  • Section 5: Annual Survey
  • Section 6: Monthly Reporting Plan
  • Section 8: LabID event (for C. diff event reporting)
  • Section 10: Monthly Summary Data
3.  NHSN Facility AdministratorDo you need to add a new administrator in NHSN because the previous administrator no longer works at your facility?   If yes, simply send a request to NHSN asking them to re-assign an administrator using this link:
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October MDS Changes- Section O

The MDS 3.0 version v1.8.11 final item sets and RAI guidance have been released, and substantial changes were made to several sections. 
Changes to section O (Special Treatments, Procedures, and Programs) include:
  • The expansion from two columns to three to reflect new timeframes:
    • On admission
    • While a resident
    • At discharge
  • Expansion on several items: 
    • Chemotherapy
    • Oxygen
    • Suctioning
    • Non-Invasive Mechanical Ventilator
    • IV Medications
    • Dialysis
    • IV access
AHCA has created an MDS Section O under MDS Updates, a resource document to help providers breakdown the changes. The information in the resource document outlines key changes to MDS Section O, Coding Instructions/RAI Guidelines for each item, and Actions to Consider for implementation across your facility.
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Maine to Establish an Office of New Americans (ONA)

Earlier this month, Governor Janet Mills signed an Executive Order directing her Administration to develop a plan to establish an Office of New Americans (ONA) in the Maine State government. 

Click HERE to learn more about the announcement.

You can also click HERE to sign up for updates about the Plan from the Governor's Office of Policy Innovation and the Future (GOPIF) and to be notified of upcoming opportunities to engage in the process, and click HERE to share your input on the development of the Plan.

The Maine Health Care Association will monitor and provide input on this new office when possible.

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NIH grant offers free Changing Talk (CHAT) Communication Training for Direct Care Staff

Dr. Kristine Williams and Dr. Carissa Coleman from the University of Kansas School of Nursing are seeking nursing homes nationwide to participate in a NIH-funded research study testing a new online version of the evidence-based Changing Talk (CHAT) communication training program.
CHAT educates staff about reducing elderspeak (infantilizing communication) and results in reduced behavioral symptoms and need for psychotropic medication for residents with dementia. The new online version - Changing Talk: Online Training (CHATO) - consists of three, one-hour interactive online modules that provide flexible and accessible access for staff.
There is no cost to participate and direct-care staff can earn a Certificate of Completion.  To learn more about CHATO and view research and training resources you may click here.
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