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White House Proposes Nursing Home Reforms Ahead of State of the Union Address

The reforms include minimum staffing requirements and other changes for which resident advocates have long fought

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The White House on Monday unveiled a slew of proposed changes to how U.S. nursing homes are regulated and run, including a vow to adopt federal minimum staffing requirements for facilities, step up enforcement of regulations and crack down on overcrowded rooms.

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President Joe Biden touched on the reforms during his State of the Union address on Tuesday, saying federal officials will “set higher standards for nursing homes and make sure your loved ones get the care they deserve and that they expect."

The announcement comes as the pandemic has ravaged U.S. long-term care facilities, where 200,000 residents and workers have died from COVID-19. These facilities have been plagued by staffing shortages for years, but they’ve gotten much worse during the pandemic and threaten resident care and infection control.

“Establishing a minimum staffing level ensures that all nursing home residents are provided safe, quality care and that workers have the support they need to provide high-quality care,” the White House said in a press release. “Nursing homes will be held accountable if they fail to meet this standard.”

Exactly what that standard looks like — or how facilities will be held accountable — are to be determined. Several aspects of Biden’s proposed nursing home reforms will need to clear public comment periods and other regulatory processes or require congressional action to take effect.

But resident advocates praised the announcement. “Not every issue gets mentioned in the State of the Union,” said Rhonda Richards, AARP’s senior legislative representative in government affairs. “It is significant that the president is talking about this. His plan will take important steps to better protect seniors in nursing homes and includes key policies that AARP has been advocating on.”

Chiquita Brooks-LaSure, administrator for the Centers for Medicare & Medicaid Services (CMS), told AARP in an interview that she has “personally met with nursing home residents, with CNAs — with certified nursing assistants — as well as the industry and ombudsmen to really hear what is happening on the ground.”

“We have an ambitious agenda,” Brooks-LaSure says. “All of the things we’re doing are really focused on helping caregivers to be able to make better decisions if nursing home care is the right decision for their loved one.”

Addressing staffing shortages

Nursing homes have recorded nearly 1 million COVID cases among residents and more than a million cases among staffers in the past two years, according to data from the CMS, which regulates the facilities along with state survey agencies. Even for staffers with mild symptoms, a positive test usually means at least a few days away from work. Huge numbers of certified nursing assistants, who generally make little more than minimum wage, have not received a COVID-19 booster shot.

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“Staffing is clearly the number one issue across the long-term care spectrum. It’s huge, not just for nursing homes but for all health care facilities,” says Mark Miller, Washington, D.C.’s long-term care ombudsman and the president of the National Association of State Long-Term Care Ombudsman Programs. “That’s going to take a long time to build up, but that's the most significant piece to this.”

While COVID deaths among residents have recently declined nationally as the omicron surge has waned, staffing shortages and cases among staff spiked in the four-week period ending Jan. 23, according to an AARP analysis of CMS data. Nearly 2 in 5 U.S. nursing homes reported a staffing shortage in that window.

In some states, the shortages were more dire. In Alaska, Kansas, Maine, Minnesota, Oregon, Washington, Wisconsin and Wyoming, more than 60 percent of facilities statewide reported a lack of staff.

growing body of research has connected short-staffed facilities with more severe COVID outbreaks, so residents are potentially at greater risk of infection when there aren’t enough nurses and other staff to go around.

But nursing home operators have long pushed back on mandatory staffing minimums, saying the real issue is that there aren’t enough interested and qualified workers to go around.

“We would love to hire more nurses and nurse aides to support the increasing needs of our residents,” Mark Parkinson, president and CEO of the American Health Care Association, which represents more than 14,000 nursing homes and long-term care facilities, said in a statement. “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.”

Increasing fines, sanctions on ‘substandard facilities’

The White House proposal calls for increasing fines and penalties on facilities that fail to meet federal care standards, asking Congress to boost the limit on fines per infraction in some cases from $21,000 to $1 million.

The administration is also calling on Congress to significantly expand federal regulators’ ability to target bad actors — and to boost CMS funding by nearly 25 percent to $500 million annually for health and safety inspections of nursing homes. Under the White House proposal, regulators would be able to better track nursing home operators’ history of penalties and infractions.

“When you get a Medicaid contract through CMS, they’re taken individually. It’s not like you’re looking at my past performance at other facilities that I owned,” says Miller, who also works with AARP’s Legal Counsel for the Elderly. “This is really going to shine a light on that.”

Among the White House’s other proposed nursing home reforms:

  • A new CMS database that will make it easier to track and compare the performance of facilities owned by the same company or owner
  • The ability for CMS to go after owners for wrongdoing, even if an individual facility shuts down
  • A phaseout of nursing home rooms with three or more residents in favor of single-occupancy rooms
  • Greater oversight of residents’ diagnoses and prescriptions, with a focus on anti-psychotic drugs
  • Continued funding and support for COVID-19 tests, vaccines and boosters in nursing homes

Miller describes the White House’s plan as “the single most significant set of proposals I’ve seen in 35 years.” But he acknowledges that many of the proposals will require congressional action during a busy and contentious midterm election year. Some aspects of the proposal, like the staffing requirements, may be able to bypass Congress but will still take time to be implemented.

​And some critics argue that they don’t go far enough to address other issues like Medicaid reimbursement rates and worker compensation. “Our system of enforcement shouldn’t be based on punishment over improvement,” Katie Smith Sloan, president and CEO of the LeadingAge association of nonprofit aging services and nursing home providers, said in a statement.

Andrew Soergel covers nursing homes and federal and state policy for AARP. He was previously a senior economics writer at U.S. News & World Report and was awarded an Economics of Aging and Work fellowship through the Associated Press-NORC Center for Public Affairs Research at the University of Chicago.

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