‘A Feasible Plan’: Inside Nursing Homes’ Push for Immigration Reform, Funding for Higher Wages, Workforce Programs

Although there is a chance the federal government’s staffing mandate may be overturned, operators should still be aware of how upcoming changes could impact their operations.

This is according to sector experts, who said that while the mandate is well-intentioned, it lacks a comprehensive plan to address the realities of staffing shortages and regional variations in patient acuity and reimbursement.

“Where are we going to find these nurses?” Meagan English, Chief People Officer at Marquis Companies, said during a recent panel interview with Skilled Nursing News. “We’re already looking for them and we can’t find them. Then there’s the funding element. [We don’t have a system] where you can negotiate your reimbursement rate and raise your rates when your expenses increase, we don’t have that capability in our sector. We have a fixed reimbursement, and we haven’t thought through those plans.”


English was joined by Sally Cantwell, Senior Vice President of Organizational Development at PACS, who said that while the intent behind the staffing mandate is understood by the industry, its practical application is problematic due to the diverse nature of nursing home environments, which range from rural areas to highly populated urban centers, making a one-size-fits-all approach ineffective.

Moreover, there is a need for a nuanced consideration of different markets and patient acuity types to ensure patient safety and employee satisfaction, Cantwell said.

“We certainly want patient safety and our employees’ experiences to be prioritized,” Cantwell said. “We want all individuals involved in our spaces to be happy and safe. The staffing mandate must consider all of these details, acknowledging that it is not a one-size-fits-all solution. We practice in both rural and highly concentrated areas, each with different access to workers. Our perspective is that a one-size-fits-all approach won’t work in this industry, but that’s what is being attempted, and we don’t see how it will be successful.”


Potential legislative pushback

Both Cantwell and English believe that the mandate could yet see changes due to political influences, financial hurdles causing facility closures and legal challenges.

“There are many congressional, judicial, and financial variables at play in this space. We could see it overturned based on who becomes president,” Cantwell said. “There are cases in front of federal courts about CMS requiring something that we can’t possibly fund. Where will our finances come from? We could end up shutting down facilities that are providing quality care but cannot meet the mandated requirements.”

English added that industry associations and leaders are advocating for changes, and said that she hopes the industry and federal government can settle on a realistic approach to staffing that considers the existing workforce limitations and financial constraints. Facilities assessments, which are due within 90 days of the final rule’s official publication, can aid in the process of accurately determining each facility’s needs.

“I think there’s a high likelihood that there could be some change coming,” she said. “The timeline and specifics of that change are up in the air. We need to start now by doing assessments and looking at where each of our communities stands relative to qualifying for a waiver and how we are performing compared to our sector. There are many things we can and should be doing right now. We need to be ready for the call to action whenever it comes because we have to be part of the solution.”

A compromise could involve assessing each facility’s performance and acuity levels individually, but the industry needs to be armed with recommendations, English said.

“There aren’t registered nurses sitting around waiting for jobs right now, especially not in our field. It’s not for lack of trying; it’s for lack of supply,” she said. “How are we going to solve that problem? It involves capacity in nursing schools and immigration law reform. If we’re asked to increase wages, who can compete with hospital systems? If we’re asked to drastically increase commercial spending on labor, then what is the funding mechanism for that? We need to come back to the table and figure out a feasible plan to overcome these obstacles before implementation. There are risks of non-compliance that could affect many communities.”

Cantwell supported this view, adding that imposing mandates on high-performing facilities is missing the point – when the focus should be on addressing supply issues, particularly in rural areas.

“In rural areas, getting an RN 24/7 is not feasible,” she said. “If that’s the case, how can we achieve that? This opens up a conversation about whether we have enough RNs in the country. There are plenty of RNs, but they don’t want to work in this area. Then we’re talking about opening up borders and addressing a larger supply and demand issue that people aren’t willing to discuss right now.”

Focus on retention and development

Regardless of whether the mandate may be overturned or changed, staff retention and development as key strategies should be areas of focus for operators as they prepare for the future, English and Cantwell said.

“People need to feel like they have a say in decision-making and that they’re heard,” Cantwell said. “Access to growth opportunities, tuition reimbursement, and partnerships with universities and colleges are all big deals for us. We’ve found that building connections with educational institutions provides high-quality experiences and future leaders. Promoting leadership in even the smallest communities and teaching staff about supervisory planning and leadership is vital.”

Cantwell said that PACS’ Administrator in Training (AIT) program has been successful in retaining high-quality leaders within the organization.

“At any given year, we have 35 to 40 participants in our program … We teach them how to perform in their role as the CEO of their building, which includes financial management, leadership training, supporting staff, employee engagement, understanding skill mix, and all the other things that, when you first enter the industry, can make you feel like you’re drinking from a fire hydrant.”

Marquis has a similar approach, involving structured internships and development programs for administrators and directors of nursing, English said.

“We have a separate five-day management training where we bring in middle management leaders to learn more about what it takes to be a leader, what’s important to us, what should be important to them, and what we expect of them. Additionally, we have a year-long leadership development program for our existing leaders that we put people through, sometimes right after their initial training. We try to embody the ‘hire slow, fire fast’ mindset, taking our time with hiring decisions to ensure that we spend enough time upfront getting to know people, their skills, strengths, and weaknesses, and then coming up with an individualized development plan for them.

She stressed the importance of individualized development plans and continuous adaptation to industry changes to ensure effective leadership.

“When we look at leadership development, sometimes those people aren’t going straight into a leadership position, such as an administrator or CEO, right away,” she said. “Instead, we might prefer for them to take an assistant administrator position for a while or sit in a department head role to learn more. This approach is also very individualized to the person and what we want to see from them to ensure their success.”

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