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How Florida's long-term care facilities are managing the COVID-19 virus
In other words, some high-performing nursing homes did well at keeping their residents safe; others did poorly. Some homes with a record of deficiencies did well, others poorly. The size of the facility didn’t seem to have much bearing either. Facilities with more residents had more cases and deaths. But an examination of 100 Florida nursing homes with the highest rate of deaths per 1,000 residents showed significant variation in facility size: They ranged from 27 beds to 276 beds and averaged about 130 beds. Zero-death facilities also ran the gamut from 18 beds to 391 beds and averaged about 114 beds, an analysis of CMS data showed.
Overall, outbreaks in nursing homes largely followed the same path as spikes of COVID-19 in the general population, with the largest number of deaths in South Florida. For the most part, outbreaks occurred in facilities where community spread is high.
Success at keeping the virus from spreading through a nursing home seems largely to come down to local management decisions and practices. Fair Havens Center, a Miami Springs nursing home with 51 COVID-19 fatalities, had a poor record even before COVID-19 hit. A February inspection by the Department of Health and Human Services detailed multiple health violations — about double the number of a typical inspection — and the home was one of 197 facilities as of late July on the state's watch list.
Following a complaint in early May, state inspectors found that the Fair Havens staff were not isolating residents who had COVID-19, failing to use PPE and not tracking infections within the facility. Mayhew issued an emergency order on May 8 halting admissions to the facility.
The Issues
The pandemic has complicated a number of longstanding issues in the industry.
Low Wages and Staffing Shortages: Registered nurses earn about $33 an hour, and licensed practical nurses earn about $22 an hour in Florida. Certified nursing assistants (CNAs) — the workhorses in nursing homes and assisted living facilities — earn about $11.80 an hour on average in Florida, according to the U.S. Bureau of Labor Statistics. CNAs say starting salaries can be even lower — $9.65 to $10.40 an hour, depending on the company.
To make ends meet, many aides work double or triple shifts. As demand for their services has increased during the pandemic, some have quit their jobs for better-paying gigs with staffing agencies, which pay anywhere from $16 to $21 an hour. Ironically, the staffing agencies have assigned some of those aides to the same facilities they left. Aides may also pick up shifts at other facilities on an asneeded basis, referred to as PRNs.
The churn worries caregivers such as Amy Runkle, who works full time at a nursing home in Venice. ‘We’re not getting a lot of full-time people now. We’re just getting the PRNs that work multiple jobs. They work here and down the street and down a little further because there are so many nursing homes,” Runkle says. She’s concerned about them potentially spreading the virus among facilities ("On the Front Lines," page 97).
Kristen Knapp, a spokesperson for the Florida Health Care Association, a trade group that represents Florida’s nursing homes and long-term care facilities, says the industry has been dealing with a staffing shortage for a while. Turnover is high. The last time it conducted a survey in 2016, the now-defunct Florida Center for Nursing at the University of Central Florida reported a 100% rate of turnover for direct care nurses (RNs and LPNs) at skilled nursing centers. The same survey estimated that half of CNAs in long-term care facilities quit each year — and Knapp says it’s hard to compete with other business sectors, such as retail, which pay better.
"We already had a workforce crisis before this pandemic began. There was a shortage of workers — nurses are retiring, and we were competing against the Targets and Amazon warehouses of the world who could frankly pay a more competitive wage,” Knapp says.
Once the pandemic hit, it got worse. Staff who became sick couldn’t come in, and some never returned. School closures and a lack of day care added to the problem, and the industry’s pipeline of new employees was cut off when testing sites for CNA exams were closed amid the shutdown. The test sites recently reopened, but there’s still a backlog of test takers.
In early July, 68 Florida nursing homes reported a shortage of aides to the Centers for Disease Control’s National Healthcare Safety Network system, and 57 facilities said they were short on nurses; 29 facilities reported a shortage of three of more categories of workers, including aides, nurses, other clinical staff and other employees, such as housekeepers.
In the meantime, the Agency for Health Care Administration is allowing skilled nursing facilities to hire a new category of direct care employees known as personal care attendants, or PCAs, to perform some of the duties usually done by CNAs. They can change bed linens, check temperatures and feed residents, for instance, but can’t help them with toileting.
Andi Clark, chief nursing officer for Maitland-based Consulate Health Care, which operates 82 facilities in Florida, told Skilled Nursing News in an April interview that the chain was making a push to try to hire nurses and caregivers laid off from hospitals and clinics during lockdowns. Clark also said the chain was having all its staff — including administrators — go through patient care assistant training. “Activity directors, social workers, HR folks, business office — just that little extra help on days when we can use a little bit of extra help, especially around some of the things that take up a CNA’s time,” she told the industry news site.
Some facilities are also offering “hero” or “hazard” pay and overtime to try to attract and retain employees. But Knapp doesn’t think the industry can pay its way out of the staffing shortage. “We’re 60% funded by Medicaid, so we don’t have the ability (to bump pay) — our rates are set by the state, and Medicaid already underfunds the cost of care,” she says.
While DeSantis approved a $105 million Medicaid increase for nursing center care in the $92.2-billion budget he recently signed, it’s not clear how much will trickle down to individual employees’ pocketbooks. “We were seeing reimbursements at 2016 rates, so this funding increase is really our inflationary cost to get us up to today’s payment level,” Knapp says.
