Vaccination rates among skilled nursing facilities’ workers continue to lag optimistic expectations. About 56% of all healthcare personnel have been fully vaccinated for the week ending June 27 vs. 79% of residents fully vaccinated, according to the most recent CMS data compiled by NIC’s Skilled Nursing COVID-19 Tracker. The reluctance among staff to get vaccinated is worrisome as the Delta variant becomes more dominant and COVID-19 cases rise among the general population across states with low vaccination coverage.

Now is the time to remember how devastating and tiring the battle against COVID was for skilled nursing facilities, particularly for frontline workers.

Exhibit 1 below shows that for the week ending June 27, about 69% of skilled nursing facilities have reported vaccination data to CMS. Regionally, the highest rate of fully vaccinated residents in skilled nursing facilities reporting vaccination data to CMS was seen in the Northeast at 82.4%, followed by the Midwest (80.8%), the West (78.5%), and then the South (75.2%). For healthcare workers, the highest rate was seen in the West and Northeast at 62.7% and 62.3%, respectively, while the lowest rate was seen in the South at 50.3%.

There seems to be a correlation between the rise of cases and regions with low vaccination rates. For instance, the South region, where vaccination rates among staff are relatively lower, reported the highest case count of newly confirmed cases among staff. The South is the only region that reported an increase in cases among staff week-over-week, up of 17%, from 190 confirmed cases on June 20 to 222 on June 27.

Exhibit 1 – Vaccination rates within skilled nursing facilities – By region.

Drilling deeper into states, Exhibit 2 below shows that 27 states reached a vaccination rate among skilled nursing residents above 80%, while 26 states had a vaccination rate among staff below 60%. Vermont has the highest percentage of its skilled nursing patients fully vaccinated against COVID-19 at 95%. Other states with a vaccination rate among skilled nursing residents of 90% or above include New Hampshire, Maine, North Dakota, Iowa, and Nebraska.

Separately, case trends among the general population in Alabama are concerning. According to data from the CDC compiled by NIC’s Skilled Nursing COVID-19 Tracker, weekly confirmed cases increased by 123% from 644 on June 20 to 1,438 on June 27, the highest increase seen week-over-week. Notably, Alabama has the lowest vaccination rate among the general population, only 33.3% of the population are fully vaccinated as of July 11.

Despite the increasing case rates in the general population, skilled nursing facilities in Alabama continued to be safe, reporting two cases among residents and seven cases among staff on June 27. About 79% of skilled nursing residents and 49% of staff are fully vaccinated in the state.

Exhibit 2 – Vaccination rates among skilled nursing patients and staff – By state and territory.

In summary, weekly COVID-19 cases among skilled nursing patients are at the lowest level since the onset of COVID-19 and continue to trend lower or flatten with relatively small increases across a few states. Additionally, 99% of skilled nursing facilities reported no new COVID-19 cases among residents for the week ending June 27. Cases among staff are up slightly for the first time since mid-April, up 3% from 492 cases on June 20 to 509 on June 27. Data continue to suggest that vaccines are still effective, but it is important to note that over 20% of skilled nursing staff have declined a COVID vaccine. The vaccine hesitancy and reluctance among staff may lead to Delta variant pockets with severe cases in some parts of the country.

As a backdrop, Israel began administering a third dose of the Pfizer vaccine to provide coronavirus booster shots and raise antibody levels among at-risk adults. While healthcare officials in the U.S. haven’t made a statement about a third shot yet, skilled nursing facilities need to be prepared in case infection rates and hospitalizations rise among vaccinated residents.

To gain in-depth insights and track vaccination rates and the week-over-week change rate for new resident cases and fatalities of COVID-19 within skilled nursing facilities at the state and county levels, visit NIC.org. You can also access the Skilled Nursing COVID-19 Tracker along with a rich trove of analysis and insight on the NIC COVID-19 Resource Center.

NIC MAP^® Data Service, powered by NIC MAP Vision, an affiliate of NIC, released its latest Skilled Nursing Monthly Report on July 1, 2021, which includes key monthly data points from January 2012 through April 2021.

Here are some key takeaways from the report:

The upward trend in skilled nursing occupancy continued in April. Occupancy increased for the third month in a row, rising 94 basis points from March to end April at 73.2%. Occupancy is now up 185 basis points from the 71.3% low point reached in January. There is optimism that occupancy will continue to increase through 2021 as vaccinations continue around the country and as elective surgeries rise, thereby supporting admissions to skilled nursing properties. However, occupancy still is very low relative to pre-pandemic levels and cash flow is a concern at some properties. Occupancy is down 12.3 percentage points from the pre-pandemic February 2020 level of 85.5%.

Managed Medicare revenue mix decreased 30 basis points to 10.8% from March to April. However, it has increased 159 basis points since the end of 2020 (9.2%) and it is up 245 basis points since the pandemic low of 8.3% set back in May 2020 when many elective surgeries were still suspended and significant restrictions to admissions were in place across the country. This revenue mix trend, along with recent increased occupancy, suggests that managed Medicare admissions have been increasing. Compared to one year ago, managed Medicare revenue mix is up 225 basis points from 8.5%.

Medicare patient day mix decreased 40 basis points to 12.0% in April from March and is down 358 basis points from the 12-month high of 15.6% reached in December 2020. In addition, and a similar trend to patient day mix, Medicare revenue mix decreased 41 basis points from March to end April at 21.1% and is down 4.2 percentage points from the 12-month high of 25.2% reached in January 2021. This decline suggests that as resident cases of COVID-19 have declined, there have been fewer patients converted from Medicaid to Medicare, which was helpful when cases among residents were elevated as CMS waived the 3-Day Rule requiring a new 3-day inpatient hospital stay.

Medicaid revenue mix increased 85 basis points from March, ending April at 50.0%. Medicaid revenue mix was 46.7% in December 2020, representing a time-series low. This was due to factors such as CMS waiving the 3-Day Rule and lower Medicaid days overall due to lower admissions. It has since increased 326 basis points. However, it is still down 449 basis points from one year ago (54.5%). Medicaid days are expected to increase as occupancy continues to increase during 2021.

To get more trends from the latest data you can download the Skilled Nursing Monthly Report here. There is no charge for this report.

The report provides aggregate data at the national level from a sampling of skilled nursing operators with multiple properties in the United States. NIC continues to grow its database of participating operators in order to provide data at localized levels in the future. Operators who are interested in participating can complete a participation form at https://www.nic.org/skilled-nursing-data-initiative. NIC maintains strict confidentiality of all data it receives.

Interested in learning more about NIC MAP data? To learn more about NIC MAP data, powered by NIC MAP Vision, and about accessing the data featured in this article, schedule a meeting with a product expert today.

Ever heard of senior housing tourists?

No, they’re not busloads of elderly travelers crisscrossing the country to visit assisted living communities. They’re not mature sightseers either, snapping photos of the latest amenity spaces.

Instead, senior housing tourists are how Kai Hsiao describes newbie investors, developers, and operators in the senior housing industry, many of whom have failed to appreciate the healthcare aspects of the business. “If there was ever a debate about whether we are hospitality or healthcare, COVID has made people realize we are part of the healthcare continuum,” said Hsiao. He explains that some pop-up developers and operators are discovering that the business is no vacation. “Senior housing tourists are just visiting,” he said.

“If there was ever a debate about whether we are hospitality or healthcare, COVID has made people realize we are part of the healthcare continuum.”

As CEO of Eclipse Senior Living, Hsiao has a lot of insights into the future of operations. Portland, Oregon-based Eclipse is a third-party manager with 106 communities in 27 states, offering independent and assisted living, and memory care. The company has three brands that cover the continuum of care at various price ranges: Elmcroft, Embark and Evoke.

Hsiao is among the thought leaders looking forward to attending the 2021 NIC Fall Conference in Houston. The Conference is NIC’s first in-person convening of leaders in seniors housing and care since the pandemic began. Many industry leaders will seize the chance to share ideas with others weathering the same challenges, while simultaneously building the relationships that will help them succeed in the future.

Financial Focus

While 2020 was a year when operators struggled to combat the COVID-19 outbreak, Hsiao thinks 2021 is the year when operators will struggle to combat the financial impacts of the outbreak. Lower occupancies and higher expenses incurred in 2020 are having a big impact today. Also, many of the financial programs set up to help operators during the pandemic like rent and debt deferrals are ending. Finally, another round of government aid hasn’t been allocated yet. Lacking experience, and strong, well-established relationships in the industry, senior housing tourists could have the roughest road ahead.

Workforce pressures are adding to industry woes. The labor pool is thin. Wages are rising. But Hsiao doesn’t believe higher wages alone are the answer. “Think like a staffing agency,” he advised. “If we can’t staff, we can’t provide services.” The idea at Eclipse is to treat the hiring pipeline like a sales pipeline. The company hired more recruiters which means more applications, more interviews and more hires. Some administrative work is centralized. If a property can’t conduct an interview within 48 hours, the central office conducts the interview. “It speeds the flow of the process,” said Hsiao.

Reflecting on the past year, Hsiao thinks the industry will definitely survive the COVID catastrophe. Occupancies are rising. The aging population that will need housing and care is growing

In the near term, Hsiao expects more industry consolidation. “COVID has proven that scale matters. The bigger a company is, the easier it is to procure goods and services, and have the resources necessary to handle challenges like a pandemic” he said. “It will be an interesting year.”

The Labor Department reported that nonfarm payrolls rose by a strong 850,000 in June 2021. The consensus estimates for June had been for a gain of 720,000. Employment is now up by 15.6 million since April 2020 but is down by 6.8 million or 4.4% from its pre-pandemic level in February 2020.

The robust jobs report followed reports earlier this week that show a strengthening economy. This includes reports of strong consumer confidence, improving outlooks for capital spending by businesses and a report from the Congressional Budget Office (CBO) that projected a full recovery of pandemic-related job losses by the middle of 2022.

Notable job gains occurred in leisure and hospitality (343,000), in public and private education, professional and business services, retail trade and other services.

Separately and from a different survey, the Labor Department reported that the unemployment rate inched up to 5.9% in June from 5.8% in May. The jobless rate is now 2.4 percentage points above the pre-pandemic level of 3.5% seen in February 2020, but well below the 14.7% peak seen in April 2020. The underemployment rate or the U-6 jobless rate was 9.8% down from 10.2% in May 2021. This figure includes those who have quit looking for a job because they are discouraged about their prospects and people working part-time but desiring a full work week.

The number of long-term unemployed (those jobless for 27 weeks or more) increased by 233,000 to 4.0 million but is 2.9 million higher than in February 2020, suggesting that this continues to be a very challenging time for many Americans. Long-term unemployed persons account for 42.1% of the total number of unemployed persons.

The labor force participation rate, which is a measure of the share of working age people who are employed or looking for work was steady at 61.6% in June and has remained within a narrow range of 61.4% to 61.7% since June 2020. The participation rate is 1.7 percentage points lower than in February 2020. Many workers have dropped out of the labor force since the pandemic began to take care of family members or out of fear of working and catching the virus.

Average hourly earnings for all employees on private nonfarm payrolls rose by $0.10 in June to $30.40, a gain of 3.6% from a year earlier and followed an increase of $0.21 in April. The data suggests that rising demand for labor associated with the recovery from the pandemic may be putting upward pressure on wages. That said, the Labor Department warns that the pandemic has affected the ability to fully interpret the wage data due to the wide swings in employment trends.

The change in total nonfarm payroll employment for April was revised down by 9,000 from a gain of 278,000 to 269,000 and the change for May was revised up by 24,000 from 559,000 to 583,000. With these revisions, employment in April and May combined is 15,000 higher than previously reported. Monthly revisions result from additional reports received from businesses and government agencies since the last published estimates and from the recalculation of seasonal factors.

The June data was encouraging after disappointing gains in April and

The primary tool the Centers for Medicare & Medicaid Services (CMS) has for enforcing care standards at skilled nursing properties are civil monetary penalties (CMPs). CMPs are essentially fines for facilities found to be out of compliance with CMS care standards. Based on a national average, CMS penalties for skilled nursing properties had been on the rise from 2016 to the third quarter of 2019.  

Impact of the COVID-19 Public Health Emergency 

As the country began to grapple with the COVID-19 pandemic and the public health emergency was announced, average CMS penalties for skilled nursing properties declined. This is likely a reflection of the more collaborative, less-punitive surveys that took place while surveyors – the CMS regulatory staff who assess compliance with Medicare health and safety regulations – and operators alike learned about COVID-19 and its spread. 

A new federal government administration and a more thorough understanding of COVID-19 and the importance of strong infection control measures may mean that these penalties could be on the rise again, a trend that seemingly has already begun.   

Source: Data.cms.gov; Nursing Home Services Data Archive, 2016-2021

A Rise in Per-Incident Penalties 

Skilled nursing properties can be penalized through the imposition of a CMP for either the number of days that a facility has been out of compliance with a federal requirement (per-day or per-diem), for each instance of noncompliance (per-instance), or CMS can deny payments for new admissions. In 2017, guidelines were changed to set per-instance CMPs, rather than per-day, as the default penalty. Per-day penalties are often applied retrospectively and can accumulate to significant fines. Although per-day penalties remained the recommended approach for major violations, their overall use has been curtailed substantially.  

This transition has meant that the total amount of fines collected through per-incident penalties increased more than eight-fold from 2016 to 2020 and are projected to be even higher at the completion of the 2021 fiscal year (on September 30, 2021). As per-day penalties can be applied retrospectively and accumulate to significant amounts, operators benefitted during these years, as they were sheltered from penalties above the per-incident maximum fine of $20,965. There is no cap on the accumulation of per-day penalties. The Center for Medicare Advocacy has opposed the switch to per-incident fines and has been working to reverse what it considers to be efforts to roll back skilled nursing resident protections.  

Source: CMS Quality, Certification, & Oversight (QCOR) Reports 

At the time of the policy change, Dr. Kate Goodrich, director of clinical standards and quality at CMS, said in a statement that unnecessary regulation was the main concern that health care providers raised with officials. “Rather than spending quality time with their patients, the providers are spending time complying with regulations that get in the way of caring for their patients and doesn’t increase the quality of care they provide,” Dr. Goodrich said. 

With a new federal administration, high vaccination rates among skilled nursing residents, and the U.S. Senate confirmation of CMS Administrator Chiquita Brooks-LaSure, we could see a change in focus and policy and possibly a return to a stricter, and potentially costlier, enforcement. 

CMP’s Impact on Workforce and Labor 

Under current law, skilled nursing properties that are assessed civil monetary penalties above a certain threshold on their annual survey automatically lose their authority to train staff to be Certified Nursing Assistants (CNAs) for two years. With critical shortages in labor pools routinely being reported, particularly among CNAs, this penalty could have a major impact on a skilled nursing property’s staffing pipeline.  

In February 2019, the bi-partisan Nursing Home Workforce Quality Act was introduced, which would allow suspensions on in-house CNA education to be rescinded once the related deficiencies are remedied, albeit while allowing additional oversight of skilled nursing properties. The Nursing Home Workforce Quality Act did not receive a vote from the 119th Congress, and in-house CNA training programs can still be impacted by a certain level of civil monetary penalties, even if the fines are unrelated to the quality of care given to residents or if the care deficiencies cited on the survey are unrelated to the CNA training program.  

While penalties from CMS are an essential tool for ensuring skilled nursing properties are complying with care standards and are protecting their residents, both the approach and severity can be markedly different between administrations. A greater emphasis on infection control has broadened the scope of surveys, and subsequently the amount of time and resources involved in survey preparation. Without additional funding, a revival of more stringent surveys and quality standards could result in added annual costs for operators.