Long-term Care Facilities React to Laws Addressing Staffing, Isolation

COURT HOUSE – Two recent state laws enacted to address issues experienced by long-term care (LTC) residents and their families following prohibitions and limitations on visitation during the height of the COVID-19 pandemic are expected to have some impacts, according to local LTC administrators.
The bills implement recommendations from the Manatt Health Report (https://bit.ly/38gk2Rw) released June 3.
Bill S2712 requires minimum ratios for the number of direct care staff to the number of residents in New Jersey LTC facilities and establishes the Special Task Force on Direct Care Workforce Retention and Recruitment. 
The task force will evaluate job supports and incentives, training opportunities, wages and benefits, educational initiatives, and certification reciprocity rules. 
The task force will be required to submit a report to the governor and Legislature within one year of its first meeting, which must occur within 180 days of the signing, which was Oct. 23.
Bill S2785 requires LTC facilities to institute policies that prevent isolation of residents, addressing issues experienced by residents and their families during the pandemic.
Not Enough CNAs to Fill Needs
“S2712 does not provide funding to support the increased staffing levels, nor does it provide a means to attract candidates to the nursing profession,” said Jennifer Hess, administrator, Crest Haven Nursing and Rehabilitation Center, Court House.
“All nursing homes have struggled for years to meet and exceed New Jersey’s required staffing,” she added. “We always want more certified nursing assistants (CNAs) to care for our residents. The increase of ratios fails to recognize that there are simply not enough CNAs in New Jersey to fill staffing needs. 
“Our CNAs and nurses work extremely hard each day. This regulation will further strain a limited workforce. S2712 also fails to take into consideration that many have left the health care profession due to the risk and strain of the COVID-19 pandemic.”
Under current regulations, the state Department of Health requires nursing homes to meet a minimum number of hours of direct care per resident per day, which is currently 2.8 hours. 
When the new law takes effect in February 2021, those requirements will change to one CNA to every eight residents for the day shift, one direct care staff member (registered nurse (RN), licensed practice nurse (LPN) or CNA) to every 10 residents for the evening shift, and one direct care staff member for every 14 residents for the night shift.
Hess said Crest Haven strived to staff at minimum one CNA for every 10 residents on the daytime shift and afternoon/evening shift. Overnight, they have at least one CNA for every 14 residents. 
“Without LPNs and RNs, we currently exceed the recommended combined staffing levels for our evening/overnight shifts,” Hess said. “We have to be creative in staffing to optimize our resources as there simply are not enough CNAs in the area.
“We have an ‘acuity aide’ on our dementia unit who works a straddled shift, providing support to other CNAs with showers and lifts, and spending one-on-one time with dining,” she added. “Staff will split shifts to provide coverage when we have a call out. We utilize hospitality coordinators to coordinate family visits, pass snacks and beverages, visits with meal set up, spend one-on-one time, and complete other non-clinical tasks. This frees up our CNAs to provide care which only they, as a qualified professional, can provide.”
Financial Incentives May Not be There
For two other organizations operating LTC facilities in the county, staffing ratios are being met at their facilities, so the impact of S2712 is expected to be minimal. 
“I think an important and concerning factor is that the number of certified people to care for these residents is very small, especially in Cape May County,” said Jessica Stewart, executive director, The Shores at Wesley Manor, Ocean City, which is operated by United Methodist Communities, who operates 10 facilities throughout New Jersey.
“We are pulling from a very small pool of people,” she noted. “With the new minimum wage increase, the financial incentive to move to a new organization will really not be there. 
“How companies take care of their associates and the work environment will be the new wave of how these professionals will view accepting their very important role in our organization. As a Great Place to Work-certified organization for three years in a row, we are confident in our ability to attract and keep our associates.”
Stewart said they staffed their facility based on acuity and the needs of the residents. Presently, their staffing exceeds the new state requirements. 
“We are blessed to be a part of an organization that puts the residents and their needs first,” she said. “While every company has a budget for staffing, this is not a number set in stone because the needs of the residents are forever evolving and changing. Georgine Tracy, our health care administrator, and myself have the autonomy to staff according to the residents’ needs.”
Genesis HealthCare Facilities’ Staffing Above Minimum
According to Dr. Richard Feifer, chief medical officer, Genesis HealthCare Inc., their facilities are staffed above the minimum state requirements. They operate four LTC facilities within the county.
At the North Cape Center, Genesis has 3.18 hours of direct care per resident per day, while Victoria Manor has 3.06 hours, and Court House Center has 3.28 hours. 
Victoria Commons, the fourth Genesis facility in the county, is an assisted living facility, which doesn’t have the same staffing requirements.
“We are already exceeding these requirements in most cases,” Feifer said. “We will be prepared for the change in February 2021.”
Social Isolation Met Head-on 
S2785 will “hopefully” lead to “creative training and resources for activities staff, elevating the profession,” Hess said. “Activities personnel have always worked to overcome social isolation for nursing home residents. Their value in the quality of life each day cannot be overlooked.”
At the height of the pandemic, Hess said, COVID-19 brought “a lot of uncertainty for all involved. Our residents are feeling more comfortable as we’ve not had a resident outbreak, but they miss their families very much,” she added. “This impacts mood, appetite, and desire to engage in activities. Electronic and outdoor visits help but cannot take the place of holding your daughter’s hand or kissing your husband when he comes to visit. While many residents understand the reason we all wear masks, they miss the smile of their loved ones and care providers.”
To try and stay connected, activity programs moved into the individual nursing units at Crest Haven. 
“We purchased more karaoke machines to use to call Bingo and conduct group activities in resident hallways,” Hess said. “We conduct small, socially distanced events in our unit lounges. Our entertainers were a big help by conducting events in our unit courtyards. This allowed small, well-distanced groups to enjoy the outdoors, as well as their favorite musicians. Our activities staff stayed connected with other professionals for creative tips and ideas during the pandemic.”
The staff at The Shores at Wesley Manor also put technology tools into play when the pandemic started, keeping residents connected with their loved ones. 
“We maintained physician appointments through telemedicine and continued to ensure residents had daily interactions with staff and with their bubble of people internally, with social distancing at the forefront,” Stewart said. “As leaders, we always have been transparent with our residents and their families.”
Stewart said she thinks the two largest impacts from the pandemic restrictions were the loss of the communal part of living and residents’ ability to see their family members. Their staff tried to bridge the gaps.
Their Community Life Team kept the momentum going from the beginning, according to the director. 
“The joy cart traveled up and down the hallways with treats, books, puzzles, crosswords and much more to hallway Bingo games, exercise programs, religious programs, golfing tournaments, car parades in the parking lot, walking clubs and virtual programming,” she explained.
“Aside from much of this taking place within their apartments or their doorways, the interaction was always there,” she pointed out. “The difference now is we are doing very small group activities outside of their apartments. 
“Their community life calendars have just about returned to pre-pandemic levels with the exception of outdoor shopping trips. They are just down-sized groups and we now host the same programming a few times a day to ensure all residents have an opportunity to participate since the groups must be socially distanced.
“Today, we are back open to indoor visitation by appointment,” Stewart added. “We provide continued interaction and programming with the residents on an individual basis. The most exciting thing for them is the beauty and barbershop being reopened, and they are back to dining in small groups, socially distanced.”
Technology Helps Prevent Isolation
Genesis facilities used Zoom and outdoor visits with families to prevent social isolation, therapeutic activities have been modified to meet infection control practices, and their interdisciplinary care teams frequently weigh in on individual resident/patient needs to identify specific interventions.
“Indoor visitation will only be offered in communities without high COVID positivity rates and in centers that are COVID-free for a period of time,” Feifer said. “As we work toward this goal, we are acquiring safety barriers for indoor visitation, identifying areas where the visits can occur, determining how many visitors can be in a center at any given time, development schedules and acquiring additional protective equipment and cleaning supplies to meet Centers for Medicare and Medicaid Services (CMS) requirements.
“We understand that families are anxious to see their loved ones, but we want to do it in a way that is as safe as possible for patients, residents, staff, and visitors,” he added. “In the meantime, we are asking families to continue to schedule outdoor visits as this continues to be the desired method at this time, as it poses the lowest risk of transmission.”
Virus Coming from Community
Feifer pointed to recent research from Harvard (https://bit.ly/36e4Ce7) and Brown universities that shows, all precautionary measures equal, there are two key factors that determine whether the virus enters and spreads. 
First is the size of the facility – the bigger it is, the more traffic in and out, no matter how many restrictions are in place. 
Second is its location – whether the surrounding community is a high-density area heavily affected by COVID-19.
“The reality is this virus is coming from the community and now more than ever we need our communities to follow masking, social distancing, and other protocols to stop this virus,” Feifer said.
Most recently, the Court House Center had five staff members test positive in October, and the North Cape Center had four staff members test positive in September, according to Feifer. 
No residents tested positive, and Feifer said the positive results were found during their “proactive routine testing of all staff members. All staff members were asymptomatic and both outbreaks have been resolved.
“These most recent situations involved asymptomatic employees who likely acquired the virus in the community,” Feifer added. “With our robust precautions and protocols, we are pleased to report that we were able to stop the virus from spreading to residents.”
Tools Track Transmission Risk
Genesis created analytic tools to help track the risk of COVID-19 transmission in each local community and tailored center-specific precautions and protocols to adapt to community risk levels. 
Feifer said centers will receive an update every week on how their local communities have done containing the virus during the past week.
When rates of local community transmissions are higher, Feifer said centers will be more restrictive with precautions. When community transmission is lower, centers will continue the “good practices of infection control – social distancing, mask-wearing, and frequent hand washing – but may be able to flex their precautions, subject to state and local rules and regulations, in areas that are extremely important to our residents and their families, including family visitation, participating in group activities and volunteer and other third-party indoor access.
“With increased implementation of testing, diligent practice of infection prevention protocols and up-to-date communication of the current risk for transmission in each community, Genesis centers are leading the way in providing safer post-acute and long-term care for our patients and residents and achieving the confidence and trust of their loved ones,” Feifer said.
Ready for a 2nd Wave?
In preparation for the second wave of COVID-19 cases, the LTC administrators are not letting their guards down.
Feifer said, “We are now almost nine months into this pandemic and are prepared now more than ever. Early on in this pandemic, there was a shortage of personal protective equipment (PPE) and testing. At this time, we are seeing substantial improvement in both.”
“Getting ready for a second wave,” Stewart asked rhetorically. “No. We have been ready. This is not something you ever let your guard down about. Even when the numbers decreased and we were on the downslope of the curve, we remained diligent. The difference is, as this evolves, you become more creative with how you can maintain normalcy for your residents and staff.
“We are blessed to be COVID-free for several months now,” she said. “Even throughout the pandemic, there was less than a handful of resident positive cases and they weren’t community-acquired. We did have staff cases, but due to weekly testing since the first of May, these were quickly caught, and thankfully, we avoided staff-to-resident transmission.”
At Crest Haven, the administrator said they stockpiled PPE and their isolation and quarantine units are ready. The Cape May County Office of Emergency Management is also involved with keeping a local stockpile of PPE for LTC facilities.  
Nine staff tested positive since the pandemic hit, and those individuals were not allowed to come into work and stayed home to minimize the risk. One resident tested positive, but facility officials believe it was a false positive.   
To contact Karen Knight, email kknight@cmcherald.com.