The Office of the Inspector General (OIG) is recommending that the federal government bolster its support to nursing homes – including through policies that help strengthen the workforce – in order to improve quality of care.
In its latest report, which draws upon lessons learned during the pandemic, OIG lays forth a set of five recommendations for the Centers for Medicare & Medicaid Services (CMS). The report released Thursday is OIG’s final installment in a three-part series about the effects of Covid-19 on nursing homes and provides a more in-depth look at the experiences of nursing homes at this time, basing the analysis on first-hand accounts from 25 facility administrators.
Part one of the OIG series released earlier focused on resident experiences, while the second focused on the nursing homes themselves, OIG said.
In making these new recommendations, OIG noted that nursing homes continue to struggle with “monumental and ongoing” workforce shortages, inflationary costs and implementing effective infection control practices.
First, OIG said the Centers for Medicare & Medicaid Services (CMS) should implement and expand on policies and programs to strengthen the nursing home workforce, while also reassessing nurse aide training and certification requirements.
Other recommendations included updating nursing home requirements for infection control to incorporate lessons learned from the pandemic, and providing effective guidance and assistance to facilities on how to comply with updated infection control requirements.
With a further focus on communication, OIG also recommended CMS facilitate share strategies and information to help the industry overcome challenges and improve care.
CMS didn’t explicitly state concurrence or nonconcurrence with the recommendations, according to the report. And, OIG attached a December letter from CMS Administrator Chiquita Brooks-LaSure with general responses to each recommendation.
Brooks-LaSure claims some recommendations are moot
When it came to expanding policies and programs to strengthen the nursing home workforce, Brooks-LaSure said CMS and other agencies within HHS have already implemented activities prior to the report’s recommendations, and suggested OIG remove this recommendation.
“CMS has issued a proposed rule that, among other things, would set a national minimum nurse staffing standard in nursing homes, the adoption of 24/7 RN requirements, and enhanced facility assessment requirements,” said Brooks-LaSure, adding that the proposal is subject to the comment and rule-making process. “In addition, CMS announced a national campaign to support staffing in nursing homes, which will invest over $75 million in financial incentives such as scholarships and tuition reimbursement.”
The staffing campaign builds on other actions through the HHS Health Workforce Initiative led by HRSA, whose scope includes workforce development, Brooks-LaSure noted.
In terms of reassessing nurse aide training and certification requirements, Brooks-LaSure took a similar stance. And, OIG should remove the recommendation since CMS already has existing regulations that allow facilities to employ nurse aides while they are undergoing state-approved training and competency evaluation programs, she said.
“Additionally, federal requirements allow states to use a variety of means for their state-approved Nurse Aide Competency Evaluation Program training curriculum, including online, classroom, or onsite training,” said Brooks-LaSure.
CMS reassessed existing nurse aide training and certification requirements considering facility experiences during the pandemic, she said, reiterating that the current requirements allow nursing homes the flexibility to train onsite.
OIG’s findings on staffing
The report dove into staffing challenges, finding that the fear of contracting Covid-19 at the beginning of the pandemic led to many staff retiring early or leaving for other health care settings. Such losses continued throughout the pandemic, OIG reported, an unsurprising find for many operators in the industry.
Certified nursing assistants (CNAs), dietary services staff, and housekeeping were particularly difficult to hire and retain, according to OIG. Instead, these workers opted for jobs in the fast-food industry, at big box stores and with delivery services, since they were oftentimes paid more and there were less physical and emotional demands compared to the nursing home industry.
“As one administrator explained, a nurse aide’s work includes heavy lifting and caring for residents who have cognitive decline yet is compensated at only $14 per hour at their facility,” researchers at OIG said. “According to nursing homes, an entry-level nurse aide position no longer has a competitive advantage as wages in other industries increased even prior to the pandemic.”
Nursing homes filled the gaps in staffing by hiring more agency workers, although with significant downsides including high costs, unreliability, and unfamiliarity with systems and residents, according to the report.
“One administrator said some agency costs increased by 40%, which was an amount the nursing home could not maintain in the long term. Another administrator noted that high agency rates put a lot of nursing facilities out of business,” OIG researchers noted.
Facilities tried changing the work environment and using incentives, but results were mixed, OIG found.
Changes to workforce culture meant taking steps to reduce workload while maintaining quality of care and introducing a variety of incentives. Some were minimally successful while others weren’t feasible if the resources weren’t there.
Other facilities adopted an “all-hands-on-deck” approach with positions taking on added responsibilities based on what was needed. It came with a cost, however, as turnover and feelings of burnout increased, the report noted.
OIG recommendations are long time coming
Nursing home associations including LeadingAge and the American Health Care Association/ National Centers for Assisted Living (AHCA/NCAL) said the OIG recommendations reinforce long-standing association demands, and that the discussion proves nursing homes don’t operate in a vacuum.
“The OIG report says more must be done to strengthen nursing homes as they face difficult and entrenched problems—and we agree. The report makes common sense recommendations for action by the Centers for Medicare and Medicaid Services (CMS),” Katie Smith Sloan, president and CEO of LeadingAge, said in a statement.
Nursing homes are a critical part of the larger health care continuum. When the industry isn’t properly supported, it’s felt in every care setting, AHCA/NCAL CEO and president Mark Parkinson said in a statement.
“We saw this during the pandemic. We saw it when we made calls for help, but it took months for public health officials to respond,” said Parkinson. “Now, we’re seeing it again with the historic workforce crisis that long-term care providers are working diligently but struggling to solve. And instead of helping nursing homes, federal policymakers want to penalize facilities.”
A strong, qualified workforce is critical to ensuring quality care, Smith Sloan said, but staffing challenges are “massive, complex and chronic.” Smith Sloan agreed with OIG that the ongoing workforce crisis can’t be solved by CMS alone saying that it’s going to need an “all-of-government” approach and creating problem solving among multiple federal government agencies and states.
“Staffing mandates are not the answer. Implementing them as CMS proposes is not feasible due to the lack of potential hires and the massive cost – anywhere from $4 billion to $7 billion in the first year alone,” she noted.
OIG’s call for CMS and nursing homes to collaborate on solutions was a welcome affirmation too, Smith Sloan said, given the agency’s punitive regulatory approach. It’s an arcane and broken process, she said.
“CMS should heed the report’s recommendations – but our leaders cannot stop there. We urge the Administration to focus on funding an array of staffing solutions across the government,” said Smith Sloan. “Of course, Congress has a role to play too. Legislative solutions are needed. Meaningful funding will yield better jobs, and better jobs will yield greater access to quality care.”
Parkinson echoed these thoughts, adding that the report highlights the importance of partnerships, and that the industry welcomes opportunities to provide insights and experiences to support a collaborative path forward.
“We agree that it’s time to transform America’s nursing homes, but we need the support of policymakers to make it happen,” he said.
Brooks-LaSure said this particular recommendation, to facilitate more collaboration, is met via the agency’s stakeholder calls, the Nursing Home Best Practices toolkit issued in March 2020, and publicly posted memos on quality, safety and oversight requirements. The agency also contracted with Quality Improvement Organizations (QIOs) to work with providers, community partners, beneficiaries and caregivers to better realize data-driven quality improvement initiatives.
“CMS contends that the agency has therefore met this recommendation,” Brooks-LaSure said. “It is important to note, however, that creating individualized communication with over 15,000 nursing homes is not feasible with CMS’s available resources.”
Companies featured in this article:
AHCA/NCAL, Centers for Medicare & Medicaid Services, CMS, LeadingAge, OIG
