ACHCA Position Statements

Statement of non-support for Minimum staffing levels in SNF/NF

February 2020:  ACHCA supports efforts to authentically and demonstrably better the quality of life and the quality of care for residents that we serve. After due consideration the ACHCA cannot support the current bills before the House and senate respectively known as the Quality Care for Nursing Home Residents Act of 2019 (SB  2943)

The proposed legislation demonstrates a fundamental lack of understanding of the care delivery system in Skilled nursing facilities/nursing facilities and the environment they operate in. Further, it treats with disregard the information available from research on the subject over the past 3 decades.

The proposed legislation directs the staffing levels in SNF/NF to be identical. Clearly SKILLED vs NONSKILLED staffed identically, is not clinically correct. While minimum staffing levels are not a bad thing, the capricious and arbitrary nature of the bill as written shows disregard of the myriad of contributing problems that need to be addressed before even thinking of implementing this mandate. Address these issues and more support for this initiative may be garnered.

The proposed legislation dictates specific hours that shifts are to be started and that they run for 8 hours. The vast majority of administrators permit flexibility in the shift start times to allow for family and personal time. Many facilities utilize modified staffing patterns while some facilities offer other modifications, all to maximize employee satisfaction and increase employee retention. This bill would appear to eliminate the use of such employee/patient centric modifications. Dictating start times and length of shift brings to focus a lack of knowledge of the processes overseen by existing regulations and the challenges of the labor market.

The proposed legislation does nothing to address the profound shortage of the number of available applicants/hires of Nurses and C.N.A.’s. This shortage has been at crisis levels for more than a decade. The bill does not increase Title XVIII and Title XIX funding specifically for wages and benefits for Nurses and C.N.A’s but it does dictate that we must have more of them.

The legislation demonstrates a lack of understanding that some states have already have designated minimums. Fact is that most states have staffing requirements in their regulations. Many operators are actively recruiting foreign nurses through the H1-B visa program as there are NO nurses applying for vacancies. Research available on the LTC staffing subject publicly available suggests that the reason for staffing crisis is the lack of qualified applicants and not owner/operators resistance to hiring more staff. The legislation should offer, from the federal level, funding remedies for this lack of staffing.

In a robust economy with low unemployment, entry level positions (C.N.A.) compete with factories, fast food, services providers and retail establishments to fill work vacancies. Each of those competitors pay at or well above SNF/NF wage rates which have been suppressed over 4 decades by the Title XVIII and Title XIX programs driven by government policy. Once hired, the candidate must then undergo (under the proposed legislation) 160 hours for training. Many states have taken the training away from the facilities and placed with the community colleges. Thus, the class takes an inordinate amount of time to train (spread over a semester) and increases the cost for jobs that are not wage competitive. The proposed legislation makes harsher the penalty for not meeting the staffing minimum by suspending training that could be done by the facility, further restricting the flow of applicants. As an aside, there are facilities that train LPN, RN, PA, NP and MD’s but cannot train C.N.A.’s. ACHCA supports other legislation currently under consideration to relax this bottle neck. This legislation increases the present bottle neck. A further demonstration of lack of understanding.

The proposed legislation does not take into account the absolute necessity of a workforce that is motivated to care for others, for the weakest most frail in our society. This standard employed by most of our members further makes the hiring – which we want to do – more difficult as it eliminates those who seek only a paycheck.

We also compete with other healthcare providers whose services are paid for at a breathtakingly higher rate than ours. Anecdotally, if our rates in 1984 ($46.00) grew at the same as Critical Access Hospitals (1327%), we would have the resources, as our rates would be in the $600 range. In the example state (IN) the rate today should be $610.00. It is less than $200.00. No wonder hospitals can and do pay dramatically more for the workers needed in LTC. This rate and therefore, wage discrepancy, will further be exacerbated by the increased number of baby boomers needing Post acute/long-term-care.

Further complicating this issue is the Rules of Participation (RoP) promulgated by CMS, changes that have been phased in over 3 years, estimated to cost the industry 65 Billion in unreimbursed expenses – eating away at already scarce resources. The effect of another recent CMS initiative, Patient Driven Payment Model (PDPM), launched on the back of ROP initiation, has not yet been determined, but it may result in lowered revenues, further exacerbating these issues.

ACHCA would support its members participating in a commission to research and offer appropriate solutions to the problems which could lend some relief to the crisis created by archaic policies and legislation.

Hazardous Occupation Orders #7 (HO7)

February 2019 - The American College of Health Care Administrators (ACHCA) strongly encourages the Department of Labor (DOL) to amend the policy within Hazardous Occupation Orders #7 (HO7).  The removal of low-speed, electric patient lifts from the HO7 category would correct a grievous overreach, and the irony of including widely accepted patient and staff safety equipment in the HO7 powered lift policy is illogical.  The current policy effectively eliminates 16- and 17-year-old resident and patient caregivers from the workforce in a skilled nursing facility, nursing home, or assisted living facility.

In an industry of shrinking revenue, such as what’s seen in long-term care settings, along with increasingly burdensome regulations and an ever-shrinking labor pool, the proposed change by DOL would be welcome and would allow many new, younger people to obtain gainful employment.  In this case, such removal of the “protection” within HO7 will have a measurable impact on a workforce already in critically short supply. 

Proper training has already been implemented for training of certified nursing assistants on patient lifts, and this would not be changed with new additions to the long-term care workforce.  Thus, when properly trained, 16- and 17-year-old caregivers using patient safety equipment (i.e., lifts) would pose no decrease to resident and patient safety.

Further, this action permits administrators to better meet the needs of the post-acute and long-term care clientele they serve.  ACHCA enthusiastically supports this change in DOL policy.

A Statement on Patient Driven Payment Model (PDPM)

October 2018 - The American College of Health Care Administrators (ACHCA) is not opposed to changing the payment model for skilled nursing facilities (SNFs).  However, we do have concerns regarding certain aspects of these proposed changesThe Centers for Medicare and Medicaid Services (CMS) will implement a new payment methodologythe Patient Driven Payment Model (PDPM)for the traditional Medicare Part A program on October 1, 2019. This action will usher in the first major change in twenty years to how SNF providers are reimbursed for the care and services provided to their residents 

During the past twenty years, CMS has placed a very strong incentive for SNFs to develop successful rehabilitation programs, largely driven by only three therapies. The exclusion of respiratory therapy and mental illness therapy during these two decades was an oversight, and subsequent requests for their inclusion did not come to fruition.  The new PDPM model seems to be missing the same two elements for reimbursing care that focuses on the respiratory and behavioral/cognitive needs of residents, especially if a care community is working to decrease the amount of psychoactive medications delivered to residents or working to increase functionality by improving lung function.Grave concerns remain that these areas will continue to be overlooked in the new PDPM model, and this should be proactively addressed given the importance of including certain aspects of care (e.g., reduction in unnecessary psychoactive medications) in the resident quality measures included on standard re-certification surveys, directly affecting a care community’s 5-Star quality rating. Additionally, the resident profile is changing to include scores of younger, mentally ill, and/or chemically addicted residents who need these services, but PDPM gives no vehicle for payment of this. 

Physical, speech and occupational therapy programs have been very beneficial for SNF residents and the driving force that has enabled many, many residents of SNFs to regain their independence and return home. The changing emphasis on these therapy programs under the new PDPM model may have the consequence of increasing the number of people who would not be able to regain that independence and would have to remain in a SNF long term and/or would be at greater risk for readmission to a hospital. The new PDPM model seemto shift the focus for SNFs to recognize increased resident acuity from the current complement of residents.  If so, then there are reasonable concerns that reimbursement be appropriately structured to ensure care communities can hire the appropriate number of staff, and also appropriately qualified staff, to meet this increased resident acuity. 

While the stated intent of CMS is for this transition to be budget-neutral, the change from the RUG-IV system to the PDPM system is staggering in its significance.  The new PDPM model has the potential to negatively impact providers whose leaders aren’t attentive to or who fail to understand the effect of the changes and what their organization needs to do differently or better during the transition. Leadership will need to start initial training and planning for collecting new or different information, including looking at admission information processes and staff competencies for understanding the PDPM model, and properly implementing it in care communitiesThe nursing home administrator must be equipped to fully understand what these changes mean for the day-to-day operations at their site, including necessary adjustments to QAPI plans.  Additional certifications on the part of some staff may be warranted, as well. 

Further, if CMS misses its budget-neutral target and lands in budget reduction territory, the effect of the change across the entire care continuum may well be catastrophic. History from the past twenty years demonstrates that many of the regional and national SNF providers experienced significant financial difficulties, including bankruptcy in some cases, under the weight of the shift from cost-based to the prospective payment system (PPS) model 

It should be clear that regulations and accompanying guidance will be provided to hospitals, in some form, to ensure accurate information is shared upon the transfer of a resident to a post-acute or long-term care setting.  This will aid SNFs in providing accurate, timely care to meet the resident needs if they have an accurate “picture” of the resident’s needs based on the acute care stay and care provided there. We would encourage the use of tools readily available for the acute care facilities to adopt that would assist post-acute facilities in improving the consistency of care. 

Further, we would encourage funding of the electronic medical record (EMR) grant created some years ago for post-acute care facilities to defray the cost associated with conversion to EMRs and the development of bi-directional interfaces to permit all care continuum providers to truly share patient information to facilitate more efficient and higher quality care. 

Other organizations have called for the establishment of a work group or taskforce of stakeholders to “proactively address transition and implementation challenge issues as well as aiding with education and dissemination of CMS guidance.” ACHCA would find such a taskforce beneficial and joins the call for such a taskforce to be created pre-implementation of the PDPM reimbursement system. 

The implementation of the PDPM model will require a culture change within organizations and their complement of staff members, along with daily use of quality improvement principles and techniques to assure the organization’s global readiness by October 2019. 

The American College of Health Care Administrators (ACHCA) represents post-acute and aging services leaders from across the country, with a mission to be the catalyst for excellence in aging services leadership. It is our position that PDPM represents a potentially positive change to how providers are paid for traditional Medicare Part A patients, and will compel providers to critically assess their systems for ICD-10 coding, their processes for better capturing of functional scores, and how their rehabilitation services are delivered to these patients in the coming year. Thus, ACHCA is inclined to support this change initiative, if the concerns brought forth are addressed to allow changes that will actually lead to improved care. Based on historical performance, we remain skeptical of what the outcomes of these proposed changes will actually be given its current form, absent information and guidance to ensure providers are properly equipped to utilize the new PDPM reimbursement model successfully and without negative financial impact. 

A Statement on Immigration Reform

July 2018 — ACHCA encourages The Department of Homeland Security, Immigration and Customs Enforcement, and the Administration to actively assess the impact of changing various immigration policies, thereby removing protection from refugee groups with protected status or other efforts to find qualified workers from other countries. We submit anecdotally that a disproportionate representation of these groups exists in the labor pool from which Skilled Nursing and assisted living facilities hire entry level staff members (e.g. food services, maintenance, direct care staff). In this case such removal of protections, potential deportations, or other changes to immigration policies will have a measurable impact on a workforce already in critically low supply for an industry that is already facing challenges on multiple other fronts.

A Statement on the Inconsistencies in Surveys of Skilled Nursing Facilities

July 2018 — The following proposed statement of position is derived from numerous anecdotal sources, including a survey of membership with a limited response (i.e., 45 responses from the current ACHCA membership).

For decades, administrators of long-term care and post-acute care centers have observed significant variations in surveyor behavior, survey protocols, survey expectations, scope and severity determinations, enforcement remedies, and informal and formal dispute resolution outcomes. We note that the prior survey structure did include different processes for surveying care communities in various states, and are hopeful that the uniform process adopted as part of the Phase II implementation of the Requirements of Participation (ROPs) will bring greater consistency to the survey and certification process. Accepting the current status quo, however, with its wide ranging dissimilarities does not serve to foster better staffing, reduce turnover in staff, improve the workplace environment, or attract workers at all levels. Additionally, inconsistencies in survey outcomes (e.g., number/type of deficiency citations issued, scope and severity of issued citations) and the varying outcomes of appeal processes do not assist care communities in their efforts to provide excellent quality of care, due to the uncertainty of how best to provide care and services without being cited further. Moreover, these inconsistencies in the survey process are also not in the best interests of the residents or clients, who we are privileged to serve, when care centers cannot respond appropriately to residents’ needs out of concern for further or more severe citations. We hope that efforts moving forward, including guidance provided to care communities and survey agencies, will ensure a more consistent and fair process with clear expectations, so that providers of long-term and post-acute services can continue to deliver outstanding resident-centered care across the country. Thus, the ACHCA urges the Centers for Medicare and Medicaid Services (CMS), as an integral part of the implementation of the new ROPs and new survey process, to take particular care and be diligent to ensure markedly greater consistency among intrastate survey teams and intrastate survey regions, between individual states, and among the ten CMS federal survey regions.

Medicaid Provisions in American Health Care Act

June 2017 — The American College of Health Care Administrators (ACHCA) represents over 2,000 administrators and other aging services professionals in the United States. Our mission is to be the catalyst of excellence in long term and post-acute care leadership. As a leader in aging services, ACHCA does not support the Medicaid reductions proposed in the American Health Care Act (House version) and the Better Care Reconciliation Act (Senate version).

Either of these pieces of legislation, which are intended to replace the Affordable Care Act, would slash Medicaid funding between $772 (Senate version) and $834 (House version) billion dollars between 2017 and 2026, severely impacting states’ ability to cover long term care services, especially those provided in skilled nursing facilities, nursing facilities, and many assisted living facilities nationwide.

Long term care in the United States is a growing field of health care delivery services; to be effective and to provide quality care to those who are most dependent on assistance during prolonged recovery periods or advanced age, resources are required. Cutting long term care coverage for Medicaid recipients will not only seriously risk the health of our aging population, but it will deny access to this care to those at lower ends of the economic scale, at a time when NO other options for these frail and elderly citizens exists.

A society is judged by how it treats the most vulnerable among them. As the leaders in aging services, we will not stand by while those we care for are at risk. ACHCA does not and will not support the American Health Care Act if this provision remains.



Strict Liability for Nursing Home Administrators

June 2017 — The American College of Health Care Administrators (ACHCA) is an advocate of excellence in long-term care and post-acute care, and our organization works to develop and educate Administrators of nursing homes to ensure quality outcomes for residents and patients.

ACHCA supports a system of holding nursing homes accountable and responsible for the safety and quality of life of those in their charge and care.

However, ACHCA does not now, nor will it ever, support the concept of strict liability for the individual nursing home administrator.

Strict liability calls for the punishment of individuals who are not trained in health care. Strict liability holds the Administrator criminally, professionally and personally liable for the actions or inactions of other people. These are business people managing health care providers in a high-pressure situation. Administrators must deal with regulations, legislation, compliance issues, staff, residents, patients, and families, in addition to reporting to their owner or board of directors.

Currently, each of the 50 states in our country has rules and regulations governing management and practices of nursing homes, in addition to the federal regulations that provide oversight and guidance to nursing homes.

It is our position that the Administrator is well-regulated and held accountable for the performance of their duties. We do not believe any additional liability should be imposed on these professionals.

The federal regulations governing nursing homes do not call for strict liability for nursing home administrators so we do not see a legal precedent for strict liability at the state level.

Nursing home administrators are motivated by a desire to serve and to help those in need. They are a special kind of person in that they have compassion and selflessness in the service of others. While they are a different kind of business person, they are in the end, business people.

As “the CEO of the building,” the Administrator is responsible for the daily management of the facility and all its departments. They are not the individual providing direct care or medical services to the residents and patients in their care.

The training of the Administrator is not clinical. They do not dispense medications; they do not tend to the sick; they do not change bandages. The Administrator makes sure that qualified staff is hired to provide these services. Holding the Administrator personally and individually liable for the actions of others in a field that they do not practice is unacceptable.

No other similar professional is held to this standard and to this level of personal liability.

Strict liability places additional stress on individuals that we need to perform at their best every day.

ACHCA believes that strict liability will create a crisis in the delivery of long-term care, as those with the passion and experience to fulfill this important role will leave the profession. It creates a barrier to new professionals entering the profession. No one should fear losing their home, their license or their freedom because of someone else’s mistake at work.

ACHCA’s position is that Nursing Home Administrators should be supported, not punished.

Policy adopted by Committee June 8, 2017
ACHCA Board approval on July 13, 2017.

Click here for a downloadable version of the ACHCA Position Statement on Strict Liability for Nursing Home Administrators.