President Joe Biden
Credit: Kent Nishimura / Los Angeles Times via Getty Images
President Joe Biden
Credit: Kent Nishimura / Los Angeles Times via Getty Images

A historic slate of reforms that would set federal staffing standards and ratchet up penalties at poor-performing facilities — but not pay more for on-site upgrades — was widely criticized by providers Monday, hours after the White House announced its efforts to increase oversight of nursing homes.

Senior administration officials on Monday painted the reform measures as part of a broader administration effort to tackle pressing competition and consumer protection problems. They’re aiming to “protect seniors and other nursing home residents by cracking down on unsafe nursing homes.” Consumer advocates, meanwhile, hailed the extensive list of initiatives as “the most important and positive changes in federal nursing home law and policy” in more than 30 years.

But Mark Parkinson, president and CEO of the American Health Care Association/National Center for Assisted Living, said in a statement that policymakers need to “prioritize investing in this chronically underfunded healthcare sector” to make real inroads.

“Those who continue to criticize the nursing home sector are the same people who refuse to prioritize our residents and staff for resources that will help save and improve lives. Additional oversight without corresponding assistance will not improve resident care,” Parkinson said.

Minimum staffing standards are one of four major strategies focused on quality that the Centers for Medicare & Medicaid Services will initiate, the White House announced ahead of the State of the Union address. While acknowledging the importance of high staff-to-resident ratios, operators have largely eschewed minimums as punitive measures during the current staffing crisis.

Other promised CMS initiatives include: reducing crowding by exploring ways to phase out rooms with three or more residents and promoting single-occupancy rooms; strengthening the Skilled Nursing Facility Value-Based Purchasing program by proposing new payment changes based on staffing and resident experiences; and launching a refocused effort to identify problematic diagnoses and reduce the use of inappropriate antipsychotic medications. 

More oversight, more resources necessary

“Long-term care was already dealing with a workforce shortage prior to COVID, and the pandemic exacerbated the crisis,” Parkinson said in a statement Monday. “We would love to hire more nurses and nurse aides to support the increasing needs of our residents. However, we cannot meet additional staffing requirements when we can’t find people to fill the open positions nor when we don’t have the resources to compete against other employers.” 

He noted the sector remains committed to improving quality of care, noting dramatic improvements over the last decade, including lower re-hospitalization rates, more one-on-one care and significant declines in antipsychotic medications.

LeadingAge added that providers know transparency, quality improvement and workforce investments are key to improving nursing homes. Yet Medicaid doesn’t fully cover the cost of care.

“Regulations and enforcement, even with the best intentions, just can’t change that math,” Katie Smith Sloan, LeadingAge’s president and CEO, said Monday. 

“It’s clear that the president understands that a quality workforce and quality care are inextricably linked. Our solutions to long-standing workforce challenges, many of which will be referenced in the address, include improving recruitment, ensuring access to initial and ongoing quality training, and providing career advancement opportunities. In addition, it’s critical that direct care professionals — most of whom are women of color — earn at least a living wage,” she added. 

The White House plan did not call for any additional funding except for a call to add to the budget for surveying. 

Harvard healthcare policy expert David Grabowski, Ph.D, said the research literature suggests more staff leads to better quality of care, but the challenge will be recruiting additional workers.

“There is a huge national shortfall in nursing home workers right now. Nursing homes will need to raise wages to recruit additional staff. Where does this money for higher wages come from? There are no additional reimbursement dollars in the current reform package,” he told McKnight’s Long-Term Care News on Monday. 

“I think there is a belief that some money will come from increased accountability of existing spending, but I am skeptical that this alone can fund the additional required staff, especially for a facility that largely cares for Medicaid residents,” he added. “Thus, I think the minimum staffing standard is a step forward, but I am worried about how facilities will fund these new staff.” 

Beefing up oversight and transparency  

The administration also intends to come down harder on consistently poor performing facilities. 

Biden plans to call on Congress to provide almost $500 million to CMS to support health and safety inspections at nursing homes. CMS will also make changes to the Special Focus Facility program that will allow the program to scrutinize more facilities and ramp up enforcement on facilities that fail to improve. 

The president is also calling on Congress to increase the dollar limit on per-instance financial penalties levied on poor-performing facilities, from $21,000 to $1 million. 

The administration also wants Congress to give CMS added authority to “require minimum corporate competency” so that individuals or entities can be barred from obtaining a Medicare or Medicaid provider agreement for a nursing home if they have had compliance problems, past or present.

President Biden also will ask Congress to allow CMS to levy penalties and enforcement actions on owners or operators, even after a poor-performing building is closed.

In addition, CMS will increase pressure on corporate owners and operators by creating a new database that will track and identify owners and operators across states “to highlight previous problems with promoting resident health and safety.”

The agency also plans to collect and publicly report “more robust” corporate ownership and operating data in a form that will be transparent across states, according to the White House briefing statement.

“These would be, without question, the most important and positive changes in federal nursing home law and policy since the Nursing Home Reform Law was enacted in 1987,” Toby Edelman, senior policy attorney for the Center for Medicare Advocacy, said in a statement. 

“With the Biden blueprint, we have a real opportunity to make real the promise of the Nursing Home Reform Law – so that each resident truly receives all the care and services he or she needs to maintain the highest possible physical, mental, and psychosocial well-being,” Edelman added.