Though Door County’s nursing homes have made it through the first phase of requirements under a new ruling on staffing from the Centers for Medicare and Medicaid (CMS), the ruling’s final effects remain to be seen.

The ruling—which contains new minimum staffing regulations for skilled nursing facilities, or nursing homes—was issued by CMS on May 10 after an initial proposal last year. The ruling will affect all nursing homes in the U.S. by requiring more detailed assessments from each facility and more skilled nursing care hours daily for each resident.

Door County has three skilled nursing facilities. In the second quarter of 2023, none of them met all of the proposed minimums. In the first quarter of 2024, the facilities had generally improved staffing levels but were still not completely meeting the new minimums, according to an analysis by Door County Knock of the latest federal staffing data in CMS’s Payroll-Based Journal.

The rule has three components, and implementation will be staggered over the next five years, depending on the location of a facility. Rural facilities will be given more time to fulfill the requirements than urban ones. 

Phase one of the requirements is an updated staffing and needs assessment for each facility. It was due on Aug. 8, 90 days after the ruling was issued. 

Phases two and three will be implemented over the next two to five years. Facilities will be required to provide 3.48 hours of skilled nursing care to each resident daily, which must include at least 0.55 hours of registered nurse care and 2.45 hours of certified nursing assistant care. Facilities may use any combination of nursing staff (RNs, licensed practical nurses, or LPNs, and CNAs) to account for the additional 0.48 hours needed to comply with the total staffing requirements.

Some facilities will be able to receive a temporary exemption from the minimum staffing requirements based on several specific criteria, including being located in a workforce shortage area. This means the supply of applicable healthcare staff is not sufficient to meet area needs, based on U.S. Department of Labor statistics, according to CMS.

If a facility is not in compliance with the finalized minimums in the time frame laid out by CMS, penalties include denial of Medicare and/or Medicaid payments, monetary penalties or termination from the Medicare and Medicaid program. Local facility representatives acknowledge penalties could lead to reduced occupancy and possible closure if staffing doesn’t improve over time.

CMS plans to continue to monitor and evaluate the final ruling and said it will update the regulations as needed.

The Biden administration initiated the new CMS staffing minimums in February 2022, in response to safety and quality concerns in the long term care industry. A landmark CMS study in 2001 linked the amount of direct daily nursing care to the quality of life and health of residents, and provided staffing recommendations. 

Most states have their own minimum requirements, but until now there has been no federal regulation. CMS’s 2001 recommendations are higher than state requirements and the new mandated minimums.

Wisconsin requires a minimum of 2.5 hours of skilled nursing care per resident per day. Of this, .5 hours must be provided by an RN or LPN. All Door County nursing homes met these criteria in the second quarter of 2023.

In terms of the new CMS staffing minimums, the federal data show mixed results for Door County nursing homes in January through March 2024. Serenity Spring at Scandia Village in Sister Bay showed improved staffing overall, including meeting the minimum for CNA care every day from Jan. 26 through March 31 after not having done so previously this year.

Door County Medical Center’s Pete and Jelaine Horton Center Skilled Nursing Facility, in Sturgeon Bay, didn’t frequently meet the CNA minimum, but its average staffing level for RN care was almost four times the minimum. A representative said the Horton Center has reallocated RN staff to take on CNA-type duties.

Sturgeon Bay Health Services had lower staffing levels overall, meeting the overall minimum level of 3.48 hours of skilled nursing care to each resident daily only 15 of the 91 days.

For and against

CMS made an initial proposal for a minimum staffing rule in September 2023. The proposal went through rounds of public comment and revision by CMS before being finalized this spring. 

CMS collected roughly 46,000 public comments in response to the proposal. 

Supporters of the federal minimum standards include the Wisconsin Board on Aging and Long Term Care. The board’s ombudsman program connects residents and families with volunteers and ombuds who check in with them regularly about their experiences and expectations related to care and treatment.

The CMS ruling is the first substantial change in protections for residents of long-term care facilities since 1987, according to Kim Marheine, the state’s long term care ombudsman. For three decades, advocates and residents have been citing staffing concerns and numerous studies showing a correlation between staffing and care quality, she said. 

Detractors of the CMS ruling, including the American Health Care Association and the National Center for Assisted Living, which together represent 14,500 long term care facilities, call it an unfunded mandate and impossible to fulfill with the number of caregivers available. 

Representatives of local nursing homes expressed mixed feelings about the ruling overall, but both Serenity Spring at Scandia Village and the Horton Center have turned in their updated assessments, according to facility representatives. 

Sturgeon Bay Health Services is owned by North Shore Healthcare. A corporate representative did not respond to requests for comment. 

CMS added the following new requirements to the assessments, which were due Aug. 8: 

  • Use evidence-based methods when care planning for residents, including those with behavioral health needs.
  • Assess the specific needs of each resident and adjust the report when significant changes occur in the resident population
  • Include the input of the nursing home leadership, management, and direct care staff.
    Facilities must also consider input received from residents, resident representatives, family members, and representatives of direct care staff.

In response to comments calling the ruling an unfunded mandate, CMS is launching an initiative to help facilities recruit and retain nursing staff. Plans are to fund the initiative using penalties collected from noncompliance with other existing regulations. There is $75 million available for the initiative, according to CMS.

The initiative will recruit nursing staff and provide funds to support their education, including tuition reimbursement. The initiative also will have an awareness campaign component, highlighting possible career paths and advancement for nursing students. 

CMS anticipates financial incentives from the initiative will be distributed to nurses in 2025, before the minimum nurse staffing standards are fully implemented.

Local facilities weigh in

Katie Casey is the regional director for Continuum Healthcare. Continuum purchased Scandia Village earlier this year, changing the home’s name to Serenity Spring at Scandia Village. 

The new assessments are a little convoluted, Casey said, and not easy to understand at first. 

“It’s a really long narrative,” she said, one that nails down the complexity of care based on the specific resident population. It tells a reader of the report how you structure your nursing home, and how you run day-to-day operations, she said. 

One of the things Scandia reported in its assessment is that some of its programming is based on the Scandinavian culture of the community and residents. 

“(Some residents) have a tradition to eat lutefisk on holidays,” Casey said. “We have special meals planned honoring that preference.” 

Scandia also included staff competencies in its assessment, she said. Scandia has a high percentage of residents who need a catheter. The assessment factored in how its staff is trained on competent catheter care. Including details like that was nothing new for Scandia, but the assessments asking for more details is a good thing, Casey said. 

CMS can really see how care is managed at a more specific level, she added. “We have more incontinence care here, for example, versus more acute care needs like IVs and things, like they do at (the Horton Center).”

As a result, Scandia does not currently need as much acute care nursing as it does staff trained in incontinence care.

The Horton Center was lucky to be able to “over-hire” RNs after the Covid pandemic, according to administrator Nancy Borman, especially because the center does tend to have more residents with the acute care needs RNs are trained for. 

CNAs were impossible to find during the pandemic, she said. The Horton Center was able to hire acute and primary care nurses instead, and the RNs would then split their general nursing duties with CNA-type care.

The Horton Center changed its nursing model to reflect the staff it had, Borman said, which is why its CNA hours are lower than the new required minimums. RN hours make up the difference, she added.

Borman said a facility assessment was not new to her staff either, but evidence-based decisions for how the facility is staffed provide more accountability. The center then can make sure its care staff is getting the training it needs for residents’ specific pathologies.

The assessments also evaluate if the minimum staffing requirement is enough for a particular facility. Based on residents’ needs, some facilities could actually be required by CMS to have more staff than the minimum. 

Future requirements

The Horton Center is not in danger of falling short of the new minimum staffing standards, Borman said, and it has no need to hire, even with the mandate. The center’s occupancy rate is 100 percent. All 32 beds are filled. 

Borman said she is very concerned with how the requirements will affect other places, however. 

“I think we are more of an anomaly,” she said, and she worries about how the Horton Center will be affected if other local facilities close or have to limit occupancy.

Scandia is making strides in recruiting staff, Casey said, and once the nursing care minimums go into effect, it is not in danger of closing or limiting occupancy for now.

The home has had a rocky couple of years, receiving fines, losing longtime staff members and going through changes in ownership. Continuum took ownership of the facility earlier this year, and the transition has not negatively impacted Scandia’s staffing, according to Casey. 

The facility received 18 citations at its last inspection, which was in April. That has more to do with processes than quality of care, Casey said. None of the citations were for harm to a resident or serious infractions. They were for things like missing a paper form or something minor, which is what happens when you lose your director of nursing, she said: Certain processes get left behind or are not implemented. 

Scandia is getting its processes in order, and the transition is moving at a normal pace, Casey said. It has hired a permanent director of nursing and an administrator. 

Seasonal CNAs and agency-supplied traveling nursing staff have been helpful, she said, and staff recruitment techniques—via face-to-face events, social media and online programs such as Indeed—are starting to be effective.

A success for Scandia has been getting at least three agency staff members to become permanent staff members, Casey said. Nurse staffing agencies provide temporary nurse staffing services to health care facilities.

“They are permanent now because they love it here,” Casey said. “We have a great core team.”  She is optimistic about the future of Scandia, she said.

Danelle Nickchen also is optimistic. A CNA, she left Scandia in 2022 feeling burned out and defeated by her experiences in the understaffed industry, she said. Before she left, she filed a complaint with CMS after being the only CNA assigned to 13 residents.  

Nickchen returned to Scandia last month and is energized by the changes she sees, she said. She missed the residents, she missed caring for them, and the facility seems to be changing for the better, she said. 

Local facility representatives said they are frustrated with what they see as a lack of support for care providers. 

Borman said she personally does not support the ruling, and more training, more education and more funding should have been put in place first.  

Casey agreed. “The ruling is not looking at the root causes of problems,” she said. “(What) if there’s no one to work? The staff simply doesn’t exist. This mandate is a workaround to satisfy people who ask (about understaffing), ‘What are you doing?’”

Andrew Phillips contributed data analysis.