The nursing home industry’s struggles during the COVID-19 pandemic are about to receive presidential attention.

On Tuesday, President Joe Biden will use his State of the Union address to announce a crackdown on conditions at nursing homes that lead to poorer outcomes for patients, including inadequate staffing, senior administrative officials told reporters Monday. The Biden administration also will scrutinize complicated ownership structures that impede oversight of skilled nursing facilities, the officials said.

Under Biden’s directive, the Centers for Medicare and Medicaid Services will publish regulations addressing safety and quality. That will include minimum staffing requirements, standards to reduce overcrowding, rules to address the overuse of antipsychotic medications and stepped up inspections and enforcement, including financial penalties for noncompliant nursing homes. Biden previously proposed minimum nurse-to-patient ratios, along with a requirement that a registered nurse be on duty at all times.

The administration wants Congress to empower CMS to publicly hold nursing home chain owners—with histories of safety and quality failures—to account. CMS also will investigate the consequences of private equity firms owning nursing homes, which has been linked to poorer care.

“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,” says a White House fact sheet published Monday.

More than 200,000 residents and staff at long-term care facilities have died of COVID-19 since the start of the pandemic, which attracted widespread negative attention to the industry. More than 1.4 million people reside in 15,500 Medicare- and Medicaid-certified nursing facilities , according to the White House.

The pandemic highlighted longstanding problems at the nation’s nursing homes. For example, regulators uncovered at least one infection prevention and control failure at 82% of nursing homes inspected between 2013 and 2017, the Government Accountability Office reported in 2020.

Biden’s slate of proposals amounts to the most extensive nursing home reforms in decades, which many observers believe was long overdue.

“These are things that we have been advocating for for a long time,” said Charlene Harrington, a professor emeritus at University of San Francisco who studies nursing facilities. The most recent effort on this scale was the Nursing Home Reform Act of 1987, she said.

Staffing rules

Although some states have laws mandating minimum staffing at nursing homes and hospitals, there is no federal standard. Research has linked smaller nursing workforces to lower-quality care.

Biden will direct CMS to determine how many nurses—and what kinds—are needed to ensure safe, quality care. The agency will propose regulations within a year that will create penalties for facilities that fail to meet the new national requirements. Records on nursing homes that fail to meet staffing minimums would be added to the Care Compare website.

Federal staffing rules would be the most significant change for the industry, Harrington said. “We know that many of the nursing homes that had problems with COVID—at least early on in the pandemic—were understaffed,” she said.

The American Health Care Association/National Center for Assisted Living warned against imposing those mandates without new government funding. “Additional oversight—without corresponding assistance—will not improve resident care. To make real improvements, we need policymakers to prioritize investing in this chronically underfunded healthcare sector and support providers’ improvement on the metrics that matter for residents,” CEO Mark Parkinson said in a statement.

Workforce retention has also been a major issue for nursing homes throughout the COVID-19 pandemic. Nursing home workers received the highest wage increases in the healthcare sector during the public health emergency, but employment is still nearly 5% lower than it was a year ago.

By making nursing home jobs more desirable, some of this pressure could be alleviated. Biden will instruct CMS to bolster the workforce by requiring employers to inform newly hired nurse aide trainees that they may be eligible for reimbursement of their educational costs. CMS will oversee this initiative to ensure that the program is publicized and that the funds are distributed fairly, according to the White House. The agency will also facilitate states’ requests to link Medicaid funding to labor costs for clinical staff.

And CMS will partner with the Labor Department, unions and others on a national recruitment and training drive for long-term care careers that will include pathways to registered nursing and other healthcare professions.

Nursing home ownership

Biden’s address will also take direct aim at corporate bad actors in the nursing home sector. The administration plans to create a public database of nursing home owners that will incorporate records of health and safety failures. CMS will also collect and publicly report more thorough information about corporate ownership and make it available on Care Compare.

“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,” the White House fact sheet says.

Private equity firmsreal estate investment trusts and other investor-ownership arrangements will come under scrutiny. After all, private equity investment in nursing homes has dramatically increased over the last decade and these companies now own about 5% of skilled nursing facilities, according to research Weill Cornell Medicine published in November. Nursing homes owned by private equity firms are associated with poorer health outcomes, the study found.

COVID-19 and safety
Biden will commit to continued COVID-19 testing, vaccinations and boosters in long-term care facilities. The Health and Human Services Department will maintain its efforts to encourage immunizations through quality payment programs and provide ongoing resources to promote COVID-19 vaccines.

CMS will explore ways to reduce the use of multi-occupancy rooms, which increase the spread of infectious diseases. The agency will also investigate “problematic diagnoses” and “inappropriate” use of antipsychotic medications.

In addition, the agency will step up enforcement against poorly performing nursing homes and evaluate per-day penalties for those not following safety and quality rules. Biden will ask Congress to raise the daily penalty limit from $21,000 to $1 million.

CMS plans to undo a 2020 policy that loosened a requirement that nursing homes must employ infection control specialists and is revisiting its emergency preparedness policies.