Operators of senior living communities — just as, if not more, hampered than primary care providers by the shortage — need to be ready to manage the fallout from the Vaught case and all the risks that are intensifying during the staffing crisis.

It’s not just individual errors such as Vaught’s that they have to guard against. It’s being on top of the necessary checks and balances practiced by the staffing agency partners they increasingly depend on, risks that aren’t under the operators’ direct control.

Vaught’s case and the damper on medical professionals

Vaught was stripped of her nursing license and sentenced last May to three years of probation, charged with criminally negligent homicide after administering the wrong medication to a patient at Vanderbilt University Medical Center in 2017. In overriding the electronic dispensing system when she couldn’t find the needed one, she mistakenly grabbed the wrong medication.

Every institution has medication administration policies spelled out, and every nurse is trained in and should be aware of best practice protocols. But the harsh criminal charges made the Vaught case a major issue, intensifying concerns over mounting pressures on nurses and other healthcare professionals at a time when they are leaving in droves.

The average turnover rate among nurses was 27.1% in 2021; 13 million are needed globally over the coming decade to stem the tide. Meanwhile, there’s also a shortage of faculty, staff and budget to train new nurses. In 2019, nursing schools turned away 80,407 applicants. The Vaught case made recruitment efforts more challenging, given the inevitability — and costs — of human error, especially when there are fewer bodies to do more work.

Impact on senior living

Nursing-related occupations, from registered nurses to licensed practical nurses and licensed vocational nurses to nursing assistants and aides, are critical to the senior living and care sector, accounting for about 52% of all employees in 2021, according to the National Investment Center for Seniors Housing & Care.  

The same pressure is on senior living and care to recruit qualified caregivers as is on health systems, having lost 210,000 jobs between February 2020 and December 2022. A return to pre-pandemic staffing levels isn’t expected until 2027.

Increasingly, operators have turned to staffing agencies to fill shortages. By 2021, as the industry was still reeling from the pandemic’s impact, 38% of senior living providers and 69% of nursing homes said in one survey that they counted on agencies to supply their manpower needs.

An expanded perspective of risks becomes that much more critical given the trends as it’s not uncommon for these staffing agencies to not carry insurance on their contracted people, pushing the risk — however unintended — on to their clients.

Assessing clinical staffing firms

Hospitals are required by accreditation organizations to develop tools to determine the competency of nurses provided by staffing agencies, augmenting the ongoing nurse evaluation processes of staff and agency nurses alike. Operators of senior living communities can avoid significant exposure by conducting similar assessment of their clinical staffing agency partners.

Here are areas the evaluation should cover:

1. Agency leadership. This part of the assessment explores how the organization is set up and sets the tone for best practices. An organizational chart, for example, should specify which individuals are responsible for quality of service. Also important is a documented code of ethics that covers conflicts of interest and a methodology for resolving complaints from staff and clients. Written policies and procedures on managing safety risks should be checked, and whether the agency keeps a log of reported accidents, injuries and safety hazards.

2. Human resources management. Written policies should be in place to confirm qualifications and competencies fit job assignments and responsibilities; similarly, they should cover current licenses, certification and registration, along with education, training and experience. Criminal background checks are critical, as are proof of identity and compliance with health screening and immunization requirements.

The agency should provide thorough orientations for clinical staff. Also important are a path for staff members to request reassignment and the agency’s openness to making job modifications to ensure competency. The agency should satisfactorily describe how it establishes and maintains the staff’s clinical competency, whether it facilitates ongoing education and conducts periodic performance evaluations. Along these lines, it’s also important to have a comprehensive plan for improvement that uses client input. 

3. Information management. It’s key to establish the adequacy of the agency’s IT processes for internal and external needs. Similarly, health and HR records for every staff member should be maintained, backed by a written policy to protect the privacy and security of staff and client information. Regular backup and storage to protect against information loss also should be checked.

Gigi Acevedo-Parker is National Practice Leader – Clinical Risk Management, for global top 5 insurance brokerage Hub International. She is a nurse executive with more than 30 years as a healthcare clinician, nursing leader, healthcare consultant and educator with a focus on healthcare risk mitigation and patient safety. She has experience in many diverse aspects of risk management and compliance, including loss prevention and mitigation, patient safety and quality, claims and litigation management, corporate compliance and privacy.

Gerald Stoll is the US Senior Care Segment Leader with Hub International. He specializes in developing comprehensive insurance and risk management solutions for the long-term care industry, including assisted living, independent living, nursing homes, clinics and urgent care centers.

The opinions expressed in each McKnight’s Senior Living marketplace column are those of the author and are not necessarily those of McKnight’s Senior Living.

Have a column idea? See our submission guidelines here.

It’s impossible to escape the impact of the pandemic on the industry when almost 40% of COVID deaths have occurred among residents and some 1,500 caregivers have died of the virus. Yet according to a recent report by the Centers for Disease Control and Prevention, 77.8% of nursing home residents accepted vaccinations compared with a median of only 37.5% of staff in the first month of the federal vaccination drive.

The senior living and care industry tends to be tough on caregivers anyway, with a worsening shortage of caregivers for the growing numbers of aging baby boomers, lagging pay rates and work that can be physically and emotionally taxing. COVID may have made their jobs among our most dangerous. It makes vaccinations an imperative for everyone’s future. Organizations that make COVID vaccinations part of their health and wellness programs will put everyone in a better position for what’s ahead.

But vaccination programs should be approached strategically. That approach requires a concerted effort to explain how they work and what employees should expect, ensuring an approach that meets federal and state workplace regulations. Here are points to consider.

1. Create better buy-in to vaccinations

Senior living and care workers may distrust the COVID vaccines, fearing that the accelerated development timeline has not yielded a safe, effective option. An education effort that validates their concerns and sets their expectations is an important backdrop to a successful vaccination program:

• Explain what can be expected with all of today’s vaccine options. Even after the first shot in a two-shot regimen, the virus can be contracted. Positive tests are less likely, but people will have the coronavirus antibodies. Those who do contract the virus after the first dose typically have milder symptoms.

• Allergic reactions usually stem from pre-existing allergies to ingredients in the vaccines. Employees should complete a medical checklist before vaccination so administrators are aware of any potential for an allergic reaction.

• Explain the science behind the vaccines. The vaccine instructs cells to make a harmless “spike protein” that fools the body into thinking “COVID was here,” so an immune response is built and protective antibodies are made.

2.  Incentives can boost participation, but are they “legal”?

The press has shared various examples of the types of incentives some employers have offered their workers to encourage them to get vaccinated. Some have offered cash. Others, paid time-off. These incentives have, in fact, encouraged participation. The issue is whether they are legal when the vaccination effort is tied to a workplace wellness program.

A big issue is the limits placed on incentives. The concern of the Equal Employment Opportunity Commission is the potential they pose, especially when they are high-value, to coerce participation and inadvertently lead participants to disclose protected medical information in the process. Proposed rules clarifying incentive limits in wellness programs were proposed in January, then frozen, awaiting review by the new administration.

In the interim, incentives should be considered with a “less is more” philosophy. Modest incentives create less pressure to participate.

Offering all employees a set amount of paid time off to get vaccinated is a one way to go, but it’s important that participants not be tracked, and no one is penalized for not getting vaccinated.

Another option for vaccination drives not connected to health and wellness programs is to offer collective, versus individual, incentives — such as department contests to reach 100% vaccination, for example. Those who have opted out would be excluded from the headcount.

3. Mandated vaccinations – you can, but should you?

Employers have mandated vaccinations for other types of diseases — Hepatitis C, for example, and other forms of flu. From a pure employment law perspective, it is legal. And it takes vaccines to achieve herd immunity – important given the need to protect the vulnerable populations in senior living and care.

The question is the affect a mandate for COVID vaccination would have on a business culture. Further, mandating vaccinations would remove the initiative from the mantle of a voluntary wellness program, another consideration.

Either way, it’s absolutely essential to involve the human resources team in the process to guard against violations of the Americans with Disability Act or Title VII of the Civil Rights Act. It’s important for the employer to find out, if employees decline vaccination, whether an underlying health condition or religious prohibitions are the reason.

• If a health issue is cited, then the Americans with Disability Act comes into play.  It requires an interactive process to determine what accommodation would be available. This process could call for the employee’s assignment to a more secluded, non-resident contact role. It does not mean that a new job must be created or another employee displaced.

• A religious-based declination involves Title VII. The matter must be discussed with the employee, who must provide documentation to prove its legitimacy. In Equal Employment Opportunity Commission matters, the CDC leans toward the employee, so the employer must resolve any conflicts. Resolution, again, typically involves moving the individual into a non-resident contact role.

• In the event of such concerns, employers must remember that they are tied to private medical information, which is not protected under HIPAA but still is to be kept secure.

Protecting their workers’ health and well-being when COVID remains a high risk is a challenge on every front. Circumstances have blurred the boundaries between human resources and employee benefits regulations that must be navigated and the risks that have only been elevated with the times. A COVID vaccination program is one way to protect everyone’s interests, but careful footwork is required.

Gigi Acevedo-Parker is national practice leader – critical risk management for global insurance brokerage Hub International. She is a nurse executive with more than 30 years as a healthcare clinician, nursing leader, healthcare consultant and educator with a focus on healthcare risk mitigation and patient safety.

Wendy King is the director of health and performance for Hub International. She manages HUB’s team of health and performance experts, who provide clients the strategic insight, multi-year plans and provider resources required to create healthy, high-performing organizations.

The industry was under substantial pressure even before the pandemic. But now it’s at the brink, financially and operationally. By late November, The Atlantic magazine’s COVID Tracking Project found that infections at facilities, including assisted living communities and care homes as well as nursing facilities, had reached a new weekly high of 46,000, the worst week in six months. Cases among the sector’s residents and staff members made up just 5.7% of all the U.S. COVID cases but accounted for 39.3% of the deaths.

The 2021 outlook is grim. Getting through it will hinge, to a large extent, on financial rescue programs at the federal and state levels. In addition, it will be important how well operators manage developing and/or deepening trends. Here’s what to look out for.

Clinical risk management has never been more important

A San Francisco Jewish senior housing complex made it through the first three months of the coronavirus pandemic without experiencing a single case. How? It had stocked up on personal protective equipment and masks for employees and residents. It stringently screened everyone walking through the door. Everyone was educated on best mitigation practices and symptoms and infection prevention protocols. One executive said an early start mattered … and their doorknobs had never been so clean.

The right procedures and controls do make the difference in disease transmission. It’s a lesson that must drive improvements to the industry’s clinical risk management programs in 2021 and beyond. COVID-19 is not likely to be our last pandemic.

Now, the industry faces an as-yet undetermined liability over COVID deaths even as insurers are responding to the uncertainty. Before COVID, premiums were escalating dramatically and coverage availability was tightening. It’s much worse as we move into 2021, though, particularly for professional liability, general liability, management liability and workers’ compensation. It makes the case to reduce your exposures and strengthen ties with your broker. 

Repairing the damaged mental health of residents

The coronavirus pandemic also spawned a mental health pandemic; the Centers for Disease Control found that more than 40% of Americans had anxiety and depression, symptoms of trauma, more thoughts of suicide and were abusing drugs and alcohol.

But if the mental health crisis was bad for the general population, it has been exponentially worse for residents in long-term care. Being isolated in their rooms with no group dining, activities or in-person family visits was stressful for residents. This reality was aggravated by factors such as too much negative television, no exercise, limited direct sunlight or fresh air.

Compounding it all (especially for those with cognitive issues) was the confusing element of caregivers whose identities were obscured by protective garb. Reversing the decline will be a critical challenge well into 2021, the urgency heightened by the risk to residents’ physical health when their mental health is not addressed.

It’s more important than ever to encourage staff members to be alert to cues of issues. They are closest to residents, especially in group settings, and can spot when they are less engaged. It’s more difficult to monitor in independent living settings, but training helps. Communities must be ready to tap into the right resources for the setting, whether primary care practitioners or psychiatric home health nurses. And ultimately, balancing mental health and safety will be key in the post-COVID world, finding ways to stimulate residents so they can re-engage again.

Staff pressures also need addressing in 2021

The much vaunted “healthcare heroes” aren’t only found in hospitals. They were right there in trenches of our senior living and care communities, dealing with the same stressors of long hours; equipment shortages; fear for their families, their residents and selves; and grief over losses.

The toll the pandemic has taken on staff members’ emotional health needs to be addressed now. If nothing else, post throughout employee spaces information about community resources (suicide prevention hotline, food banks, etc.). Also consider sponsoring an Employee Assistance Program. Such programs offer confidential mental health counseling in a variety of formats (telehealth and, when it’s safer, one-on-one, for example). It’s key, however, that staff member are informed about the EAP and how to access its resources.  

The pandemic also has brought home long-standing understaffing issues that have aggravated the emotional well-being and performance of employees but also undermine the structural soundness of the industry. Understaffing makes providing basic care a challenge. It adds to the difficulties of monitoring residents – for COVID-19 now, but for any contagion. It also makes it more difficult for caregivers to follow protocols consistently.

The unprecedented events of 2020 make the case for addressing the deficiencies in the system; 2021 is the logical time to start if we are going to avoid a repeat.

Pete Reilly is the practice leader and chief sales officer for Hub International’s North American Healthcare Practice. Gigi Acevedo-Parker is national practice leader, critical risk management, for Hub.

The opinions expressed in each McKnight’s Senior Living marketplace column are those of the author and are not necessarily those of McKnight’s Senior Living.

Have a column idea? See our submission guidelines and answers to FAQs here.