Staffing and Ownership Structure Take Center Stage in Senate Hearing on COVID-19 in Nursing Homes

The Senate Finance Committee on Wednesday held a hearing on the impact of COVID-19 on nursing homes, and witnesses from the frontlines to the academic sphere testified to the fact that the pandemic exacerbated problems that long predated the novel coronavirus.

And while the hearing contained its share of partisan talking points — ranging from the Trump administration’s failure to provide sufficient resources and information on COVID-19 to facilities to the policies of Democratic governors surrounding nursing home admissions of post-acute COVID-19 patients — it was clear from the testimony provided that the systemic problems of the sector transcended political parties.

“The terrible impact of COVID-19 on seniors in long-term care isn’t a red state or a blue state issue,” Sen. Ron Wyden, the Oregon Democrat who chairs the committee, said in his opening statement. “It is a nationwide tragedy. If you look at the 10 states where nursing homes have been hit the hardest, it’s five Republican-led states and five Democratic-led states.”


Dr. R. Tamara Konetzka of the University of Chicago, echoed this point, testifying that “multiple rigorous studies” have found standard quality metrics do not have a meaningful association with COVID-19 outcomes for nursing homes; even prior infection control citations were not associated with COVID-19 outcomes, she said.

“More than 99% of nursing homes in the nation have had at least one COVID-19 case, and more than 80% have had at least one death,” Konetzka testified. “This is clearly not a bad-apples problem, and no subset of nursing homes has found a magic bullet to keep the virus out.”

Staffing necessary for best practices

Over and over again, the witnesses testifying in the hearing emphasized that the issue of low staffing in nursing homes predated the pandemic — a point that was also made in one of the first hearings on the impact of COVID-19 in nursing homes in 2020.


As a result, when the pandemic hit, the staffing levels went from a strain to a crisis unto itself for many nursing homes.

“We’re extremely short-staffed,” Adelina Ramos, a certified nursing assistant (CNA) at the Greenville Center nursing home in Greenville, R.I., and a member of SEIU District 1199 New England, testified of her experience throughout the pandemic. “At one point, I was caring for 26 critically ill residents with only the help of one other CNA, a nurse and a housekeeper … I was horrified. We begged management for more staff on each shift, but they said they couldn’t find anyone.”

Ramos was also clear that staffing problems had been an issue well before the pandemic, for a variety of reasons. For one thing, the average starting wage for nursing home workers in Rhode Island is $12.34, forcing some staffers to work multiple jobs — and with inadequate staff, those who are present at work cannot spend enough time with their residents, Ramos said.

This problem is not unique to Rhode Island. A recent study in the journal Health Affairs documented just how pervasive this issue is; even before the pandemic, the median staff turnover in U.S. nursing homes was 94%.

Nurses and CNAs leave their roles for multiple reasons, Ramos testified. But the short staffing conditions tend to feed into that turnover, because it creates an unsustainable workload, alongside low wages that necessitate multiple jobs.

“I feel a call to do this job and care for others, but passion can’t pay bills,” Ramos said at a different point in her testimony.

Though community spread of COVID-19 and facility size have proven to be the top predictors of nursing home outbreaks in multiple studies, staffing does have an effect on how a COVID-19 outbreak plays out, Konetzka testified. More staff did not reduce the chance of outbreaks, but more staff hours meant fewer deaths and cases once an outbreak occurred, she said.

In fact, addressing insufficient staffing seems to be one of the few areas of agreement “in the often-contentious world of nursing home policy,” Konetzka said in her opening statement. Though true reform would take a long-term effort, a short-term measure could include using strike teams deployed by states in the height of the COVID crisis to quickly fill staffing gaps in an outbreak, she said.

The American Rescue Plan, the sweeping $1.9 trillion stimulus package recently signed into law by President Biden, includes $200 million for infection control and $250 million for strike teams.

“You really can’t implement the best practices that we now know can address a COVID outbreak — such as testing all residents as soon as there’s a case in the facility, such as separating residents and assigning dedicated staff to COVID-positive versus COVID-negative residents so they don’t have to go back and forth between the two — all of those things take staff,” Konetzka said. “And in the short run, we can’t incentivize facilities into finding more staff and hiring them in the middle of a crisis.”

In the long run, workforce retention and recruitment must feature prominently in the response to COVID-19, according to both Dr. David Gifford, the chief medical officer of the nursing home trade group American Health Care Association (AHCA), and Quiteka Moten, state long-term care ombudsman in Tennessee.

Gifford pointed to facets of the policy proposals put forth by AHCA, which primarily represents for-profit providers, and LeadingAge, the trade association for non-profit senior housing and care providers, which called for programs dedicated to cultivating workers for long-term care facilities through loan forgiveness, tax credits, and keeping those nurses and workers from being hired away by hospitals.

Moten also stressed the need to put a workforce strategy into any COVID-19 response, calling for a “comprehensive plan for recruiting and retaining staff” as an actionable item for facilities.

“Staffing issues are nothing new in the most regulated industry in this country,” Moten said in her opening remarks. “Nursing homes were already dealing with a workforce shortage, and COVID exacerbated that issue further.”

Transparency in ownership and cash flow

Calls for enhanced staffing from advocates and regulators — whether in the form of increased registered nurse coverage and enhancing the infection preventionist role such as AHCA and LeadingAge have recommended, or hiring more CNAs and paying them higher wages — are usually met with the response from SNFs that more “unfunded mandates” are impossible to implement.

This debate represents one of the major challenges to addressing staffing issues, according to Konetzka.

“Direct care staffing needs to be increased,” she said in her opening statement. “Addressing this challenge requires resources, which is where the agreement about staffing ends, and the harder problems begin. Many argue — and I largely agree — that America’s long-term care system is grossly underfunded. At the same time, the growing role of related party transactions and private equity ownership makes it difficult to see where taxpayer money is being spent, and what profit margins truly are. Greater transparency about the flow of money is urgently needed.”

In February, a group of experts ranging from academics to executives pointed to transparency of ownership as one of the critical tools for reform in a post-COVID world in a commentary in the journal Health Affairs.

“Quality issues persist as policy makers are unable to oversee how nursing homes spend Medicare and Medicaid payments,” the group wrote. “The growth in complex nursing-home ownership structures has limited financial transparency by allowing nursing homes to hide public payments and stint on direct resident care.”

Another study, one that found its way into the Wednesday hearing on multiple occasions, was a National Bureau of Economic Research working paper that found a variety of bad outcomes for nursing homes taken over by private equity ownership: an elevated risk of death for short-term Medicare patients, higher rates of antipsychotic drug use, and increased taxpayer spending on episodes of care.

In fact, Sen. Sherrod Brown of Ohio requested to enter the paper into the record for the hearing along with his and other legislators’ letters to a range of private equity firms with nursing home ownership histories.

Wyden emphasized that he wanted the Finance Committee to investigate the involvement of private equity in the nursing home field in response to Konetzka’s opening statement. It was a point she did not dispute, pointing to those worse outcomes for private-equity owned nursing homes as a reason to examine how those entities are using the government funds they receive.

“I think regulators have been reluctant to interfere with ownership transactions in the industry, an industry that was mostly for-profit,” Konetzka said. “But it may be time to do so, at least in the sense of transparency, so if we think about assistance or potentially increasing reimbursement rates, we at least know where the money is going.”

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