During a Pandemic, Boosting Infection-Control Fines on Nursing Homes May Do More Harm Than Good

The federal government announced on Monday that it would be cracking down on infection control violations in nursing homes, with fines increasing for facilities with a history of deficiencies in this area — a move that came alongside the announcement that almost 26,000 skilled nursing residents died from COVID-19 across the country.

But two researchers who have focused their academic work on quality in long-term care facilities both were adamant that increased penalties, at least during a global pandemic, are not the right solution for containing the virus and keeping it out of the nursing home setting.

“I think these policies are at best premature, and at worst, probably a little dangerous,” R. Tamara Konetzka, a professor of health services research in the Department of Public Health Sciences at the University of Chicago, told Skilled Nursing News on Tuesday. “Most of the research that’s been done on quality and the probability of a nursing home having a COVID outbreak, or COVID-related deaths, has shown that there’s actually not much of a relationship with quality.”


In recent testimony before the U.S. Senate, Konetzka discussed preliminary research into COVID-19 data that found “a strong and consistent relationship between race and the probability of COVID-19 cases and deaths” — and no correlation between outbreaks and factors such as federal star ratings or profit status.

She reiterated this point in light of the announcement by the Centers for Medicare & Medicaid Services (CMS) that it would be increasing the civil monetary penalties (CMP) for infection control violations in nursing homes. In some cases, facilities with a history of problems in that area could face per-instance fines of $20,000.

While she acknowledged that previous studies have been focused on overall quality ratings — of which infection control is only one portion — on CMS’s Nursing Home Compare tool, Konetzka told SNN that she believed past infection control violations would not be indicative of which nursing homes had COVID-19 outbreaks.


Though she emphasized that quality is important, the scope of the pandemic makes it a challenge for even high-quality providers to contain the virus.

“What we’ve seen in the research is that even the highest-quality homes were vulnerable to this, and the relationship between quality and the probability of an outbreak is even inconsistent from state to state,” Konetzka told SNN. “So in some states, you see higher-quality homes being more likely to have an outbreak. What is correlated is where the virus is circulating.”

In announcing the bolstered enforcement efforts, CMS pointed to signs in early federal data that indicated a higher chance of outbreaks at facilities with a one-star rating from the federal government as opposed to a five-star rating, as well as an apparent correlation between staffing and COVID risk.

“We also know that the data is correlated with staffing, so those that have higher staffing ratios — that means less staff to the patients — in those particular cases, we’re also seeing some more issues there,” CMS administrator Seema Verma said.

But David Grabowski, a professor of health care policy at Harvard Medical School and a member of the Medicare Payment Advisory Commission (MedPAC), was similarly skeptical about the ability of the increased fines to force improvements in how nursing homes are responding to the COVID-19 pandemic, describing it as “the wrong approach.”

An article by Grabowski and other researchers that was published in the Journal of the American Geriatrics Society on Tuesday found that the increased probability of a COVID-19 case in a nursing home was related to several factors: larger facility size, urban location, greater percentage of African-American residents, non‐chain status, and state.

The sample size in their research was 9,395 nursing homes.

Several different researchers appear to be coming to the same conclusions about the correlation between race and COVID-19 in nursing homes, which is also correlated to large urban areas where the virus is circulating, Konetzka told SNN.

“Which nursing homes were hit were really about where they’re located, and who their staff are, and who their residents are, and not about the quality of the facility,” she said.

That means that taking a more punitive stance, especially given that the nursing home sector is still in crisis mode and in many places remains under-resourced, is bad timing on the part of CMS, Konetzka argued.

Grabowski agreed.

“CMS should be doing two things. First, they should be providing facilities with testing and personal protective equipment. Second, they should be looking to provide education and guidance to facilities on best infection control practices,” Grabowski wrote in an e-mail to SNN Tuesday. “If the goal is to save lives and protect residents, then this is not the right enforcement action. Facilities have limited resources right now.”

Both Grabowski and Konetzka emphasized strongly that nursing homes do need to be held accountable and provide good care to their residents. But given how quickly COVID-19 can spread inside a facility, nursing homes need all the resources they can, and though money and resources have been allocated, Konetzka pointed out that it’s been slow to arrive.

And even if the short-term challenge is met, the underfunding of long-term care remains a major challenge, she added. Many nursing homes do need to improve on infection control, and those procedures are clearly important, Konetzka said.

But at the present moment, the time just isn’t right for fines, in both her and Grabowski’s view.

“We have all found that COVID-19 cases are largely a function of where the facility is located and not their prior quality,” Grabowski wrote to SNN. “This suggests COVID-19 in nursing homes is not limited to ‘bad apples,’ but rather a system problem requiring system solutions. CMS should focus on distributing testing and personal protective equipment to nursing homes. Increased fines to punish ‘bad apples’ are misguided right now.”

Given that CMS also announced 26,000 deaths in nursing homes according to its first round of COVID-19 data collected from facilities, the costs of misplaced focus are incalculable.

“I really don’t think it’s about quality right now,” Konetzka told SNN. “This is a crisis, and we need to just think about which places need resources in order to save lives.”