Bloomberg Law
March 15, 2022, 9:22 AM

Problem Nursing Homes to See Push for Fast Upgrades That Last

Tony Pugh
Tony Pugh

Underperforming nursing homes will be getting more federal help to improve their quality of care, but they’ll have less time to do it as the Biden administration moves to speed up the way it brings troubled facilities into compliance.

As part of its sweeping nursing home reform effort, the Centers for Medicare & Medicaid Services will be “retooling” the Special Focus Facility program, which targets the worst operators in each state, CMS Administrator Chiquita Brooks-LaSure said.

About 10% of facilities that enter the program have their Medicare and Medicaid certifications terminated for unresolved deficiencies, but most significantly improve care within 18 to 24 months. That’s too long for Brooks-LaSure, who said some facilities “churn in and out” of the program by showing improvement, only to have old problems re-surface.

“We are going to shift that focus more to actively trying to bring those facilities into compliance quickly and then terminate if they’re not able” to improve, she said in an interview. “Our goal is really to improve care at the lowest-performing facilities more rapidly” through more direct engagement when a facility first enters the program.

The expedited improve-or-terminate process could end up hurting access to care for low-income Medicaid beneficiaries who typically make up the bulk of residents in low-quality facilities, said David Grabowski, a Harvard Medical School professor of health-care policy who studies nursing homes.

Increasing penalties on these providers or pulling their Medicare and Medicaid certifications could be “taking dollars and access away from beneficiaries who don’t have anywhere else to turn,” he said. “There’s not always operators lining up to enter into those markets.”

Brooks-LaSure didn’t provide details on how long facilities will have to resolve deficiencies under the shortened timetables. The CMS didn’t respond to a question about Grabowski’s comments.

Focus on Poor-Quality Providers

While the nursing home industry has opposed the main CMS reform initiative—imposing mandatory minimum staffing requirements within a year—providers have signaled support for directing more attention and oversight to poor-quality facilities.

“We agree that we need to focus on the poor providers. We need to help them get better, and if they can’t get better, they shouldn’t be providing care,” Mark Parkinson, president and CEO of the American Health Care Association, said during a recent press briefing. “To the extent that the administration is willing to focus on that part of the provider group, we’ll be right there with them arm-in-arm trying to improve the poor-providing facilities.”

The Biden administration has proposed the most far-ranging overhaul of health, safety, and transparency regulations for nursing homes in decades. The actions follow the Covid-19 deaths of more than 200,000 residents and staff at long-term care facilities, according to the Kaiser Family Foundation.

The nursing home industry added 2,100 jobs in January, the first monthly job growth since July 2019, according to the AHCA and the National Center for Assisted Living. But facilities have still lost 238,000 positions, about 15% of their workforce, since the pandemic began.

In addition to a staffing requirement, the Biden administration has called for an additional $500 million to improve and expand nursing home inspections, more transparent reporting of facility ownership and how federal funds are spent, and the establishment of a database of nursing home owners and operators with a history of health and safety problems.

Limited Slots

More than 1.4 million people reside in over 15,500 Medicare- and Medicaid-certified nursing homes. As of February, nearly 2,500 facilities had a one-star rating on their health inspections, the lowest rating on the one- to five-star scale. The Special Focus Facility program has only 88 slots, with another 435 facilities listed as program candidates.

Nursing homes are selected for the program using a point system based on the number and severity of deficiencies cited in the last three inspections. Nursing homes with the most points in a state either become candidates for the program or enter the program. Once in the program, facilities are inspected at least every six months rather than annually. State inspectors apply progressive enforcement—penalties, fines, withholding of payments—until the facilities significantly improve or are terminated from Medicaid and/or Medicare.

Some facilities in the program improve care- and safety-related problems temporarily but are often cited for similar deficiencies on later inspections. The facilities that yo-yo in and out of compliance seldom address their underlying problems, Brooks-LaSure said.

“Now we see facilities that churn in and out” of the program, “and so we really want to move towards sustained improvement in the standard of care,” she said.

To contact the reporter on this story: Tony Pugh in Washington at

To contact the editors responsible for this story: Brent Bierman at; Fawn Johnson at