Kaitlin Smith was getting increasingly worried about covid-19 outbreaks at Quality Life Services, a nursing home chain where she works as a clinical reimbursement specialist. For weeks, she had been on daily calls with all of the facility administrators, hearing about rising infections and staffing struggles.

Then one Friday last month, the chain’s Sarver facility in Winfield Township became so strapped for nurses, there wasn’t a single nurse to cover the overnight shift in its non-covid units.

Smith, a registered nurse who used to work at a North Hills nursing home, volunteered to help. She went home, slept a few hours, then worked double shifts, from 2:30 a.m. to 4:30 p.m. the next day — a total of 14 hours.

“You jump in and do what you need to do. Even as an RN, you scrub the floor if that’s what’s needed,” Smith said. Her actual job at the chain involves coordinating insurance matters with families.

Quality Life Services is no anomaly. A Tribune-Review investigation and analysis of data from the Center for Medicare & Medicaid Services found nursing home facilities are increasingly reliant on outside help, whether it’s using nurses like Smith or relying on staffing agencies.

Fatigue and mental health tolls are mounting among long-term care workers, many of whom must take on extra shifts and care for more residents as covid rates climb to record highs. Maintaining adequate staff levels in long-term care facilities — a challenge that has persisted for years — is now a daily scramble.

“Right now, the biggest concern is staffing,” said Zach Shamberg, president and CEO of the Pennsylvania Health Care Association, which represents more than 400 long-term care providers, including QLS facilities. “That’s what keeps me up at night, that’s what keeps our providers and our workers on the front lines up at night, is really having enough staff to care for our most vulnerable residents.”

At Quality Life Services, the situation is so dire that roughly a dozen corporate office workers have been trained as temporary nurse aides. Employees who were formerly nurses have jumped in to help, picking up overnight and back-to-back shifts when spates of employees got sick or quarantined at home.

Nurses and aides put on brave faces as they helped dying residents say goodbye to loved ones on iPads. Then, they broke down into tears in break rooms and on their drives home.

“When you see the people and the anxiety level that they are going through, it’s very sad,” said Paul McGuire, chief operating officer of Quality Life Services. For most of November, he was filling in for Sarver’s administrator, who was out dealing with a medical issue. “In my office, people were having nervous breakdowns about what was going on.”

McGuire says he has witnessed staff confront more stress and challenges in the past three months than he has in more than three decades working in the long-term care sector.

At least 372 of the chain’s roughly 1,500 staffers — or nearly 1 in 4 — have contracted covid-19.

Staffing agencies step in

The Tribune-Review’s analysis of data from the Centers for Medicare & Medicaid Services shows that nursing homes took a hit in staffing hours when covid outbreaks occurred, and many took advantage of agency nurses to make up for it. The number of hours logged by contracted registered nurses (RNs) and licensed practical nurses (LPNs) hired through agencies increased substantially in facilities across the state.

• From April to June, the number of hours logged by contracted registered nurses — those working in facilities via an agency — increased by 20%.

• In the 11-county region of Western Pennsylvania, while employed RN hours declined by 1.6%, contracted hours went up 12%.

• At some individual facilities, the figures are more drastic. QLS Apollo reported a 68% increase in the number of hours contracted RNs were working from April to June.

“Agency staff has been relied on more than ever in Pennsylvania, and that’s not necessarily a good thing,” Shamberg said. “You’re bringing in new agency employees who don’t necessarily have standing in a nursing home, who don’t have that connection with residents, and you’re essentially switching out caregivers. And that’s not really building to the high-quality experience that we would expect our loved ones to receive.”

McGuire and other administrators continue to make daily calls to travel staffing agencies. Across the 10 facilities operated by Quality Life Services, about 10% to 15% of staff now are contracted outside hires, compared to few to no contracted employees at the same facilities three years ago.

McGuire, Shamberg and other providers lament that some travel nurse agencies have raised their prices, creating an added expense when facilities are already in crisis. Agencies have more than doubled the rates charged to the chain for a certified nurses aide, for instance, from a prepandemic $20 an hour to as high as $50 an hour. Some agencies are also poaching in-house nursing home staffers by luring them with higher pay rates — costs that get passed on to the providers.

“Quite frankly, they’re not our friends, but we use them by necessity,” Mary Tack-Yurek, co-owner of the chain, said of staffing agencies, “and then they’re making it even worse by coming into our buildings, recruiting our staff, overcharging us, and they’re really in the driver’s seat in that.”

None of the staffing agencies reached by the Trib returned calls for comment.

Covid worsens years-long staffing shortages

Even before the pandemic, Pennsylvania’s nursing homes were operating with dangerously low staffing levels, according to a 2016 audit and 2019 updated report by state Auditor General Eugene DePasquale.

The report found the state’s staffing requirements for nursing homes to be “totally unsafe,” citing shortages of registered nurses and direct care workers.

“Long-term care has been in a staffing crisis, but the pandemic certainly has exacerbated that,” Tack-Yurek said.

Federal agencies recommend at least 4.1 hours of care per resident each day “to prevent harm or jeopardy to residents.” But the median number of hours for nursing homes in Pennsylvania is about 3.68 hours. State regulations mandate only 2.7 hours.

Quality Life Services’ Apollo nursing home reports an average of 3.5 hours of care per resident. In 2019, the most recent data available, the Washington Township facility reported it had 110 total staff members, including 12 registered nurses, 24 licensed professional nurses and 74 nursing aides. But manpower was stretched thin when as many as 47 staff tested positive for the virus and dozens of others were exposed at the height of the outbreak last month.

“All of a sudden you’ve got 15 or 20 employees who are positive, and you’re losing those hands on care,” McGuire said. “It’s all hands on deck.”

Staffing has become more burdensome in Pennsylvania after six years of flat Medicaid funding, which a majority of residents rely on when Medicare’s 100-day nursing home coverage runs out. Providers would like to increase rates but already are underfunded as costs continue to rise, McGuire said. He noted nurse aides make only about $13 to $15 an hour, akin to some fast food jobs.

“We’re competing with the McDonald’s of the world, where years before we weren’t,” he said.

Like other providers, Quality Life Services has relied on financial relief from state and federal coronavirus packages to offer incentives during the pandemic, such as a $5 raise for nurses aides working in covid “red zones.”

Facilities statewide have relied on National Guard rapid-response and the state’s Regional Response Health Collaborative program to supplement staff and resources — but even those entities are stretched thin. The National Guard is awaiting Gov. Tom Wolf’s decision on how to keep its work going, after the Trump administration reduced federal funding by 25% through March.

“We have no control over which direction it’s going to go,” said National Guard Lt. Col. Keith Hickox. “We don’t self-fund, we can’t self-deploy. We are a military force ultimately at the discretion of our appointed civilian authorities.”

The National Guard has 250 members actively supporting long-term care facilities in Pennsylvania, including 200 who visited nursing homes during 80 missions since March. About 30 missions were for staffing support.

Inevitable obstacles

Even when nursing homes do everything right, experts say it’s difficult to stave off infections entirely. The facilities are facing a deluge of obstacles and challenges, and as transmission rises in the community, infections are likely to appear inside nursing home walls.

“Community spread of covid-19 equals a greater likelihood of spread in our long-term care facilities,” Shamberg said. “That has held true across the state as we’ve seen confirmed cases go up.”

The challenges are not lost on the family members of residents. When he first heard about an outbreak in QLS-Apollo, Jim Dunmire figured it was a matter of time before his 60-year-old sister, a resident there, tested positive. The facility recorded at least 84 resident cases last month.

And Dunmire knew the consequences could be severe, given his sister’s underlying conditions. He said in 2019, pre-pandemic, she had needed ventilation no less than seven times.

He was right.

About three weeks after her initial positive test, she is still positive for the virus. She was transferred to Forbes Hospital in Monroeville, and then to Allegheny General in Pittsburgh, experiencing seizures and pneumonia. Dunmire asked that the Tribune-Review not print his sister’s name, to protect her privacy. She is now attached to a ventilator and in a medically-induced coma, he said. He can’t visit her.

“It’s difficult because you’re always thinking about what could go wrong, what could go wrong,” Dunmire said. “It’s even harder knowing I can’t be there with her. She can’t hear a familiar voice.”

Instead, Dunmire said he finds himself at home, waiting for the daily phone call from his sister’s doctors. When he sees the number appear across his phone screen, he gets nervous, not knowing if the news will be good or bad.

Tack-Yurek and her two co-owners spent several nights and weekends manning the phones at strapped QLS facilities to keep family members informed while staffers were busy collaborating and attending to residents. McGuire loaned an iPad to a resident’s son who didn’t own a smartphone or tablet to use outside the Sarver facility to chat with his mother, inside.

On top of providing medical care, facilities everywhere are scrambling to keep families connected to their loved ones, including those on their deathbeds — like the family of William A. King, 90, who died of covid-19 complications at Hempfield Manor in late November. Two of his daughters were able to say goodbye through video conference, something they say was infinitely valuable to them.

“(Hempfield Manor) took such good care of my dad,” said Laurie Puklavec, 53, of Herminie, one of King’s daughters. “They were like family.”

And in some cases, they really were — the nurse holding the iPad for King, standing near his bed wearing layers of personal protective equipment, also happened to be his granddaughter.

During multiple shifts working at QLS Sarver, Smith had to break the news to families about positive covid cases. She tried to give them a chance to at least see their sick family member via video conference.

“A lot of family just wanted to have that visual that their mom or sister is OK, and I think that helped a lot,” she said.

Smith pointed out some residents don’t even have loved ones to check on them.

“Some of these people come in and the facility staff is their only family,” she said.

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