PruittHealth continues on its track toward growth, particularly in urban markets, but its CEO Neil Pruitt says the federal government needs to put more resources toward rural markets for operators.
The Norcross, Georgia-based operator has set its sights on expanding into contiguous markets while deepening its presence in certain states – Tennessee is next on the list, with Florida and North Carolina already in its footprint with room to grow.
Expansion efforts are all against a backdrop of staffing initiatives in the midst of a workforce crisis, outlined by the Biden administration and already set in motion by the Centers for Medicare & Medicaid Services (CMS).
The company has obtained approval for several counties in Tennessee so far, he said, and are under contract to build their very first skilled nursing facility in the new market.
In Florida, Pruitt has received approval to open up 13 SNFs, including a location in Tampa.
Pruitt told Skilled Nursing News that he’s most excited for what the company has planned in Raleigh, N.C. – the operator has acquired The Oaks at Whitaker Glen, a for-profit continuing care retirement community (CCRC).
The team has already renovated the independent living units and are gearing up to replace skilled nursing and assisted living beds, building upwards of 300 additional independent living units, 100-plus skilled beds and 93 assisted living units. Construction is set to begin in the fall.
One commonality among all of Pruitt’s expansion efforts – they’re all in urban markets. Smaller market, more rural areas are difficult to break into right now given available resources, he said, and without state or federal support.
“I think it’s important that our policymakers really discuss how we can bring those same innovations to the rural market,” Pruitt told SNN. “It’s something that the government should address because there’s no reason why someone in a small town shouldn’t receive the high standard of physical points you’re able to receive in an urban market.”
As Pruitt continues to move toward expansion efforts, the company is working on long-term and short-term solutions to the labor crisis to staff such facilities once they come online.
Rebuilding the workforce
Pruitt started to see hiring improve about six months ago while agency reduced, a trend in line with what Skilled Nursing News has also heard from real estate investment trusts (REITs) in the space.
Specifically, agency use was upwards of 10% about nine months ago. That number has since fallen to less than 1% — primarily concentrated in two buildings.
The operator has hired three employees for each staff member that leaves, he said.
“It shows that we are making progress,” Pruitt said. “While we’re experiencing positive momentum, we’ll still have some time before we catch up to where we need to be.”
Pre-pandemic, Pruitt had about 16,000 employees – that number has dropped down to 12,200. In order to meet its current staffing models, Pruitt needs to get to about 14,000 staff members total, leaving a gap of about 1,800.
The industry-wide staffing shortage has been made worse by the pandemic – 223,700 nursing home workers have left the sector since 2020, according to Bureau of Labor Statistics (BLS) data.
Without assistance, workforce recovery in the sector will not happen until at least 2026, the American Health Care Association and National Center for Assisted Living (AHCA/NCAL) has projected.
Workforce incentives
Pruitt’s 24% average wage increase for its workforce, from this time last year, has also been targeted to areas where the company was considered behind in the market.
For one, senior certified nursing assistants (CNAs) are now paid $17 per hour regardless if they’re at a facility in Ashburn or Atlanta, Pruitt said.
Other incentives involve team building trips that had to be put on hiatus during the worst of the pandemic. A popular customer service training and advanced training for CNAs in Disney World brings two CNAs from each building to Orlando as part of the company’s ladder program.
“Pre-pandemic, we had a less than 12% turnover rate with CNAs who went through that program. We can’t wait to get back to things we know work and … employee appreciation is part of our strategy,” said Pruitt.
The Georgia operator rounds out its workforce incentives with referral bonuses for both the current employee and new hire.
“Good staff attracts good staff; it’s always worked for us in the past and as we return to normal we think it’ll work for us again,” he said.
The international initiative and bureaucratic bottlenecks
A staffing solution that falls more on the long-term end – international workers – has hit a bureaucratic bottleneck after prospective staff gets hired by Pruitt. Overseas nurses are waiting to obtain visas from U.S. embassies in their country.
The original plan was to recruit more than 1,000 nurses and CNAs primarily from the Philippines, Pruitt said. Currently, the company has hired 202 nurses who are in various stages of the federal immigration process.
Only one nurse has actually started working at a Pruitt facility in South Carolina, with several more set to start work in the coming weeks.
Pruitt’s story is similar to efforts by a fellow operator, the Evangelical Lutheran Good Samaritan Society – the nonprofit has been trying to bring 250 nurses in from overseas with one success.
“It’s not a quick fix, but we think it will supplement our other efforts that we have already,” Pruitt said. “What hasn’t worked is the immigration process. A large number of those 202 that I mentioned are waiting on embassy interviews in their home country before they can be awarded a visa.”
About 500 international CNAs have offers outstanding, he said.
Some legislative action on immigration at the federal level could bring more health care workers to U.S. shores, but the fate of these bills remains uncertain — while other countries are way out ahead in attracting workers from other countries.
Immigration does fall outside of the purview of CMS, which means immigration policy as a long-term solution to staffing shortages would have to be a cross-agency lift.
The staffing reform backdrop
Workforce goals and expansion efforts are all put against the backdrop of minimum staffing requirements, among other reform initiatives. Some staffing reform efforts are still on the horizon, like the federal minimum staffing ratio, while others have already arrived – staffing data was incorporated into the five-star rating system last month.
Pruitt said the company’s five-star changes as a result of the staffing updates fall in line with other providers across the nation. A third of centers have had a decrease in staffing ratings, resulting in a quarter of all facilities experiencing a lower star rating overall.
“What started off as a noble system to help customers has really turned into a punitive system. I’m not a big fan of the changes they made,” added Pruitt. “If they spent half their time investing in our education programs so that we could get more nurses, we would actually be able to accomplish something.”
Pruitt likened the changes to moving goalposts. CMS sets the bar, operators think they’re doing good, and then they change the metrics – “it’s very frustrating,” he said.
Pruitt urges CMS to focus more on bridge programs for CNAs looking to become RNs or LPNs, creating career paths for the people looking to enter long-term care or further their career with a different position.
Taking on a wider perspective, Pruitt said the amount of regulation and adversarial position the agency has taken has forced operators in the industry to create their own narratives to boost public perception.
“I think the government can be more proactive in creating a narrative that entices people to care for our elderly instead of scolding providers and caregivers for useless regulations,” he said. “I frankly see it as politics at its worst.”
While frustrated over staffing changes at the federal level, Pruitt did express appreciation for the 2.7% increase in Medicare rates, much like operator colleagues and those in the REIT space.
“What’s encouraging is the way that they changed how they looked at the data. They counted more for inflation,” said Pruitt. “If they don’t do that in the future, providers are going to be underwater and in bankruptcy, to be quite honest with you. Increasing our costs in supplies is not keeping pace with increasing our rate increases both from Medicaid, commercial private sources and Medicare.”
Companies featured in this article:
Centers for Medicare & Medicaid Services, Evangelical Lutheran Good Samaritan Society, PruittHealth
