YOUNGSTOWN, Ohio – Mahoning Valley senior care homes weathered years of challenges following the Covid pandemic, developing plans to attract and retain staff.
Four years later, a federal staffing mandate looms.
The mandate, which takes effect in two or three years depending on if a home is rural or urban, requires 3.48 nurse hours per resident day.
According to a fact sheet issued in April by Vice President Kamala Harris’s office, the rule means homes must have 3.48 hours per resident per day of total staffing including “a defined number from both registered nurses (0.55 hours per resident per day) and nurse aides (2.45 per resident per day).
This means a home with 100 residents would need at least two or three RNs and at least 10 or 11 nurse aides as well as two additional nursing staff (who could be registered nurses, licensed professional nurses, or nurse aides) per shift to meet the minimum staffing standards.”
That’s a concern for nursing home operators.
“Obviously, we’ve been in the business for over 65 years,” says Danny Rowland, marketing director of Windsor House. “Our seniors do require the quality of care. But I think a one-size-fits-all approach…with the competition among providers and hospitals for that same staff member – it becomes a challenge.”
Besides a diminished pool of employees, the new ratio excludes LPNs as nursing staff, Rowland says.
Eric Murray is executive director of senior services at Senior Living by the Youngstown Area Jewish Federation on Youngstown’s north side. Those homes and services include Heritage Manor, a skilled nursing home; Adult Day Services and Levy Gardens Assisted Living.
He says Heritage Manor runs close to 4.1 nurse hours per resident day. It’s one of the highest staff nursing homes in the area, Murray says.
“By design, we really believe that our quality is what is most important, not only for the residents and their families, but also our staff members,” he says.
The 4.1 nurse hours per resident at Heritage Manor applies to clinical, on-the-floor staff, Murray says. He envisions problems with the new staffing requirements.
“Those nursing hours would be RNs, LPNs, CNAs,” he says. “Those hours do not include any of our nursing administration team, which are very important and work behind the scenes to make sure everything’s in order. And we’re doing all the things we need to do.”
Joe Cilone is the president and co-owner of Inspira Health Care Center, which operates four skilled nursing centers in North Lima, Calcutta, Carrollton and Twinsburg. The Twinsburg home is also an assisted living center. Inspira also operates Elmwood, a residential care assisted living home in Hubbard.
At Inspira Health Care Center, the staff-to-patient ratio fluctuates from building to building and from skilled nursing to assisted living, Cilone says, “but the company bases staffing ratios on acuity.”
For example, if Caprice has 70 residents, it likely has five nurses on the floor, a director of nursing, six aides, three shower aides, a full-time wound care nurse and two unit managers.
“So the staffing ratios are really good,” Cilone says.
Hiring Staff
Hiring proved difficult during and after the pandemic but it’s started to ease over the last three to six months, Murray says.
Covid ran many out of the health care industry in general, Cilone says.
“Now we’re still living through the repercussions of all of that and I just think we lost a lot of workforce during that time,” he says. “Slowly, it’s starting to come back.”
But challenges persist, particularly for nurses and state tested nurse’s aides.
“I think health care as a whole, the whole umbrella, they’re looking for those positions,” Rowland says. “So we’re competing against hospitals and other nursing home operators and health care companies that are all trying to attract that talent pool. And speaking of which, that’s a struggle. Because the talent pool seems to be kind of shrinking as well.”
That challenge began before Covid, Rowland says, but the pandemic amplified it.
“I think Covid probably scared people away,” he says. “At Windsor House, we saw people that have retired from health care and it’s hard to replace the staff with longevity that have been with us for 20, 30-plus years of service.”
About 18 months ago, Inspira hired a full-time recruiter, Cilone says.
That person runs ads, schedules interviews and works different hours and days to match when prospective employees may be available.
Training Provided
Cilone’s son, Joey Cilone, is the administrator at both Elmwood and Caprice, which is in North Lima. He says the company also attends many job fairs to recruit employees.
“We have three nursing schools that come to Caprice to do their clinical rounds there, which is huge for us,” Joey Cilone says. “We also have an in-house [state tested nurse’s aide] class at each one of our facilities. It’s on a two-week rotation that we pay for, totally free.”
Those run monthly at each center.
“In two weeks, you can be trained to be an STNA,” Joey Cilone says. “We pay for the testing and our classes are anywhere from eight to 12 [people] every month. That’s been huge for getting aides.”
Windsor House offers similar training for STNAs. Rowland says the company has taken efforts to attract and retain employees including raising wages, instituting hiring and retention bonuses and enhancing benefits packages.
“One thing that we have been focusing on post-Covid is our new staff onboarding and retention of new staff,” he says. “That’s important to get them past that 90-day window of employment. So, making sure we have key staff that works with our new hires on guiding them through the day – the job responsibilities.”
The centers began to mentor programs with experienced nurse aides guiding newer employees. Administrators and directors of nursing at Windsor House homes also meet regularly with new hires, the marketing director says.
Joe Cilone says that because all homes compete for the same talent, some new employees may leave if another offers slightly higher wages.
“The challenge is we kind of keep battling each other because we’re all competing for the same talent pool and there just isn’t enough of them,” he says.
As far as employees though, Joe Cilone says Inspira does as well, if not better, than other homes because of its core of veteran workers.
“We’ve grown up together, literally,” he says. “We have some long-term employees who have been with us forever.”
That’s helpful because when a home is short-handed, it has the core employees who pick up the slack, Joe Cilone says.
“That’s been a blessing for us because we have a really good corporate team who come in and pitch in and help,” he says.
It’s everybody’s job, Joe Cilone says.
More about Mandate
Even though Heritage Manor maintains a staff-to-patient ratio that exceeds the federal mandate, Murray doesn’t support that impending change.
“Not all nursing homes are the same and so not every nursing home needs the same level of staffing,” he says. “The two biggest challenges to this is there aren’t enough staff in this country. And there isn’t enough money to pay for the proposed mandate. So, it’s essentially an unfunded mandate.”
He offers an example of the 3.48 nurse hours per resident day requirement: a home with 50 residents would need to provide 174 hours – 50 residents times 3.48 hours — of nursing coverage, as a minimum that day.
The pandemic that saw media coverage of nursing homes with high numbers of patient cases spawned the directive, Murray says. But he doesn’t believe it’s going to achieve what its authors intend. Incentives for improved patient outcomes would be a better strategy, he believes.
There aren’t enough nurses in the country nor enough people coming out of nursing schools in the United States, Murray points out. “So you can mandate all you want,” he says. “But there just simply aren’t enough staff.”
The other issue is how to pay for it, Murray says.
“In their proposal, the government had like $75 million in assistance, which really is exceedingly below even Medicare’s projected 10-year financial impact,” he says.
That projected impact is $43 billion.
“There aren’t enough workers. There isn’t enough money to pay for this,” Murray says. “But it’s coming and so nursing homes are stuck trying to figure out how we’re going to navigate this.”
He fears that will mean some nursing homes will close. Or they’ll stop accepting referrals including those from hospitals.
That means already stressed hospitals, particularly in rural areas, will call nursing homes to take referrals and the nursing homes will be unable to take the patient, Murray says. That won’t solve any of the problems the change is trying to solve. “It makes things worse,” he says.
Joe Cilone agrees. Inspira’s ratio meets the new requirement but he believes many other homes won’t survive.
The Ohio Health Care Association, on whose board Joe Cilone sits and is secretary/treasurer, advocates for the industry. It represents for-profit complexes. He also sits on the political action committee of the association.
Murray sits on the board of Leading Age Ohio, an organization that represents nonprofit senior care centers and is also talking to elected officials about the issues with the mandate. Senior Living by Youngstown Area Jewish Federation is nonprofit.
Rowland worries that the new staffing mandate will worsen staffing. Pennsylvania effected new staffing requirements last year. The Windsor House home in that state lies in a rural area, miles from another area, making it hard to attract staff.
Inspira tries to meet the staff ratio and also uses respiratory therapists because it cares for ventilator-dependent patients. Joe Cilone says it’s a little ahead of the game because of that.
“I think we’ll be OK. But I don’t think the industry as a whole will,” he says, “and we’re really trying to prevent that from happening.”
One of the ways Windsor House works to meet rapidly changing regulations in the nursing home industry is by relying on its corporate quality assurance department. That department helps to ensure the company keeps abreast of changes, Rowland says. The office is experienced and knowledgeable about the requirements and regulations in both Ohio and Pennsylvania, he says.
“That’s a department that we are expanding to work closely with our communities on the changes,” Rowland says.
Reimbursements
That’s not the only challenge facing senior care homes. They’re also competing for indirect care employees with places like WalMart and Sheetz.
“We’re competing with some places where 20-25 bucks an hour is a given,” Joe Cilone says. “Whereas we have kind of a fixed reimbursement and it is what it is.”
Roughly 70% of Inspira patients/residents are on Medicaid with another 20% on Medicare. The remainder are private insurance/private pay.
“It’s not like I can just raise rates and say, ‘OK, I’m going to pay more,’” Joe Cilone says. “I have to live within the structure of my reimbursement.”
And he points out that reimbursement hasn’t kept up with inflation.
Covid exacerbated that too, he adds. There was some relief from various avenues through the federal government. He says the business wouldn’t be operating without it.
Between 40% and 70% of residents at most nursing homes are on Medicaid, Murray says: “That stems from the fact that nursing homes are very expensive and most people simply don’t have the assets to pay for long-term care.”
And Ohio has the sixth-oldest population in the country. “So the answer can’t always be more money, more money,” Murray contends. “We really need to think about: Can we do things differently or more creatively? And I think Ohio has done some nice work to begin to move in that direction. And I would say, I think Ohio is further along than other states.”
Positive Change
One of those changes in a recent state budget was to increase the waiver rate for assisted living, he says. That allows people without financial resources who need care to go into assisted living, which is less expensive than nursing home care.
There had been waiver reimbursement for assisted living homes in Ohio but it was low so most homes didn’t accept it. Levy Gardens did.
“Ohio decided to significantly increase the reimbursement for the waiver,” Murray says. “Now, Ohio assisted living [centers] are moving into that space, creating beds for individuals.”
Another positive change in Ohio during the last year is increased funding for adult day services. Such programs help seniors who are lonely and also benefit caregivers who have to work or those who need a break, he says.
“And so what the state of Ohio did is they significantly increased the adult day reimbursement,” Murray says. “That does several things. It slows down the transition into nursing homes by keeping people in their home, which is where they really want to be. But it also allows the caregiver to work. And that’s fundamental to a lot of different things.”
Background
Inspira Health Care started in 1995 and Joe Cilone began working there the following year as a registered nurse with a baccalaureate in nursing. After a few years, he earned his administrator’s license in 1999 and took over Caprice. He became vice president of operations in 2004 and in 2007 he and some investors bought out the previous owner.
“We rebranded about two years ago under the Inspira umbrella,” he says.
Joey Cilone entered the business in 2020, earning his administrator’s license that same year. That’s when he began at Caprice and then in 2021, at Elmwood. Shortly thereafter, he secured his seal as a certified executive in assisted living.
“But that being said, I’ve grown up in nursing homes,” Joey Cilone says, adding that he started coming to work with his father as a toddler and traveling to outings with residents. Now his three children are growing up in the homes too.
Windsor House, founded in 1959, operates 17 homes: 16 in Ohio and one in Marienville, Pa. They comprise 12 nursing homes and five assisted living communities.
The president of Windsor House, John Masternick, is the son of founders John and Dorothy Masternick.
“He’s heavily involved in the organization,” says Rowland, who’s been with Windsor House for more than 20 years. “He’s in the trenches with our staff and working to meet our mission statement to provide the best possible quality of life for our residents.”
Heritage Manor opened in the mid-’60s and Levy Gardens in 1997. Murray came on board about four years ago. Although the homes are part of the Youngstown Area Jewish Federation, they’re open to residents of other faiths.
Joe Cilone has three partners – Chief Financial Officer Nick Berardino, Vice President Tim Huber and Secretary/Treasurer Larry Petrozzi – and all four are from and live in the area and are involved in operations. Other operators may live out of state and come to town only quarterly.
“This is obviously our careers. But it’s not just an investment to us,” he says. “It’s our life.”
Even residents have his phone number. “I’ve had calls while I’m in church on Sunday morning because one of our residents in Twinsburg got scrambled eggs and wanted fried eggs …” Joe Cilone says.
“That’s just the way we operate.”
Pictured at top: Joey Cilone, administrator at Inspira Health Group’s Elmwood and Caprice facilities, and his father, Joe Cilone, president and co-owner, stand in front of Elmwood in Hubbard.