Nursing Home Care Finds a Spotlight in State of the Union

Officials say vast reform is needed.

With all eyes, both domestically and internationally, on Ukraine and its invasion at the hands of Russia, it strained credulity to imagine that any other topic would find a bright spotlight shone on it during President Biden’s State of the Union address earlier this week.

But one in particular, in fact, did: nursing home care.

“All people deserve to be treated with dignity and respect and to have access to quality medical care. And in no case should a healthcare facility be causing a patient harm,” the White House said in a statement issued prior to the address. “The President believes we must improve the quality of our nursing homes so that seniors, people with disabilities, and others living in nursing homes get the reliable, high-quality care they deserve.”

With that, Biden laid out a long list of proposed reforms, developed by and implemented through the U.S. Department of Health and Human Services (HHS), that the Administration says will “improve the safety and quality of nursing home care, hold nursing homes accountable for the care they provide, and make the quality of care and facility ownership more transparent so that potential residents and their loved ones can make informed decisions about care.”

The list of proposed reforms was so lengthy, it had to be divided into five separate categories, the first dealing with general management. Specifically, the Administration proposed that HHS:

  • Establish a strict minimum nursing home staffing requirement, with this being the measure most closely linked to the quality of care residents receive;
  • Reduce resident room crowding;
  • Strengthen the Skilled Nursing Facility (SNF) Value-Based Purchasing (VBP) Program; and
  • Reinforce safeguards against unnecessary medications and treatments.

The next category was “enhancing accountability and oversight,” with the Administration proposing:

  • Adequately funding inspection activities;
  • Beefing up scrutiny on more of the poorest performers via CMS’s Special Focus Facility (SFF) program, which identifies the poorest-performing nursing homes in the country for increased scrutiny;
  • Expanding financial penalties and other enforcement sanctions (with a proposal to drive individual penalties up from a maximum of $21,000 to $1 million);
  • Increasing accountability for chain owners of substandard facilities; and
  • Providing technical assistance to nursing homes to help them improve.

The third category, increasing transparency, included announcements that:

  • CMS will create a new database that will track and identify owners and operators across states to highlight previous problems with promoting resident health and safety;
  • HHS will move to improve transparency of facility ownership and finances;
  • Officials will enhance Nursing Home Care Compare, the rating website designed to help families pick a facility for their loved ones; and
  • HHS will examine the role of private equity in the industry.

The fourth category announced an emphasis being placed on creating pathways to good-paying jobs, with the free and fair choice to join a union, as well as pledges that:

  • Steps will be taken to ensure that nurse aide training is made more affordable;
  • Support will be given to state efforts to improve staffing and workforce sustainability; and
  • A National Nursing Career Pathways Campaign will be created.

Lastly, in light of the COVID-19 pandemic, the Administration said it wanted to ensure that:

  • COVID-19 testing in long-term care facilities continued;
  • COVID-19 vaccinations and boosters continued to be available in long-term care facilities;
  • Requirements for on-site infection preventionists continue to be strengthened; 
  • Requirements for pandemic and emergency preparedness continue to be enhanced; and
  • Pandemic lessons be incorporated into nursing home requirements.

Biden specifically pointed to the COVID-19 pandemic as something that highlighted the “tragic impact of substandard conditions at nursing homes,” noting that while an estimated 1.4 million people live in over 15,500 Medicare- and Medicaid-certified nursing homes across the country, in the past two years, more than 200,000 residents and staff in long-term care facilities died from COVID-19, marking nearly a quarter of such deaths overall.

“Despite the tens of billions of federal taxpayer dollars flowing to nursing homes each year, too many continue to provide poor, sub-standard care that leads to avoidable resident harm,” the White House said. “In fact, failure to comply with federal guidelines at nursing homes is widespread. The Government Accountability Office found that, from 2013 to 2017, 82 percent of all inspected nursing homes had an infection prevention and control deficiency, including a lack of regular handwashing, that was identified through Medicare and Medicaid surveys.”

The White House also noted that private equity firms have been buying up struggling nursing homes at a breakneck pace, with research showing that such facilities tend to have significantly worse outcomes for residents. Private equity firms’ investment in nursing homes reportedly grew from $5 billion in 2000 to more than $100 billion in 2018, with about 5 percent of all nursing homes nationwide now owned by such companies.

In a lengthy article on the topic, the Associated Press described the proposed reforms as “sought by advocates and opposed by the industry.” Likewise, individual reviews were mixed.

“Overall, these are very positive developments,” the article quoted Harvard health policy professor David Grabowksi as saying. “If you ask the industry, they’ll tell you this will put them out of business. If you ask an advocate, they’ll say there’s plenty of money in the system. I think the truth is probably somewhere in the middle.”

To wit: the article cited an industry group advocate who said what nursing homes need is “more resources and not finger-pointing.” Another official representing nonprofit facilities was quoted as pointing out that Medicaid doesn’t fully cover costs.

Consumer advocates did indeed feel differently.

“This plan is a major step forward for quality and safety in our nation’s nursing homes,” Terry Fulmer, president of the nonprofit John A. Hartford Foundation, which works to improve long-term care, told the Associated Press. “It will be essential that it get implemented quickly and monitored closely for the improvements we need now.”

To review the White House’s statement in its entirety – all but an imperative for providers in the field – go online to

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Mark Spivey

Mark Spivey is a national correspondent for,, and Auditor Monitor who has been writing and editing material about the federal oversight of American healthcare for more than a decade.

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