Skilled Nursing Operators Put ‘Pedal to the Metal’ to Increase RN Staffing in Light of Federal Mandate

The recently proposed federal nursing home staffing mandate includes the requirement that all facilities have a registered nurse on staff around the clock, every day of the week. Operators are taking some early steps to prepare for this requirement even as they rally against this aspect of the mandate, arguing that 24/7 RN staffing will be impossible for certain facilities.

In particular, providers are mobilizing to hire more RNs or training licensed practical nurses (LPNs) for the role, executives at regional and national nursing home chains said at Skilled Nursing News’ recent RETHINK conference in Chicago.

For companies with facilities in both rural and urban areas, the staffing proposal’s sweeping standards are a source of particular concern. Signature HealthCARE, which operates 74 buildings across 8 states, and is the largest nursing home chain in Kentucky with 38 buildings, is among these organizations, said Amber Kirwin, senior vice president of talent acquisition and recruiting.

Signature is taking a “multi-pronged” approach to the mandate, Kirwin said, while “waiting to see where it’s going to lead.”

Leaders with CarDon & Associates and Elmbrook Management echoed Kirwin’s concerns about the one-size-fits-all nature of the proposed mandate and described how their organizations are nonetheless pushing to increase their RN workforce.

A push for upskilling

One of the biggest challenges in responding to the staffing mandate is simply managing the emotional response that the proposal has generated, said Amy Haug, chief human resources officer at CarDon, which owns and operates 19 senior housing and rehabilitation communities in Indiana.

“Right now, there’s that frustration,” she said. “It’s already been so hard, and we thought, ‘Okay, we’re over Covid, we’re through it, we’ve got it, and then this hits, and it’s like, ‘Okay, take a breath. We can do this.’”

Like Signature, CarDon operates in rural and urban locations, and Haug is cognizant of how differently facilities will be affected based on their market.

“But what we really want to do is just keep the pedal to the metal with hiring RNs and trying to source and retain,” Haug said. “And, we really have shifted a lot on developing our LPNs.”

Leaders at CarDon are reaching out to LPNs to encourage them to consider becoming RNs and providing necessary support, she explained. Haug is optimistic about the ability to upskill many LPNs to become RNs by the time the staffing mandate is slated to take effect.

That said, the conversations with LPNs to gauge their interest in climbing the career ladder are just beginning.

“We don’t know yet how many of them will be receptive, but we do have a career development program,” Haug said. “We have the bones in place and the process in place to be able to put them on to that track if they identify as being interested.”

LPN training no panacea

While supporting more LPNs to become RNs could help meet the mandate’s requirements, LPNs too are in short supply, Kirwin noted.

“The LPN population has been decreasing – it did have a rise over the course of the last three years with Covid – but prior to that, particularly in Indiana, we saw a lot of LPN colleges and technical schools close down because of it,” she said.

Even before the mandate hit, Kirwin was working with the EVP of operations at Signature to focus more on recruiting RNs versus LPNs.

Indeed, there are more job ads for RNs at skilling nursing facilities now, judging by postings on nursing forums and confirmed by SNF operators.

Adding another wrinkle to the situation: The proposed mandate excludes counting LPN hours entirely. This adds further incentive to recruit and train more RNs, but providers across the industry also are pushing back hard against the LPN exclusion.

“We can hopefully have changes from what we’re hearing now,” said Toni Headstream, director of clinical education at Elmbrook Management, an Oklahoma-based provider that operates 11 SNFs and one assisted living facility.

But she also struck a cautious note about how the Centers for Medicare & Medicaid Services (CMS) might go about adding LPNs to the mandate’s requirements. The concern is that the total number of required hours-per-patient-day will increase if LPNs are brought into the mix.

“Our legal team at work is a little bit more pragmatic, and they say, ‘Oh, yeah, if we count LPNs, they’ll just change the measurement …. And so, we’re balancing, giving our feedback now [to CMS] but still doing what we would probably be doing anyway in terms of upskilling and shifting the LPN to RN,” said Headstream.

With many rural nursing homes already on the brink, CMS’ proposal has instilled fears of closures for many operators in such regions. Headstream said that quelling anxiety among workers is one of the main challenges at the moment.

“We’re just trying to be productive and balanced, encouraging learning about this with our workforce versus not making it be an unproductive distraction or a worry for them,” she said. “So I’m like the eternal cheerleader … it’s not something I think any of us would have wanted.”

And while much of the current focus is on supporting professional development of LPNs to RNs, Headstream zoomed out to the bigger workforce picture, noting that career paths take many different arcs within skilled nursing.

Elmbrook offers careers ladders from the CNA, CMA, phlebotomist, LPN to RN, facilitating the path financially and by supporting education. And by allowing Elmbrook nurses to teach at area colleges, and then bringing those students into facilities to do clinicals, the organization is also creating a pathway to recruitment.

Doing so hopefully will open students’ eyes to the realities and rewards of long-term care nursing, and she urged more providers to partner with nursing schools to bring students into these clinical settings.

“Let’s face it, everybody wants to be like Grey’s Anatomy … but the reality is, there are also other options,” Headstream said.