Pandemic lessons must spur federal action to protect nursing home residents

About one-third of Americans who reach age 65 will need nursing home care in their lifetimes — which can be a daunting thought if you recall the suffering of residents as the Covid-19 pandemic exposed long-standing problems in nursing homes.

These problems did not fade away with the end of the public health emergency, and nursing home residents continue to be disproportionately affected by Covid-19.

Meaningful change to keep nursing home residents safe requires broad collaboration with partners and stakeholders across government, the nursing home sector, and the broader health care industry. The underlying problems in nursing homes must be addressed because they set the stage for the tragedies that occurred during the pandemic. Everyone who enters a nursing home, whether they stay for one day or several years, deserves safe, high-quality care.

Challenges that hurt nursing homes’ response to Covid-19

In a three-part series of reports, the Department of Health and Humans Services Office of Inspector General (HHS-OIG) illuminates the widespread and unrelenting toll the pandemic exacted on nursing homes and their residents. Despite herculean efforts by many individual nursing care professionals, systemic shortcomings in the nursing home industry and government oversight of it left residents extremely vulnerable to morbidity and mortality. We hope these reports fuel the urgency to find long-term solutions and sweeping reforms.

There are approximately 15,000 certified nursing homes in the U.S. Most were unprepared for a pandemic and could not adapt effectively when Covid-19 emerged. The surge in nursing home cases and deaths in the spring of 2020 made clear that nursing home residents were especially vulnerable to SARS-CoV-2, the virus that causes Covid-19. Yet even after much more was known about prevention, there was an even greater surge of nursing home Covid-19 cases and deaths in the fall of that year.

More than 1,300 nursing homes had extremely high infection rates during the surges, with at least 3 out of every 4 of their Medicare beneficiaries diagnosed with Covid-19 or likely Covid-19 in a matter of weeks. Throughout the pandemic, nursing homes struggled to maintain adequate staffing and effective infection control.

The Centers for Medicare and Medicaid Services and state agencies regularly inspect nursing homes to determine if they meet federal requirements for infection prevention and control. Even though nearly all nursing homes were inspected multiple times during 2020, the majority of those with extremely high infection rates were not cited with any deficiencies in infection control, and few were cited with serious deficiencies. In other words, nursing homes with the highest rates of Covid-19 in the country were passing Medicare’s infection-control test.

Promising measures that could lead to solutions

The HHS-OIG series includes many recommendations to CMS to improve the serious and lingering nursing home problems the report revealed.

The system in place to protect nursing home residents from a pandemic was not up to the task. But it needs to be going forward. Two pillars in the protection system — staffing and infection control — must be fixed. Since 1987, all nursing homes have had the same minimum requirement for registered nurse care regardless of their size or the health of the residents: just eight consecutive hours per day, whether a home has five or 500 residents.

Although the overwhelming majority of nursing homes with extremely high infection rates met or exceeded the minimum requirement for nursing hours, this minimum requirement did not suffice to keep residents safe from infectious disease. HHS-OIG has called on Medicare to reexamine current nursing staff requirements. Medicare issued a final rule in April 2024 to increase them. Nursing homes must now have a registered nurse on site 24 hours per day, seven days a week.

Of course, nursing homes can increase staffing levels only when there are enough willing and qualified workers to fill positions. The pandemic pushed an already struggling nursing home workforce to its limits. Sustained action is needed to build back a strong workforce that can provide quality care to nursing home residents.

HHS-OIG also has recommended that CMS update requirements for infection control to incorporate lessons learned from the pandemic, and for CMS to improve the inspection process so it more effectively identifies infection control risks in nursing homes.

The pandemic sounded a call to action on many fronts, which is still ringing loudly as the virus continues to take its toll. Staffing challenges need to be addressed and infection control must be improved to better protect nursing home residents. HHS-OIG’s recommendations are aimed at overcoming these longstanding problems with nursing home care.

All Americans have a stake in this. Nursing homes should provide good care and be a safe, viable option for anyone needing long-term care now and in the future. Let’s make sure that nursing homes live up to their name and, like any good home, provide safety, comfort, and dignity.

Julie K. Taitsman is the chief medical officer for the Department of Health and Human Services Office of Inspector General, serving as the agency’s primary resource on clinical and scientific issues, and lends medical expertise to audits, evaluations, inspections, and enforcement actions. Nancy Harrison is a deputy regional inspector general for evaluation and inspections in HHS-OIG’s New York region, overseeing a staff of social science analysts working on evaluation reports, particularly related to care in nursing homes, hospices, and hospitals.