Montana's long-term care facilities could face staffing challenges and financial uncertainty if the Biden administration moves forward with a plan to require Covid-19 vaccinations for staff at federally funded nursing homes.

The Centers for Medicare and Medicaid Services, along with the Centers for Disease Control and Prevention, announced on Aug. 18 they were developing an emergency regulation aimed at protecting nursing home residents and staff from the coronavirus. Facilities that don't comply with the requirement could have their Medicaid and Medicare payments cut off.

Several nursing home operators in the Flathead Valley say they'll have to comply with the new rule because they can't risk losing federal funding, although the vaccine requirement is likely to drive away employees who adamantly oppose getting the shots.

A CMS spokesperson told the Daily Inter Lake on Thursday that the agency intends to issue the regulation later this month.

"CMS strongly encourages nursing home residents and staff members to get vaccinated as the agency undergoes the necessary steps in the rulemaking process over the course of the next several weeks," the spokesperson said via email. "CMS expects nursing home operators to act in the best interest of residents and their staff by complying with these new rules, which the agency expects to issue in September. CMS also expects nursing home operators to use all available resources to support employees in getting vaccinated, including employee education and vaccination clinics, as they work to meet this staff vaccination requirement."

THE RULE would impact more than 15,000 nursing homes across the country that largely rely on Medicare and Medicaid funding. The Biden administration considers it a necessary step to protect elderly nursing home residents, who are especially vulnerable to Covid-19.

The CDC says the virus has killed more than 134,000 nursing home residents and 2,000 nursing home employees since the start of the pandemic.

But some worry the move will hurt facilities with lower-than-average staff vaccination rates. And in rural areas around Montana, where many facilities struggle to hire and retain employees, an exodus of those unwilling to get vaccinated would exacerbate the problem.

Flathead County Health Officer Joe Russell said Thursday he understands the motive behind the proposed rule and believes it would protect residents, but he predicted it could cost nursing homes throughout the valley nearly a third of their employees.

"A lot of these homes will have to mandate vaccines because so much of their income comes from federal agencies. They don't really have a choice in that," Russell said. "There are people who are vehemently opposed to the vaccine. So when that happens, those people will probably find work elsewhere."

Managers of local facilities, where vaccination rates among staff range from 53% to 84%, echoed that concern.

"With staffing a tremendous challenge across the nation and the fact that our teams must wear protective gear continuously because the vaccine does not prevent the spread or prevent anyone from contracting Covid, people do not want to have that stress or the stress that they may have brought it into the facility, so many are choosing different career paths," said Wendy Soulek, chief operations officer of Lantis Enterprises, which owns Lake View Care Center in Bigfork and Heritage Place in Kalispell.

"We are reaching a point where the passion to care for others does not exceed the demands placed on them as nursing home employees," Soulek said.

AS OF Aug. 22, nearly 84% of residents in CMS-certified nursing homes across the country were vaccinated against Covid-19. But the same was true for only 62% of staff at those facilities, according to data collected through mandatory reports to the CDC.

Louisiana had the lowest vaccination rate among nursing home staff — less than 48% — while Hawaii had the highest rate at 89.5%. In Montana, the rate was just over 59%. Those figures likely have risen or fluctuated with staffing changes in recent weeks.

Montana has 70 CMS-certified nursing homes, including six in Flathead County: the Montana Veterans Home, Lake View Care Center, Heritage Place, Immanuel Skilled Care Nursing Center, the Brendan House and Whitefish Care and Rehabilitation.

Whitefish Care, which experienced a deadly Covid-19 outbreak in fall 2020, is the only one of those facilities that hasn't reported vaccination data to CMS as required. The CMS spokesperson said that when facilities fail quality-assurance checks — which can happen for a number of reasons — all data for those sites is excluded from statewide and nationwide calculations.

Whitefish Care did not respond to phone calls from the Daily Inter Lake.

At the other five facilities, vaccination rates among staff range from a low of 53% at Lake View Care Center in Bigfork to a high of 84% at the Montana Veterans Home in Columbia Falls. Lake View and Brendan House, which is operated by Logan Health, are the only two in Flathead County that fall below the national average. Their vaccination rates do, however, outpace at least 23 others across the state.

With the exception of Brendan House, all facilities fall well above the national average for resident vaccination rates. However, while the Aug. 22 data shows roughly 77% of residents at the Brendan House were vaccinated, hospital spokeswoman Mellody Sharpton said that figure is now at 81%.

ASKED WHETHER they would implement the new rule, representatives with Immanuel Lutheran, Lake View and Heritage Place acknowledged that vaccines among staff would help reduce transmission rates and offer an added level of protection for residents, but they also noted they feel backed into a corner by the directive. While they cannot suffer additional blows to staffing levels, they also can't sacrifice federal funding, which accounts for 90% of their facilities' revenue streams.

"We can't risk the chance of losing federal funding, and that's something we've been transparent about with our staff," Immanuel Lutheran CEO Jason Cronk said. "Our next steps will be to continue educating our staff on the importance of being vaccinated. We won't have a choice if this rule comes out. We'll have to adopt it."

Cronk said he expects the skilled care center will lose some staff should the rule go into effect, but anticipates he will be able to bring on vaccinated people to replace those that leave.

Roughly 60% of staff are vaccinated at the center, which is the only arm of the Immanuel Lutheran system that is CMS-certified. Aside from assisted living, the "life plan community" also provides memory care and post-acute care services.

Cronk said the continuum of care will allow Immanuel Lutheran to withstand the upcoming mandate better than standalone entities because, among other things, the system isn't solely financially reliant on CMS.

But such is the case for Heritage Place and Lake View, where, Soulek said, because so much of their funding is federally subsidized, "if the Biden-Harris administration ties vaccination to reimbursement, no nursing home or their staff will have a say (on whether the rule should be adopted)."

Soulek pointed to other concerns including a pandemic-driven increase in costs associated with staffing, overtime expenses, and supplies, as well as regulatory demands on the industry. She said, "quite frankly, nursing homes will soon reach the point where they cannot continue to operate due to the current circumstances."

While many of the nation's nursing homes received financial assistance through the CARES Act, Cronk and others say those funds helped offset only a portion of expenses accrued due to the pandemic. And financial burdens associated with Covid-19 are ongoing and more support is needed, he said.

For example, because Flathead County has a high transmission rate, all non-vaccinated staff at CMS-certified homes must be tested twice weekly. If a positive case is detected, the facility must go into "lockdown mode," meaning they cannot accept new residents or visitors for at least two weeks.

"That's where our census suffers. When we can't accept more residents our income is impacted and we also end up having to pay more for other things like overtime for people to cover the person that is now in quarantine," said Cronk, adding that Immanuel Lutheran is roughly 75% occupied due to recent lockdowns and ongoing staffing shortages.

On Thursday, Russell estimated 10 long-term care facilities, some of which are CMS-certified, were under lockdown orders.

It's unclear what sort of financial or workforce support may come from state and federal leaders. The Montana Department of Public Health and Human Resources did not immediately answer questions from the Daily Inter Lake.

The state took a hard stance on mandated vaccines earlier this year with the passing of House Bill 702. The recently enacted law prohibits the vast majority of businesses in the state from requiring their employees to be vaccinated.

An exemption in the bill, however, allows long-term care facilities to require shots if their federal funding is at stake — an exception that has prompted some nursing home executives to turn to state leaders for support.

HB 702 was extended to hospitals and health-care settings, which adds an extra layer of confusion as to how long-term care facilities that operate within a hospital system, such as the Brendan House, should navigate the potential new rule. Sharpton, speaking for the Brendan House, said via email "we are aware of the potential requirement and are working with other hospitals across the state to evaluate the next path."

Reporter Kianna Gardner may be reached at kgardner@dailyinterlake.com.