As the nursing home sector tried to move out of COVID-19’s shadow in 2022, new challenges rushed in.

It was a year filled with more, largely unwanted, attention from lawmakers and regulators, and legal challenges that could define how skilled nursing providers hire, operate and serve patients for years to come. Here are the top stories that grabbed our readers’ attention in what’s been a landmark year.

White House throws nursing homes into historic spotlight

A sobering February announcement from the White House outlined ambitious plans to “improve the safety and quality of care” in US nursing homes, setting the regulatory tone for the year ahead. The 21-point plan was issued hours before a historic State of the Union Address in which President Joe Biden criticized private equity’s involvement in nursing homes and promised higher standards on his watch.

“Medicare is going to set higher standards for nursing homes and make sure your loved ones get the care they deserve ,” President Joe Biden said in his 2022 State of the Union address.

The White House plan has been a driver of a lot of high-stakes action coming from the Centers for Medicare & Medicaid Services ever since. It has included initiatives aimed at setting minimum staffing standards; beefing up enforcement capabilities and related penalties; expanding the Special Focus Facility program; and increasing ownership transparency.

Much of the rhetoric was immediately blasted by provider groups, including American Health Care Association President Mark Parkinson, who said the administration’s premise that quality in nursing homes had gotten worse couldn’t be “further from the truth.” While he said a minimum staffing requirement would be “unrealistic and impossible” amid the ongoing workforce crisis, AHCA and LeadingAge supported other initiatives aimed at helping poor-quality providers improve. 

CMS walks back pay cuts after intense pressure

Providers breathed a sigh of relief in late July, as CMS announced it would phase in cuts related to the Patient Driven Payment Model. And instead of being hit with a major reduction proposed in April, providers got a modest 2.7 % net pay increase.

The SNF Prospective Payment System final rule included a 3.9% SNF market basket and a 2.3%, or $780 million, downward parity adjustment to address alleged Patient Driven Payment Model overpayments. Initially, CMS had threatened to take back 4.6% in PDPM payments in a single year, but after thousands of provider comments decried the “heartless” move, the administration decided to phase the cuts in over a two-year span. In total, providers were expected to see an increase of about $904 million (rather than a $320 million proposed decrease) in Medicare Part A payments in fiscal 2023. 

Supreme Court upholds healthcare worker vaccine mandate 

After months of uncertainty, the Supreme Court in January allowed to stand a COVID-19 vaccine requirement for staff at all US nursing homes and other federally funded healthcare facilities. The 5-4 decision put the vaccine rule back in place in 25 states that had been covered by injunctions.

The U.S. Supreme Court building
The Supreme Court allowed a healthcare worker vaccine mandate to stand in a 5-4 ruling. Credit: Joe Daniel Price/Getty Images Plus

Though providers, especially those in rural areas, had expressed concern about the ability to keep staff when faced with mandatory vaccines, the CMS administrator and academic and independent studies revealed that the rule did not ultimately lead to mass departures that skeptics forecast. In the months after the mandate went into effect, vaccine coverage among staff rose 25 percentage points to peak at 88%. The rule does allow for medical exemptions.

In recent weeks, however, talk has arisen that if the administration backs off of its mandate for members of the military, the healthcare worker mandate could be next.

State reduces staffing requirement while feds study their own version

Florida Gov. Ron DeSantis (R) gave nursing homes more flexibility in April, when he signed a measure that “modernizes outdated staffing requirements.” The bill, which was backed by the Florida Health Care Association, reduced the minimum time of direct care per resident day provided by certified nurse aides to 2.0 hours. A higher overall standard also now accounts for time non-nurses, including therapists, spend with residents.

The adjustment came as providers in the state, and across the nation, have struggled to fill thousands of open jobs. The state move appeared to counter a move by CMS to put more stringent staffing requirements in place nationwide. Florida lawmakers also passed a 7.8% increase in Medicaid funding for nursing homes, a total of about $419,000 per facility. Providers across the nation advocated for higher state Medicaid rates amid ongoing staffing shortages in 2022.

CMS revises COVID-19 vaccine mandate guidance

Several months after the COVID-19 vaccine requirements went into effect, CMS began to clarify the policy and related enforcement actions.

In April, the agency said that “good-faith efforts” by providers, such as holding vaccine clinics, should be rewarded by surveyors. That clarification also told facilities that staff suspended or on extended leave would not account against their vaccinated rate. The agency also gave more examples of how providers could reassign, test and mask exempted employees.

CMS issued its latest updated memo to surveyors in October, encouraging inspectors to limit or avoid enforcement action if a facility could demonstrate it had implemented a plan to achieve a 100% vaccination rate.

Nurse aide certification waivers and other COVID flexibilities stripped away

Temporary nurse aide waivers, a key flexibility for providers nationwide, were stripped away by CMS, months after the agency said it would begin walking back some relaxed rules it enacted due to the pandemic.

Providers had 60 days’ warning on the nurse aide revocation, which then triggered a requirement that any nurse aides without certification complete testing by October. That caused panic in many states where testing capabilities had not yet recovered from early COVID closures and nurse-proctor shortages.

At the eleventh hour, the agency issued a series of waiver extensions to 15 states and hundreds of individual nursing homes or companies. Most of those will run through the end of the public health emergency.

More than 400 nursing home closures projected for 2022

A study conducted by AHCA predicted about 400 nursing homes could close in 2022.

More than 1,000 nursing homes have closed since 2015 — with 776 happening before the pandemic and 327 during the crisis, an analysis of government data found. The closed facilities tended to be urban settings with high-Medicaid census and had fewer than 100 beds. Dozens of closures have followed the April announcement, with rural areas in particular reflected in many public announcements.

US nursing homes system ‘ineffective, unsustainable,’ major report finds

A long-awaited National Academies report found that the way the United States finances, delivers and regulates nursing home care is “ineffective and unsustainable.” Across 605 pages, authors called for immediate action to bring meaningful changes to the system and better meet the needs of residents and staff.

Ambitious recommendations included: requirements for higher 24/7 nurse staffing and a full-time social worker in all nursing homes; research on minimum and optimum staffing levels; and making facility-level data on finances, operations and ownership of all nursing homes publicly available.

The findings in large part aligned with the White House reform plan announced earlier in the year, though the Academies authors also honed in on the underinvestment of the nursing home sector that has suffered from “for decades.” 

Other big storylines that kept skilled nursing providers busy this year included two other major regulatory concerns: 

In June, CMS released final guidance on Phase 3 of the requirements of participation after years of delay. New rules regarding infection preventionists, resident rights, behavioral health and staff data reporting went into effect Oct. 24

Then, in September, CMS surprised nursing home operators with a draft of updated Minimum Data Set specifications. Changes, including removal of a section many states use to calculate Medicaid payments, will go into effect Oct. 1, 2023.