Nursing Home Industry Targets RN Staffing, PPE Stockpiles in Reform Pitch — But Ownership Untouched for Now

The two largest trade groups for nursing homes proposed a policy agenda to address the systemic issues in the sector illuminated by COVID-19, with reforms centered on improving nursing hours, staff retention and infection control — in addition to increasing reimbursement from Medicaid, the largest payer for nursing home care, to cover the costs.

The proposals from the American Health Care Association (AHCA), which represents primarily for-profit nursing homes and assisted living facilities, and LeadingAge, which represents non-profit providers, are centered around four areas: clinical care, workforce, oversight, and structure.

They include a federal requirement that nursing homes maintain 24-hour “on-staff” registered nurse (RN) coverage, developing a strategy for recruiting and retaining workers in long-term care, addressing issues at “chronic poor performing facilities,” and encouraging the development of private rooms.


The total cost of the proposal is about $15 billion, with about $11 billion of that covered in the clinical suggestions: additional RN hours, extra employees for infection control, and a requirement of a minimum 30-day supply of personal protective equipment (PPE), AHCA president and CEO Mark Parkinson said in the Monday press conference announcing the policy proposals.

The other $4 billion would address “long-term underfunding of states to their Medicaid system,” Parkinson said; Medicaid and government funds are a major focus of the proposals from AHCA and LeadingAge. There are four investment strategies centered around funding from the government in the proposals:

  • Enhancing the Federal Medical Assistance Percentages (FMAP), the portion of Medicaid funded by the federal government and sent to states, with the stipulation that states use the additional dollars for nursing facility rates.
  • Establishing a federal framework for defining the terms “allowable cost” or “reasonable cost.”
  • Updating Medicaid rates to keep pace with the cost of care and regularly adjusting them as that increases.
  • Requiring states to form and maintain a committee with the state, health plans, and SNFs on value-based purchasing, with specific guidelines and deadlines for submitting reports. The goal is to potentially open avenues for other resources.

In terms of clinical enhancements, the first is enhancing the infection control preventionist role by establishing “an updated guideline for staffing infection preventionists in each nursing home based on proven, successful strategies,” the proposal document said. This would be funded by the Medicaid payment policy updates.


Under the Trump administration, the Centers for Medicare & Medicaid Services (CMS) had in July of 2019 proposed making some changes around the role of infection preventionist in the nursing home setting, namely altering the role from part-time to one that has “sufficient time” to enact a facility’s infection control program. The rule never went past the proposal stages, and it was published well before COVID-19 appeared as a pathogen, but it became a flashpoint as the pandemic hit nursing homes in the U.S.

The clinical proposals also include a new federal requirement that each nursing home have an RN “on-staff”; in the press conference, Dr. David Gifford, AHCA’s chief medical officer, said the groups support “a 24-hour registered nurse in the buildings.” Medicaid policy changes and Medicare rates would fund this, according to the proposals.

Several steps need to happen for this requirement, according to a policy brief on the 24-hour proposal, ranging from loan forgiveness for recently graduated RNs who work in nursing homes to a national campaign to recruit RNs for nursing homes. AHCA and LeadingAge also recommended that policymakers provide flexibilities around the requirement, such as waivers during an emergency situation, allowing telehealth RNs in times of a shortage or in small or rural facilities, or including nurse practitioner hours by NPs who are RNs as hours to comply.

In terms of oversight, AHCA and LeadingAge called for improving systems so they are more “resident-driven,” with changes to surveys; addressing poorly performing nursing homes through a multi-step process beginning with identification and ending with the implementation of a plan of correction; and incorporating customer satisfaction into the government’s five-star rating system.

But for now, transparency around ownership of SNFs is not part of those proposals, which are focused on “care at the bedside,” Parkinson said.

Both AHCA and LeadingAge emphasized that transparency measures — a tool for reform called for by voices ranging from academic experts on nursing homes to embattled New York governor Andrew Cuomo — are steps they would support.

“LeadingAge has long endorsed full transparency, and the reason we do is because it’s absolutely crucial to establishing a trusting relationship between nursing homes and care providers, residents, families and the government,” Katie Smith Sloan, the president and CEO of LeadingAge, said during the conference. “So it’s essential that we look at solutions towards full transparency.”

Parkinson agreed, noting that AHCA is “happy to do it” in terms of bringing that information to light. But he argued that alone would not be enough to address the issues of patient care the proposals are focused on.

“I wish that they would pass the transparency proposal just to get this issue off the table. It is a distraction from the quality issues,” Parkinson said. “There’s this view that: Oh my goodness, if we just knew who owned all these buildings, things would get better. That’s not going to improve things.”

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