If the sector is going to make meaningful progress in rebuilding its depleted workforce pool, federal government agencies need to begin unwinding many of the stringent Covid-19 related guidelines nursing homes have adhered to over the last two-plus years.

Until that occurs, the skilled nursing industry will likely remain stagnant, according to Carespring CEO Chis Chirumbolo.

A lot has changed since the start of the pandemic, Chirumbolo said, both in the large percentage of staff and resident vaccination levels, and the overall understanding of the coronavirus.

And for six months running, the rate of Covid-19 deaths among nursing home residents has been less than 1 per 1,000 residents, according to the American Health Care Association/National Center for Assisted Living (AHCA/NCAL).

Still, nursing homes continue to be one of, if not the only, health care sector that continues to practice under these very challenging federal guidelines, he added.

“I think that’s step one … And I’m not talking about patient safety related stuff, how to manage infection, I’m not talking about infection control criteria — all those things are vitally important. But what we can stop is doing the things that really don’t impact resident quality care and really hinders the health care delivery for our staff,” he said during an episode of the Rethink podcast.

Chirumbolo specifically pointed to the active screening process that all health care employees have to undergo before entering a facility as well as contacting families if there is a new Covid case in the building — even if that case has nothing to do with their respective family member — as two Covid-related requirements that could be pulled back at this point in the pandemic.

Highlights of Chirumbolo’s podcast, edited for length and clarity, are below. Subscribe to Rethink via Apple Podcasts, Google Podcasts, or SoundCloud.

On CMS’s final SNF rule and how Carespring could be impacted:

Yeah, I think it’s somewhat positive news.

I think what also is an optimistic approach is for all providers to understand that your voice matters. You have to stand up and make your voice heard, not just for this but into the future. During this rule. CMS received thousands of comments during the rulemaking process, many of which came from facilities, nurses, aides and other staff and I think globally that message from the frontlines matters.

I think it will help somewhat [for Carespring], but as we all know, our costs have exploded during the pandemic and patients on Medicare — which is what this rule, the fee for service world talks about — just makes up a portion of the patients we serve. The challenge is, I think, going forward is how do we rectify the several year, decades long issue in some states with a chronic underfunding of Medicaid. This population represents roughly about 60 to 70% of the SNF residents, so looking at that layered in with managed care as it comes into more facilities across the country, that component can be 70 to 80, 85% of the total population.

As we’re going forward, those segments either don’t cover the costs or, in some cases, Medicaid grossly don’t cover the cost. I have to give some states credit during the pandemic with added FMAP money, with that federal dollars that’s helped some states push those dollars to facilities and so that’s been a help. But I think it’s very much a reactive approach for, as I said, before decades long of underfunding.

On Chirumbolo’s confidence level in the government’s ability to work with operators:

I think I have no change in confidence. The federal government and CMS need to truly, truly listen to providers. You know this has been the long standing issue, from federal and state government, but it starts with the federal government because the state government follows the federal lead. So when you look at that, it’s time to innovate on all fronts, and so the regulatory and survey process today focuses mostly on compliance over quality of care, and this needs to be revamped as it distracts and often destroys the morale of our staff in SNFs.

As a result, what’s happened because of the pandemic, it’s pushed good people out of the industry. Why work in a SNF, a skilled nursing facility, when you can practice in another health care sector, like a hospital or [other] health care field, and not have to deal with this overall practice, this punitive practice by the federal government?

We have to do everything we can to keep these great people in our industry along with developing these next generation leaders. We have to fix those issues by stripping back and simplifying some of the Covid regulations. It’s not 2020 anymore, it’s 2022. We know so much more. The practices have changed so much more. In reality, we’re the only health care sector still practicing off of some of these CDC and CMS guidelines.

I think that’s step one because until some of those things run wound, and I’m not talking about patient safety related stuff, how to manage infection, I’m not talking about infection control criteria — all those things are vitally important. But what we can stop is doing the things that really don’t impact resident quality care and really hinders the health care delivery for our staff.

Also on a national and state level, how do we develop more vocational nursing and STNA programs in high schools? How do we develop STNA programs so anybody who wants to become an STA can do it free of cost? Maybe you create a fund to do that. We have to get to the next generation of people … And at the end of the day, until we develop a system between the federal government that listens and adapts and adjusts based upon actual feedback, frontline feedback. We’re going to be stagnant.

On how rising costs and inflation impact Carespring’s bottom line:

The biggest cost is just we’re paying our staff more. Our focus has been to try to be agency free and I think we’ve globally done a really good job with that.

Early in 2020 we started paying our staff more right there because we knew there was a fear factor in 2020. We didn’t know what we were dealing with, people were scared, we needed them to continue to help us take good care of the patients.

Then 2021, 2022 the global inflation has ballooned and it’s challenging in the sense that how do you forecast, predict and figure out how you’re going to be able to afford paying your staff that much more, paying for your food, paying for all those supplies? That’s where again, going back to the advocacy approach, is trying to work back with the governments and making sure that we can keep getting reimbursed or getting an adjustment in reimbursement going forward and in helping tell the story.

So how do we manage it? We just manage it day by day. We’ve got to make sure we’re meeting the patient’s expectations but also the challenging part layered it is we’ve limited some of the admissions we’ve taken in our buildings because we want to try to remain agency free. That’s a challenging decision to have to make in a position like me. It’s a no brainer from a quality care standpoint, but the challenging part is there’s patients out there who need to be taken care of, there’s hospitals banging on facility’s doors, asking for help asking for to get the throughput through.

But also, when you want to invest and innovate, it’s hard to do that when, as an industry as a whole, you’re only reimbursed at a stagnant fixed reimbursement rate.

On what Carespring looks at when considering growth:

There’s unfortunately a lot of facilities that are on the market because a lot of facilities are struggling and a lot of people just want to get out of the industry altogether. So taking over buildings that have that like mindedness makes it a lot easier going forward. The regional footprint is very much important. We do not really want to stretch out into multiple other states because that’s where you lose control, in our minds, of the overall operations and the vision and the mission of the organization.

So when you look at a building do they have relatively good processes? And if they don’t, that’s still okay. Do they have [a] good physical plant to get [it] done the way you want to provide care or is it going to be something where the building’s 50 years old and needs to completely be rebuilt?

Is it within a general physical footprint so we can be there within an hour or two, or a couple of hours … But I think at the end of the day, having the like mindedness and approach, going back to what I said before, and how they provide care, and doing the right thing at the right time, even if it’s more expensive … We tend to try to find those opportunities.

On Carespring’s continued staffing successes and challenges:

So we created this role at each of the facilities, like a retention hiring coordinator. This person’s role kind of melds a lot with the nursing department … Our statistics show if we keep team members beyond that three to six-month mark, they generally stay longer term so how do we get them from hire date to that point, and help them problem solve, bring up issues when issues come up.

I think another thing … I do a CEO talk every couple of weeks. So as we hire new team members, I virtually get on with all the new people at all the buildings and explain who we are, explain what we’re trying to do, be as transparent about the challenges, transparent about how we’re trying to manage the challenges but also trying to empower them on becoming the next generation of leaders … We have to get people to see it’s not just a job, it’s a career. It’s not just becoming a nurse aide, it’s becoming a nurse. It’s not becoming just a nurse, it’s becoming a leader, a manager or director of nursing or into some other role and it doesn’t have to be pigeonholed just for nursing. Since our buildings are regionally concentrated, those team members also have the ability to be promoted from sister building a to sister building b and be able to grow where some operators, some buildings might be just limited by their facility in their just one location.