Describing “the way in which the United States finances, delivers, and regulates care in nursing homes settings [as] ineffective, inefficient, fragmented, and unstainable,” the National Academy of Sciences, Engineering, and Medicine’s Committee on the Quality of Care in Nursing Homes calls for “immediate action to initiate fundamental change.”[1] The Committee released its report, The National Imperative to Improve Nursing Home Quality; Honoring Our Commitment to Residents, Facility, and Staff, and described its findings and recommendations at a webinar on April 6, 2022. Remarkably, many of the Committee’s findings and recommendations mirror President Biden’s nursing home reform agenda, which was described in a February 28 White House Fact Sheet[2] and announced by the President in his State of the Union address on March 1.
The 605-page report addresses concerns that advocates for residents have been raising for many years – inadequate staffing levels, failure to enforce standards of care, lack of requirements and accountability for how public reimbursement is spent, among others – and proposes specific solutions that advocates have urged. While the Committee recognizes that additional financial resources will likely be required to implement its recommendations, it cautions that
this investment should not be viewed as simply adding more resources to the nursing home sector as it currently operates, because that alone would not likely result in significant improvements. Rather, the committee calls for targeted investments that (combined with current funding) would be inextricably linked to requirements for transparency. Such transparency will enable stronger and more effective oversight to ensure resources are properly allocated to improving the quality of care.[3]
The Committee rejects industry arguments that Medicaid reimbursement is always inadequate, writing, “The lack of transparency or accountability in payment, funds flow, and nursing home finances make it extremely difficult to assess the adequacy of current Medicaid payments.”[4]
Some of the excellent recommendations included in the report’s seven broad goals are:
Workforce
- Registered nurse(RN) coverage 24 hours per day/seven days per week, “with additional RN coverage that reflects resident census, acuity, case mix, and the professional nursing needs for residents as determined by the residents’ assessments and care plans” (Recommendation 2B, p. 510)
- A study “to identify and rigorously test specific minimum and optimum staffing standards for direct-care staff,” with findings implemented in updated federal and state regulatory requirements (Recommendation 2C, p. 511)
- An increase in minimum training hours for CNAs from 75 to 120 (Recommendation 2F, p. 514)
Transparency
- “HHS should collect, audit, and make publicly available detailed facility-level data on the finances, operations, and ownership of all nursing homes (e.g., through Medicare and Medicaid cost reports and data from Medicare’s Provider Enrollment, Chain, and Ownership System)” (Recommendation 3A, p. 518)
- “HHs should ensure that accurate and comprehensive data on the finances, operations, and ownership of all nursing homes are available in a real-time, readily usable, and searchable database so that consumers, payers, researchers, and federal and state regulators are able to use the data to:
- “Evaluate and track the quality of care for facilities with common ownership or management company.
- “Assess the impact of nursing home real estate ownership models and related party transactions on the quality of care.” (Recommendation 3B, p. 519)
Financing
- “[M]ove toward the establishment of a federal long-term care benefit that would expand access and advance equity for all adults who need long-term care” (Recommendation 4A, p. 520)
- Direct care ratios: “[R]equire a specific percentage of nursing home Medicare and Medicaid payments to be designated to pay for direct-care services for nursing home residents, including staffing (including both the number of staff and their wages and benefits), behavioral health, and clinical care” (Recommendation 4C, p. 522)
Survey and enforcement
- “CMS should ensure that state survey agencies have adequate capacity, organizational structure, and resources to fulfill their current nursing home oversight responsibilities for monitoring, investigation, and enforcement.” (Recommendation 5A, p. 526)
- “Greater use of enforcement remedies beyond civil monetary penalties, including chain-wide corporate integrity agreements, denial of admissions, directed plans of correction, temporary management, and termination from Medicare and Medicaid.” (Recommendation 5B, p. 527)
- “When data on the finances and ownership of nursing homes reveal a pattern of poor quality care across facilities with a common owner (including across state lines), federal and state oversight agencies (e.g., CMS, state licensure and survey agencies, the Department of Justice) should impose oversight and enforcement actions on the owner,” including “Denial of new or renewed licensure,” sanctions, “including the exclusion of individuals and entities from participation in Medicare and Medicaid,” and “strengthened oversight (e.g., through an improved and expanded special focus facilities program.” (Recommendation 5D, p. 529)
March 7, 2022 – T. Edelman
[1] NASEM, The National Imperative to Improve Nursing Home Quality; Honoring Our Commitment to Residents, Facility, and Staff, p. 2 (2022). The report can be downloaded through a link at https://nap.nationalacademies.org/catalog/26526/the-national-imperative-to-improve-nursing-home-quality-honoring-our. NASEM will make the webinar and the PowerPoint used in the webinar available on its website.
[2] White House, “Protecting Seniors and People with Disabilities by Improving Safety and Quality of Care in the Nation’s Nursing Homes” (Fact Sheet, Feb. 28, 2022), https://www.whitehouse.gov/briefing-room/statements-releases/2022/02/28/fact-sheet-protecting-seniors-and-people-with-disabilities-by-improving-safety-and-quality-of-care-in-the-nations-nursing-homes/ . See “Biden Administration Issues Bold and Comprehensive Nursing Home Reform Agenda” (CMA Alert, Mar. 2, 2022),
[3] NASEM, The National Imperative to Improve Nursing Home Quality; Honoring Our Commitment to Residents, Facility, and Staff, p. 4 (2022).
[4] Id. 433.