It took a pandemic and tens of thousands of deaths before most people became aware of just how bad circumstances were in many U.S. nursing homes. Long-term care residents bore the brunt of COVID-19 cases and deaths, particularly in the early days of the crisis. The Biden administration wants the Centers for Medicare and Medicaid to tighten standards and oversight to avoid anything like this from happening again.
While the initiative only got passing mention in the March 1 State of the Union address, the White House released a lengthy fact sheet ahead of the speech, detailing several key initiatives it’s directing CMS to implement:
- Increasing minimum staffing requirements.
- Reducing resident room overcrowding.
- Strengthening the Skilled Nursing Facility (SNF) Value-Based Purchasing (VBP) Program.
- Reinforcing Safeguards against Unnecessary Medications and Treatments, actions they say “will improve the safety and quality of nursing home care, hold nursing homes accountable for the care they provide.”
- Making the quality of care and facility ownership more transparent so that potential residents and their loved ones can make informed decisions about care.
More than 200,000 residents and staff in nursing homes have died from COVID-19 — nearly a quarter of all COVID-19 deaths in the United States, according to the Kaiser Family Foundation. Despite current regulations, The Government Accountability Office found that from 2013 to 2017, 82% of all inspected nursing homes had an infection prevention and control deficiency, including a lack of regular handwashing, that was identified through Medicare and Medicaid surveys.
“There is a tremendous amount that CMS can do in just improving the way they grade citations. Some of the worse deficiencies are rated as no harm when that is clearly not correct,” said Charlene Harrington, Ph.D., R.N., Professor Emeritus at the University of California, San Francisco School of Nursing. She also served on the Institute of Medicine (IOM) Committee on Nursing Home Regulation, whose 1986 report led to the passage of the Nursing Home Reform Act of 1987 and has written widely about nursing home safety and quality.
President Joe Biden’s proposal has already received wide support from long-term care advocates and some non-profit industry associations.
“This is the biggest and most positive news for nursing home residents in 35 years since Ronald Reagan signed the Nursing Home Reform Act,” Richard Mollot, executive director of the Long Term Care Community Coalition said in a statement.
And Katie Smith Sloan, president and CEO of LeadingAge, the association of nonprofit providers of aging services, including nursing homes said, “If the past two years have shown us anything, it is that our country’s insufficient and fractured aging services infrastructure is in desperate need of an overhaul. And nursing homes are a key component of that infrastructure.”
Sloan also called earning a living wage “critical” for direct care professionals — most of whom are women of color. This level of compensation, according to the association’s research, would reduce turnover and staffing shortages, boost productivity, enhance the quality of care and increase overall economic growth in communities across the country.
The Biden administration’s background document specifically called out staffing, safety, and other ongoing problems at private equity-owned nursing homes, citing recent research showing resident outcomes are significantly worse at these facilities. About 5% of the 15,500 Medicare and Medicaid-certified nursing homes are now owned by private equity firms, according to the White House.
Biden wants Congress to increase CMS funding by 25%, to nearly $500 million to support additional health and safety inspections. The plan also calls for:
- Overhauling the special focus facility program to improve care more quickly for the affected residents and toughening requirements and fines for facilities, up to and including termination from the Medicare and Medicaid programs.
- Increasing penalties against poor-performing facilities based on reviews of data submissions in addition to on-site inspections.
- Increasing accountability for chain owners of substandard facilities based on the Medicare compliance history of their other owned or operated facilities
- Creating a new database to track and identify owners and operators across states to highlight previous problems with promoting resident health and safety.
- Providing technical assistance to nursing homes to help them improve.
- Enhancing nursing home care compare, including prominently displaying whether a facility is meeting these minimum staffing requirements, making information more user-friendly, and ensuring ratings more closely reflect verifiable rather than self-reported data.
- Making nurse and staff training more available and free or low cost; new requirements would ensure nurse aide trainees are notified about their potential entitlement to training reimbursement upon employment.
“I think private equity should be banned from owning nursing homes entirely but I doubt that Congress would be willing to do that,” Harrington said in an email. “Certainly, we need stricter criteria on who can own nursing homes and I think this is what the administration intends to do.”
Harrington recently co-authored a paper looking at how the second-largest for-profit nursing home chain used a web of sub-corporations to manage its 228 long-term care holdings.
Nursing homeowners want an increase in Medicaid rates but there’s no financial transparency, according to Harrington. She thinks the government should require consolidated cost reports by certified accounting firms to more easily track how nursing homes are pulling profits out of their related third-party organizations.
CMS also plans to continue COVID-19 testing, vaccinations and booster shots for residents and staff and says it will also strengthen requirements for on-site infection prevention.
Harrington said nursing homes will have to raise wages to attract and retain staff. This approach will also decrease the use of antipsychotic medications, an ongoing and prevalent problem despite the danger to vulnerable residents, as this New York Times investigation found.
CMS will issue proposed rules within one year after conducting a new study to determine the appropriate level and type of staffing to ensure safety and quality.
Resources for journalists
- AARP Nursing Home COVID dashboard CMS COVID 19 Nursing Home Dashboard
- KFF Policy Watch: Over 200,000 Residents and Staff in Long-Term Care Facilities Have Died From COVID-19
- Covid-19 Disparities in Nursing Homes (provides a global perspective)
- How to avoid more COVID-19 nursing home deaths — Op-ed from the American Enterprise Institute
- COVID-19 had little financial impact on publicly traded nursing home companies — commentary by Kingsley and Harrington published in the Journal of the American Geriatrics Society
