2/28/22, 3:26 PM FACT SHEET: Protecting Seniors and People with Disabilities by Improving Safety and Quality of Care in the Nation’s Nursing Ho...

BRIEFING ROOM

FACT SHEET: Protecting Seniors and People with

Disabilities by Improving Safety and Quality of Care in the

Nation’s Nursing Homes

FEBRUARY 28, 2022 • STATEMENTS AND RELEASES

All people deserve to be treated with dignity and respect and to have access to quality medical

care. And in no case should a health care facility be causing a patient harm. The President

believes we must improve the quality of our nursing homes so that seniors, people with

disabilities, and others living in nursing homes get the reliable, high-quality care they deserve.

That’s why he is announcing a set of reforms—developed by and implemented through the

Department of Health and Human Services (HHS)—that will improve the safety and quality of

nursing home care, hold nursing homes accountable for the care they provide, and make the

quality of care and facility ownership more transparent so that potential residents and their

loved ones can make informed decisions about care.

To do this, the reforms the President is announcing will ensure that:

every nursing home provides a sufficient number of staff who are adequately trained to

provide high-quality care;

poorly performing nursing homes are held accountable for improper and unsafe care and

immediately improve their services or are cut off from taxpayer dollars; and

the public has better information about nursing home conditions so that they can find the

best available options.

The pandemic has highlighted the tragic impact of substandard conditions at nursing homes,

which are home to many of our most at-risk community members. More than 1.4 million

people live in over 15,500 Medicare- and Medicaid-certified nursing homes across the nation.

In the past two years, 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.

Despite the tens of billions of federal taxpayer dollars flowing to nursing homes each year, too

many continue to provide poor, sub-standard care that leads to avoidable resident harm. In

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2/28/22, 3:26 PM FACT SHEET: Protecting Seniors and People with Disabilities by Improving Safety and Quality of Care in the Nation’s Nursing Ho...

fact, failure to comply with Federal guidelines at nursing homes is widespread. 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.  

Without decisive action now, these unacceptable conditions may get worse. Private equity

firms have been buying up struggling nursing homes, and research shows that private equityowned nursing homes tend to have significantly worse outcomes for residents. Private equity

firms’ investment in nursing homes has ballooned from $5 billion in 2000 to more than $100

billion in 2018, with about 5% of all nursing homes now owned by private equity firms. Too

often, the private equity model has put profits before people—a particularly dangerous model

when it comes to the health and safety of vulnerable seniors and people with disabilities.

Recent research has found that resident outcomes are significantly worse at private

equity-owned nursing homes:

A recent study found that residents in nursing homes acquired by private equity were 11.1%

more likely to have a preventable emergency department visit and 8.7% more likely to

experience a preventable hospitalization, when compared to residents of for-profit nursing

homes not associated with private equity.

One working paper examining 18,000 nursing home facilities over a seventeen-year period

found that private equity ownership increased excess mortality for residents by 10%,

increased prescription of antipsychotic drugs for residents by 50%, decreased hours of

frontline nursing staffing by 3%, and increased taxpayer spending per resident by 11%. That

suggests an additional 20,150 lives lost as a result of private equity ownership.

Another study found that private equity-backed nursing homes’ COVID-19 infection rate

and death rate were 30% and 40% above statewide averages, respectively.

Research also suggests that, despite depriving residents of quality care, private equityowned nursing homes actually led to an uptick in Medicare costs, too.

Today, the Biden-Harris Administration is announcing new steps by Department of

Health & Human Services (HHS) through its Centers for Medicare & Medicaid Services

(CMS), to improve the quality and safety of nursing homes, to protect vulnerable

residents and the health care heroes who care for them, and to crack down on bad actors.

The Administration is committed to these urgent actions as first steps toward fulfilling a

broader commitment to ensure taxpayer dollars go toward the safe, adequate, and respectful

care seniors and people with disabilities deserve—not to the pockets of predatory owners and

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operators who seek to maximize their profits at the expense of vulnerable residents’ health

and safety.

Ensuring Taxpayer Dollars Support Nursing Homes That Provide Safe, Adequate, and

Dignified Care

CMS is launching four new initiatives to ensure that residents get the quality care they need—

and that taxpayers pay for. These initiatives will help ensure adequate staffing, dignity and

safety in their accommodations, and quality care.

Establish a Minimum Nursing Home Staffing Requirement. The adequacy of a nursing

home’s staffing is the measure most closely linked to the quality of care residents receive.

For example, a recent study of one state’s nursing facilities found that increasing registered

nurse staffing by just 20 minutes per resident day was associated with 22% fewer

confirmed cases of COVID-19 and 26% fewer COVID-19 deaths. CMS intends to propose

minimum standards for staffing adequacy that nursing homes must meet. CMS will

conduct a new research study to determine the level and type of staffing needed to ensure

safe and quality care and will issue proposed rules within one year. 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. Nursing

homes will be held accountable if they fail to meet this standard.

Reduce Resident Room Crowding. Most nursing home residents prefer to have private

rooms to protect their privacy and dignity, but shared rooms with one or more other

residents remain the default option. These multi-occupancy rooms increase residents’ risk

of contracting infectious diseases, including COVID-19. CMS will explore ways to

accelerate phasing out rooms with three or more residents and to promote singleoccupancy rooms.

Strengthen the Skilled Nursing Facility (“SNF”) Value-Based Purchasing (“VBP”) Program.

The SNF-VBPprogram awards incentive funding to facilities based on quality performance.

CMS has begun to measure and publish staff turnover and weekend staffing levels, metrics

which closely align with the quality of care provided in a nursing home. CMS intends to

propose new payment changes based on staffing adequacy, the resident experience, as well

as how well facilities retain staff.

Reinforce Safeguards against Unnecessary Medications and Treatments. Thanks to CMS’

National Partnership to Improve Dementia Care in Nursing Homes, the nation has seen a

dramatic decrease in the use of antipsychotic drugs in nursing homes in recent years.

However, inappropriate diagnoses and prescribing still occur at too many nursing homes.

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CMS will launch a new effort to identify problematic diagnoses and refocus efforts to

continue to bring down the inappropriate use of antipsychotic medications.

Enhancing Accountability and Oversight

Holding nursing homes accountable for their performance requires a robust compliance

program—a program that has adequate funding to perform inspections and that imposes

meaningful penalties when deficiencies are found. Federal taxpayer dollars should not flow to

nursing homes that are unsafe.

Adequately Fund Inspection Activities. For over seven years, funding to conduct health

and safety inspections has remained flat while the number of complaints about nursing

homes has surged. To protect residents and crack down on unsafe nursing homes,

President Biden will call on Congress to provide almost $500 million to CMS, a nearly 25%

increase, to support health and safety inspections at nursing homes.

Beef up Scrutiny on More of the Poorest Performers. CMS’s Special Focus Facility (SFF)

program identifies the poorest-performing nursing homes in the country for increased

scrutiny in an effort to immediately improve the care they deliver. The SFF program

currently requires more frequent compliance surveys for program participants, which

must pass two consecutive inspections to “graduate” from the program. The SFF program

will be overhauled to more quickly improve care for the affected residents, including

changes that will make its requirements tougher and more impactful. CMS will also make

changes that allow the program to scrutinize more facilities, by moving facilities through

the program more quickly. Facilities that fail to improve will face increasingly larger

enforcement actions, including termination from participation in Medicare and Medicaid,

when appropriate.

Expand Financial Penalties and Other Enforcement Sanctions. CMS will expand the

instances in which it takes enforcement actions against poor-performing facilities based

on desk reviews of data submissions, which will be performed in addition to on-site

inspections. In July 2021, CMS rescinded a Trump Administration change that lowered

penalty amounts on bad actor nursing homes for harmful deficiencies by imposing only a

one-time fine, instead of more aggressive per-day fines that charge for each day a facility is

out of compliance. CMS will now explore making such per-day penalties the default

penalty for non-compliance. CMS will also use data, predictive analytics, and other

information processing tools to improve enforcement. President Biden is also calling on

Congress to raise the dollar limit on per-instance financial penalties levied on poorperforming facilities, from $21,000 to $1,000,000.

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Increase Accountability for Chain Owners of Substandard Facilities. President Biden is

calling on Congress to give CMS new authority to require minimum corporate competency

to participate in Medicare and Medicaid programs, enabling CMS to prohibit an individual

or entity from obtaining a Medicare or Medicaid provider agreement for a nursing home

(new or existing) based on the Medicare compliance history of their other owned or

operated facilities (previous or existing). He is further calling on Congress to expand CMS

enforcement authority at the ownership level, enabling CMS to impose enforcement

actions on the owners and operators of facilities even after they close a facility, as well as

on owners or operators that provide persistent substandard and noncompliant care in

some facilities, while still owning others.

Provide Technical Assistance to Nursing Homes to Help them Improve. CMS currently

contracts with Quality Improvement Organizations that help providers across the health

care spectrum make meaningful quality of care improvements. CMS will ensure that

improving nursing home care is a core mission for these organizations and will explore

pathways to expand on-demand trainings and information sharing around best practices,

while expanding individualized, evidence-based assistance related to issues exacerbated

by the pandemic.

Increasing Transparency

For too long, corporate owners and operators have not been held to account for poor nursing

home performance. CMS will improve the public transparency of facility ownership and

safeguard nursing home residents.

. CMS will create a new database that will track and identify owners and operators across

states to highlight previous problems with promoting resident health and safety. This

registry will use information collected through provider enrollment and health and safety

inspections to provide more information about prospective owners and operators to states.

Giving the public a resource to better understand owners’ and operators’ previous

violations will empower states to better protect the health and safety of residents.

Improve Transparency of Facility Ownership and Finances. CMS will implement

Affordable Care Act requirements regarding transparency in corporate ownership of

nursing homes, including by collecting and publicly reporting more robust corporate

ownership and operating data. It will also make this information easier to find on the

Nursing Home Care Compare website.

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Enhance Nursing Home Care Compare: CMS will implement a range of initiatives to

improve Nursing Home Care Compare, the rating website designed to help families pick a

facility for their loved ones. Under the Biden-Harris Administration’s leadership, CMS has

already published new measures on Care Compare, which allow users to consider nursing

home staff turnover, weekend staffing levels, and other important factors in their decisionmaking process. When the new minimum staffing requirement comes online, Care

Compare will also prominently display whether a facility is meeting these minimum

staffing requirements. CMS will further improve Care Compare by improving the

readability and usability of the information displayed—giving you and your family insight

into how to interpret key metrics. Finally, CMS will ensure that ratings more closely reflect

data that is verifiable, rather than self-reported, and will hold nursing homes accountable

for providing inaccurate information. The President is calling on Congress to give CMS

additional authority to validate data and take enforcement action against facilities that

submit incorrect information.

Examine the Role of Private Equity. As described above, private equity investors are

playing a growing role in the nursing home sector, and published research increasingly

indicates that facility ownership by investment groups leads to worse outcomes while

costing taxpayers more—particularly as these owners have sought to cut expenses at the

cost of patient health and safety, including during the COVID-19 pandemic. HHS and other

federal agencies will examine the role of private equity, real estate investment trusts

(REITs), and other investment ownership in the nursing home sector and inform the

public when corporate entities are not serving their residents’ best interests.

Creating Pathways to Good-paying Jobs with the Free and Fair Choice to Join a Union

Ensure Nurse Aide Training is Affordable. Lowering financial barriers to nurse aide

training and certification will strengthen and diversify the nursing home workforce.

CMSwill establish new requirements to ensure nurse aide trainees are notified about their

potential entitlement to training reimbursement upon employment. CMS will further

work with states to ensure reimbursement is being distributed and that free training

opportunities are widely publicized.

Support State Efforts to Improve Staffing and Workforce Sustainability. Strengthening the

nursing home workforce requires adequate compensation as well as a realistic career

ladder. CMS will develop a template to assist and encourage States requesting to tie

Medicaid payments to clinical staff wages and benefits, including additional pay for

experience and specialization.

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Launch National Nursing Career Pathways Campaign. CMS, in collaboration with the

Department of Labor, will work with external entities—including training intermediaries,

registered apprenticeship programs, labor-management training programs, and labor

unions—to conduct a robust nationwide campaign to recruit, train, retain, and transition

workers into long-term care careers, with pathways into health-care careers like

registered and licensed nurses.

Ensuring Pandemic and Emergency Preparedness in Nursing Homes

Continued COVID-19 testing in long-term care facilities. Throughout the pandemic, the

Biden-Harris Administration has provided approximately 3 million tests per week to all

Medicare- and Medicaid-certified nursing homes and thousands more assisted living

facilities, supporting outbreak testing and regular testing of staff. HHS will continue to

support this key mitigation strategy for vulnerable residents and the staff that care for

them.

Continued COVID-19 vaccinations and boosters in long-term care facilities. The BidenHarris Administration has provided the full support of the federal government to states in

ensuring that staff and residents across long-term care facilities have access to

vaccinations and booster shots. Today, facilities are required to ensure staff are vaccinated

and more than 87.1% of residents have received their primary series. CDC continues to

offer all facilities the ability to be matched with a federal pharmacy partner to host an onsite vaccination clinic. CMS has reached out to thousands of these facilities directly to

offer support, and the Agency for Healthcare Research and Quality has made a wide set of

tools available. HHS will continue to promote access to these clinics and efforts to

integrate vaccinations into routine services, incentivize vaccinations through provider

quality payment programs, and continue to provide a full range of resources to continue to

build confidence in the vaccine.

Strengthen Requirements for On-site Infection Preventionists. CMS will clarify and

increase the standards for nursing homes on the level of staffing facilities need for on-site

infection prevention employees, undoing the Trump Administration’s changes to these

requirements to help improve resident health and safety.

Enhance Requirements for Pandemic and Emergency Preparedness. Both the pandemic

and the increase in natural disasters have demonstrated how critical proactive emergency

preparedness is to keeping residents of nursing homes safe. CMS is examining and

considering changes to emergency preparedness requirements and is working to bolster

the resiliency of the health care sector as part of an Administration-wide effort to be ready

for the next pandemic and the next weather-related emergencies.

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Integrate Pandemic Lessons into Nursing Home Requirements. The pandemic has

underscored the need for resident-centered updates to nursing homes’ requirements of

participation in Medicare and Medicaid. CMS will integrate new lessons on standards of

care into nursing home requirements around fire safety, infection control, and other areas,

using an equity lens.

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