CMS in ‘Full Court Sprint’ to Carry Out Biden’s Nursing Home Reforms

The Centers for Medicare & Medicaid Services (CMS) is in a “full court sprint” toward fulfilling the Biden administration’s proposed nursing home reforms first announced last week, CMS Principal Deputy Administrator Jonathan Blum said during a stakeholder call on Thursday.

Twenty-one initiatives across five strategic goals will have short-, mid- and long-term timelines for implementation, Blum said. Only the minimum staffing standard was given a definitive timeline, with a new standard to be proposed within one year.

Curbing inappropriate use of antipsychotics was also mentioned as a short-term initiative, as well as overhauling the special focus facility program and increasing accountability and transparency among nursing home owners.


No specific timeline was given for these short-term reforms.

“Other initiatives listed will have their own timeline,” Will Harris, senior advisor, Office of the CMS administrator, said on the call. “In all cases, we want to make sure we’re building in meaningful stakeholder feedback so that we can get the details right.”

More than 2,500 listeners tuned in to learn more about how CMS will implement Biden’s wide-ranging reforms.


A seat at the table

Feedback from stakeholders, Harris said, is one of CMS Administrator Chiquita Brooks-LaSure’s six pillars her team aims to stick to while running the agency. For each initiative, there will be the opportunity for meaningful feedback to inform policy making, he added.

Industry leaders, however, haven’t felt that they haven’t gotten a proper seat at the table, prior to major reform and mandates coming out.

“The announcement, frankly, caught the sector off guard a little bit,” said Matt Hartman, executive director of the Illinois Health Care Association (IHCA). “We felt a little blindsided.”

The American Health Care Association and National Center for Assisted Living (AHCA/NCAL) penned a letter to the agency this week asking to meet with members of the administration regarding the reforms.

AHCA President Mark Parkinson said in a news conference last week the association had some discussions with CMS prior to the Biden reforms being announced. Prior to that, the Biden administration was preparing to get initiatives rolling that Congress cut from the Build Back Better Act.

“Virtually every one of the proposals that was outlined on Monday was attempted in the reconciliation bill up on the hill and obviously that bill was not successful,” said Parkinson. “We were not surprised that the effort would then be to do things administratively. The good news is that a lot of this stuff can’t be done administratively. It has to be done with congressional input.”

Parkinson’s comments from last week stand in stark contrast to CMS’ announced efforts to carry out a study to develop “evidence-based and appropriate [staffing] requirements,” followed by proposed staffing minimum requirements based on that study.

CMS will “adopt a careful, considered approach to implementing this initiative,” Deputy Director of the Center for Clinical Standards and Quality Jean Moody-Williams told listeners during the stakeholder call.

Staffing reform ‘won’t happen overnight’

CMS recognizes that staffing increases “won’t happen overnight,” Harris said, as the government agency looks to take a holistic approach to improving the long-term sustainability of nursing home workforce.

As part of that approach, CMS plans to address financial barriers to training and expanding recruitment for the industry as a way to strengthen the worker pipeline.

Improvements to job quality through advancement opportunities and ensuring safe staffing levels will help increase retention and support new recruits, Harris added.

“We’ve heard directly from nursing home workers that creating meaningful career ladders, recognizing experience and ensuring a safe work environment would increase retention as well as the quality of care that is delivered in nursing homes across the country,” Harris said.

Since the start of the pandemic, 238,000 caregivers have left the profession, according to the U.S. Bureau of Labor Statistics; workforce levels in the nursing home industry are at the lowest they have been in 15 years.

Up to 400,000 residents could be displaced, professional services firm CliftonLarsonAllen (CLA) found in a report released last week, as nursing homes continue to operate with a -3% to -8% margin this year and no replenishment of Provider Relief Funds (PRF) in sight.

Understanding what staffing is required for safer care is one of CMS’ three primary themes behind its comprehensive plan to fully realize Biden’s reforms, Blum told listeners.

A focus on dedicating resources to providers that present the overall greatest risk and greater transparency within ownership status among nursing homes are the other two themes, he said.

“We have heard many calls from consumers, their families, their advocates, states, and Congress to provide greater transparency to the ownership status for those facilities that participate in Medicare, Medicaid,” Blum noted.

CMS is working to build more “tools” so the public can better understand the relationships between who owns real estate, who operates a facility, who provides management services and who might have a vested interest in a given property.

Outlining who is participating within the Medicare and Medicaid programs and how that connects to overall care drives CMS’ look into financial transparency, added Blum.

“As we put forward regulations, new guidance documents, new data systems, that will be done in continual partnership,” Blum explained. “While we have an obligation to promote safer care, or more consumer centric care, we also have an obligation to work in full partnership to understand the full complexity of these issues.”

Federal funding talks absent

There was no mention of potential funding for staffing minimum standards, nor any of the other initiatives during the call. Lack of federal monetary support has been the main sticking point for operators and senior care associations ever since the reforms were announced.

Brooks-LaSure did say adequate funding is a “piece” of the agency’s holistic approach to reforming the nursing home industry in an interview with Bloomberg; the CMS administrator was referring to strengthening the industry’s workforce.

In a statement following the initial White House fact sheet published Feb. 28, LeadingAge President and CEO Katie Smith Sloan said the organization was gratified to see the Biden administration prioritizing long-term care, but well intentioned reforms don’t “change the math,” referring to chronic underfunding of Medicaid for long-term care services.

AHCA’s Parkinson pointed out that more oversight without federal assistance would not improve resident care.

The White House only listed a $500 million bump to CMS Survey and Certification to support nursing home health and safety inspections.

The 24% increase is to compensate for flat survey funding over seven years, while the surge in complaints has surged, according to the fact sheet.

“We understand that the federal and state environment for oversight, by definition, has constraints, has limited resources, and to our mind we really want to focus on where we have the greatest risk, where we have the greatest opportunity for improvement, but also to ensure safer care,” Blum said.

CMS officials also outlined booster initiatives briefly during the call, applauding the 73.4% resident booster rate being above the national average while encouraging operators to continue getting staff boosted; just over 40% of nursing home staff have received the booster, according to recent data published by the agency.

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