Nursing Home Industry Takes National Stage Again as House Hearing Skewers For-Profit Ownership


The nursing home industry was thrust back into the national spotlight this week as federal lawmakers called out for-profit ownership for their lack of resources during the early months of the pandemic and confounding corporate structures.

The Congressional Select Subcommittee on the Coronavirus Crisis, chaired by Rep. James Clyburn, held a hearing on Wednesday to delve further into the impact of Covid-19 in nursing homes.

“The ferocity with which the Coronavirus swept through our nation’s nursing homes in 2020 exposed vulnerabilities that have been building for years,” Clyburn said during the hearing. “These long standing problems helped to drive outbreaks and exacerbated the risks.”

What was notably absent, according to industry experts and advocacy organizations, were future-looking conversations and actionable solutions to many of the concerns raised.

The scheduled hearing was coupled with a report issued the same daywhich specifically took to task several large nursing home chains including Genesis HealthCare, Life Care Centers of America, the Ensign Group (Nasdaq: ENSG), SavaSeniorCare and Consulate Health Care.

Lifting the veil and finding solutions

David Grabowski, professor of health care policy at Harvard Medical School and witness during the hearing, said residents felt the pandemic “lifted the veil” on what has been an invisible social ill for decades.

“There have been over 1.2 million COVID cases among residents leading to roughly 172,000 Covid-related fatalities. Over 2,600 nursing home staff members have died from Covid, making the nursing home worker the most dangerous job in America,” he said during the hearing.

Grabowski urged members of Congress to increase vaccination levels through mandating boosters, and improve staffing, underscoring existing efforts to establish a minimum federal staffing ratio, increase staff pay and benefits and provide workers with opportunities for career advancement and a better work environment.

Those recommendations were met with little follow-up from Congressional attendees during the Q&A period.

“I feel like we had an opportunity here and we didn’t take advantage of that opportunity during this hearing, in terms of focusing on where we go and really drilling down on a set of ideas,” Grabowski told SNN after the hearing.

One member, US Rep. Bill Foster of Illinois, did ask about how immigration might play a role in bridging the staffing gap. He called immigration reform an “obvious solution” to the labor shortage, with “hordes of very competent, well-trained nurses around the world” that have traditionally entered the US workforce to fill the labor pipeline.

Adelina Ramos, a certified nursing assistant (CNA) in Rhode Island and member of 1199 SEIU New England, and Daniel Arbeeny, the son of a nursing home resident who died during the pandemic, also spoke at the hearing.

Ramos said unions have helped CNAs and other essential workers in the nursing home obtain sick leave and better health insurance, while owners and lawmakers continue to devalue the workforce more than two years into the pandemic.

“A union contract means management has to follow the rules,” Ramos said during the hearing. “It means workers have a seat at the table. It means we can fight for our residents to have better care, but not every nursing home has a union and the workers and the residents are suffering.”

A hearing that missed the mark, systemic inequities and call for action

One witness and a select group of Congressional members spent a fair bit of time discussing the infamous March 2020 directive by former Gov. Andrew Cuomo, who ordered nursing homes to accept Covid-positive patients despite their lack of readiness to do so.

Other states like Michigan, New Jersey, and Pennsylvania followed suit with such a mandate, which went against federal recommendations and flew in the face of special units being assembled specifically for Covid-positive patients.

“I’m a bit underwhelmed with regard to the attention to … the actions that took place over two years ago, and the decreased focus on where we go from here, with regards to making meaningful change to nursing homes and the processes that are in place,” said Jasmine Travers, assistant professor at NYU Rory Meyers College of Nursing and a witness during the hearing.

In having such intense focus on New York, the subcommittee missed a chance to view state decisions as a reflection of a systemic failure in how federal and state agencies respond and address issues in the nursing home sector, added Travers.

Subcommittee members could have examined the ways in which decisions were made across state and federal lines, she told Skilled Nursing News, and how these decisions were detrimental to the health, well-being and safety of residents.

She had hoped subcommittee questions would focus more on ways to support nursing homes in the future while also holding them accountable in ways that are appropriate.

In her testimony, Travers told the subcommittee that staffing shortages, inadequate pay and benefits, and a lack of advancement opportunities – which were first outlined by Grabowski – can be traced back to structural inequities.

“It is important to highlight the systemic inequities that have perpetuated disparities among nursing home residents – homes with any black residents experienced significantly more Covid infections and deaths than homes with no black residents,” Travers said during the hearing. “Black and Latino residents are more likely to experience pressure ulcers, falls and under treatment for pain.”

More training to better understand residents from other cultures, added scrutiny around biases and more of an effort to hire staff that is culturally congruent to residents is needed in the sector, she said.

The need to address long standing issues of care quality and inadequate support facing nursing homes has only intensified in urgency, Alice Bonner, senior advisor for aging at the Institute for Healthcare Improvement and chairperson of Moving Forward: Nursing Home Quality Coalition, told the subcommittee.

In a separate letter to Rep. Clyburn and Ranking Member Steve Scalise, Bonner drew attention to six key issues lawmakers and nursing homes must work on in partnership, as a growing number of older people enter the post-acute care continuum.

Funded by the John A. Hartford Foundation, the coalition is a two-year initiative to advance recommendations in the 2022 National Academies of Sciences, Engineering, and Medicine (NASEM) report.

“I think what we really wanted to convey was this sense that we must take action now. It’s been too long, there’s been too much devastation,” Bonner told SNN. “This is not about writing another big report. We have the NASEM report – it’s 600 pages, it’s full of recommendations. It will keep all of us busy for the rest of our careers if we just focus on that report, and the recommendations in that report.”

Report sheds light on for-profit corporate structures

Hours before the hearing, the subcommittee released a report detailing “dire conditions” of for-profit nursing homes in the early months of the pandemic – murky corporate structures helped such companies obscure profits and avoid legal and regulatory accountability, authors wrote.

The report used Genesis as an example, referring to its over 700 discrete corporate entities as of June 2020. Many acted as service providers to other facilities within its corporate structure.

The subcommittee went on to recognize that these larger nursing homes chains, including Genesis, underwent “significant reorganization” since June 2020 — the furthest point in time from when the data was collected.

Congressional members are referring to a shift to the small market model first tested by Ensign, and then Genesis, among other named entities. Larger companies set up local-driven leadership teams to address unique challenges in individual markets across the country.

The model has allowed companies like Ensign to push through Covid trends, effectively use government waivers and navigate political climates, according to CEO Barry Port.

Consulate underwent rebranding and restructuring after a bankruptcy filing and financial settlement with the Department of Justice last year.

In an email to Skilled Nursing News, Genesis spokesperson Lori Mayer told Skilled Nursing News that it is “common practice for large companies to have varied entities and structures,” in response to the report.

The Kennett Square, Pa. company provides services at more than 200 affiliated locations.

Attempts to reach Ensign, SavaSeniorCare, Life Care Centers of America and Consulate were not immediately returned.

Old data targets for-profit entities

Other key findings from the report suggest many facilities were severely understaffed in the early months of the pandemic, and that for-profit nursing home chains didn’t supply workers with adequate personal protective equipment (PPE).

The report also found nursing homes pressured staff to continue working despite having Covid symptoms or testing positive.

Aging services organizations like the American Health Care Association (AHCA) were quick to point out that every long-term care provider – regardless of business structure – were pleading for public health agencies and policymakers to send support during the early days of the pandemic.

LeadingAge CEO Katie Smith Sloan said non-profit nursing homes “begged for critical resources,” including PPE, Covid tests and increased support for staff, particularly nurse aides and other frontline staff.

“We ask Congress and the [Biden] administration to take responsible action toward broader change. It’s time to fix our country’s broken system of financing, oversight and support for nursing homes,” Sloan said in a statement.

Once the sector started receiving the aid they needed, long-term care providers started seeing “tremendous progress” in reducing cases and deaths in nursing homes, AHCA CEO Mark Parkinson said.

“It’s unfortunate that we need to remind lawmakers what those early days were like,” he said in a statement. “Nearly every nursing home in the country struggled with acquiring personal protective equipment due to supply chain disruptions, testing due to limited supply, and additional staff support due to most government support being directed toward hospitals.”

AHCA urges Congress to focus on serious challenges that remain at this point in the pandemic, including a historic workforce shortage.

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