care policy .” They add , “ Here , as in many other countries , nursing homes have been ill equipped to stop the spread of the virus . They lacked the resources necessary to contain the outbreak , including tests and personal protective equipment , and their staff are routinely underpaid and undertrained . Furthermore , nursing homes were sitting ducks for COVID-19 , housing people who are particularly vulnerable to poor outcomes of the virus , often in shared living quarters and communal spaces , making social distancing or isolation difficult , if not impossible .”
Just as the COVID-19 pandemic exposed an ongoing lack of preparedness in acute-care institutions , it aggravated the chronic obstacles to quality care in long-term care and other post-acute facilities .
Werner , et al . ( 2020 ) remind us that this crisis in nursing homes is not a new problem : “ Long-term care in the United States has been marginalized for decades , leaving aging adults who can no longer care for themselves at home reliant on poorly funded and insufficiently monitored institutions . Although major regulatory policies , including the Federal Nursing Home Reform Act of 1987 , have attempted to address deficiencies in the quality of care , COVID-19 has highlighted the fact that better monitoring is not enough . The coronavirus has exposed and amplified a long-standing and larger problem : our failure to value and invest in a safe and effective long-term care system .”
In 1974 , a U . S . Senate Special Committee on Aging report identified nursing home shortfalls : “ Lack of human dignity ; lack of activities ; untrained and inadequate numbers of staff ; ineffective inspections and enforcement ; profiteering ; lack of control on drugs ; poor care ; unsanitary conditions ; poor food ; poor fire protection and other hazards to life ; excessive charges in addition to the daily rate ; unnecessary or unauthorized use of restraints ; negligence leading to death or injury ; theft ; lack of psychiatric care ; untrained administrators ; discrimination against minority groups ; reprisals against those who complain ; lack of dental care ; advance notice of state inspections ; false advertising .”
There have been some significant changes in the years since , as skilled nursing facilities became more regulated due to the passage of the Nursing Home Reform Act , part of the Omnibus Reconciliation Act of 1987 . The extensive standards established by OBRA 1987 were resident-focused and outcome-oriented , emphasizing quality of care , resident assessment , residents ’ rights , and quality of life .
However , much work remains , policy experts emphasize . In his March 6 , 2019 testimony before the U . S . Senate Committee on Finance , David C . Grabowski , PhD , a professor in the Department of Health Care Policy at Harvard Medical School , noted , “ Nursing home quality of care continues to be an important public policy issue despite prolonged public outcry and government commissions . Often the number of nurses per resident is low and the staff turnover rate is high . Residents may develop new health problems after admission from physical restraints and missed medications . There are studies documenting mistreatment of older adults in nursing homes . Amenities that are common within a nursing home – including the food , activities and public spaces – are too often sub-standard . The quality of life in many U . S . nursing homes is inadequate and large numbers of residents suffer from isolation and loneliness .”
In May 2020 , the Government Accountability Office ( GAO ) analyzed Centers for Medicare & Medicaid Services ( CMS ) nursing home infection prevention and control deficiency data , finding that prior to the COVID-19 pandemic , most nursing homes were cited for infection prevention and control deficiencies . About half of these homes had persistent problems and were cited across multiple years .
CMS is responsible for ensuring that approximately 15,500 nursing homes nationwide meet federal quality standards . These standards require , for example , that nursing homes establish and maintain an infection prevention and control program . CMS enters into agreements with state survey agencies to conduct surveys and investigations of the state ’ s nursing homes and to cite nursing homes with deficiency citations if the home is not in compliance with federal standards . Infection prevention and control deficiencies cited by surveyors can include situations where nursing home staff did not regularly use proper hand hygiene or failed to implement preventive measures during an infectious disease outbreak , such as isolating sick residents . Many of these practices can be critical to preventing the spread of infectious diseases , including COVID-19 .
GAO ( 2020 ) analysis of CMS data shows that infection prevention and control deficiencies were the most common type of deficiency cited in surveyed nursing homes , with most nursing homes having an infection prevention and control deficiency cited in one or more years from 2013 through 2017 ( 13,299 nursing homes , or 82 percent of all surveyed homes ). In each year , GAO ( 2020 ) found that about 40 percent of surveyed nursing homes had infection prevention and control deficiencies , and this continued in 2018 and 2019 . About half — 6,427 of 13,299 ( 48 percent )— of the nursing homes with an infection prevention and control deficiency had this deficiency cited in multiple consecutive years from 2013 through 2017 . This is an indicator of persistent problems at these nursing homes , the GAO ( 2020 ) says .
In each year from 2013 through 2017 , nearly all infection prevention and control deficiencies ( about 99 percent in each year ) were classified by surveyors as not severe , meaning the surveyor determined that residents were not harmed . GAO ( 2020 ) review of CMS data shows that implemented enforcement actions for these deficiencies were typically rare ; from 2013 through 2017 , CMS implemented enforcement actions for 1 percent of these infection prevention and control deficiencies classified as not severe .
Pandemic-Driven Challenges
The American Health Care Association ( AHCA ) confirms that , “ LTC facilities ( including nursing homes and other congregate facilities for older adults ) have been considered the epicenter of the pandemic , as more than 1 million cases and 170,000 deaths have been linked to these facilities across the country . Researchers tracking COVID-19 data in the United States and world-wide remained consistent in their findings in 2020 . LTC residents made up a small percentage of total cases yet were a disproportionate share of each country ’ s deaths . This research demonstrates the vicious nature of the virus on frail and elderly adults with comorbidities . Protecting older adults from this virus should have been our nation ’ s top priority . It was not and , tragically , the seniors in our long-term care facilities were left behind . It is critical that we figure out what happened , why it happened , and what we can do to keep it from ever happening again . It is time for the country to decide if it will make sacrifices to help those who have sacrificed so much for us . It is time for bold , transformative , and meaningful action .”