As the Administration works on the Nursing Home Quality Initiative, “we are very interested in hearing what is happening on the ground,” CMS Administrator Chiquita Brooks-LaSure told Katie Smith Sloan and members during a meeting on March 31. Sloan was joined by leaders of four LeadingAge member nursing homes; the Administrator was accompanied by Deputy Administrator Jon Blum, and other CMS staff working on the Nursing Home Quality Initiative. The rich discussion focused on staffing, quality, and funding.

Deke Cateau (AG Rhodes in Atlanta), Danny Williams (Eliza Bryant in Cleveland), Jeff Farber (New Jewish Home in NY), and Sondra Norder (St. Paul’s in WI) joined Sloan in representing LeadingAge. Each of the four offered initial comments after Sloan began with LeadingAge’s request for an “all of government” set of solutions – the only way to solve some of the longstanding challenges.

As the nursing home leaders spoke, they all demonstrated a mission-focused approach to caring for people and a commitment to the same goal on which the Administration is focused – continuous quality improvement. Clearly and courteously, each of the provider leaders also pointed out that some of the recommendations and tone of the initiative “rub salt in the wounds” of people who have been risking their lives for the more than two years of the pandemic to serve older people.

Deke Cateau talked about the workforce crisis, describing it as a supply issue. He said that for the first time he has had to turn to agency staff, to whom he pays up to four times as much as permanent staff. He specifically asked that the Administration do something about price gouging.

Administrator Brooks-LaSure asked him why workers are more attracted to agencies; Cateau answered, of course, they pay higher rates (though often no benefits), but said he is relying on agency workers because “the fewer people we serve, the less we can do our mission.” All the leaders agreed that without sufficient staff to provide quality care, they would not agree to admit people.

Danny Williams described how his 126-year-old organization, Eliza Bryant, the oldest still-operating African-American organization taking care of older people in Cleveland, had to make the heartbreaking decision to close this June. “We are a living case study of what happens when Medicaid rates don’t cover the cost of care,” he said.

Jeff Farber described his own background as a geriatrician and his passion as providing quality care to older people with dignity and respect. He added that his goals align with the Administration’s goals, but the proposed actions in the initiative will not produce the desired results. “More penalties won’t get us to better care,” he said. “Doubling down on punishments won’t work.” He added that the media has been counterproductive during the pandemic. Still, he said, “we’re not going to not take care of people.” He suggested ideas to improve the training of geriatricians, described the staff demands and frustration caused by duplicative reporting requirements, and concluded: “We are not the problem. We are your partners. We are part of the solution. Nonprofit and like-minded mission-focused nursing homes will continue to spiral down and disappear or be sold if they continue to be under-funded.”

Sondra Norder talked about the deep personal commitment of frontline staff. “When the rest of the world was separated by plexiglass, these are the people who were helping older residents” with personal activities of daily living. She pointed out that the language of the initiative appears to assume that all or most nursing homes have major issues with infection control, but this is not the reality. For example, she described her organization being cited for an infection control deficiency because a staff member washed their hands improperly between glove changes. “Fines are a punishment, not an incentive,” she added.

Lack of resources, particularly sufficient Medicaid rates, were a recurring theme. One participant pointed out that nursing homes don’t routinely have access to interoperable electronic health records; “many still use fax machines!”

As he said during the nursing home policy session at Leadership Summit, Jonathan Blum indicated an interest in looking at a risk-based allocation of survey resources. He asked explicitly for the red flags that would indicate likely problems in the future.

Norder suggested that the research shows that leadership changes are one possible risk factor. Farber suggested focusing on the medical director. LeadingAge plans to follow up with some additional suggestions.

Cateau offered that nursing homes that work closely with their QIOs could be surveyed differently.

“This is a human business – that is the story and the narrative,” one participant added. “CMS should focus on what really matters.”

In thanking the group, the Administrator reported that CMS has met with residents and CNAs and heard stories, like one from a woman who came back quickly after giving birth – putting her life and her family at risk – because of her deep commitment to the mission of her organization. “We are very interested in what happens on the ground; we acknowledge all you are doing and look forward to continuing to work with you,” she concluded.