What Is the Path to Quality Nursing Home Care?

America’s population is aging rapidly: 10,000 baby boomers will reach age 65 each day until 2030.

Nursing home care is, and will continue to be, a crucial component of our country’s health care system. Nursing home care and oversight has been a topic of congressional concern and media attention in recent months.

Our members, which include nearly 2,000 nonprofit providers of skilled nursing, do not excuse poor care, nor do we oppose care oversight and regulations. Our members are committed to improving quality of care and quality of life for older adults as evidenced by the significant time, expense and staff attention devoted to implementation of the new requirements for participation, which added to and reorganized existing rules of care.

Revised to reflect the “substantial advances that have been made … in the theory and practice of service delivery and safety,” these changes were announced in 2016 and rolled out in three phases, the last of which must be implemented in November 2019. From increased staff training, greater focus on resident rights and person-centered care to improved infection prevention and a decrease in the use of antipsychotics in favor of non-pharmacologic interventions, these rules are widely considered as an expression of best practices. Following them is what all providers strive to do.

The assertion that care in nursing homes today is declining due to fewer regulations and lax oversight of providers is not based in fact. Furthermore, it is simply inaccurate to conclude that our country’s nursing home providers do not meet quality standards, as The Washington Post did recently, based on one very passionate organization’s analysis of fines levied at fewer than 40 providers deemed poor performers, a group representing 0.256 percent of the 15,600 nursing homes in the United States.

The focus on fines imposed as a measure of whether nursing homes are meeting quality standards — and even more important, whether they are providing good, person-centered care — is misguided. There are several important distinctions to understand here.

Fines are one component of a program that nursing home surveyors use to develop with a provider to fix a problem of regulatory noncompliance. Infractions that warrant a fine apply to all aspects of nursing home operations. These monetary penalties are levied for a range of violations, from failing to properly replace the cap on a resident’s eyedrops to insufficient labeling of stored food, poor infection control or others that threaten a resident’s life. However, fines are not the only remedy that the Centers for Medicare and Medicaid Services can impose, and not all types of problems (“deficiencies” in CMS-speak) merit a monetary penalty.

The second fallacy with equating fines as an indicator of quality care is that the number and severity of fines levied vary widely by state. The numbers alone beg questions.

Look at Alabama and Arkansas, which have nearly the same number of provider homes: 227 and 231. Alabama’s total deficiency count is 2,935 including 92 serious deficiencies, compared to Arkansas’ 4,503 and 245, respectively. Alabama logged 54 fines, with providers charged $3,068,623, while Arkansas logged 158 — nearly three times more than Alabama — for total fines of $3,829,725.

Some ask how can the current administration’s oversight of nursing homes be trusted based on reduced fines for poor performers if we can’t even trust the administration to hold these facilities accountable. How can we trust it to properly regulate less seriously troubled nursing homes?

Some critics believe that only large fines will force nursing homes to do better. Others, however, question our punitive approach to reform. Fines may be appropriate for deliberate malfeasance, but the regulatory system is supposed to be remedial, with corrections used to progress to compliance with best practices.

Vanderbilt University health policy professor David Stevenson recently noted in Health Affairs that “there is relatively limited evidence about whether penalties effectively deter poor-quality care and what their optimal level or form might be.” For over three decades, with the launch of the Nursing Home Reform Act of 1987, regulation has provided an array of remedies for care deficiencies in addition to fines, including directed plans of correction, in-service trainings and appointment of temporary management. Might we consider that fewer fines overall indicate care has improved?

By several measures, nursing home care has improved under the Nursing Home Reform Act: Harmful practices, such as the use of physical restraints, are all-but-eliminated. The overuse of antipsychotics is declining, with significant attention continuing to focus on finding alternatives to their use. Person-centered care, as required under the 2016 requirements for participation, is now the norm.

We agree that poor performers must improve. We do not tolerate bad care. But to suggest, based on the analysis of one narrow slice of the whole, that nursing home regulation is not sufficient does a significant disservice to all of us — providers, policymakers and consumers — by misrepresenting the state of care today. We have improved and must continue to do so. This is not a simple us-versus-them problem, one that is solved by finger pointing.

It is time to assess what has been learned since the Nursing Home Reform Act and to ask: Have we reached the limits of the effectiveness of fines and other punishment as mechanisms for achieving acceptable quality nursing home care? Can we find new approaches to ensure consistent, high-quality care in all of our nation’s nursing homes?

We are all growing older. Addressing this now matters, not only to today’s older adults and those who love them and care for them, but also to those who will be the older adults of tomorrow.


Katie Smith Sloan is president and CEO of LeadingAge, the association of nonprofit providers of aging services, including nearly 2,000 nursing homes.

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