Biden’s March 1st State of the Union speech included a promise to bring Nursing Home Industry Reforms including minimum staffing requirements, enhanced nursing home oversight, and greater transparency of facility ownership with a focus on private equity firms. The White House shared a fact sheet outlining a vision “to improve quality of care and quality of life for nursing home residents.”  CMS will host a National Nursing Home Stakeholder Call on March 10 at 3 p.m. ET to overview the plan and an implementation strategy. CMS described 4 initiatives as part of the Biden-Harris plan including these key takeaways …

      • Establish a Minimum Nursing Home Staffing Requirement. 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 single-occupancy rooms.
      • Strengthen the Skilled Nursing Facility (“SNF”) Value-Based Purchasing (“VBP”) Program. The SNF-VBP program 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. CMS will launch a new effort to identify problematic diagnoses and refocus efforts to continue to bring down the inappropriate use of antipsychotic medications.


In addition, the following measures were proposed aimed at “Enhancing Accountability and Oversight

Through funding of inspections and imposition of penalties for deficiencies with the goal of preventing the flow of funding to” unsafe” facilities.  Targeted measures proposed include:

      • Adequately Fund Inspection Activities with a call on Congress for $500 million in funding 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 poor-performing facilities, from $21,000 to $1,000,000.
      • 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.


Other measures outlined address the affordability of nurse aide training, development of a wage template for the nursing home workforce, a career pathways campaign with emphasis on the free choice to join a labor union, continued pandemic and emergency preparedness including, but not limited to continued support for testing, vaccinations, strengthened requirements for on-site Infection Preventionists and integration of pandemic lessons into nursing home requirements.


Amie Martin OTR/L, CHC, RAC-CT, MJ

Learn more about the rest of the Proactive team.